| NVAA 2000 Text |
Chapter 10 Sexual Assault
Rape is the most underreported crime in America. Significant changes to improve the treatment of sexual assault victims have occurred in the last two decades. The impact of reforms, led by the women's movement, can be seen in the legal, medical, mental health, and victim services arenas. During the 1970s, the first rape crisis center was established. The treatment of victims in the criminal justice system was questioned, and hundreds of laws were passed to protect rape victims in the courts. Medical protocols have been developed and widely accepted. The mental health impact of rape is now well documented in the literature, and the practices of mental health professionals have improved. Although the treatment of rape victims today is vastly different from two decades ago, many victims still do not report the crime, and they do not receive the assistance and treatment they need.
Upon completion of this chapter, students will understand the following concepts:
As noted elsewhere (Crowell and Burgess 1996, chap. 1; Kilpatrick 1983; Kilpatrick et al. 1998), obtaining an accurate measurement of rape and other types of sexual assault poses many challenges. The number of rapes and other types of sexual assault depends on how these crimes are defined and how they are measured. These definitional and measurement issues will be discussed subsequently, but the important thing to consider in reviewing the following statistics is that they are derived from different sources and often measure different things using different methodologies.
Although rape has occurred throughout history, the anti-rape movement in the United States did not begin until the early 1970s. In 1972, the first rape crisis centers were established in San Francisco, CA (Bay Area Women Against Rape) and Washington, DC (DC Rape Crisis Center), both of which are still in existence today. These grassroots centers were an outgrowth of the women's movement, which recognized that rape was an all too common part of women's lives and that it had a devastating impact on women's health and freedom. The explicit goals of rape crisis centers were to educate society about the problem of rape, to change society in ways that could help prevent rape, and to improve the treatment of rape victims.
In the nearly three decades since its birth, the anti-rape movement has accomplished many of its goals. Major accomplishments include widespread reform of rape statutes and other related legislation, improvements in the criminal and juvenile justice system's treatment of rape victims, greater understanding of the scope and impact of rape, improved medical and mental health services for rape victims, and better funding for rape crisis centers and others who provide services and advocacy for rape victims. Despite this progress, much remains to be done. Most rapes still go unreported (Kilpatrick, Edmunds, and Seymour 1992; Crowell and Burgess 1996; Ringel 1997), resulting in cases that can never be detected, investigated, or prosecuted. Although vast improvements in forensic, law enforcement, and prosecution protocols have been made, further improvements are needed. Too few victims who sustain rape-related mental or physical health problems obtain effective treatment. The fact that well over a million people of all ages are raped each year in the U.S. suggests that efforts to prevent rape have not been entirely successful.
This chapter will address the following questions: (1) How are rape and other forms of sexual assault defined? (2) What are the scope and mental health impact of rape? (3) What are victims' key concerns? and (4) How can we best address these concerns to improve victims' cooperation? One major focus of the chapter is to identify how the answers to these questions can be used to improve the treatment of rape victims by the criminal and juvenile justice systems as well as by victim assistance and allied professionals. A second focus is to identify ways that this information could be used to improve the investigation and prosecution of rape cases.
EVOLUTION OF THE DEFINITION OF SEXUAL ASSAULT AND RAPE
Several authors (Estrich 1987; Koss 1993) have observed that many people still believe that rape occurs only when a total stranger attacks an adult woman using overwhelming force. Using this definition, boys or men cannot be raped; girls and adolescents cannot be raped; no one can be raped by someone they know well; and forced oral or anal sex does not constitute rape. Thus attempts to discuss the topic are often frustrating because many people define rape differently.
Before the 1960s, the legal definition of rape was generally a common law definition used throughout the United States that defined rape as "carnal knowledge of a women not one's wife by force or against her will." In 1962, the United States Model Penal Code (MPC) was established, thus updating the definition of rape. The MPC defined rape as: "A man who has sexual intercourse with a female not his wife is guilty of rape if . . . he compels her to submit by force or threat of force or threat of imminent death, serious bodily injury, extreme pain, or kidnapping" (Epstein and Langenbahn 1994, 7). In addition to limiting the definition of rape to a crime against a woman, this code was also very narrow for the following reasons:
In the 1970s and 1980s, extensive rape reform laws were enacted throughout the states, and the legal definition of rape changed dramatically. Michigan's Criminal Sexual Conduct Statute, enacted in 1975, became the national model for an expanded definition of rape. Today, Illinois' Criminal Sexual Assault Statute is considered the national model (Epstein and Langenbahn 1994, 8). Both statutes have the following characteristics that broadly define rape:
THE FEDERAL DEFINITION OF RAPE
In spite of these legislative changes, much of the current debate about what constitutes sexual assault and rape stems from how rape should be defined (Crowell and Burgess 1996).
For purposes of this chapter, rape and other forms of sexual assault are defined using the Federal Criminal Code (Title 18, Chapter 109A, Sections 2241-2243) as a guide. Although criminal statutes differ somewhat across states in their definitions, the Federal Code is national in scope. For example, in addition to incorporating the reform provisions discussed above--gender neutrality and incorporation of a broad definition of acts of sexual abuse--the Federal Criminal Code definition includes the following points:
The 1986 federal statute defines two types of sexual assault:
Aggravated sexual abuse.
Aggravated sexual abuse by force or threat of force. When a person "knowingly causes another person to engage in a sexual act" . . . "or attempts to do so by using force against that person, or by threatening or placing that person in fear that the person will be subjected to death, serious bodily injury, or kidnapping."
Aggravated sexual abuse by other means. When a person "knowingly renders another person unconscious and thereby engages in a sexual act with that other person; or administers to another person by force or threat of force, or without the knowledge or permission of that person, a drug, intoxicant, or other similar substance and thereby:
Aggravated sexual abuse with a child: When a person "knowingly engages in a sexual act with another person who has not attained the age of twelve years, or attempts to do so."
Clearly the definition for aggravated sexual abuse by force or threat of force is analogous to what is usually called forcible rape. Aggravated sexual abuse of children is a serious form of what is generally called statutory rape. However, aggravated sexual abuse by other means is a type of nonforcible rape whose perpetrator "shall be fined . . . imprisoned for any term of years or life, or both."
Sexual abuse. The Federal Criminal Code definition of sexual abuse includes two types of acts:
Abusive sexual contact is defined as when no sexual penetration actually occurred but when "the intentional touching . . . of the genitalia, anus, groin, breast, inner thigh, or buttocks of any person with an intent to abuse, humiliate, harass, degrade, or arouse or gratify the sexual desire of any person" occurs.
Sexual abuse of a minor or ward is defined as knowingly engaging in a sexual act with a person between the ages of twelve and fifteen years. (For additional information on sexual crimes against children, see Chapter 11, Child Victimization.)
IMPLICATIONS OF DEFINITIONS
While great reforms have been made, these criminal code-based definitions of violent crimes addressing sexual assault, abuse, and rape imply the need to know the following information:
As a part of the Violence Against Women Act of 1994, the U.S. Congress directed the National Research Council to develop a research agenda on violence against women. The National Academy of Sciences convened a panel of experts to implement this directive; an important aspect of the panel's charge was to evaluate the nature and scope of violence against women, including sexual violence. Chapter 2 of the panel's report (Crowell and Burgess 1996) provides an overview of statistics regarding rape and sexual assault taken from official governmental and other data sources. This overview also describes numerous reasons why estimates of how many women are raped frequently differ.
Without getting too technical, estimates of the number of rapes and/or the number of women who have been raped differ because the sources that produce these estimates use different samples, different definitions of rape, different time frames of measurement, different ways of measuring whether a rape has happened, and different units of analysis in reporting statistics. Prior to briefly reviewing some of the major data sources, it is useful to consider a few key distinctions.
First, there is a difference between rape cases and rape victims because women can be raped more than once. Second, there is a difference between the incidence of rape and the prevalence of rape. Incidence generally refers to the number of cases that occur in a given period of time (usually a year), and incidence statistics are often reported as rates (i.e., the number of rape cases occurring per 100,000 women in the population). In contrast, prevalence generally refers to the percentage of women who have been raped in a specified period of time (i.e., within the past year or throughout their lifetime). Third, there is clearly a difference between estimates based on reported versus nonreported rape cases. Fourth, estimates of rape are derived from two basic types of sources: official governmental sources and studies conducted by private researchers, which are often supported by grants from federal agencies.
With respect to official governmental sources, the Federal Bureau of Investigation Uniform Crime Reports (UCR) provides data on an annual basis about the number of rapes and attempted rapes that were reported to law enforcement agencies in the United States. Clearly, the UCR records only those rapes that were reported to law enforcement agencies and that the agencies in turn reported to the FBI. As noted by Crowell and Burgess (1996), another limitation of the UCR is that it still uses the narrow common law definition of rape (i.e., "carnal knowledge [penile-vaginal penetration only] of a female forcibly and against her will), meaning that other types of rapes as defined by federal law are not reported.
The Bureau of Justice Statistics conducts the National Crime Victimization Survey (NCVS) each year to measure unreported as well as reported crimes, including the crimes of rape and other sexual assaults. The NCVS interviews all residents twelve years or older in approximately 50,000 randomly selected households each six months about crimes that occurred since the last interview. In addition to data about the number of rape cases that occur each year and rape rates (i.e., number of cases per 10,000 women), the NCVS provides information about the percentage of rape cases that are reported to police as well as about case characteristics. Because the NCVS is primarily designed to measure the number of rapes per year among those ages twelve and older, it cannot measure rapes that occurred prior to the six-month reference period or to children younger than age twelve. The NCVS as well as most other studies cannot measure rapes experienced by women who are homeless.
There are three major nongovernmental studies that provide additional data about the scope, nature, and impact of rape.
Providing effective services to rape victims, assisting in effective investigation, and facilitating effective prosecution of rape cases cannot occur without accurate information about who rape victims are, and what rape cases are really like. The best way to obtain such information is from the national victimization surveys that have just been described (i.e., the National Crime Victimization Survey, the National Violence Against Women Survey, and the National Survey of Adolescents). These surveys are ideal for this purpose because they include information about unreported, as well as reported, rape cases. Since only a small percentage of rape cases are ever reported to law enforcement, it is critically important that more is learned about the unreported cases and the victims who do not report them.
Prior to describing the scope and case characteristics data, it is important to consider the following general points:
As was previously described in the Statistical Overview section, the National Violence Against Women (NVAW) survey produced an estimate that 14.8% of adult women in the U.S. had been raped sometime during their lives and that another 2.8% had been victims of an attempted rape (Tjaden and Thoennes 1998). For adult men, comparable lifetime prevalence estimates for rape and attempted rape were 2.1% and 0.9% respectively. The National Women's Study (NWS) found that 12.7% of adult women had been victims of completed rape and 14.3% had been victims of other types of sexual assault. The National Survey of Adolescents (NSA) estimated that 13.0% of female adolescents and 3.4% of male adolescents had been victims of a sexual assault at some point during their short lives (Kilpatrick and Saunders 1997). All of these studies confirm that the lifetime prevalence of rape is such that millions of adolescents and adults in the U.S. have been raped. Women are at greater risk than men for such assaults.
Data from the NWS and NSA also indicate that revictimization is an important problem for many women and adolescents. Thirty-nine percent of rape victims in the NWS were raped more than once, and 41.7 percent of the adolescent sexual assault victims in the NSA said that they were sexually assaulted more than once.
Due to the many myths, misconceptions, and social attitudes about rape and sexual assault, the National Center for Victims of Crime, in partnership with the National Crime Victims Research and Treatment Center at the Medical University of South Carolina, published Rape in America: A Report to the Nation in 1992 (Kirkpatrick, Edmunds, and Seymour). The report was based on The National Women's Study--funded by the National Institute of Drug Abuse--a three-year longitudinal study of a national probability sample of 4,008 adult women, (age eighteen or older), 2,008 of whom represented a cross-section of all adult women and 2,000 of whom were a sample of younger women between the ages of eighteen and thirty-four.
Providing the first national empirical data about forcible rape of women in America, the study found:
Prior to this study, national information about rape was limited to data on reported rapes from the FBI Uniform Crime Reports or data from the Bureau of Justice Statistics National Crime Survey (NCS) on reported and nonreported rapes occurring in the past year. The number of rapes per year in Rape in America were approximately five times higher than either the Uniform Crime Reports or the NCS. Recently, the NCS has been redesigned due to concerns that it failed to detect a substantial proportion of rape cases.
AGE OF RAPE VICTIMS
The National Women's Study (NWS) found that "rape in America is a tragedy of youth," with the majority of rape cases occurring during childhood and adolescence:
The National Violence Against Women Survey (NVAW) found that "rape is primarily a crime against youth" (Tjaden and Thoennes 1998, 6):
Note: The NWS data represent a breakdown of victims' ages at the time of all rape cases whereas the NVAW data are a breakdown of age at the time of the first rape only.
The National Study of Adolescents (NSA) also provided information about 462 cases at the time the sexual assault was experienced by twelve- to seventeen-year-old adolescents (Kilpatrick November 1996):
Note: In the remaining 8.7% of cases, victims were not sure or refused to provide age data.
RELATIONSHIP OF THE VICTIM TO THE OFFENDER
The National Women's Study (NWS) dispelled the common myth that most women are raped by strangers:
In addition to the data just presented, the NWS also gathered information about new cases of rape that happened to adult women during the two year follow-up period. Thus, these data on the forty-one such cases provide excellent information about the breakdown for new rapes that are experienced by adult women (Kilpatrick et al. 1998).
The National Violence Against Women (NVAW) survey used different categories for victim-perpetrator relationships but reported similar findings with respect to the types of perpetrators that are most prevalent in rape cases occurring after the age of eighteen.
In summary, only a small percentage of cases involved perpetrators who were strangers; most were intimate partners.
The National Survey of Adolescents (NSA) provides a different perspective because it provides data on cases during childhood and adolescence (Kilpatrick 1996).
DEGREE OF PHYSICAL INJURY
Another common misconception about rape is that most victims sustain serious physical injuries. The statistics show the following:
Not surprisingly, the percentage of new rape cases resulting in physical injuries (N=41) experienced by adult women in the NWS was somewhat higher than cases that included childhood and adolescent rapes (Kilpatrick et al. 1998).
The NVAW survey data provide a detailed breakdown of physical injuries sustained and medical treatment received in the recent cases of rapes women experienced since the age of 18.
In the NSA, 85.5% of child and adolescent cases resulted in no physical injuries. Only 1.3% of victims reported serious injuries, and 11% reported minor injuries (Kilpatrick 1996).
There are three major implications of the aforementioned findings. First, information from all of these sources provides compelling evidence that most rapes are not committed by strangers, but by individuals well-known to their victims. This finding has profound implications for how rape cases should be investigated and prosecuted. If most victims know the identity of their perpetrators, then the key investigative issue is not finding out "who did it" by collecting evidence that permits the investigator to identify the perpetrator. Instead, most cases are likely to require evidence that permits refutation of claims by the alleged perpetrator that the sexual activity was consensual and did not constitute sexual battery. Known perpetrators are unlikely to use "misidentification" defenses because forensic examinations can conclusively link the perpetrator to the assault.
Second, Susan Estrich (1987) notes that successful prosecution of rape cases often requires victims to produce evidence of physical injuries to prove that they did not consent.
The fact that the vast majority of rape victims do not sustain major physical injuries also has clear implications for investigation and prosecution of rape cases. The first implication is that most victims will not exhibit overt physical injuries that most people think are characteristic of violent sexual attacks. Therefore, many people are likely to conclude that the victim consented unless physical injuries are present. The second implication is that forensic examinations must focus on detecting evidence of physical injuries that are not consistent with consensual sexual activity. A third implication is that law enforcement, prosecutors, judges, jurors and paroling authorities need to be informed about these physical injury data.
Third, all of these data indicate that most rapes other than sexual assaults involve relatively young victims--not adult women as most people believe. This suggests that separate investigative protocols should be established for adult and child victims.
Implications for Sexual Assault Forensic Medical Examinations
In sexual assault cases, the victim's body is the primary "crime scene," and the forensic medical examination is an extremely important part of evidence collection. Based on the victim's report of what types of sexual acts were involved, the forensic exam collects evidence from the victim's body that can be used to establish that sexual activity occurred, identify who committed the sexual act, and establish whether the sexual act produced physical injuries consistent with forced sex.
As was previously noted, the typical rape involves a perpetrator who is known by the victim and whose attack does not produce major physical injuries. In these cases, the key issue in the forensic exam is not establishing the alleged perpetrator's identity because that is already known. The exam needs to collect evidence documenting that a sex act occurred to counter the possible defense that a suspect never had sex with the victim. The exam also needs to collect DNA or other evidence that can be used to prove that the sexual act occurred and that the defendant was responsible for it. The only remaining defense a suspect can use if the "nothing happened" and "misidentity" defenses are refuted by forensic evidence is a "consent" defense. Thus, the forensic examination must collect evidence that speaks to the issue of whether the sexual activity was consensual or not. Evidence that physical injuries occurred to the victim's vulva, vagina, or anus that are inconsistent with consensual activity would be a powerful tool to refute a consent defense. Therefore, it is extremely important that the forensic medical exam be conducted in such a way that such physical injuries can be detected because such forensic evidence is one of the few ways that a consent defense can be refuted.
Most sexual assault protocols for adult victims do not include state-of-the-art procedures for detecting physical injuries to the victim's vulva, vagina, or anus. Fortunately, new technology exists that has the potential to dramatically increase detection of physical injuries. The colposcope is a standard tool used by gynecologists for the evaluation of microscopic cervical, vaginal, or vulvar disease. Using a colposcope, the vulva, vagina, cervix, and/or anus can be examined at magnifications over thirty times the actual size. This permits detection of small or microscopic tears, bruises, or abrasions that are not visible to the naked eye. Colposcopic examination provides a much more objective and sensitive way of seeing and documenting genital, anal, and other injuries in sexual assault victims.
The ideal acute sexual assault examination protocol has two components. The first part is similar to the existing sexual assault exam protocol, which is conducted within seventy-two hours after the assault. However, the protocol is changed to include a colposcopic exam. The second part of the forensic exam protocol also includes a colposcopic exam and is conducted four to six weeks after the assault. The purpose of this second part of the forensic exam is to collect evidence of the victim's recovery from the physical injuries detected during the first exam. This evidence of recovery can only be documented if the two exams are conducted, and provides a strong basis for an expert examiner to testify about recovery from injuries that are not consistent with consensual sex.
A final advantage of the colposcope is that technology exists to take photographs or make videotapes of what is visualized. Thus, it is possible to have a documentation in the form of color photographs and/or videotapes of the physical injuries detected. This visual documentation of injuries sustained by sexual assault victims has been described as having a powerful impact on jurors and on defendants, many of whom have entered guilty pleas when confronted with this evidence that "consensual sex" produced physical injuries consistent with the victim's statement.
Sexual Assault Nurse Examiner (SANE) programs (discussed more fully herein at page 25) have developed in recent years in many jurisdictions throughout the country in response to the need for victim-sensitive treatment in gathering crucial medical/evidentiary information in forensic medical examinations of rape victims.
NEED FOR MULTIDISCIPLINARY MEDICAL CARE PROGRAMS ADDRESSING THE NEEDS OF RECENT RAPE VICTIMS
Initial medical examination immediately post-rape is recommended for sexually transmitted diseases and for provision of prophylactic treatment available to treat specific sexually transmitted diseases. Such examinations also include counseling and provision of emergency contraception in relevant cases (CDC 1998). It is also recommended that rape victims be seen for follow-up medical examination to assess new infections that may be related to assault and counsel victims about STDs and hepatitis B as well as to treat existing diseases. CDC guidelines recommend offering follow-up care at two weeks post-assault for repeat STD testing and additional blood testing for syphilis and HIV that can be repeated at six, twelve and twenty-four weeks post-assault. While these guidelines for initial and medical care follow-up have been recommended (Young et al. 1992), the reality is that in most states provision of initial post-rape medical care is financially supported by the state or by third party payment from sources like Crime Victims Compensation in cases in which a formal report of rape has been made to police within a set number of hours post-assault (Crime Victims Compensation Quarterly, 1995).
Since the vast majority of rape victims do not report the assault to police (Kilpatrick, Edmunds, and Seymour 1992), this means that they would be ineligible for subsidized medical treatment of acute injuries. For those rape victims who do report a rape to police, the emphasis has been on provision of immediate medical follow-up. For most states there are no specific provisions for medical follow-up of women in the weeks following the assault.
Currently there are some model programs that include follow-up medical care for victims (Young et al. 1992; Holmes, Resnick, and Frampton 1998). Holmes provides a description of the Sexual Assault Follow-up Evaluation (SAFE) clinic program developed at the Medical University of South Carolina. This program provides medical care to women regardless of whether or not they have reported an assault to police. In addition, follow-up care is provided at six weeks and six months post-assault. Such care includes re-assessment and treatment of sexually transmitted diseases and long term follow-up blood testing for HIV and hepatitis B. In a sample of over 300 women and adolescents Holmes et al. noted that the follow-up clinic provided an opportunity to also address women's mental health and social service needs as well as to counsel them about medical and other concerns post-rape. Such education about health risk behaviors and normalization of physical arousal symptoms might help to prevent later health problems and inappropriate use of medical care (i.e., emergency room visits). The SAFE clinic includes a multidisciplinary team of OB-GYN professionals, staff from the National Crime Victims Research and Treatment Center, and staff from the local rape crisis center, People Against Rape (PAR). The team provides for easy referral for mental health treatment and for PAR follow-up of additional referral or counseling needs.
Another multidisciplinary aspect of the program at the Medical University of South Carolina is the development and evaluation of a brief video-based intervention to help prepare women for the acute postrape medical exam and to provide education and instruction designed to reduce postrape symptoms of PTSD, substance abuse, panic, and depression. Psychologist Dr. Heidi Resnick and colleagues at the National Crime Victims Research and Treatment Center have implemented this program in coordination with the local rape crisis center (People Against Rape), Dr. Melisa Holmes of the MUSC Obstetrics and Gynecology Department, medical personnel at the MUSC Trauma Center, and the MUSC General Clinical Research Center (GCRC).
Major ideas that led to this project included the fact that all women who report a rape are seen for medical care within hours of their assault. Thus, this medical care setting provides an opportunity to provide early intervention that could prevent some of the negative mental health consequences of rape. In addition, for some women it may be the only opportunity to provide such an intervention since many women may not seek out needed services or may do so only many years later. A second factor that led to the project development was that rather than reducing anxiety the medical exam contains many cues that might actually increase rape victims' distress. Previous data indicated that women's initial post-rape distress is a strong predictor of longer term distress. Therefore, an intervention that could reduce distress at the time of the medical exam might help women in their longer term recovery. Evidence for the usefulness of brief education plus instructional approaches in an emergency room setting also influenced the content of the intervention as well as the need to address a range of mental health problems that rape victims are at increased risk of developing in the aftermath of assault.
To address these concerns, an acute time-frame hospital-based video intervention was developed to: (1) minimize anxiety during forensic rape exams, and (2) prevent post-rape posttraumatic stress disorder (PTSD), depression, and substance abuse. This video-based intervention has been implemented at a sexual assault outpatient exam room located at a central hospital serving rape victims.
Victims are first seen in the emergency room of the hospital to determine whether they require additional treatment of physical injuries. All study participants complete informed consent at the time of the emergency room exam which takes place within 72 hours post-rape. Participation in the study is completely voluntary and does not affect receipt of medical care in any way. Participating women are randomly assigned either to a video or standard treatment as usual condition at the time of the exam. Pre- and post-medical exam measures of anxiety are administered at the time of the emergency room exam. In addition, women are reinterviewed at six weeks and six months post-rape to determine mental health status at those time points. Preliminary data (Resnick et al. 1999) indicate that women participating in the video intervention condition were significantly less distressed following the medical examination than women in the standard condition group, after controlling for pre-exam levels of distress/anxiety. Data also indicate that distress following the medical exam is significantly correlated with all measures of mental health functioning at six weeks post-rape. Preliminary data also support the efficacy of providing an intervention at the acute post-rape medical exam that may reduce anxiety in the medical setting and that may be related to reduction of some long-term mental health problems among rape victims.
The fact that most rape cases are never reported to police means that most rapists are never detected, arrested, or successfully prosecuted. Rape in America (Kilpatrick, Edmunds, and Seymour 1992) included information on rape victims' concerns that are relevant to why most victims are reluctant to report. Major concerns identified by victims were being blamed by others, their families finding out about the rape, other people finding out, and their names being made public by the news media. A rape victim with these concerns would likely have substantial reservations about reporting the rape to police. However, it is reasonable to assume that addressing these concerns might encourage victims to report.
The report also described the results of a national survey of 522 organizations that provided crisis counseling services to victims of rape, at least some of whom did not report to police. Representatives from these agencies provided a list of actions and activities that would be effective in increasing women's willingness to report rapes to police:
Sexual assaults of men are "silent crimes" that are even less likely to be reported than rapes of women. Heterosexual men often fear that if they report being raped by a man, it may be thought that they are gay, and they may feel emasculated by the assault (TCLEOSE 2000). Men are likely to report a sexual assault only if they sustain severe bodily harm suggesting that they attempted to thwart the attack (Pino and Meier 1990).
Efforts to increase the reporting of rape cases must be as big a priority as the effective processing of cases that are reported. This effort will require a great deal of public education about rape in general and about acquaintance rape in particular. It will also require making sure that rape victims know that they can get the supportive services they need and that their privacy will be protected to every extent that is legally possible. It also requires a public education campaign that stresses the importance of reporting all rape cases.
The National Women's Study produced dramatic confirmation of the mental health impact of rape by determining comparative rates of several mental health problems among rape victims and women who had never been victims of rape. The study ascertained whether rape victims were more likely to experience these devastating mental health problems than women who had never been crime victims (Kilpatrick, Edmunds, and Seymour 1992).
POSTTRAUMATIC STRESS DISORDER
The first mental health problem examined was posttraumatic stress disorder (PTSD), an extremely debilitating mental health disorder occurring after a highly disturbing traumatic event, such as military combat or violent crime.
OTHER MENTAL HEALTH PROBLEMS
Major depression is a mental health problem affecting many women, not just rape victims. The National Women's Study (NWS) found that 30 percent of rape victims had experienced at least one major depressive episode in their lifetimes and 11 percent of all rape victims were experiencing a major depressive episode at the time of assessment. In contrast, only 10 percent of women never victimized by violent crime had ever had a major depressive episode and only 6 percent had a major depressive episode when assessed (Ibid.).
Thus, rape victims were three times more likely than nonvictims of crime to have ever had a major depressive episode (30% vs. 10%) and were 3.5 times more likely to be currently experiencing a major depressive episode (21% vs. 6%).
Some mental heath problems are life-threatening in nature. When asked if they ever thought seriously about committing suicide, rape victims' answers reflected the following findings: 33 percent of the rape victims and 8 percent of the nonvictims of crime stated that they had seriously considered suicide.
Thus, rape victims were 4.1 times more likely than noncrime victims to have contemplated suicide. Rape victims were also 13 times more likely than noncrime victims to have actually made a suicide attempt (13% vs. 1%). The fact that 13 percent of all rape victims had actually attempted suicide confirms the devastating and potentially life-threatening mental health impact of rape.
Finally, there was substantial evidence that rape victims had higher rates of drug and alcohol consumption and a greater likelihood of having drug and alcohol-related problems than nonvictims. Compared to women who had never been crime victims, rape victims with rape-related PTSD (RR-PTSD) showed the following results:
The NWS findings on increased suicide risk provide compelling evidence about the extent to which rape poses a danger to American women's mental health--and even their continued survival (Ibid.). Rape is a problem for America's mental health and public health systems as well as for the criminal and juvenile justice systems.
Rape victims should not be further traumatized by being given an unnecessary mental health label. However, it is imperative that victim advocates be aware of the symptoms of depression and be able to differentiate these symptoms from "normal" PTSD. It is the role of the victim advocate to make referrals for treatment when needed. Advocates should become concerned when victims report depressed moods most of the day, no interest in activities that used to give them pleasure, significant weight loss or gain that was not intended, insomnia or oversleeping nearly every day, fatigue, excessive feelings of worthlessness or guilt, lack of concentration, or recurrent thoughts of death, as they are symptoms of severe depression (DSM-IV). When victims express clear suicidal ideation, advocates should take steps to ensure victim safety such as recommending a mental health consultation to determine referral options, including the possible need for hospitalization. Advocates should be aware of which community mental health professionals are competent to deal with victimization issues and make referrals for longer-term interventions appropriately.
In order to effectively respond to rape victims, service providers and criminal and juvenile justice officials need to understand the major concerns of rape victims. Without accurate information about victims' concerns after rape, it is difficult to create and implement policies and programs to meet their most critical needs.
The National Women's Study (NWS) identified several critical concerns of rape victims (Ibid.). In order to determine if rape victims' concerns have changed over time, the study divided these concerns into those of all rape victims, and those of victims that had been raped within the past five years (1987-91). The following results highlight which concerns do and do not change:
The stigma still associated with rape is reflected in the high percentage of rape victims being concerned about people, such as family members and friends, finding out. Thus, from a victim service provider perspective, maintaining confidentiality and respecting the privacy needs of rape victims are important goals of service and assistance.
Rape victims have many needs, and improving the investigation and prosecution of rape cases cannot be accomplished by any single agency. In 1992, the Office for Victims of Crime provided support for a national-scope project to evaluate the system of multidisciplinary services that have been developed at the community level. Looking Back, Moving Forward: A Guidebook for Communities Responding to Sexual Assault (NCVC 1993) developed a "victim-centered" model for responding to rape victims. The report identified a number of agencies that should play a key role after a sexual assault occurs:
The combined functions that each of these agencies provides to rape victims would create a model response to rape victims that accomplishes the following:
Victims who report rapes to law enforcement will likely have contact with medical, victim service, and law enforcement professionals. If an arrest is made, prosecutors become involved. If there is a conviction, then institutional or community corrections becomes involved. The NCVC report strongly advocates establishment of community sexual assault interagency councils with representation of all these professionals and agencies. The report also argues that these interagency councils should negotiate a multiagency/multidisciplinary protocol specifying how sexual assault cases should be handled.
Clearly, no agency can do the job alone. Although establishment of a community sexual assault interagency council is difficult and may be impractical in some communities, the importance of cooperation and teamwork cannot be overemphasized. Law enforcement is critically important, but law enforcement cannot succeed without the assistance and support of other agencies.
The United States has numerous police and prosecutorial jurisdictions. No one protocol can be developed that fits the needs of all these jurisdictions. It might be feasible to develop special sex crimes investigation units in large law enforcement agencies or in large metropolitan areas, but in small jurisdictions, this may not be feasible. Likewise, large metropolitan areas have many law enforcement agencies as well as major medical centers, rape crisis centers, and other victim service agencies. Small law enforcement agencies are often located in towns or rural jurisdictions that lack ready access to medical centers and to victim services. Large agencies often have victim advocates, but small agencies rarely do.
Thus, the major issues in developing a protocol in large metropolitan areas or in large law enforcement agencies are likely to be quite different than those in rural areas and in small agencies. Although victims' needs are the same and the elements of effective investigation and prosecution are the same irrespective of the jurisdiction, the protocol itself should reflect the circumstances within different jurisdictions.
The system for services and support for victims of rape and sexual assault should include emergency or crisis services, support throughout the criminal or juvenile justice system, and medical, mental health, financial, legal, or other types of support as needed.
In many communities across America, a system of responses takes place for rape victims who choose to report the crime to law enforcement. Rather than looking at the response to rape victims in the traditional way (i.e., what each agency and/or individual should do for a rape victim), the "victim-centered" approach looks at the needs of the victim at each stage and recommends various agencies that could provide the needed service or support.
ROLE OF THE FIRST RESPONDER TO RAPE VICTIMS
The first responder can be a hotline operator, a rape crisis center advocate, a police officer--all of whom must be trained in victim sensitivity and crisis response techniques, with a special focus on telephone communication skills. The basic victim assistance needs at this initial stage include the following:
The First Response to Victims of Crime handbook developed by the Office for Victims of Crime (January 2000) suggests that first responders be prepared for any type of emotional response by victims. First responders are cautioned to avoid interpreting a victim's calmness or composure as evidence that a sexual assault did not occur. The desire to forget details of a horrific crime is normal and should not be interpreted as resistance to giving a statement. First responders are instructed to be supportive without appearing overprotective or patronizing.
Medical care following rape. Emergency medical care, especially the collection of evidence through a forensic examination, is critical for both the victim and the protection of evidence for prosecution. Medical care providers must fulfill two sometimes conflicting roles: they must meet the rape victim's medical and emotional needs, and they must collect evidence to be used in a legal proceeding. Comprehensive medical protocol in the aftermath of rape includes the following components:
Many hospitals across the country have established protocols on treating sexual assault and rape victims. However, The National Women's Study asked victims if they had a medical examination following the assault. The study found the following:
In addition, many recommended practices and protocols did not occur in all rape examinations:
Despite some improvements in the dissemination of information about testing for pregnancy, HIV/AIDS, and sexually transmitted diseases to rape victims, the following conditions remain:
Sexual Assault Nurse Examiner (SANE) programs offer an innovative approach to handling the medical/evidentiary aspects of sexual assault and child abuse cases through the use of technology, nurse examiners, and specialized settings. Instead of having doctors handle these cases in busy emergency rooms, SANE programs create a special environment for victims and use trained nurse examiners to conduct the evidentiary medical examination and present the forensic evidence at trial. According to the Tulsa Police Department, the nationally recognized Tulsa SANE program has substantially improved the quality of forensic evidence in sexual assault cases.
The Sexual Assault Resource Service (SARS) of Minneapolis developed a guidebook entitled SANE Development and Operations Guide to be used by jurisdictions interested in developing SANE programs (Ledray 1999). This guidebook (available online for downloading at <www.sane-sart.com>) stresses the need for a community approach when developing the program. Some programs such as the Memphis Sexual Assault Resource Center have a free-standing location where only sexual assault victims are seen. This center has nurses and advocates on call 24 hours a day and a counseling program on site. Whether co-located in a single facility or, more commonly, located throughout the community, the collaboration of law enforcement, medical professionals, justice system and rape crisis programs is essential to meet the needs of rape victims.
Rohypnol and other drugs used in rape. Rohypnol (roofies), Gamma Hydroxybutrate (GHB) and Ketamin have been termed "acquaintance rape drugs." These drugs have been used to incapacitate potential sexual assault victims (Hindermarch and Brinkman 1999). Rohypnol, the best known of these drugs, is not approved for medical use in the United States. It is a benzodiazepine that was developed for use as a treatment for insomnia and as a pre-medication for anesthesia. Rohypnol has physiological effects similar to Valium although Rohypnol is approximately ten times more potent (DEA 1999).
Rohypnol has a hypnotic effect and sedation begins twenty to thirty minutes after ingestion. The effects peak at one to two hours and may persist for six to eight hours. The drug causes anterograde amnesia which means that the user remembers little about the time during which he or she is sedated. Another widely reported effect of Rohypnol is disinhibition (Smith, Wesson, and Calhoun n.d.). The combination of Rohypnol with alcohol increases its sedative and amnesic effects, making it the "drug of choice" for some rapists who use this drug on unsuspecting victims.
LAW ENFORCEMENT
Innovations in law enforcement-based victim assistance. The past two decades have been marked by two significant advances in law enforcement's response to rape cases:
1. The creation of specialized sex crime units to enhance the agency's efficiency and send a message to the community that the department is deeply committed to solving sex crimes.
2. The development of in-house victim/witness assistance units that review all reports, sort out the felonies, and contact each victim of a felony crime, usually by phone. Law enforcement-based victim assistance professionals make referrals to rape crisis centers, contact victims who have delayed reporting, and provide community education in rape awareness and prevention.
Reporting rapes to law enforcement. New methods for reporting rape and for guarding victims' privacy have been developed over the last two decades in an attempt to increase victims' willingness to report crimes and to cooperate throughout the investigation.
In deciding whether to report the assault, a victim has the following options:
Interviewing rape victims. Victims are now interviewed at different stages and with new techniques. In The Criminal Justice and Community Response to Rape, a checklist for law enforcement officers who are conducting initial interviews with rape victims, developed by the King County (Washington) Prosecuting Attorney's Office, is offered (Ibid.):
In addition, extensive experience of victim advocacy from the law enforcement perspective points out the need to:
For example, a rape victim who was sexually assaulted in her bedroom wanted to know when she could get her bedspread back from the police. Both the law enforcement agency and victim advocate in the case wrongfully made the assumption that she would not be interested in ever seeing the quilt again. However, since the bedspread matched the decor of her room that she had taken great pride in decorating, the victim was eager to have this evidence returned.
The information obtained by law enforcement in its initial and ongoing investigation is critical to the district attorney's decision whether or not to prosecute. As such, the collection and monitoring of law enforcement information should be closely coordinated with prosecutors' offices.
PROSECUTION
Many district attorneys utilize a vertical prosecution approach to rape cases, with prosecutors who are specially trained in sexual assault case management. The same prosecutor handles a case from the investigation through the decision to prosecute to the verdict and sentencing, when applicable. In many jurisdictions, specialized units--which include investigators, prosecutors, and victim advocates--serve to further streamline the prosecutorial process, and ease the trauma of the victim in rape cases.
Roles and responsibilities of prosecutors relevant to rape victims. Upon initial contact with a rape victim, prosecutors should explain their specific roles and responsibilities in the criminal or juvenile justice continuum. These include the following:
VICTIM SERVICES
One of the goals of providing assistance to rape victims is helping them to gain a sense of empowerment. It is important that advocates and mental health professionals encourage victims to regain a sense of control in their post-rape lives. Since victims frequently blame themselves for the assault, it is important for victim advocates to remind victims that, even if there were choices within their control that could have contributed to greater personal safety, they are in no way responsible for the fact that they were sexually assaulted.
On the other hand, victims may have limited control of the aftermath of a reported rape. Advocates can assist victims by explaining the justice system processes. Frequently an arrest is not made or is made more slowly than a victim would prefer. Sometimes cases are not prosecuted due to insufficient evidence. Advocates can help victims overcome these hurdles by giving them accurate information and coordinating meetings with law enforcement, prosecutors, and correction officials. Knowing they have been heard by the "system" is essential for victims, as it often allows them the comfort of knowing that they did everything possible to promote their desired outcome.
Sexual assault advocates may be paid professionals or trained volunteers who are committed to working with victims. They share the common goal of assisting victims as they navigate through the horrific aftermath of an assault. Sexual assault advocates:
The specific duties of victim advocates differ depending on the setting. Advocates at a rape crisis center may--
Advocates who work within a law enforcement agency may--
Advocates who work for the prosecutor may--
Advocates who assist victims, post-conviction/adjudication, may--
The needs and desires of the victim should always be the advocate's primary concern. Advocates must be aware of conf