SEXUAL VIOLENCE RESEARCH INITIATIVE BRIEFING PAPER Mental Health Responses for Victims of Sexual Violence and Rape in Resource-Poor Settings INTRODUCTION “Any sexual act, attempt to obtain a sexual and reproductive health effects and, as act, unwanted sexual comments or importantly, it is linked to profound long- advances, or acts to traffic, or otherwise term mental health consequences (Astbury directed, against a person's sexuality using & Jewkes, in press; Jewkes, Sen & Garcia- coercion, by any person regardless of their Moreno, 2002). relationship to the victim, in any setting, including but not limited to home and work”. The needs of rape survivors* are often Sexual violence as defined by the World overlooked by public sector health services Report on Violence and Health (Jewkes, Sen in resource poor settings. Where services & Garcia-Moreno, 2002) for rape survivors do exist, generally they are limited to the provision of medico-legal “Physically forced or otherwise coerced services (Sundstrom, 2001), with little penetration – even if slight – of the vulva or attention given to addressing the anus, using a penis, other body parts or an psychological impacts of rape (Astbury & object.” Rape as defined by the World Jewkes, in press). Health Organisation (Jewkes, Sen & Garcia- Moreno, 2002) Rape, given its specific definition within the broader context of sexual violence, has Sexual violence is a pervasive yet, until been the subject of the majority of the recently, largely ignored violation of relevant literature. As a result, this briefing women's human rights in most countries paper will focus predominantly on rape. To (WHO, 2005; Kohsin Wang & Rowley, 2007). date, most of the evaluation of It occurs across socio-economic and interventions targeting the mental health demographic spectrums, and is frequently consequences of rape has taken place in the unreported by victims (Rennison, 2002; developed world. The extent to which Tjaden & Theonnes, 2006). Sexual violence these findings remain valid in other settings is associated with negative physical, sexual remains unknown. * The terms survivor and victim of sexual violence will be used interchangeably throughout this briefing paper. * This briefing paper was written by Thomas Callender and Liz Dartnall. 2 Mental Health Responses for Victims of Sexual Violence and Rape in Resource-Poor Settings This briefing paper provides: an overview of (Campbell, 2001; Rothbaum et al, 1992). existing literature on the mental health For many victims these feelings will resolve effects of sexual violence and rape; a themselves within this period, however for summary of effective interventions; and others, symptoms continue far longer outlines a brief research agenda for mental (Dunmore, Clark & Ehlers, 2001; McNally, health responses to sexual violence. It is Bryant & Ehlers, 2003). Rothbaum et al based on work commissioned by the SVRI (1992) found that, of those who developed on mental health and sexual violence and is PTSD post-rape, at three months half were informed by the knowledge and still suffering with the condition. Similarly, experiencesinthisareaoftheSVRI even with counselling, half of victims still Coordinating Group. suffer from stress after three months The Mental Health Aftermath of (Tarrier et al, 1999; Kilpatrick et al, 1992). Sexual Violence High levels of fear and anxiety as well as A global meta-analysis of child abuse patients still meeting PTSD diagnostic prevalence figures found self-reported CSA criteria have been found up to 16 years after prevalance ranged from 164/1000 to the event (Kilpatrick et al, 1992; Ellis, 197/1000 for girls and 66/1000 to 88/1000 Atkenson & Calhoun, 1981). for boys (Stoltenborgh et al, 2011). Amongst adults, estimated prevalence of Factors that Influence the Psychological sexual violence at the hands of their Impact of Sexual Violence: intimate partners is greater, falling between - A victim's socio-biological characteristics. 10-50% of women (WHO, 2005). Up to 30% - A victim's perception of their rights and their status. of respondents in a multi-county study - A victim's belief about what constitutes reported that their first sexual experience sexual violence. was forced (WHO, 2005). - Prior history of trauma, be that sexual or other. - Prior mental health issues. Rape is a particularly traumatic violation of - The relationship of the offender to the an individual (Kessler et al., 1995; Resnick et victim. al, 1993; Koss et al, 2003). Women are more - A victim's appraisal of the circumstances of commonly victims, although men are also the violence (e.g. threat to life, self-blame). sexually abused and appear to suffer the - A victim's coping mechanisms. - Positive family and social support. same mental health impacts as women - Cultural background. (Stevens, 2007; Tolin & Foa, 2006; Breslau et - Perceived and actual response of society, al, 1997; Ullman & Filipas, 2005). including any formal services approached, to disclosure of sexual violence. Immediately post-assault, most victims will - For childhood sexual abuse the duration, frequency and severity of the abuse, in experience shock, intense fear, numbness, addition to the relationship of the offender to confusion, feelings of helplessness, and / or the victim. disbelief, in addition to self blame, hyper- Campbell, Dworkin & Cabral, 2009; Hillberg arousal and high levels of anxiety et al, 2011; Jewkes, Penn-Kekana & Rose- (Campbell, Dworkin & Cabral, 2009; Jewkes Junius, 2005; Briere & Jordan, 2004; Yuan, & Dartnall, 2008; Chen et al., 2010; Koss & Stone, 2006. Vickerman & Margolin, 2009). One third of rape survivors will go on to develop PTSD* * PTSD can be diagnosed using either the WHO's (1992) (WHO, 2009; Yuan, Koss & Stone, 2006). ICD-10 criteria or the American Psychiatric Association's (1994) DSM-IV criteria. In contrast to Symptoms typically increase in severity over ICD-10, under DSM-IV guidelines, a victim cannot be diagnosed with PTSD in the first month after a trauma. the first three weeks before a progressive Instead, during the first month, their symptoms are decline over the next three months referred to as Acute Stress Disorder. The WHO's definition has been employed in this paper. BRIEFING PAPER 3 Coping with Sexual Violence structures on which they may rely (Ahrens & Campbell, 2000). Additionally, disclosed Survivors must negotiate and interpret not sexual assault can cause traumatisation of only the assault itself but the responses of the close family or friends of survivors, their society to their disclosure of the potentially complicating the recovery assault (Campbell, 2001; Campbell, process (Veronen et al., 1989 cited in Dworkin & Cabral, 2009). Throughout the Campbell, 2001; Campbell & Wasco, 2005). world, sexual violence remains highly Importantly, any negative responses or stigmatised, with 53 countries yet to legally attitudes by close social support structures, define marital rape as a crime (Women Face or the feeling that one lacks social support, Bias, 2008). In many cases, blame is cast on have a disproportionate effect on the the victims rather than the perpetrators, mental health aftermath of rape, with the victim suffering dishonour and underlining the need for more general shame sometimes thought to extend to the interventions to change societal attitudes whole family (Kohsin Wang & Rowley, 2007; towards sexual violence as well as efforts Jewkes et al., 2002; Jewkes, Penn-Kekana & designed to educate those to whom the Rose-Junius, 2005). Disbelief of the victim survivors may disclose (McNally, Bryant & and the commonly reported perception Ehlers, 2003; Campbell, Dworkin & Cabral, that the victim provoked the rape lead to 2009). secondary victimisation of the survivor at the hands of family and friends as well as the In the aftermath of rape, no survivor should health care, police and judicial services feel unsupported or unable to disclose (Ahrens, 2006; Filipas & Ullman, 2001; assault. Survivors of sexual violence bear Kohsin Wang & Rowley, 2007; Campbell, the brunt of the psychological burden but all 2001; Campbell, Dworkin & Cabral, 2009; society must come to grips with its Patterson, Greeson & Campbell, 2009). consequences. Lack of disclosure is associated with more Child Sexual Abuse severe psychological consequences, particularly in children, and it is therefore of Child sexual abuse (CSA) is associated with great importance that societal perceptions significant rates of mental health disorders of rape are changed so that victims may feel that can extend well into adult life, safer in revealing assault (Stevens, 2007; particularly if the sexual abuse involved Ruggiero et al., 2004). actual intercourse (Jonas et al., 2010; Cheasty, Clare & Collins, 1998; Briggs & Rape fundamentally challenges a survivor's Joyce, 1997). As with adults, child victims “world of meaning” as well as concepts of have an increased risk of a range of safety and trust in one's environment psychopathologies in the aftermath of (Conte, 1988 cited in Koss, Figueredo & sexual violence, including PTSD, depression, Prince, 2002; Campbell, 2001). In the anxiety, and dissociation (Maniglio, 2009; aftermath of rape, strong social support Seng et al., 2005). Compounding this, both protects survivors from prolonged and even children and adults suffering from PTSD are more severe psychological consequences of highly susceptible to physical co- rape (Campbell et al., 2001). However, at morbidities such as circulatory problems, the same time, the reactions of survivors respiratory