Introduction

The links between traumatic experience and psychological distress have been reflected in art and literature for centuries. Our scientific understanding of these links, however, and the reactions of victims, has only developed over the past 100 years. Victims or survivors, as many would prefer to be known, are just that: people who have experienced adverse circumstance and have lived in spite of the adversity. Rape and serious sexual assault are perpetrated against women and men, boys and girls; considerations such as social status, ethnicity, sexual orientation and religious persuasion are unlikely to affect the likelihood of an individual becoming a victim of such. The research would suggest, however, that most victims are female; therefore, while not forgetting child victims or male survivors, this chapter is written to address primarily (although not exclusively) the psychological consequences of sexual assault on women. Reference will be made to rape and serious sexual assault, as well as the more generic terms of sexual violence, sexual offences, or both; much of the research has focused on the former, although many of the difficulties seen in rape victims are equally applicable to those subject to other forms of serious sexual assault. We will use the terms interchangeably.

Sexual violence is a global problem. The lifetime risk of attempted or completed rape is estimated to be 20% for women, and 4% for men. British Crime Survey data from 2000 indicated that 0.4% of women respondents, aged between 16 and 59 years, disclosed that they had been raped in the preceding year; assuming the findings would be generalisable to the other years, this would equate to one in every 250 women being raped in the UK each year. Of the sexual crimes disclosed by respondents to the above survey, only 18% had been reported to the police. This figure is consistent with other research, which variously indicates that between 5 and 25% of rapes are reported to police.

Sexual offences are serious crimes with far-reaching consequences. Recently, a plethora of newly published, victim-focused guidance has been published for police, Crown Prosecution Services Prosecutors, Sexual Offence Examiners and Practitioners, Sexual Assault Referral Centres, and other professionals who come into contact with rape complainants, implementation, of which, has been patchy. Baroness Stern’s 2010 review into how rape complaints are handled by public authorities in England and Wales states that:

‘it is time to take a broader approach to measuring success in dealing with rape. The conviction rate, however measured, has taken over the debate to the detriment of other important outcomes for victims. We do not say that prosecuting and convicting in rape cases is in any way unimportant…… But in dealing with rape there is a range of priorities that needs to be balanced. Support and care for victims should be a higher priority.’

Notwithstanding this, it is essential for those victims who choose to become complainants, that those interacting with them through the criminal justice process understand the significant physical and psychological consequences resulting from issues such as sexually transmitted infections, depression, anxiety and post-traumatic stress disorder (PTSD); conditions that can have a long-lasting effect on people’s well-being and future functioning.

Myths and stereotypes

When hearing the word ‘rape’, many people will conjure up an image of a stranger attacking a woman at knife point in a dark public place. In reality, this situation is extremely rare. Most rapes, and other sexual assaults, are committed by someone known to the victim. Common categories of perpetrators include current or ex-husbands and partners, recent acquaintances, colleagues and people in positions of trust. This, in turn, means that many assaults take place in private, including inside the victim or perpetrator’s home, and in the context of daily lives. And yet, for some, including the victims themselves, such encounters are not always defined as rape; indeed, it was not until 1991 that rape within marriage was criminalised in England and Wales.

The issue of force is another area around which myths abound. The use of force does not feature in the legal definition of rape in England and Wales, and most rapes do not involve overt physical assault or threat. Often, victims do not actively resist and many are not physically injured. If the victim themselves, however, or others hearing of the incident, hold the inaccurate assumption that rape always involves violent force, and that a victim of rape will be injured, this may cloud the judgements made about whether an incident was or was not rape.

Anyone can be the victim of rape and all have the same rights to protection under the law. Desirability, in the way that individuals who engage in consensual sex understand it, has little to do with how and why rapists select their victim. Stereotypically ‘beautiful’ people are not more likely to be raped than stereotypically less beautiful people. Sex offenders, in the main, use the following to select their victim(s): asexual interest criteria; vulnerability; and accessibility. Once the offender has identified people who meet these criteria, they will focus on remaining undetected; perhaps the person they consider will be least likely to disclose, or the person least likely to be considered credible, if they do disclose; in this process sex offenders are very much assisted by the myths, stereotypes and societal judgements being addressed in this section of the chapter.

Vulnerable women, such as those with, for example, a history of childhood sexual abuse, mental health problems, or learning disability, are more likely to be targeted by sex offenders, and are more likely to be subject to repeat victimisation ; and yet, multiple reports of rape or sexual assault by an individual are, on occasion, used to suggest that they are lying; that they are a serial false complainant; or that they are attention-seeking.

Men who are raped, and men who rape men, are often wrongly assumed to be homosexual. On the contrary, both victims and offenders of male rape are frequently heterosexual. The resulting shame, confusion and sense of isolation, that the effect of such ignorance can have on male victims of rape, are frequently profound.

Curiously, victims of rape are often judged as being culpable for the violation they have endured, and their behaviours before the rape perceived as having been ‘risky’. This was illustrated in a 2005 report by Amnesty International, and more recently in a 2010 survey, of UK residents. Over one-half (56%) of the respondents thought that there were some circumstances where a person should accept responsibility for being raped; for those people, the circumstances were as follows: performing another sexual act on someone (73%); getting into bed with someone (66%); drinking to excess or blackout (64%); going back to someone’s home for a drink (29%); dressing provocatively (28%); dancing in a sexy way with someone at a night club or bar (22%); acting flirtatiously (21%); kissing someone (14%); accepting a drink and engaging in a conversation at a bar with someone (13%).

It cannot reasonably be assumed that a woman is consenting to sex from the way in which she is dressed, her reputation, whether she has previously agreed to levels of intimacy or even agreed to sex with the accused on another occasion. Yet, it seems that many of the general public believe that such behaviours make women responsible for being raped. This is clearly at odds with the law as it stands, and can have devastating consequences for recovery as guilt and shame are compounded.

Myths and stereotypes

When hearing the word ‘rape’, many people will conjure up an image of a stranger attacking a woman at knife point in a dark public place. In reality, this situation is extremely rare. Most rapes, and other sexual assaults, are committed by someone known to the victim. Common categories of perpetrators include current or ex-husbands and partners, recent acquaintances, colleagues and people in positions of trust. This, in turn, means that many assaults take place in private, including inside the victim or perpetrator’s home, and in the context of daily lives. And yet, for some, including the victims themselves, such encounters are not always defined as rape; indeed, it was not until 1991 that rape within marriage was criminalised in England and Wales.

The issue of force is another area around which myths abound. The use of force does not feature in the legal definition of rape in England and Wales, and most rapes do not involve overt physical assault or threat. Often, victims do not actively resist and many are not physically injured. If the victim themselves, however, or others hearing of the incident, hold the inaccurate assumption that rape always involves violent force, and that a victim of rape will be injured, this may cloud the judgements made about whether an incident was or was not rape.

Anyone can be the victim of rape and all have the same rights to protection under the law. Desirability, in the way that individuals who engage in consensual sex understand it, has little to do with how and why rapists select their victim. Stereotypically ‘beautiful’ people are not more likely to be raped than stereotypically less beautiful people. Sex offenders, in the main, use the following to select their victim(s): asexual interest criteria; vulnerability; and accessibility. Once the offender has identified people who meet these criteria, they will focus on remaining undetected; perhaps the person they consider will be least likely to disclose, or the person least likely to be considered credible, if they do disclose; in this process sex offenders are very much assisted by the myths, stereotypes and societal judgements being addressed in this section of the chapter.

Vulnerable women, such as those with, for example, a history of childhood sexual abuse, mental health problems, or learning disability, are more likely to be targeted by sex offenders, and are more likely to be subject to repeat victimisation ; and yet, multiple reports of rape or sexual assault by an individual are, on occasion, used to suggest that they are lying; that they are a serial false complainant; or that they are attention-seeking.

Men who are raped, and men who rape men, are often wrongly assumed to be homosexual. On the contrary, both victims and offenders of male rape are frequently heterosexual. The resulting shame, confusion and sense of isolation, that the effect of such ignorance can have on male victims of rape, are frequently profound.

Curiously, victims of rape are often judged as being culpable for the violation they have endured, and their behaviours before the rape perceived as having been ‘risky’. This was illustrated in a 2005 report by Amnesty International, and more recently in a 2010 survey, of UK residents. Over one-half (56%) of the respondents thought that there were some circumstances where a person should accept responsibility for being raped; for those people, the circumstances were as follows: performing another sexual act on someone (73%); getting into bed with someone (66%); drinking to excess or blackout (64%); going back to someone’s home for a drink (29%); dressing provocatively (28%); dancing in a sexy way with someone at a night club or bar (22%); acting flirtatiously (21%); kissing someone (14%); accepting a drink and engaging in a conversation at a bar with someone (13%).

It cannot reasonably be assumed that a woman is consenting to sex from the way in which she is dressed, her reputation, whether she has previously agreed to levels of intimacy or even agreed to sex with the accused on another occasion. Yet, it seems that many of the general public believe that such behaviours make women responsible for being raped. This is clearly at odds with the law as it stands, and can have devastating consequences for recovery as guilt and shame are compounded.

Psychological reactions during rape and serious sexual assault

It is important to understand that it is the perception of threat, not the actual threat, that governs individuals’ responses during an assault. Most will be profoundly affected; fearful, disorientated, and helpless. Others, particularly where repeat victimisation is a factor, may cut off, dissociating from reality. Some women may submit to sexual intercourse from fear of what might happen if they were to resist, or even merely to protest.

Most people, when asked to predict how they would react if somebody attempted to rape them, would likely respond that they would actively defend themselves by, for example, screaming, fighting or running. The corresponding reality is that most people faced with such threat do not actively defend themselves. The reason for the mismatch between our predicted reaction and our actual reaction is neurobiological. When imagining our response, we use our higher brain function and think rationally and logically; yet, when the experience actually occurs, our higher brain functions are likely to be impaired (as a result of the threat we are experiencing), and we respond instinctively.

When faced with a perceived threat, the human system broadly responds in one (or more) of five predictable ways: ‘fight, flight and freeze’ (well-documented responses to threat), and ‘friend’ and ‘flop’, The survival strategy used in any given situation will depend upon a number of factors, namely: what is most likely to ensure survival (and also maintain vital attachments)?; what worked in the past?; and what was unsuccessful in the past?

These processes mean that some women resist, run away or cry for help, whereas others will take a far more passive approach; indeed, they may appear frozen and unable to act. Submission or taking a passive stance is not, however, the same as consent: consent is actively given and actively reinforced, it is not passively assumed, and yet people might wrongly assume that if there is no injury, torn clothing, struggle or cries for help, then an assault was not committed.

Dissociative mechanisms, such as de-realisation (a sense that the world around is not real), de-personalisation (a sense that it is not happening to ‘me’, rather it is occurring to someone else), and dissociation (a sense of being cut off from the actual situation) can result from extreme fear. It is likely that dissociative processes at the time of the trauma will permit the victim to endure the otherwise unendurable ; consequences of dissociation occurring at the time of the trauma include the following: losing track of what was going on; engaging in behaviours without actively deciding to do so; time becoming altered (e.g. things seem to be happening in slow motion, or at speed); sensory disturbances (e.g. moments when one’s body appears distorted or changed) ; and increased likelihood of the individual developing PTSD.

A further, grave, consequence of a victim having dissociated from an experience, and thus not having integrated or ‘owned’ it, is that it limits the individual’s capacity to learn from the experience. This, in turn, increases the victims’ vulnerability to future sexual assault.

As a result of the impaired brain functioning that perceived threat induces, it is probable that the vital role of the higher brain structures in mediating explicit memory will also be disrupted. Memories of traumatic experiences are, therefore, more likely to be stored predominantly as implicit memory, which is emotional, sensory, less adaptable, context-free, and concerned with unconscious procedural learning.

The hippocampus is one of the brain structures whose functions are disrupted under threat conditions. Hippocampi are essentially involved in the storage of explicit memory, and they play a central role in the organisation of spatial and temporal information. This means that the threatened individual will potentially perceive the passing of time and concepts such as space, distance and proximity inaccurately. Ultimately, this is likely to affect how such concepts are recalled. For some, the distortion in how they experienced an event will be recognised and they may, for example, declare ‘it felt like hours but, I suppose, it could have been a minute – I don’t know’; for others, however, they may not be aware that fear has influence the objective accuracy of their recollection and, as a result, their recall may be distorted, particularly with regard to spatial and temporal perception.

The effect on brain function, as outlined above, can severely impair the person’s ability to recall details of the assault and recall may change over time. Memories of the traumatic event are often initially experienced as fragmented. Thus, for victims, sensory components, feelings and emotions may be more easily recalled while a detailed narrative may not, initially, be accessible.

If a victim is to be questioned soon after the assault, questions that focus on perceptions (e.g. what did you feel, smell or hear), will likely yield better evidence than those that demand explicit narrative from the victim. With time, and especially with sleep (specifically rapid eye movement sleep), the higher brain structures will potentially process memory that has been encoded implicitly and, in doing so, explicit recall may increase. With further questioning and processing of the event (e.g. by sleeping, talking it though, or both), more of the narrative component may become accessible, and the victims’ account will change (usually by becoming more detailed).

Psychological reactions after sexual assault

Many factors will affect an individual’s response to trauma, and psychological reactions vary greatly between individuals. The ‘meaning’ that a victim ascribes to the incident is likely to be significant, a fact that is illustrated by the differences between stranger and acquaintance rape. It might be assumed that the former would be far more traumatic, but this is often not the case, and research has shown that rape victims have similar levels of depression and greater difficulty re-establishing intimate relationships after acquaintance rape.

A woman raped by an acquaintance potentially has to question everything she ever held ‘true’. If she cannot trust her own judgement, nor her previous positive illusions about the world, and of how she would respond if faced with sexual threat, how can she go about her daily life? The world is suddenly a malevolent place where sex offenders are people she knows, and not strangers ‘out there’ to be mistrusted and avoided.

Other elements that research indicates will contribute to the victim developing more severe post trauma responses include the following: the victim believes that the rapist will kill them, will sustain physical injury, or both ; the rape is completed (as opposed to attempted) ; the offender is someone known to the victim, and thus the element of ‘betrayal’ is significantly greater ; the victim dissociates at the time of the incident, exhibits dissociative symptoms immediately afterwards, or both ; the victim is unable to move as a result of their own nervous system response, or some external restraint ; the victim is very young or very old at the time of the incident; the victim has previously experienced psychological trauma, has prior psychiatric history, or both; the victim is in an environment of captivity at the time of the rape.

One of the most important factors that predicts severity of post-trauma symptomatology in any rape victim is the post-trauma response received from the environment. For example, where a victims’ experience of rape is ignored (deliberately or as a result of people simply not knowing), not recognised, minimised, or both; and where victims are blamed, judged as culpable, met with further violence, violation, or both. Lack of empathy and understanding can, therefore, reduce the prospects for a recovery.

Immediate emotional responses will vary between individuals after rape, and should be viewed as a normal reaction to an abnormal event. The victim may be expressive and tearful, quiet and controlled, distressed, shocked or in denial. Early presentation may include anxiety, tearfulness, shame, physical revulsion and helplessness. Guilt and self-blame are also normal post-trauma reactions. They serve as a means of reinstating positive illusions and defending against the unpredictability and uncontrollability of a world where bad luck can happen.

In the weeks that follow, symptomatology may become more apparent and severe, symptoms may include anxiety, depression or PTSD, and a wide array of psychosomatic complaints may develop. Most women will experience extreme distress and disruption in many areas of their lives. Originally described as ‘rape trauma syndrome’ by Burgess and Holmstrom, many of the more persistent psychological symptoms observed in survivors of rape are now recognised as being compatible with a diagnosis of PTSD.

Research indicates that most women recover from the acute effects of the attack at between 3 and 4 months. For example, Rothbaum et al. found that, soon after the crime (mean 12.64 days), 94% of their sample met symptomatic criteria for PTSD but, at 94 days (mean) after the assault, only 47% continued to do so. Many survivors, however, will experience more prolonged distress and develop difficulties such as persistent PTSD, substance abuse, anxiety, irritability, anger and depression. Kilpatrick et al. found that 51% of rape victims had developed PTSD sometime after the assault, and 16.5% still had PTSD when re-assessed some years later.

Post-traumatic stress disorder can only be diagnosed after a traumatic incident; diagnostic classification systems vary in defining the nature of stressors that can cause PTSD, but rape and other serious sexual assaults meet the criteria in either system. Post-traumatic stress disorder has three broad symptom groups (as outlined in DSM IV-TR ): (1) persistent re-experiencing of the traumatic event; (2) persistent avoidance of stimuli associated with the traumatic event and numbing of general responsiveness; (3) persistent symptoms of increased arousal.

For a formal diagnosis to be made, the symptoms must last for more than 1 month, and lead to clinically significant distress or impairment in social, occupational, or other important areas of functioning.

Post-traumatic stress disorder is an extremely distressing and disabling condition. Intrusive symptoms such as flashbacks, nightmares and feeling as though the assault is reoccurring are profoundly upsetting to individuals who experience them. Their psychological response is often to become avoidant of thoughts, feelings, places and other reminders of the assault. This, in turn, will mean that individuals with PTSD will not want to talk about what has happened to them; they may also forget important aspects of the events in question. Some individuals present with significant levels of numbing and detachment, a presentation that can lead those observing them to believe that they are not at all distressed, when in fact these symptoms are characteristic of PTSD. Sufferers also experience increased levels of arousal, with difficulty sleeping, poor concentration, anger and irritability, jumpiness and an exaggerated startle response.

As a result of these symptoms, many with PTSD (up to 30%) will use substances to cope with the unpleasant feelings; characteristically, depressant drugs, such as alcohol, marijuana or benzodiazepines, are commonly used by survivors of rape to ‘self-medicate’. Additionally, some survivors of rape will injure themselves and engage in other self-harmful behaviours.

Other long-term difficulties reported include generalised and phobic anxiety, depression, difficulties with social adjustment and sexual functioning. Kilpatrick et al. reported that, of the 507 victims of rape surveyed, 30% had experienced at least one episode of major depression and 21% were depressed at the time of the survey. In contrast, only 10% of women who had never been raped had ever experienced major depression, and only 6% were depressed at the time of survey. Feelings of shame and humiliation are commonly described, often persist and clearly contribute to loss of self-esteem and depression. The level of suicidal ideation and attempts among rape victims is notable. Kilpatrick et al. found that 33% of rape victims compared with 8% non-victims had ever contemplated suicide, whereas 13% of rape victims compared with only 1% of non-victims had made a suicide attempt.

Burgess and Holmstrom found 78% of their sample ( n = 81) had been sexually active at the time of rape but, of these, 38% gave up sex for at least 6 months and 33% decreased their frequency of sexual activity after rape. Studies comparing sexual satisfaction of rape victims with non-victims all report that rape survivors experience less sexual satisfaction.