Margot L. Waitz, DO
OMED 2014
Seattle, Washington

• Better understand the connection between sexual abuse and the development of an addiction.
• Review concerns of sexual assault while under the influence – victim and/or assailant.
– What is happening on our college campuses today?
• Discuss treatment options for the individual with dual diagnosis – addiction and sexual abuse.

http://www.childhelp.org/pages/statistics

• Increased likelihood of victim developing longlasting problems when:
– Abuse done by a primary caretaker
• Father or stepfather
– Violent, forceful
– Prolonged
– Intrusive physical violation
The National Center For Post-Traumatic Stress Disorder PTSD Research Quarterly
Volume 3, Number 3, Summer 1992

• More than a third of adolescents with a report of abuse or neglect will have a substance use disorder before their 18th birthday, three times as likely as those without a report of abuse or neglect.
http://www.childhelp.org/pages/statistics

• Teens with alcohol and drug problems
– 6 – 12 times more likely to have a history of physical abuse
– 18 – 21 times more likely to have been sexually abused
• www.mhanys.org

• Male victims are:
– 4 times more likely to suffer from major depression
– 3 times more likely to have bulimia
– 2 times as likely to:
• Develop an antisocial personality disorder
• Have behavioral problems
• Suffer from low self-esteem
• Run away from home
• Have legal problems www.icasa.org/docs/emotional-&-physical_effects-_draft-4.doc

• More likely to engage in high risk sexual behaviors placing them at risk of STDs and causing pregnancy.
• Four times as likely to have forced sexual contact with another boy.

• Depression
– Suicidal thoughts and attempts
• Post Traumatic Stress Disorder
• Eating Disorders
• Sexual Promiscuity
• Dissociative Symptoms
• Aggressive Behaviors
• Delinquency

• Lower Social Competence
• Lower Self Esteem
• Borderline Personality Disorder
• Substance Abuse http:ptsdassociation.com/ptsd-researchphp?Longitudinal%20Study%20Childhood%20Sexual%20Abuse-20

• 3 times more likely to suffer depression,
• 6 times more likely to suffer post-traumatic stress disorder,
• 13 times more likely to abuse alcohol
• 26 times more likely to abuse drugs
• than those who have not been sexually abused. http://alcoholrehab.com/drug-addiction/substance-abuse-consequence-sexual-abuse/

• Hormonal imbalance
– Higher levels of:
• Leptin – appetite regulation
• Irisin – energy metabolism
– Lower levels of adiponectin – reduces inflammation
• Obesity – secondary to above hormonal imbalance
• http://consumer.healthday.com/kids-health-information-23/child-developmentnews-124

• Gastrointestinal problems
– Abdominal pain
– Irritable bowel syndrome
• Breast disorders including fibrocystic changes to cancer.
• Pelvic pain including PID
• More bladder infections
• Chronic pain – backaches and headaches
• www.icasa.org/docs/emotional-&-physical_effects_-_draft-4.doc

• Frequently the most common symptom of survivors of childhood sexual abuse.
• www.icasa.org/docs/emotional-&-physical_effects_-_draft-4.doc

• Affects women more than men.
• Can be seen in the pre-adolescent, adolescent and adulthood – symptoms of PTSD may not develop for years after the abuse.
• Certain rites of passage may trigger emergence of PTSD
– Initiation of sexual activity
– Childbirth http://www.medscape.com/viewarticle/731970_print

• Women diagnosed with this disorder are four times more likely to have been sexually abused in childhood
– Frequently the perpetrator is the father
• www.icasa.org/docs/emotional-&-physical_effects_-_draft-4.doc

• As many as 2/3 of sufferers of anorexia or bulimia nervosa have histories of child sexual abuse.
– Body shame
– Coping techniques
• Bulimia
– Binge/purge cycle allows for escape from the emotions, reduce awareness of thoughts https://www.nationaleatingdisorders.org/sites/default/files/ResourceHandouts/TraumaandEatingDisorders.pdf

• Abused children are 25% more likely to experience teen pregnancy.
• Abused teens are more likely to engage in sexual risk taking, putting them at greater risk for STDs.
• http://www.childhelp.org/pages/statistics

• As many as two-thirds of the people in treatment for drug abuse reported being abused or neglected as children. http://www.childhelp.org/pages/statistics

• A mechanism to cope or escape the trauma of sexual abuse
• A way to reduce feelings of isolation and loneliness
• A form of self medication
• To improve self esteem and boost confidence
• A form of self-destructive behavior or self-harm http://alcoholrehab.com/drug-addiction/substance-abuse-consequence-sexual-abuse/

• Screening and Treatment

• WHO, AMA, AAP, American Nurses Association
– recommend screening female patients for sexual violence
• ACOG recommends screening for sexual assault.
• USPSTF – does not recommend for or against screening citing insufficient evidence.

• Should be done at each visit
– Patient may not be comfortable with disclosure the first time the subject is broached
• Should be done in a nonjudgmental manner
– No blame or discounting
• Evaluate, educate and refer:
– Make sure the patient is currently safe, not suicidal or homicidal and determine if substance abusing. http://www.medscape.com/viewarticle/821206_print

• Seeking Safety
– Present-focused model
– 25 topics to teach coping skills for PTSD and Substance
Use Disorder (SUD)
– Four domains
• Cognitive
• Behavioral
• Interpersonal
• Case management http://www.medscape.com/viewarticle/564893_print

• Seeking Safety
– Designed for:
• males and females
• All types of trauma and substance abuse
• Group or individual setting
• The only model of treatment that has been found to be effective in treating this dual diagnosis
• Website – www.seekingsafety.org

• Trauma-Focused Cognitive Behavioral Therapy
– (TF-CBT)
– Specific elements include:
• Feeling expression skills
• Coping skills training
• Recognizing the relationships between thoughts, feelings and behaviors
• Gradual exposure
– Creating child’s trauma narrative
• Cognitive processing of the abuse experience http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1201422/

• Specific elements include:
• Joint parent-child session
• Psycho-education about child sexual abuse and body safety
• Parent management skills
• This approach was found to improve PTSD, depression, behavior problems, and shame in children with a history of sexual abuse.

• 25% of American women have experienced sexual assault
– Approximately one-half of those cases involved alcohol consumption by the perpetrator, victim or both. http://pubs.niaaa.nih.gov/publications/arh25-1/43-51.htmh

• About 4 out of 5 college students drink alcohol
– About half of college students who drink, binge drink
– http://www.niaaa.nih.gov/alcohol-health/special-populations-cooccurring-disorders/college-drinking

http://www.alcohol101plus.org/downloads/CollegeStudents.pdf

Annually – 18 – 24 year olds
• DEATH - 1,825 college students die each year from alcohol related unintentional injuries
• ASSAULT - more than 690,000 students are assaulted by another student who has been drinking
• SEXUAL ABUSE – more than 97,000 students are victims of alcohol-related sexual assault or date rape http://www.niaaa.nih.gov/alcohol-health/special-populations-cooccurring-disorders/college-drinking

• The full scope of this problem is difficult to ascertain as many individuals do not report the assault.
• Estimated between 20 – 25% of female college students have been victims of either completed or attempted rape during their college career.

• “In one study, one in 20 (4.7%) women reported being raped in college since the beginning of the year – a period of approximately 7 months – and nearly three quarters of those rapes (72%) happened with the victims were so intoxicated they were unable to consent or refuse.”
• Less than 5% of victims report the assault to law enforcement.
Mohler-Kuo, M., Dowdall, G., Koss, M., & Wechsler, H. (2004). Correlates of Rape While
Intoxicated in a National Sample of College Women. Journal of Studies on Alcohol.65, 37-45. http://www.nsvrc.org/saam/campus-resource-list#Stats

• Drinking alcohol does not cause the sexual assault.
• However, pre-existing beliefs and stereotypes about alcohol and sex set the stage.
– Alcohol will cause a man to feel more powerful, sexual and aggressive.
– Women who drink are more promiscuous, want sex. http://www.collegedrinkprevention.gov/SupportinResearch/Journal/abbey.aspx

• Federal Response

• Overview: Title IX promotes equal opportunity by providing that no person may be subjected to discrimination on the basis of sex under any educational program or activity receiving federal financial assistance. A school must respond promptly and effectively to sexual harassment, including sexual violence, that creates a hostile environment. When responsible employees know or should know about possible sexual harassment or sexual violence they must report it to the Title IX coordinator or other school designee.
• Sexual Harassment: Sexual harassment is unwelcome conduct of a sexual nature, including unwelcome sexual advances, requests for sexual favors, and other verbal, nonverbal, or physical conduct of a sexual nature.
• Sexual Violence: Sexual violence is a form of sexual harassment. Sexual violence refers to physical sexual acts perpetrated against a person’s will or where a person is incapable of giving consent ( e.g
., due to the student’s age or use of drugs or alcohol or an intellectual or other disability that prevents the student from having the capacity to give consent). Sexual violence includes rape, sexual assault, sexual battery, sexual abuse, and sexual coercion

• Overview: The Clery Act promotes campus safety by ensuring that students, employees, parents, and the broader community are wellinformed about important public safety and crime prevention matters.
Institutions that receive Title IV funds must disclose accurate and complete crime statistics for incidents that are reported to Campus
Security Authorities (CSAs) and local law enforcement as having occurred on or near the campus. Schools must also disclose campus safety policies and procedures that specifically address topic such as sexual assault prevention, drug and alcohol abuse prevention, and emergency response and evacuation. The Clery Act also promotes transparency and ongoing communication about campus crimes and other threats to health and safety and empowers members to take a more active role in their own safety and security. https://www.notalone.gov/assets/ferpa-clerychart.pdf

• Publish an Annual Security Report
• Have a public crime log
• Disclose crime statistics for incidents that occur on campus, in unobstructed public areas immediately adjacent to or running through the campus and at certain non-campus facilities
• Issue timely warnings about Clery Act crimes which pose a serious or ongoing threat to students and employees
• Devise an emergency response, notification and testing policy
• Compile and report fire data to the federal government and publish an annual fire safety report
• Enact policies and procedures to handle reports of missing students http://clerycenter.org/summary-jeanne-clery-act

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Higher Education Institutions with Open Title IX Sexual
Violence Investigations
HI
ID
IL
IL
IN
IN
MA
MA
MA
MA
MA
MA
CT
DC
FL
GA
CO
CO
CO
CO
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State
AZ
CA
Institution
Arizona State University
Butte-Glen Community College District
CA
CA
CA
Occidental College
University of California-Berkeley
University of Southern California
Regis University
University of Colorado at Boulder
University of Colorado at Denver
University of Denver
University of Connecticut
Catholic University of America
Florida State University
Emory University
University of Hawaii at Manoa
University of Idaho
Knox College
University of Chicago
Indiana University-Bloomington
Vincennes University
Amherst College
Boston University
Emerson College
Harvard College
Harvard University—Law School
University of Massachusetts-Amherst
PA
PA
PA
PA
PA
NY
NY
NY
OH
OH
OH
OK
MD
MI
MI
NC
NC
ND
NH
NJ
NY
TN
TX
TX
VA
VA
WA
WI
WV
WV
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Frostburg State University
Michigan State University
University of Michigan-Ann Arbor
Guilford College
University of North Carolina at Chapel Hill
Minot State University
Dartmouth College
Princeton University
Cuny Hunter College
Hobart and William Smith Colleges
Sarah Lawrence College
Suny at Binghamton
Denison University
Ohio State University
Wittenberg University
Oklahoma State University
Carnegie Mellon University
Franklin and Marshall College
Pennsylvania State University
Swarthmore College
Temple University
Vanderbilt University
Southern Methodist University
The University of Texas-Pan American
College of William and Mary
University of Virginia
Washington State University
University of Wisconsin-Whitewater
Bethany College
West Virginia School of Osteopathic Medicine

Campus Accountability and Safety Act
Bipartisan, Federal Legislation
• New Campus Resources and Support Services for Student Survivors
• Minimum Training Standards for On-Campus
Personnel
• Campus Accountability and Coordination with
Law Enforcement
• New Historic Transparency Requirements
• Enforceable Title IX Penalties and Stiffer
Penalties for Clery Act Violations

• Not Alone – Together Against Sexual Assault
– An official website of the federal government
– Information on resources on how to respond and prevent sexual assault
– Find a crisis service site specific to your area
– Learn your rights under federal law and the school’s responsibility
– Learn how to file a complaint against your school or university
– View school-by-school resolution agreements and compliance reports.

• Many universities have a program that the incoming freshman must take on line and pass a test regarding alcohol use and safety.
• Blue lights on campus
• Certain apps are being tried
– Circle of 6
– OnWatchOnCampus
– Rave Guardian http://www.bostonglobe.com/metro/2014/08/26/colleges-enlist-smartphone-apps-help-combatcampus-sexual-assault/2wUPdW5W52gLqD1mUlky8I/story.html

• Education – many of these students come to our office for their pre-college physicals
– Inform these students to the concerns
– Educate them to help them be more aware and ideally more responsible
– Encourage them to find out more once they are on campus as to what their college/university is doing to address this concern
• Is their college utilizing one of the apps mentioned?

“Perhaps most important, we need to keep saying to anyone out there who has ever been assaulted: you are not alone. We have your back. I’ve got your back.”
President Barack Obama, January 22, 2014