Debunking Three Rape Myths Mary Carr, MD1, Avis J

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Debunking Three Rape Myths Mary Carr, MD1, Avis J. Thomas, MS2, Daniel Atwood, BS3, Alexandra Muhar, BA4, Kristi Jarvis, BS, SANE-A, RN, EMT-B5, and Sandi S. Wewerka, MPH, EMT-B, CCRC6

ABSTRACT Background: Stereotypes and prejudicial misconceptions are prevalent regarding sexual assaults and victims’ responses. These are collectively referred to as rape myths. This study examines three rape myths purporting that sexual assault victims (1) immediately report the crime, (2) experience severe physical and/or anogenital injuries, and (3) forcefully resist their assailant. Study Design: This is a cross-sectional descriptive study examining presence of physical or anogenital injury, level of physical resistance during a sexual assault, and time to sexual assault report. Study subjects were female sexual assault victims examined by a sexual assault nurse examiner at Regions Hospital in St. Paul, Minnesota, in 2011 and 2012. Results: Sexual assault nurse examiner reports for 317 subjects met the inclusion criteria and were reviewed. Twelve (4%) victims experienced physical injury requiring medical intervention. Thirty-four (11%) sustained anogenital injuries requiring medical intervention. Overall, 253 (81%) victims did not actively resist at some point during the assault, with 178 (57%) victims never actively resisting. Nearly half (129, 43%) did not appear in the emergency department for 12 or more hours from the time of the assault. Conclusion: Women who seek emergency department assistance after a sexual assault take a variable amount of time to present to the emergency department, rarely experience moderate or severe physical or anogenital injury, and commonly do not exert strong physical resistance against their attacker during at least part of the assault. KEY WORDS: anogenital injuries; delayed reporting; physical injuries; physical resistance; rape myths; sexual assault

n 2012, the Centers for Disease Control and Preven- of offenders. In the United States (U.S.) legal changes have tion (CDC) reported that nearly one in five women ex- occurred in every state, shifting the focus away from victim Iperience sexual assault at some time in their lives (CDC, blame and directing it toward the behavior of the defendant 2012; McCall-Hosenfeld, Freund, & Liebschutz, 2009). (Clay-Warner & Burt, 2005). Medical evaluations of rape Sexual violence against women is a pervasive public health victims have become more patient centered since the advent issue, but fortunately, advancements have been made in the of sexual assault nurse examiner (SANE) programs (Ledray, evaluation and treatment of victims and in the prosecution Faugno, & Speck, 2001). In addition, DNA analysis has been Author Affiliations: 1Department of Emergency Medicine, Regions incorporated into alleged rape investigations, and the useful- Hospital; 2Health Partners Institute for Education and Research; ness of these analyses continues to improve (Garvin, Fischer, 3Medical College of Wisconsin; 4University of Minnesota Medical Schnee-Griese, & Jelinski, 2012). However, successful pros- School; 5Sexual Assault Nurse Examiner Program, Regions Hospital; ecution of assailants continues to be challenging (Ellison & 6 and Critical Care Research Center, Regions Hospital. Munro, 2009). One or more nonconsensual sexual act(s) must Disclaimer: The use of the word victim in this study is merely as be proved to have occurred. Lay people empaneled as jurors a descriptor and is not based on legal outcomes, as that measure was not tracked. rely on forensic evidence, witness testimonies, and good judg- The authors declare no conflict of interest. ment to determine the guilt or innocence of the defendant. Correspondence: Mary Carr, MD, Department of Emergency Rape myths remain prevalent; one of the harmful con- Medicine, Regions Hospital, 640 Jackson St., St. Paul, MN 55101. sequences is low conviction rates for offenders (Aronowtiz, E-mail: [email protected]. Lambert, & Davidoff, 2012; Deming, Covan, Swan, & Received March 10, 2014; accepted for publication August 15, 2014. Billings, 2013; Heath, Lynch, Fritch, & Wong, 2013; Rich Copyright © 2014 International Association of Forensic Nurses & Sefrin, 2012; Weiss, 2009). Rape myths were described DOI: 10.1097/JFN.0000000000000044 by Burt in 1980 and defined as stereotypical, prejudicial, or

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false beliefs about rape, rape victims, and rapists that are gen- although there is a significant body of research available (Long, erally untrue but widely held (Buddie & Miller, 2001; Weiss, Palmer, & Thome, 2010). When expert witnesses rely on 2009). Rape myths perpetuate and support male upon female their own experience rather than empirical evidence, de- sexual violence and serve to justify or deny male sexual ag- fense attorneys sometimes question their experience and cre- gression against women (Brownmiller, 1975). Societies with dentials (Campbell et al., 2007). Referring to formal research a more egalitarian view of contributions by men and women, within their own areas of expertise may enhance their effec- and with less male dominance, are not as apt to have a rape tiveness as educators for jurors and the court (Long, 2007). culture. In contrast, cultures with hostility toward women The court’s decision to admit expert testimony must be commonly are noted to have a higher acceptance of rape based on whether it has foundational reliability and will myths (Livingston, Buddie, Testa, & VanZile-Tamsen, 2004; help the jury. In the Minnesota Supreme Court, a majority Suarez & Gadalla, 2010). decision ruling was issued in State v. Obeta (2011), stating In general, U.S. society is willing to treat rape as a crime that, in cases of criminal sexual conduct where consent is when it meets the “traditional” or “classic” scenario of a male an issue, district courts are given discretion to admit expert versus female stranger rape involving a woman who is alone opinion evidence on the typicality of delayed reporting, lack at night and sober. In the traditional scenario, the woman of physical injuries, and “submissive conduct” by sexual as- attempts to fight off her attacker with such force that she is sault victims. This court decision continues to be interpreted injured and then immediately seeks help (Deming et al., 2013). in Minnesota courts. The original court decision, State v. In actuality, most rape victims know their attackers. The CDC Saldana (1982), prohibited the admission of expert testimony reports that female victims of sexual assault identified their on the typical rape-victim behaviors in adult criminal sexual assailant as an intimate partner (51.1%) or an acquaintance conduct cases. (40.8%; Black et al., 2011). Victims who have been sexually State v. Obeta (2011) is a significant case, both in assaulted by a known perpetrator are less apt to view it as Minnesota and throughout the U.S. It set precedence in the a crime, more likely to excuse and justify the sexual assault, state and provides guidance to the courts after 30 years of and believe that they are at least partially responsible for the confusion regarding how, when, and why to use expert assault. As a result, these victims are less apt to report to po- testimony in cases of sexual assault regarding victim behav- lice or seek help for themselves (Clay-Warner & Burt, 2005; iors, particularly delayed reporting, lack of injuries, and sub- Deming et al., 2013; Weiss, 2009). Even when the victim ap- missive behavior, but can be applied to other victim behaviors propriately identifies the assault as a crime, family and friends as well. may not be as supportive when the scenario does not conform On the basis of outcome and importance of the case, to social stereotypes (Deming et al., 2013; Sarmiento 2011). we used the expert witness testimony granted in the Obeta Although men are more apt to endorse rape myths than decision to formulate a study in which we present statistical women, police, prosecutors, clergy, medical providers, and summaries of data obtained from an urban SANE program therapists of both sexes have been known to endorse rape with emphasis on evaluating the time to seek medical care myths (Aronowitz et al., 2012; Rich & Sefrin, 2012; Suarez after a sexual assault, the seriousness of injuries sustained & Gadalla, 2010). Juries participating in mock sexual as- by the victim, and the resistance strategy used by the victim sault cases displayed tacit acceptance of rape myths when during the assault. In addition to serving as a reference for they expected to learn that the victims in the mock trials use by expert witnesses during testimony, the results of this would fight back against their attacker, experience serious study may also be used in the context of forums present- physical injury, report the attack immediately, and appear ing sexual assault information to students and the general tearful and distressed when reporting (Ellison & Munro, public. 2009; Norfolk, 2011). However, when the mock juries were exposed to general expert testimony, the social and psycho- ▪Methods logical information that was provided allowed the jurors to Study Design more reasonably evaluate behaviors they otherwise would This was a cross-sectional descriptive study examining the have found incomprehensible or counterintuitive (Ellison & time from assault to arrival at the hospital for evaluation, Munro, 2009). level of physical and/or anogenital injury, and use of physical In every state, expert witness testimony for the pur- resistance during the assault. Data were gathered on female pose of combatting rape myths and educating jurors about sexual assault victims undergoing examination by a SANE the realities of sexual assault either has not been expressly at Regions Hospital in St. Paul, Minnesota. banned or has been supported by legal changes expressly indicating that it is admissible (Ellison & Munro, 2009; Institutional Review Board Approval Long, 2007; Lonsway, 2005). General expert testimony Before collecting data, approval was obtained from the about the behavior of sexual assault victims is often based Health Partners Institute for Education and Research Insti- on years of professional knowledge rather than formal studies, tutional Review Board.

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Study Population requiring repair; stab wounds; strangulation; and pregnant The study population included all qualified patients pre- with significant blunt abdominal trauma such as thrown down senting to Regions Hospital Emergency Department stating stairs or kicked in the abdomen were considered severe phys- they had been sexually assaulted from January 2011 to ical injuries. The most severe category was assigned to victims December 2012. Inclusion criteria included female gender, with injuries in several categories. age of 13 years or older, presentation to emergency depart- Anogenital findings were similarly summarized in four ment within 120 hours (5 days) of sexual assault, completed categories: none, mild, moderate, and severe. Written narra- examination by a SANE, and signed consent allowing the tive of the findings alone was used to categorize the injuries. chart to be used in scientific studies. Exclusion criteria in- Mild anogenital injuries did not require medical attention. cluded declining the SANE examination and patient inability Language in the SANE report for mild anogenital injures to answer questions because of cognitive difficulties, altered included one or more of the following: bruises, tenderness mental status, or lack of memory about the assault. Further- to touch in anogenital area, redness, and abrasion. Moderate more, patients who delayed more than 5 days (120 hours) anogenital injuries required medical attention. Language found from the end of the assault to their appearance in the emer- in the SANE report for this category included superficial tears/ gency department were excluded. sharp force injuries. Severe anogenital injuries required medical attention. Language found in the SANE report prompting Data Collected placement in this category were deep lacerations/sharp force During the study period, Regions Hospital SANE program wounds of the anogenital region requiring repair in the emer- was staffed by 16 SANEs, all of whom completed training gency department or the operating room and vaginal bleeding according to the International Association of Forensic Nurses with evidence of a foreign body. The most severe category was guidelines (International Association of Forensic Nurses, assigned to victims with injuries in several categories. 2013). These nurses also received ongoing training at monthly Physical resistance was categorized as no physical resis- staff meetings and were offered continuing education at local, tance throughout the assault, physical resistance only in the state, and national levels. Nine of the 16 SANEs were SANE-A second half of the assault, physical resistance only in the first certified. SANEs ranged in experience from 1 to 13 years. half of the assault, and actively resisting throughout the as- Demographic data were collected for each patient includ- sault. Absence of active physical resistance included remain- ing age, race, and ethnicity. Data were also collected regarding quiet, following commands, tonic immobility, and verbal ing time to seek medical care, documentation of statements denial of consent (saying “no”). Language within the SANE indicating active physical resistance, and physical and ano- reports indicating “no resistance” included wanting the as- genital injuries as documented by direct physical examina- sault to be over, fear for safety, feelings of immobility, and tion (including colposcopic examination) during the SANE asking the assailant to stop. Language in the SANE report evaluation. Data reported were based on the nurse examiner’s indicating active resistance included forceful verbal denial direct observation whenever possible or on patient self-report of consent (screaming for help), forceful attempts to keep when information was not directly observable. The nurse clothes on, forceful assault against attacker (kicking, pushing, examiners collecting the data are trained to be objective and punching, and biting), and attempts to run away from the to systematically document information in a standardized attacker. Verbal, physical, or implied (weapon in vicinity) format. This study is based entirely on the nurse examiners’ threats that were reported by the victim to the SANE were documentation; study investigators did not gather informa- also recorded. tion from other sources such as law enforcement or from To determine the time to seek medical care, we calculated direct contact with patients. the hours from the end of the assault (as reported by the Physical injuries were divided into four categories: none, victim) to the victim’s arrival to the emergency department. mild, moderate, and severe. Mild physical injuries did not If the patient did not know when the assault occurred, the require medical intervention. Language within the SANE data were reported as missing. The presence or absence of report for mild injury included one or more of the following a police report before or during the SANE examination was words: swelling, redness, sore muscle, abrasion, scrape, bruise, also documented systematically. hematoma, tenderness to palpation without other physical findings, petechiae, and contusion from bite. Victims placed Data Abstraction in the moderate physical injury category required medical Because of the subjective nature of the data and its impor- intervention and had language in the SANE report including tance to the article, the absence or presence of active resistance one or more of the following: superficial tears/lacerations during the assault was examined with great care. Terms were or sharp force injuries and chipped tooth. Physical injuries clearly defined in a data dictionary, using objective criteria requiring medical attention and containing the language; and listing key words that would indicate active resistance. broken bones including arms, hands, and facial bones; trau- Each victim’s SANE chart was analyzed by two independent matic brain injury; deep lacerations or sharp force wounds investigators, one man and one woman, who were blinded

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to each other’s work. The two investigators’sscoreswere compared; for the 15% of patients where the raters dis- agreed, a third investigator adjudicated the difference. Most of the disagreements occurred when one rater coded this as “verbal resistance only” and the other rather coded this as “lack of physical resistance throughout the assault.” This occurred in 29% of the cases that were reviewed by a third rater. The final rating was determined by consensus. Early informal analysis revealed that ratings for physical injuries were highly consistent between the raters. Because of this, formal analysis of interrater reliability for this and sim- ilar variables was not deemed necessary. Objective measures that were clearly stated in the SANE report (e.g., time of arrival to the emergency department, race, and age) were collected by a single rater, as these values were recorded directly from the SANE report and would not reveal variance between raters.

Data Analysis FIGURE 1. Flow diagram. Frequency counts and proportions were used for categorical data. Time was divided into categories for inclusion in tables and graphs. Tests for statistically significant relationships as severe. Ninety-five (30%) of the victims experienced no between unordered categorical variables relied on Fischer’s injuries of any type. There were 49 victims assaulted by mul- exact test and logistic regressions. Relationships involving tiple assailants (17%). Individuals assaulted by multiple as- ordinal variables (e.g., level of injury) were analyzed using sailants had twice the risk for physical and anogenital injury multinomial logistic regressions (0 = no injury,1=mild injury, compared with those with a single assailant (OR = 2.07, 95% 2=moderate injury,and3=severe injury). A small number of CI [1.12, 3.84], p = 0.02; see Table 2). The risk was also patients had incomplete data for one or more questions. These roughly doubled if the assailant made threats (OR = 1.74, patients were excluded from analyses for those particular 95% CI [1.11, 2.74], p = 0.02). There was a trend toward questions but were included in other analyses whenever pos- increased risk for injury if the victim was intoxicated (OR = sible. The statistical analysis was completed in SAS 9.2 and 9.3. 1.48, 95% CI [0.96, 2.29], p =0.08).Nostatisticallysignif- icant relationship was seen between level of injuries versus the relationship with the assailant, level of active resistance, ▪Results or demographic characteristics. Three hundred fifty-nine sexual assault patients were seen Over half (n = 178, 57%) of the victims did not actively at the Regions Hospital Emergency Department between resist during the assault, using the definition outlined above. January 2011 and December 2012. Of these, 317 patients A quarter (n = 75, 24%) actively resisted during part of the met inclusion criteria, and 42 patients were excluded (see assault, and a fifth (n = 61, 19%) actively resisted through- Figure 1). Because this article is focused on rape myths re- out the assault. Several potential predictors of the absence lated to female victims, the 16 men identified as rape victims of active resistance were considered. Intoxication was the were excluded. Nineteen patients were excluded because of only potential predictor that was statistically significant (OR = inability to answer questions or an incomplete SANE ex- 1.76, 95% CI [1.12, 2.77], p = 0.01). Of the 178 victims who amination, and 7 were excluded for other reasons. did not physically resist throughout the assault, 67% sus- Demographic characteristics and characteristics of the tained injury (physical and/or anogenital), as compared with assault are summarized in Table 1. Two hundred thirty-six 70% of those with some physical resistance and 77% of (75%) study subjects reported the sexual assault to the police those who physically resisted throughout (see Table 3). The before or during the SANE examination. The time between trend, however, was not statistically significant (p =0.15for the end of the sexual assault and presentation to the emer- three-level physical resistance as a predictor of any injury). gency department varied widely, with 78 (26%) presenting Time lags of 12 hours or more from the end of the as- in less than 4 hours after the assault and 84 (28%) delaying sault to presentation were seen in 129 (43%) of the subjects. presentation 1–5 days. Active resistance was the strongest predictor, with increased One hundred eighty-five (59%) victims had some form resistance associated with lower odds of delay (p = 0.002; of physical (nonanogenital) injury, with only nine (3%) sus- see Figure 2). The presence of a threat was also associated taining severe physical injuries; 134 (43%) patients experi- with reduced odds of later presentation (OR = 0.61, 95% enced some form of anogenital injury, with six (2%) classified CI [0.38, 0.99], p = 0.04). Intoxication, relationship with

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TABLE 1. Patient and Assault Characteristics Patient characteristics Characteristic Number with data Age, years 317 13–17 18–30 31–82 52 (16%) 186 (59%) 79 (25%) Race 317 White Black Asian American Indian Other 166 (52%) 77 (24%) 28 (9%) 15 (5%) 31 (10%) Hispanic 306 Yes 22 (7%) Intoxicated 315 Yes 161 (51%) Assault characteristics No account 317 5 (2%) of assault Police report 316 236 (75%) on file Relationship 299 Acquaintance Stranger Intimate 190 (60%) 81 (26%) 28 (9%) Multiple assailants 286 49 (17%) reported General threat 300 160 (53%) reported Specific threat 271 No Verbal Physical Implied reported 141 (47%) 37 (12%) 72 (24%) 21 (7%) Active resistance 314 None First part of Second part Throughout assault only of assault only assault 178 (57%) 34 (11%) 41 (13%) 61 (19%) Injury to victim 314 None Mild Moderate Severe Overall injury 314 95 (30%) 179 (57%) 29 (9%) 11 (4%) Physical injury 314 129 (41%) 173 (55%) 3 (1%) 9 (3%) Genital injury 314 180 (57%) 100 (32%) 28 (9%) 6 (2%) Time from assault 298 0–3.9 hours 4–7.9 hours 8–11.9 hours 12–23.9 hours 1–5days to ED arrival 78 (26%) 48 (14%) 43 (14%) 45 (15%) 84 (28%)

the assailant, and number of assailants were not signifi- Time from the end of the assault to presentation in the cant predictors. emergency room varies widely, with one fourth of this study’s patients presenting in the first 4 hours, another fourth presenting in 4–12 hours, and nearly half presenting in the emer- ▪Discussion gency room 12 hours or more after the assault. The 317 victims studied here had a wide range of experi- The myth that rapes will be immediately reported was ences regarding injuries, use of active resistance, and time studied by McCall-Hosenfeld et al. (2009). In their analysis, lags from the end of the assault to presentation in the emer- the median time to presentation for medical care by sexual gency room. Previous studies also support the idea that there assault victims was 16 hours. They concluded that victims is no stereotypical behavior exhibited by victims during or presented in an “expeditious manner.” It was shown by Millar, after a rape (CDC, 2012; Ellison & Munro, 2009; Long, 2007; Stermac, and Addison (2002) that victims of a stranger rape Lonsway, 2005; McCall-Hosenfeld et al., 2009; Tetreault, 1989). report more quickly than victims of a known assailant. Millar

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TABLE 2. Univariate Predictors of Three Key Outcomesa Predictors One-unit increase in injury level No active resistance Time to presentation 12 hours OR (95% CI) p value OR (95% CI) p value OR (95% CI) p value Intoxicated 1.48 (0.96, 2.29) 0.08 1.76 (1.12, 2.77) 0.01 0.68 (0.43, 1.08) 0.10 Relationship with 0.38 0.26 0.29 assailant Acquaintance Reference Reference Reference Stranger 1.07 (0.50, 2.34) 0.78 (0.35, 1.73) 0.53 (0.22, 1.27) Intimate 1.44 (0.86, 2.40) 1.45 (0.85, 2.47) 0.78 (0.45, 1.34) Multiple assailants 2.07 (1.12, 3.84) 0.02 1.14 (0.61, 2.13) .68 1.34 (0.71, 2.53) 0.37 Threat (Y/N) 1.74 (1.11, 2.74) 0.02 0.73 (0.46, 1.17) .19 0.61 (0.38, 0.99) 0.04 Active resistance 0.65 n/a 0.002 None Reference n/a Reference Mixed 1.30 (0.73, 2.31) n/a 0.30 (0.15, 0.59) Throughout 1.14 (0.67, 1.94) n/a 0.66 (0.37, 1.16) aDemographic variables (age group, race, and ethnicity) were not significant predictors for any of these three outcomes. et al. refuted previously held beliefs that higher socioeco- of fear causing them to seek safety sooner. Another partial nomic, White, and sober women would report more often explanation for the variability in time to report may stem and quicker than other victims. from the victim’s emotional state or level of intoxication. The data in this study support varying times to arrival McCall-Hosenfeld et al. further noted that the variables of for medical care after a sexual assault. Forty-three percent an assault occurring in the home and an assailant known (43%) of the victims appeared in the emergency department to the victim were each associated with later presentation. over 12 hours after the assault ended. There is a wide var- Intoxicated victims may feel shame regarding their impaired ianceintimetopresentation,with 26% reporting in less than state and thus prolong reporting the crime. Intoxicated vic- 4 hours and 28% reporting 1–5 (120 hours) days later. The tims may also require time to become sober and fully com- variability in time to presentation may be partially explained prehend the crime. However, this was not supported by by the dissimilar nature of sexual assaults. For instance, Millar et al. (2002). McCall-Hosenfeld et al. (2009) found that severe violence If a victim is threatened by her assailant with further and verbal threats were associated with earlier presentation. harm if she reports, she may delay reporting or never re- Victims of unusually aggressive sexual assaults may have a port at all. higher prevalence of moderate-to-severe injuries requiring Sexual assaults where the victim and offender have a pre- immediate medical attention and necessitating early presen- vious or current relationship may be excused or justified by tation to the emergency department. Victims of extremely the victim. Similarly, the victim may blame herself and be less aggressive sexual assaults may also have a greater feeling willing to identify persons she knows, commonly noting not wanting to “get them in trouble,” as motive for this course

TABLE 3. Frequency of Any Injury During the Assault, Shown Separately by Level of Resistancea Behavior during assault Injured during assault (y/n) (%) No physical resistance 67% throughout (178 victims) Began not resisting and then 71% actively resisted (34 victims) Began actively resisting, then 70% stopped resisting (41 victims) Active physical resistance 77% throughout (61 victims) ap = .15 for physical resistance (modeled as none, part of the time, and throughout) as a predictor for any injury, estimated using logistic regression. FIGURE 2. Delay from the end of assault to ED presentation.

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of action (Weiss, 2009). The victim may also fear the social no active resistance, and only 19% actively resisted through- repercussions if she reports a friend to the police. out. According to Fusé, Forsyth, Marx, Gallup, and Weaver It has been shown, overall, that victims of sexual assault (2007), approximately one third of sexual assault victims are less likely to report incidences to police than victims of actively resist their attacker by either fighting, fleeing, scream- other violent crimes (Chen & Ullman, 2010). In our study, ing, convincing them to stop, obtaining outside help, or a 75% of victims who came for a medical/forensic evaluation combination thereof. also reported the incident to police. Others have found re- Twenty-four percent of victims in this study shifted be- porting rates to vary from as low as 5%–54% (Heath et al., tween not resisting and actively resisting approaches. Shifts 2013). in the victim’s approach may mirror shifts in the assailant’s Another myth is to expect injury to be found on victims approach, with the victim possibly matching the level of overt of rape. In our study, 30% of patients experienced no injury, aggression or else being cowed by serious threats or injury. and only 4% experienced severe injury. Anogenital injury Victims may also choose to not resist, hoping it will reduce has been studied by many researchers (Anderson & Sheridan, the risk for physical or anogenital injury. 2012; Anderson, Parker, & Bourguignon, 2009; Fraser et al., Contrarily, the victim’s behavior may shift to the oppo- 1999; Jones, Rossman, Harman, & Alexander, 2003; site of the assailant’s behavior. This might be a defense mech- Larkin, Cosby, Kelly, & Paolinetti, 2012; Lincoln, 2001; anism to prevent further injury. For instance, if the victim Lincoln, Perera, Jacobs, & Ward, 2013; Slaughter, Brown, is resisting the assault, and then the assailant injures her, she Crowley, & Peck, 1997; Sommers, 2007). The frequency, may stop resisting to prevent further injury. Although this location, and total number of injuries have been investi- contradicts the claim that a victim’s behavior matches that gated. All studies showed that rape can occur without gen- of the assailant’s, it does help explain the variability in vic- ital injury. Location and number of anogenital injuries, when tim behavior, which is dictated by a multitude of factors. they do occur, have had in some instances a limited ability Tonic immobility may explain some cases of victims not to differentiate consensual from nonconsensual sexual acts physically resisting. Tonic immobility is a natural state of (Anderson & Sheridan, 2012; Larkin et al., 2012, Lincoln, motor inhibition in response to high-fear situations that often 2001; Lincoln et al., 2013; Sommers, 2007). involve threats and/or restraints (Galliano, Noble, Travis, The predominant lack of serious injury may be the result & Puechl, 1993). It is an involuntary body response that of several factors. The tissues of the orifices involved in sex- results in the body feeling paralyzed or “frozen,” essentially ual assault are elastic and do not necessarily sustain injury being unable to physically resist or call out for help. Previ- with penetration (Bowyer & Dalton, 1997; Wells, 2006; ously, this inability to move or call out was referred to as White & Mclean, 2006). The penis of a man is susceptible “rape-induced paralysis” (Marx, Forsyth, Gallup, Fusé, & to injury too, so the assailant may exert force by physically Lexington, 2008). As many as 37% of rape survivors re- restraining the woman resulting in less force needed for ported experiencing some paralysis during their sexual assault penile penetration. (Burgess & Holmstrom, 1976). It is important to understand The relationship between the assailant and the victim that tonic immobility is both temporary and reversible. The may play a role in the rate of victim injury. Acquaintances exact time when tonic immobility begins during a sexual as- and/or intimate partners have a different emotional investment sault, and when it ends, varies between victims. In a study in the victim than a stranger. The assailant may be less prone conducted by Fusé et al. (2007) of college-age women, 88 to injure the victim if he knows her, and the victim may be had experienced sexual assault. In evaluating these subjects less prone to fight back. However, we were unable to detect for tonic immobility during their assault, it was found that a statistically significant relationship in our data (p =0.38). approximately 42% reported significant immobility and The number of assailants also plays a role in victim injury. 10%–13% reported extreme immobility. Of note, most sub- If there are multiple assailants, the sexual assault may be more jects reported having known the perpetrator, and only a small aggressive and may cause more injury. In our study popu- number of individuals reported any injury or use of a weapon lation, victims with multiple assailants were twice as likely or restraint during the assault. to experience injury or greater injuries. The assailant’s level Both women with a history of child sexual abuse or of aggressiveness during the assault may also dictate phys- adolescent/adult sexual victimization were more likely to ical and anogenital injury. Siegel, Sorenson, Golding, Burnam, experience immobilization than women with no prior history and Stein (1989) found that the victim’sresistancestrategy (Gidycz, Van Wynsberghe, & Edwards, 2008). matched the assailant’s strategy (Prentky, Burgess, & Carter, It has been shown that jurors find it hard to accept tonic 1986; Scott & Beaman, 2004). They also found that assailants immobility in cases where the victim knows the perpetrator who were less aggressive during the assault were correspond- even when educated to its existence by an expert witness ingly less likely to personally injure the victim. (Ellison & Munro, 2009). It is confusing to people to learn Expecting victims to actively resist their attackers is an- that the victim is able to clearly recall details of the assault other myth. In this large population, 57% of victims showed and yet was physically and/or verbally unable to resist. Tonic

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immobility response by victims is clearly an important area in Anderson, S. L., Parker, B. J., & Bourguignon, C. M. (2009). Pre- need of further study and with that education of the public. dictors of genital injury after nonconsensual intercourse. – There are several limitations to this study. We were able Advanced Emergency Nursing Journal, 31(3), 236 247. Aronowtiz, T., Lambert, C. A., & Davidoff, S. (2012). The role of to study only patients presenting for medical care. It is be- rape myth acceptance in the social norms regarding sexual lieved that most victims do not seek medical care after a behavior among college students. Journal of Community sexual assault (Gartner & MacMillan, 1995). When physical Health Nursing, 29,173–182. evidence was not available to the examiner, for instance, re- Black, M. C., Basile, K. C., Breiding, M. J., Smith, S. G., Walters, M. L., … garding lag time from assault to presentation or resistance Merrick, M. T., Stevens, M. R. (2011). The national intimate partner and sexual violence survey (NISVS): 2010 summary strategies offered by the victim, SANE nurses relied on the report. Atlanta, GA: National Center for Injury Prevention and victim’s self-report. SANE nurses did not directly ask a victim Control Centers for Disease Control and Prevention. about their degree of resistance during part or all of the as- Bowyer, I., & Dalton, M. (1997). Female victims of rape and their sault. Study investigators had to glean this information from genital injuries. BJOG: An International Journal of Obstet- – SANE examiners’ notes, thus subjecting them to interpreta- rics and Gynaecology, 104,617 620. Brownmiller, S. (1975). Against our will: Men, women and rape. tion error. To address this risk, we used two independent New York, NY: Simon and Schuster. chart abstractors and third investigator servicing as an ad- Buddie, A. M., & Miller, A. G. (2001). Beyond rape myths: A judicator. Final decisions were made by consensus. The ex- more complex view of perceptions of rape victims. Sex Roles, amining nurse’s written findings of physical and anogenital 45(3/4), 139–140. injury were taken at face value without review of photo- Burgess, A. W., & Holmstrom, L. L. (1976). Coping behavior of the rape victim. American Journal of Psychiatry, 133(4), 413–418. graphs to corroborate findings. Burt, M. R. (1980). Cultural myths and support for rape. Journal of Personality and Social Psychology, 38(2), 217–230. Campbell, R., Long, S. M., Townsend, S. M., Kinnison, K. E., ▪Conclusion Pulley, E. M., Adames, S. B., & Wasco, S. M. (2007). Sexual assault Three rape myths that are not intuitive to the general public, nurse examiners’ experiences providing expert witness court – who may be serving on a jury, are that victims report their testimony. Journal of Forensic Nursing, 3(1), 7 14. Campbell,R.,Patterson,D.,&Bybee,D.(2012).Prosecutionof sexual assault immediately after the assault, they experience adult sexual assault cases: A longitudinal analysis of the im- physical injury during the assault, and they aggressively fight pact of a sexual assault nurse examiner program. Violence Against off their assailant. Our study, which was based on the 317 Women, 18(2), 223–244. documented SANE examinations at the Regions Hospital Campbell, R., Patterson, D., & Lichty, L. F. (2005). The effectiveness in 2011–2012, debunks these myths. Victims in our case series of sexual assault nurse examiner (SANE) programs. Trauma, Violence, & Abuse, 6(4), 313–329. had a wide range of lag times from the end of the assault to Canaff, R. (2009). Nobility in objectivity: A prosecutor’scaseforneu- presentation in the emergency room. Moderate and severe trality in forensic nursing. Journal of Forensic Nursing, 5(2), 89–96. physical or anogenital injuries were rare, and only a minority Centers for Disease Control and Prevention. (2012). Sexual vio- of victims resisted physically throughout the entire assault. lence facts at a glance. National Center for Injury Prevention – Studies have linked SANE testimony with greater con- and Control Division of Violence Prevention. Retreived from http://www.cdc.gov/violenceprevention/pdf/sv-datasheet-a.pdf viction rates and increased provictim sentiment among jurors Chen, Y., & Ullman, S. E. (2010). Women’s reporting of sexual and (Campbell, Patterson, & Bybee, 2012; Campbell, Patterson, physical assault to police in the national violence against women & Lichty, 2005; Canaff, 2009; Ledray & Barry, 1991; Ledray survey. Violence Against Women, 16(3), 262–279. et al., 2001; Wasarhaley, Simcic, & Golding, 2012). Clay-Warner, J., & Burt, C. H. (2005). Rape reporting after re- Many professionals in addition to SANEs can qualify and forms: Have times really changed? Violence Against Women, 11, 150–176. testify as experts to the behavior of sexual assault victims Deming, M. E., Covan, E. K., Swan, S. C., & Billings, D. L. (2013). (Long et al., 2010). They include medical providers, victim Exploring rape myths, gendered norms, group processing, advocates, and therapists as well as members of law enforce- and the social context of rape among college women: A – ment and academia (Long et al., 2010). All expert witnesses qualitative analysis. Violence Against Women, 19(4), 465 485. Ellison, L., & Munro, V. E. (2009). Turning mirrors into windows? can benefit from access to rigorously done statistical anal- Assessing the impact of (mock) juror education in rape trials. yses that underscore their personal observations and dem- British Journal of Criminology, 49, 363–383. onstrate their objectivity (Long, 2007; Tetreault, 1989). Fraser, I. 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