Effects of Sexual Assault Running Time: Materials: Target Audience: various audiences 2 hours Flipchart with stand and markers, or chalkboard with chalk; large index cards; tape. Handouts: Posttraumatic Stress Syndrome Can be used for awareness-raising with or participants. This session is designed to increase participants’ knowledge about the effects of sexual assault. The physical, mental, behavioral, chronic and reproductive effects of sexual assault are also discussed. The session concludes by briefly describing how someone might respond to a victim of a recent sexual assault. Note: It is possible that this training module could be emotionally stressful for some participants, particularly those who have experienced sexual assault. Facilitator should anticipate the possibility of participants becoming overcome with emotion and be prepared to respond to their needs. The Facilitator might set out ground rules, ask participants to ensure that the room feels like a safe space, or have a response plan ready in case someone becomes emotional or needs to leave the room. Introduction Facilitator: Now that we have finished examining the different theories about why sexual assault happens, we will look at the different effects that sexual assault can have on a victim. Sexual assault can have a wide variety of impacts, such as physical, mental, chronic, reproductive, social and societal effects. We will end by briefly addressing how someone should respond to a victim who has experienced a recent sexual assault. Learning Objectives: Facilitator: At the end of this session, participants will be able to: - Identify the physical, mental, behavioral and societal effects of sexual assault. - Describe how to respond to a victim of a recent sexual assault. Activity 1: Effects of Sexual Assault 1. Facilitator divides participants into small groups of four or five participants. Each group should be given is given a card with one of six categories of consequences written on it: 1) physical, 2) mental, 3) reproductive health, 4) social/behavioral, 5) chronic conditions, and 6) societal. Each group is given 10 minutes to list possible effects of sexual assault under each category. 2. Each group presents what effects they listed, writing each of them on the flipchart. Facilitator should encourage all participants to share information about any of the effects as each group presents. Facilitator should mention effects that are not mentioned and highlight a few points after each group is finished presenting. Sample facts to highlight are added beneath each category, but Facilitator should feel free to add or use other facts. Physical effects HIV, STDs Physical injuries Functional impairments Poor health Permanent disability Severe obesity Suicide EXAMPLE: During forced vaginal or anal penetration, cuts and tears are common, which facilitate transmission of the HIV virus if it is present. This is especially likely in young girls. Women who are victims of sexual assault are more likely to attempt or commit suicide than other women; in Ethiopia, 6% of raped schoolgirls had tried to commit suicide. Mental effects Posttraumatic stress syndrome Anxiety Depression Phobias or panic disorder Eating disorders Sexual dysfunction Low self-esteem Substance abuse EXAMPLE: Without trauma counseling, negative psychological effects may last for more than a year following a sexual assault. Even with counseling, up to half of women who were raped still showed symptoms of stress. Chronic conditions Chronic pain syndrome Irritable bowel syndrome Gastrointestinal disorders Sleeping problems Fibromyalgia EXAMPLE: Studies have found a link between rape and sleep difficulties, depression symptoms, somatic complaints. Reproductive health Unwanted pregnancies Abortions and possible ill-health as a result of abortions Gynecological disorders, such as vaginal bleeding or infection, fibroids, urinary tract infections Pregnancy complications Miscarriage or low birth weight Pelvic inflammatory disease EXAMPLE: Research in Mumbai showed that 20% of all pregnancies among teenagers seeking abortion was the consequence of forced sexual intercourse. A study in Thailand indicated that 1 in 10 rape victims were infected with an STD. In many countries, women with unwanted pregnancies must choose between bearing the child or risking their lives with an illicit abortion. Social and behavioral effects Smoking Alcohol abuse Drug abuse High-risk sexual behavior Physical inactivity Overeating Stigmatization by the community and family EXAMPLE: Sexual assault at a young age contributes to a woman viewing her sexuality as something outside of her control. As a result, she is less likely to use condoms or other contraception in future sexual activities. In some areas, the community and family may also create negative consequences for the victim. They may shun the victim, force her to marry her rapist, or even possibly kill her to preserve honor. Societal costs Costs of medical and psychological treatment for victims Loss of victim’s healthy years to illness and disease Lost days of productivity for victims EXAMPLE: According to the World Health Organization, rape and domestic violence account for 5% to 16% of lost healthy years of life for women of reproductive age. Rape in the U.S. costs more than any other victimization, with annual victim costs of $126 billion in medical expenses, lost earnings and victim assistance. 3. The Facilitator should give a mini-lecture on the general progression of effects after a sexual assault, from the initial effects to long-term effects. Using the flip chart, the Facilitator should outline the progression of rape trauma syndrome, describing each of the points below. The Facilitator should stress that every woman deals with sexual assault differently, and this is only a model for a response progression. Research on sexual assault and PTSD has led to a more specific description of victim response, called “rape trauma syndrome.” Rape trauma syndrome may occur as either a compounded reaction (the sexual assault dredges up additional difficulties with other psychiatric conditions) or silent reaction (the victim does not tell anyone about her experience) to sexual assault. There are two stages to rape trauma syndrome, which are the immediate phase and the long-term process phase. The first stage includes the immediate impact reaction, physical effects and emotional effects. The first stage lasts anywhere from a few days to a few weeks. At first, the victim is likely to feel a wide variety of emotions, including shock and disbelief, in the first hours after the sexual assault. Some victims express their emotion, demonstrating anger, fear or anxiety. Other victims control their emotions, masking their feelings and exhibiting a composed or calm manner. Many victims will also have physical consequences after the sexual assault. This may include soreness over the entire body or just in the areas of the assault. Victims may have difficulty sleeping and possibly scream out in their sleep. They also may experience a decrease in appetite, stomach pains and nausea. The emotional response is primarily that of fear. The victim usually has a fear of physical injury and death, from which stems the symptoms associated with posttraumatic stress syndrome. In addition to fear, victims may also express other feelings, such as humiliation, guilt, shame, embarrassment, degradation, self-blame, anger and a desire for revenge. They are prone to irritation with other people, as well as feeling cautious toward others. Finally, the victim may attempt to repress the memory of the assault, even though she replays the incident in her mind, trying to assess how she might have handled the situation differently. The second stage is a long-term process that includes changes in lifestyles, nightmares and phobias. Changes in lifestyle will include disruptions to her normal routine of living, turning to family members who she may not see on a normal basis, and moving away or changing residences and phone numbers. During this time, it is not uncommon for the victim to be unable to function more than minimally, to stay at home, to seek support from family but not explain her reasons. Victims usually have two types of nightmares. The first type is where the victim dreams she is living another sexual assault, but is unable to escape it. The second type of dream demonstrates mastery, where the victim is committing acts of violence against other people. Both can be very disturbing to the victim, whether she is the victim or the actor in these dreams. Finally, it is common for the victim to develop phobias to circumstances following the sexual assault. She may become paranoid or develop many phobias, including fears of being alone, of people, of certain characteristics associated with the perpetrator or of sex. Activity 2: Responding to and assisting a victim of sexual assault 1. Facilitator leads a brainstorming session on how to assist a victim of sexual assault. Participants are encouraged to share their ideas randomly or in turn. The ideas are not criticized or discussed; participants may build on ideas voiced by others. The questions for brainstorming are: What are some guidelines for helping a victim of sexual assault? What should you do or not do when helping a victim of sexual assault? Write down each answer as they are offered on a flipchart or chalkboard without any comments, notes or questions for 5 minutes. After discussing the ideas, post the list on the wall or leave the list on the chalkboard so it is visible throughout the training workshop. 2. Facilitator summarizes the results of the brainstorming and then concludes by highlighting the following concepts in a mini-lecture format: Believe the victim. One of the greatest fears of sexual assault victims is that no one will believe them. Accept whatever you hear, regardless of her reputation, the perpetrator’s reputation or the victim’s demeanor. Do not be judgmental. Listen. Allow the victim to tell her story at her own pace. If the victim is silent and simply needs someone to sit with her, be patient and wait for the victim to choose to talk. Emphasize that the sexual assault was not the fault of the victim. Avoid questions that ask “Why?” and may sound as though they blame the victim. Allow the victim to talk about any selfblame she feels, but help her to realize that the sexual assault was not her fault. Encourage the victim to report the assault and save evidence. The sooner the sexual assault is reported, the greater the chances that the perpetrator will be convicted. The victim should not bathe, brush her teeth or change her clothing until she can be seen by a doctor. Encourage the victim to seek medical attention. The victim may have been exposed to sexually transmitted diseases or have suffered internal injuries. In addition, she could also be at risk for an unwanted pregnancy. Even victims whose sexual assault experience occurred a long time ago should be tested for sexually transmitted diseases; not all diseases result in physical symptoms. Suggest counseling and other support services. Seeking counseling does not mean that a victim must report the sexual assault to the police. Counseling will simply provide the victim the support she needs in the critical hours following an assault. Offer options to the victim, but ensure that she makes the decision on how to proceed. It is important for the victim to regain a feeling of control. Try to separate how you may feel from what is best for her healing. Even if she chooses not to report the sexual assault, show your support for her even if you disagree with her decision. Handout: Overview of Post-Traumatic Stress Syndrome. Compiled from: What is Posttraumatic Stress Disorder, National Center for PTSD Fact Sheet, available at http://www.ncptsd.org/facts/general/fs_what_is_ptsd.html. Summary and Closing: Facilitator closes by summing up the discussion: We discussed the different effects that victims may experience, as well as the progress that we might expect a victim to undergo as she recovers from the sexual assault. This includes physical, mental, chronic, reproductive and behavioral impacts on the victim. While these will vary from victim to victim, these are the general effects that are associated with sexual assault. In addition, sexual assault results in high costs to society, in terms of medical expenses, lost productivity and poorer health of victims. We also discussed some guidelines on how to respond to victims of a recent sexual assault. While getting the victim medical treatment and preserving evidence is important, believing and supporting the victim should be a priority. Questions and Comments: Facilitator should end the session by asking if there are remaining questions or comments related to this material. Keeping track of feedback will allow the facilitator to make useful changes to future presentations. It would be helpful to ask participants to generate a list of questions they have about sexual assault. Facilitator should record these questions and make sure all of them are answered by the end of the training workshop. Sources: Assisting Victims/Helping Yourself, George Mason University, available at http://www.gmu.edu/facstaff/sexual/assisting_victims.html. Ivana Bacik, Catherine Maunsell, & Susan Gogan, The Legal Process and Victims of Rape 28-30 (September 1998). Peter Gordon & Kate Crehan, Dying of Sadness: Gender, Sexual Violence and the HIV Epidemic. L. Heise, M. Ellsberg, and M. Gottemoeller. Ending Violence Against Women. Population Reports, Series L, No. 11. Baltimore, Johns Hopkins University School of Public Health, Population Information Program, December 1999, available at http://www.infoforhealth.org/pr/l11/l11figs.shtml#fig3. Ann Wolbert Burgess and Lynda Lytle Holmstrom, Rape Trauma Syndrome Coping and Reactions, Minnesota Coalition Against Sexual Assault Training Manual, available at http://www.mncasa.org/manuals_lit/trainingmanual/health.html#anchor444548 Chapter 6, World Report on Violence and Health, World Health Organization (2002), available at http://www.who.int/violence_injury_prevention/violence/world_report/wrvh1/en/. Chapter 4, World Health Report 2002: Reducing Risks, Promoting Healthy Life, World Health Organization 34 (2002). Copyright © 2003 The Advocates for Human Rights; available from http://www.stopvaw.org. Permission is granted to use this material for non-commercial purposes. Please use proper attribution. HANDOUT Posttraumatic Stress Syndrome Definition Posttraumatic Stress Syndrome (PTSD) is a psychiatric disorder that may follow a lifethreatening event, such as a natural disaster, terrorist attack, major accident or sexual assault. People who do not experience the event firsthand, but only witness it, may also develop PTSD. While there are cultural ad gender-based features of PTSD, the disorder occurs in men, women and children, across all ethnic groups and countries and at all socioeconomic levels. Approximately twenty percent of women who are exposed to a stressful event will develop PRSD, and 30% of this group will develop a chronic form of PTSD that continues throughout their life. How common is PTSD Women are twice as likely to develop PTSD as men. The most traumatic events for women are usually rape, sexual molestation, physical attack, threats with a weapon and childhood physical abuse. The chance that a woman will develop PTSD after being raped is between 50% to 95%. How PTSD develops Usually, people who experience a traumatic event will begin feeling some of the symptoms of PTSD in the following days and weeks. Symptoms of PTSD Headaches, gastrointestinal problems, immune system complaints, dizziness, chest pain and bodily discomfort are common problems in people with PTSD. In one study, 79% of women with PTSD also were diagnosed with another psychiatric disorder, including depression (48.5%), phobias (29%), social phobias (28.4 %) and alcohol dependence (27.9%). People with PRSD may also experience problems in family and interpersonal relationships, work and crime. Treatment of PTSD Professionals may treat PTSD through medications, cognitive behavioral therapy, group therapy or exposure therapy. Compiled from: What is Posttraumatic Stress Disorder, National Center for PTSD Fact Sheet, available at http://www.ncptsd.org/facts/general/fs_what_is_ptsd.html.