Rape: How Women, the Community and the Health Sector Respond1

Research summary Rape: How women, the community and the health sector respond1

Background Research findings his research summary is based on a desk review Societal responses Ton women’s responses to sexual violence and the No rape free societies exist today. Sexual violence appropriateness and effectiveness of sexual violence remains the least researched form of gender-based services in meeting their needs as survivors. The violence. For the perpetrator and the society he rep- review examines the societal factors that influence resents, sexual violence serves multiple functions rates of sexual violence, women’s immediate and long including its use as a socially sanctioned strategy term responses to such violence, including a range of to punish women; a tactic to assert masculinity and health related harms, and the interventions and treat- maintain a patriarchal social order; a method to ments developed to respond to the needs of survivors ‘resolve’ domestic conflicts; and a male behaviour to of sexual violence and reduce its prevalence. take sexual pleasure. Sexual violence is maintained The review draws together existing evidence and through socio cultural beliefs about what constitutes identifies gaps in the current knowledge base on this rape and what elements reduce the likelihood of issue. It also identified the following limitations in women defining forced sex as rape, rape myths that the existing literature on sexual violence. result in victim blaming and social stigmatization of victims and various cultural and religious beliefs • Limited information on many dimensions of sexu- that perpetuate rape prone societies. al violence, including violence prevention Other negative social reactions include disbelief, • Inadequate understanding of women’s responses distraction responses or simplistic advice to ‘move to and recovery from sexual violence on’, as well as controlling reactions by the person to • Lack of geographical representation and strong whom the victim has disclosed. Stigmatization confers North American bias, with most of the research a discredited identity on the victim who is disgraced, undertaken in high income countries dishonoured and tainted by the sexual violence per- • Sparse evidence on the efficacy of screening petrated against her and is most pronounced in male interventions dominated societies that stress female chastity and • Some research on hospital and clinic based serv- purity and make these characteristics synonymous ices and referral networks with a woman’s worth as a human being. Societies • Some research on more commonly available com- that view rape as an affront to male/family ‘honour’ munity based services adopt strategies to erase the shame of this stain on honour such as coercing the victim to marry the rap- 1 This research summary is based on a review with the same title, ist. Family and social rejection of victims is also com- commissioned by the World Health Organization for the Sexual Violence Research Initiative (SVRI), an international initiative of monplace in war and conflict situations. the Global Forum for Health Research. The review was written by The highest rates of sexual violence have been Shirley Kohsin Wang and Elizabeth Rowley and this summary was prepared by Jill Astbury and reviewed by Liz Dartnall and Claudia repor ted in relation to rape by intimate par tners includ- Garcia-Moreno. ing husbands. Recognition that rape can and does 2 Rape: How women, the community and the health sector respond

occur within marriage, however, is far from universal. The wide variations in the prevalence of sexual How rape in marriage is regarded, varies socially and violence between countries highlight the pivotal legally, within and between countries. Women may role of social, cultural and legal arrangements and feel unclear about the boundary between the uses beliefs in determining the extent of sexual violence versus abuses of their bodies in marriage and make reporting and the importance of targeting social a distinction between ‘unwanted sex’ and ‘rape’. Many attitudes in sexual violence prevention programs. societies continue to privilege the ‘rights’ of husbands and instruct women that their marital obligation is to Women’s responses to sexual violence have sex whenever their partners wants it. Immediate responses In the first 2-3 hours after assault, a US study found Lessons learned that 96% of victims experienced physical shak- Research indicates that hostile, victim blaming ing, trembling and shock. Equally high numbers of responses are common and exacerbate the harm women felt scared and worried or terrified and con- already experienced by the victim. A cross cultural fused. Three common survival modes were observed study that tested the level of acceptance of the belief in another US study of survivors receiving emergency that ‘A healthy woman can fight off a rape’ found department care namely, anxiety indicating a flight 20% of US students endorsed this belief, compared response; anger expressing a fight response and dis- with 45% of those surveyed in Turkey, 50% in India sociation representing a frozen response. After this and 56% in Malaysia. Much lower rates of agree- initial period, symptoms of depression, exhaustion ment were reported in Germany (7%) and the Unit- and restlessness emerged that together with post ed Kingdom (8%). Similarly, 64% of US students traumatic stress disorder (PTSD) can be long lasting agreed women provoked rape, 60% agreed women for many survivors. A French study found that 87% who go out alone place themselves at risk of rape of victims had PTSD post assault, 70% had PTSD 3 and less than 50% of students in Barbados, Canada, months later and even 6 months post assault, 65% Israel, Malayasia, Mexico, Turkey, Singapore, US and of victims still met the criteria for PTSD. Zimbabwe believed male perpetrators were responsible for rape. Medium to long term effects Another study conducted in the Dominican Repub- Psychological effects in the medium to long term lic, Peru and Venezuela, many service providers held encompass heightened fear, anger, anxiety, guilt, self survivors, not perpetrators, responsible for rape. The blame, loss of trust, flashbacks and PTSD, depression, anticipation of negative responses from support per- dissociation, phobias, panic disorder, and obsessive sonnel in the formal service sector causes delays in compulsive disorder. When sexual violence occurs the disclosure of sexual violence to medical, legal before the age of 16 years, the risk of developing and mental health services. Community or family negative psychological outcomes is increased 3 to 4 disapproval of victims contacting such services can fold compared with that in older victims. further delay help seeking. Negative responses damage the victim’s positive Physical and behavioural health consequences sense of self, lead to self devaluation, higher levels Women who have experienced sexual violence com- of psychological symptoms and poorer self rated pared with their non victimized counterparts have recovery while stigmatization predicts the severity poorer self rated health and increased rates of risky of symptoms of Posttraumatic Stress Disorder. health behaviours including drinking, smoking and Positive responses have been identified that substance misuse as well as self harming behaviours result in better psychological and other outcomes for such as suicidal thoughts and actions. Survivors also victims. These include living in a society that has a have more medical diagnoses, higher rates of acute cultural and legal definition of sexual coercion and and chronic pain syndromes, cardiac arrhythmia, assault as a crime and a rights violation; disclosing asthma, hyperventilation, nausea and choking sen- straight after being victimized; being believed; being sations. Sexual and reproductive health problems understood; being offered empathy and getting psy- include menstrual difficulties and sexual dysfunction, chosocial support/counselling. increased rates of sexually transmitted infections, Research summary 3 unwanted pregnancy, unsafe abortion, genital fistu- compelling evidence to suggest that screening has a lae and pelvic inflammatory disease. Women raped by positive effect on the women who are screened. One their husbands who have also suffered physical part- benefit of routine screening is that it legitimizes dis- ner violence, exhibited higher rates of PTSD, depres- closure and can reassure victims they are not being sion, anxiety, fear and sexual dysfunction than those singled out. No consensus has yet been reached on who experienced physical violence alone. appropriate outcome indicators for assessing the effectiveness of screening interventions. Mediating factors Clinical interventions need to be tailored to meet Coping responses by individuals that reduce the risk the needs of and increase feelings of control in indi- of PTSD include positive distancing from the incident vidual survivors. It is necessary to provide support of sexual assault, having a positive self assessment, for women from different socioeconomic and cultural optimism, acceptance, having an explanation, actively backgrounds who may have different sexual violence reducing thoughts of the assault and engaging in pro- narratives to recount. It is also necessary to offer active, protective behaviours such as moving house. options regarding medical, mental health, legal and Research suggests that victims’ perceptions and social services. In low income countries such options responses are influenced by whether they name their are unlikely to be available. Integrated care or ‘one experiences as rape/sexual assault; the extent to stop shop’ approaches have produced promising which victims accept/endorse victim blaming beliefs results in the period immediately after the assault and rape myths and their understanding of legal defi- occurs but their quality is dependent on adequate nitions of rape. Why the same sexual acts are named interagency training to ensure all professionals have as ‘rape’ by some but not all victims is unclear, but cul- appropriate knowledge, attitudes and behaviours. tural and legal context are relevant. Other confidential sources of support include hot- lines that offer telephone counselling and referral Interventions and internet based sources of counselling and refer- The vast majority of primary prevention pro- ral. Shelters and refuges are another source of sup- grammes have been developed and implemented in port although they usually only cater for survivors the US. They have consisted primarily of education of intimate partner violence not survivors of sexual programmes, targetted at mixed sex groups of uni- violence alone who may have an equally high need versity students and assume that positive attitude for safe, alternative, affordable forms of shelter. changes will result from involvement in the program Faith based groups can offer support to victims but and lead to sustained changes in sexual behaviour. mixed results regarding the quality of the support Inconsistent results have been reported. Some posi- from members of the clergy have been reported. tive attitude changes have been documented immediately post program but has not been sustained in Mental health interventions the longer term. Other studies show a rebound effect Diverse therapeutic interventions have been devel- and a return over time to pre intervention attitudes. oped in high income countries to meet the mental Interventions have also been implemented to effect health needs of survivors and prevent or ameliorate change in the level of community awareness about symptoms of PTSD, depression and anxiety. Cogni- sexual assault and rape and promote more positive tive behavioural therapies (CBT) include Prolonged attitudes towards victims. In developing country Exposure (PE) therapy, Cognitive Processing Therapy settings, community based services offered by non (CPT) and Stress Inoculation Training (SIT). Common government organizations can play a critical role in elements in these therapies include the use of ‘home- sexual violence service provision when government work’ between sessions, psychoeducation designed to funded services are absent or inadequate. challenge irrational cognitions and graded exposure Screening interventions targetting health profes- and systematic desensitization to threatening mate- sionals to routinely identify victims of violence have rial associated with the violence. In CPT, exposure is focused on violence by intimate partner and not other in the form of writing and reading about the traumatic forms of sexual violence. Increases in rates of detec- event and this has also been shown to be effective in tion of violence have been reported but there is no reducing symptoms of PTSD and depression. 4 Rape: How women, the community and the health sector respond

All three types of CBT approaches as well as sup- perspective of victim/survivors as well as developing portive counselling reduce symptom levels of PTSD, models of intervention and practice that are effective, anxiety and depression immediately after the inter- acceptable and affordable in diverse cultural settings. vention has taken place, although findings on the com- parative effectiveness of these therapies are complex. Additional research has revealed beneficial effects for Research on survivors’ perspectives feminist and some other therapies. Feminist therapies • Establish the causes of various forms of sexual seek to help the survivor to see her experience as part violence identified by survivors, their needs of a larger social problem and thus to socially reframe as victims and their perceptions of different the causes of her sexual violence experience and intervention practices reduce long term feelings of personal guilt, shame and • Determine the psychological consequences self blame. Group therapy can be effective in reducing of sexual violence according to the coping strategies used by victims/survivors such feelings and group work is also a common ele- • Systematically document the psychological ment in feminist services. Relational therapies that effects on victims of the responses of the integrate a survivor’s social network into treatment criminal justice system have been reported as more effective than individual • Document processes of recovery/ healing, therapy in reducing depression. Traditional healing including how the disclosure process affects practices that address the supernatural dimension of recovery distress have not been evaluated adequately. Intervention models and practices Criminal justice system interventions • Expand research on primary prevention A tension exists between survivors’ needs and the programs beyond university settings in high income countries, to general populations in a evidentiary needs of the criminal justice system. For range of settings particularly in middle- and survivors, validation and belief is central to recov- low-income countries ery but they often face disbelief and suspicion from • Document how traditional healing practices the criminal justice system. The current adversarial and faith based approaches impact on recovery system operating in most countries causes revic- • Determine the impact of screening practices timization and increases the trauma of survivors. on women’s emotional and physical health outcomes Restorative justice approaches may more effectively • Evaluate integrated clinical care practices meet victims need to have the perpetrator acknowl- and different mental health therapies on the edge the crime he has committed and its impact on perceived well being of victims their lives and health. • Review the use and relevance of PTSD diagnostic guidelines as the main method of measuring the psychological impact of sexual Research recommendations violence in a variety of settings particularly in To respond better to the needs of sexual violence middle- and low-income countries survivors, it is essential to conduct research from the

For the full document and further information on the SVRI go to www.svri.org or www.who.int/gender