9.3 Sexual Abuse and Assault

Types of Rape

The definition of rape by the U.S. Department of Justice (2012) does not mention gender when defining the victim and perpetrator, demonstrating that rape is not always male against female. It also states that rape can be performed with an object, not only a body part. Rape is penetration without consent; this lack of consent could be caused by drugs or alcohol, by mental or physical incapacitation, or by the victim’s age being below the age of consent (United States Department of Justice Archives, 2012).

Types of rape include date or acquaintance rape, intimate partner rape, diminished capacity rape, age-related rape, incest, aggravated rape, and other types of rape (Someplace Safe, n.d.; Tracy, 2021). Two-thirds of rapes are committed by someone the victim knows (Tracy, 2021). This type of rape is called date rape or acquaintance rape, which occurs between two people who know one another. When a partner or previous partner sexually assaults the other partner, it is called intimate partner rape. It can include physical assault, torture, perverse sexual acts, and power/control over the other partner (Tracy, 2021). When a person cannot consent to a sexual act because of physical or intellectual disability or intoxication, the sexual act is considered diminished capacity rape. Also known as statutory rape, age-related rape occurs when one sexual partner is below the age of consent, which is determined by each state (Tracy, 2021). Rape of a close family member (e.g., parent and child, uncle and niece or nephew, etc.) is considered incest. Rape that includes a threat of death or bodily harm is called aggravated rape. Other types of rape include gang rape or rape as part of a hate crime (Tracy, 2021).

Common Misinformation about Rape

Rape myths are false beliefs about rape that are widely held and perpetuated (Tilton, 2022). According to Tilton (2022), these myths include denying the existence of rape, excusing the behavior, and denying that rape is a serious crime. She discusses the mistaken beliefs that women routinely lie about rape, that they could resist rape if they wanted to, and that consent cannot be withdrawn after it has been given. She further describes the myth that women who dress provocatively or who get drunk are “asking for it.” These myths blame the victim and overlook the role of the perpetrator. Other myths include that rape always involves physical force, always happens in dark alleys at night, is committed by strangers, and is committed by a person incapable of caring for women (Tilton, 2022). These myths are debunked by the facts that most rapes are committed by someone close to the victim and do not always involve physical force.

Characteristics of Rapists

Characteristics of rapists are difficult to generalize; however, one study identified the following common characteristics among rapists: lack of empathy, narcissism, and feelings of hostility toward women (Aqel, 2020). Perpetrators use sexual assault to dominate women because rape is a crime of power and violence (Aqel, 2020). Rapists may see women as there to fulfill their sexual needs; women are objects instead of people. Rapists might believe that when a woman says no, they are just “playing hard to get” or challenging him but really mean yes (Aqel, 2020). Men called incels, “involuntary celibates,” believe they are entitled to a romantic or sexual relationship and are known for extreme misogynistic ideas and promotion of violence against women (Trotta, 2022). Several types of rapists exist: the rapist who loses self-control under the influence of drugs or alcohol; the sadist who wants to humiliate victims; the vindictive rapist who shows anger and aggression toward women, believing he has been rejected or wronged by past relationships with women; and rapists who deny rape and justify their actions (Aqel, 2020). The CDC (2021b) suggests the characteristics of an intimate partner perpetrator are low self-esteem, low income, heavy drug and alcohol use, anger and hostility, and having strict gender role ideas of male dominance.

Roles of Substances in Sexual Assault

Drug-facilitated sexual assault occurs when the use of a substance (drugs or alcohol) compromises the victim’s ability to give consent for sex. Intoxication of the partner allows the perpetrator to commit sexual acts with little resistance and can also prevent the survivor from remembering the rape. “Date-rape drugs” are used to incapacitate victims. Alcohol is the most common “date-rape drug” and is easily accessible (Rape, Abuse & Incest National Network [RAINN], n.d.). Other drugs include sleep aids, anxiety medications, muscle relaxers, tranquilizers, and street drugs such as GHB, Rohypnol, ecstasy, and ketamine (RAINN, n.d.). Warning signs that a person has unknowingly been given drugs include difficulty in breathing, feeling drunk when little to no alcohol has been consumed, loss of bladder or bowel control, nausea, sudden change in body temperature, dizziness, disorientation, blurred vision, and waking with no memory or missing large portions of memories (RAINN, n.d.).

Date Rape and Violence on the College Campuses

Sexual assault on college campuses is a common problem. One in five women in college experiences sexual assault, with the highest risk in the first few months of their first or second semester in college (U.S. Department of Health and Human Services’ Office on Women’s Health [USDHHS/OWH], 2021). Sexual assault includes any unwanted sexual activity, from unwanted touching to rape, and often involves alcohol or drugs. Nurses can teach college-aged persons to get to know someone prior to spending alone-time with them, to go to parties with friends instead of alone, to meet dates in public places, to be aware of alcohol or drug intake, to keep control of their drinks, to be aware of their surroundings, and to always have a plan for how to get home (USDHHS/OWH, 2021).

Phases of Rape Trauma Syndrome

The three phases of rape trauma syndrome include the acute phase, outward adjustment phase, and resolution phase. The acute phase occurs immediately after the assault, lasting a few days to several weeks (Rape trauma syndrome, 2020). The person experiences three categories of reactions:

• expressed (the person is openly upset, cries, has anxiety attacks),
• controlled (emotionless, acts as if nothing happened), and
• shocked disbelief (strong sense of disorientation, difficulty in concentrating and making decisions, may have poor recall of the assault).

The person then experiences the outward adjustment phase. This phase occurs once the person appears to resume normal life but is experiencing extreme inner turmoil (Rape trauma syndrome, 2020). The person uses minimization (“everything’s fine”), dramatization (the attack dominates their life and identity), suppression (refuses to discuss the attack), explanation (analyzes what happened), and flight (moving, changing appearance) as coping mechanisms (Rape trauma syndrome, 2020). Nurses should be aware of the following symptoms of this phase: severe mood swings, fear, depression, rage, insomnia, eating difficulties, withdrawal from friends or family, difficulty in concentrating, and flashbacks.

The resolution phase occurs when the attack is no longer the person’s main life focus. The person has not forgotten the assault but has dealt with and accepted the rape as part of their life history (Rape trauma syndrome, 2020). The person’s pain and symptoms lessen over time.

Posttraumatic Stress Disorder after Rape

Posttraumatic stress disorder (PTSD) can occur after a sexual assault, and women have a higher incidence of PTSD after rape than men do (Nöthling et al., 2022). Nöthling et al. (2022) found a lifetime PTSD prevalence rate of 36.2 percent in those who experienced rape. The study found that women who were younger and single and who had a lower level of education and lower income developed PTSD more often than those without these risk factors. Positive reliance (having a positive perspective of the world and oneself, positive beliefs about one’s coping mechanisms, positive perceived control over one’s emotional recovery) was found to be protective against developing PTSD. They also found that women with childhood trauma, depression, and alcohol use disorder also had a higher incidence of PTSD. Finally, the study suggested that the severity of the rape (multiple perpetrators, multiple sex acts, physical injuries, and longer duration of assault) can influence the degree of a survivor’s PTSD.

Care and Support of the Sexual Assault Survivor

Sexual assault survivors can experience a variety of adverse health consequences, such as mental health problems, suicidal ideation, PTSD, eating disorders, sexual and reproductive health problems, and chronic illnesses (Cannon et al., 2023). They also are at risk for STIs, pregnancy, and risky behaviors. Nurses help these persons cope with the health consequences of their assault by listening and by providing referrals for mental health providers, resources for support groups, and suicide hotlines.

Long-term effects of sexual abuse can be profound. Survivors may struggle with low self-esteem, trust issues, and difficulty in forming healthy relationships. They may also be at higher risk for developing mental health disorders, such as depression, anxiety, or substance misuse. In some cases, the impact of abuse can be so severe that it can lead to suicidal thoughts or behaviors.

It is essential for anyone who has experienced sexual abuse or assault to seek help and support from trained professionals, as well as from family and friends, to begin the healing process and move forward with their lives. With the right help and support, healing from sexual abuse is possible.

Start by Believing Campaign

Start by Believing (SBB) is a campaign created by End Violence Against Women International (EVAWI). EVAWI (n.d.) found that most survivors of sexual assault never report it to authorities due to the response they receive from friends and family. The SBB campaign focuses on preparing professionals and loved ones to respond appropriately to persons discussing their sexual assault. The EVAWI found that negative responses worsen the trauma to survivors and allow perpetrators to go unpunished for their crimes. By others believing the survivor’s story, the person is more likely to talk about their attack and feel heard. The survivor feels that someone believes them, which overcomes the myth that women lie about rape. Women might feel strong enough to report and prosecute the perpetrator if they know they have support. SBB was launched in 2011, and now 701 campaigns exist around the world. These campaigns teach everyone to believe and support the survivor.

Detailed History

The SANE collects a detailed record of the person’s current health history, medications, social history, and family history. The SANE also takes a detailed history of the assault. Guidelines recommend the survivor seek care within 120 hours of the assault to ensure prevention of STIs, prescription for emergency contraception, and adequate evidence collection (Cannon et al., 2023).

Evidence Collection

Sexual assault nurse examiners perform a medical forensic exam, a thorough head-to-toe exam to document trauma to any part of the body for the purpose of treating trauma, treatment of possible STIs, referral for counseling and medical follow-up, and the collection of evidence to be used in legal proceedings (Paxton, n.d.). The SANE uses an evidence collection kit to gather physical evidence. Evidence collection usually takes place in a hospital emergency department by trained SANEs because it offers a safe environment and is open 24 hours a day. Some colleges and community centers provide SANE collection sites (Cannon et al., 2023). The SANE is trained in collecting the appropriate evidence, and studies have shown that prosecutors have increased the number of guilty pleas from perpetrators because of better evidence collection and evidence of force noted by SANEs (Ledray & Simmelink, 2020).

Prevention of Sexually Transmitted Infections

The evidence kit collected by the SANE includes testing for STIs. The most frequently diagnosed STIs are gonorrhea, chlamydia, and trichomoniasis; however, HIV, hepatitis B, and syphilis testing is also completed (Ragpa et al., 2019). Prophylactic antibiotics are given for gonorrhea, chlamydia, and trichomoniasis; and postexposure prophylaxis for HIV is administered (Ragpa et al., 2019). Postexposure hepatitis B vaccination along with immune globulin is recommended in persons previously unvaccinated (Ragpa et al., 2019).

Prevention of Pregnancy

A pregnancy test is performed with the evidence collection. If the result is negative, emergency contraception will be offered to prevent pregnancy after a sexual assault. The nurse explains that emergency contraception is not an abortion pill; it delays ovulation to prevent fertilization of the egg. (See Chapter 5 Family Planning for more information on emergency contraception.)

Prosecution of the Perpetrator

The U.S. Department of Justice refers to publications by the Rape, Abuse, & Incest National Network (RAINN) that state the rape survivor can make an initial report, and the police can decide to move forward with the investigation; however, only the state can decide to press charges (RAINN, n.d.). Even if the state does not press charges, reporting the crime can help shed light on the perpetrator for future crimes. If the case goes to trial, the survivor will most likely be asked to testify; however, every state decides on rules and resources to protect rape survivors. Advocates are usually assigned to survivors to help with this process.

Self-Care for Nurses of Rape Survivors

Caring for women surviving rape can result in nurses developing their own stress and trauma. Those nurses must engage in activities that will allow them to let go of stress and trauma caused by discussing assaults and performing rape exams. Self-care is the action of promoting physical, emotional, intellectual, and spiritual wellness. Nurses, especially those caring for women after rape, must practice self-care. Self-care includes caring for the mind, body, and spirit in an individual way that brings that person peace. Activities of self-care can be meditation, exercise, yoga, art, music, and so on. To care for others, nurses must care for themselves.