Best Practice & Research Clinical Obstetrics and Gynaecology 27 (2013) 27–37

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Best Practice & Research Clinical

Obstetrics and Gynaecology
journal homepage: www.elsevier.com/locate/bpobgyn

Psychological consequences of sexual assault

Fiona Mason, MB BS FRCPsych DFP, Consultant Forensic Psychiatrist and
Chief Medical Officer a, *, Zoe Lodrick, MSc. BA Hons (1st), Psychotherapist b
a
St Andrew’s Healthcare, Billing Road, Northampton NN1 5DG, UK
b
The United Kingdom Council for Psychotherapy, London, UK

Keywords:
Sexual violence is an important issue worldwide and can have
rape long-lasting and devastating consequences. In this chapter, we
sexual assault outline the psychological reactions to serious sexual assault and
psychological reactions rape, including development of post-traumatic stress disorder.
post-traumatic stress disorder Myths and stereotypes surrounding this subject, and their poten-
autonomic nervous system tial effect on the emotional response and legal situation, are
discussed.
Ó 2012 Published by Elsevier Ltd.

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.

* Corresponding author: Tel.: þ44 (0) 1604616000; Fax: þ44 (0) 1604232325.
E-mail address: fmason@standrew.co.uk (F. Mason).

1521-6934/$ – see front matter Ó 2012 Published by Elsevier Ltd.

http://dx.doi.org/10.1016/j.bpobgyn.2012.08.015
28 F. Mason, Z. Lodrick / Best Practice & Research Clinical Obstetrics and Gynaecology 27 (2013) 27–37

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.1,2 British Crime Survey data from 20003 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 respon-
dents 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.4–6
Sexual offences are serious crimes with far-reaching consequences. Recently, a plethora of newly
published, victim-focused guidance has been published for police,7,8 Crown Prosecution Services
Prosecutors,9 Sexual Offence Examiners and Practitioners, Sexual Assault Referral Centres,10 and other
professionals11 who come into contact with rape complainants, implementation, of which, has been
patchy.12 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.’12
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.13

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.6,14,15 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,3 such encounters are not always defined as rape; indeed, it was not until 1991 that
rape within marriage was criminalised in England and Wales.16
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,17 and most rapes do not involve overt physical assault
or threat. Often, victims do not actively resist and many are not physically injured.18 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. Desir-
ability, 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 iden-
tified 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 victimisation19–23; and yet, multiple reports of rape or sexual assault by an
 F. Mason, Z. Lodrick / Best Practice & Research Clinical Obstetrics and Gynaecology 27 (2013) 27–37 29

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.24,25 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,26 and more recently in a 2010 survey,27 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’,28 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.29 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
unendurable29; 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)30; and increased likelihood of the
individual developing PTSD.31
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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.31
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.32,33
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.28
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.32 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 rela-
tionships after acquaintance rape.34
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?35 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 both36; the rape is completed (as opposed to attempted)36; the offender is someone
known to the victim,37 and thus the element of ‘betrayal’ is significantly greater38; the victim disso-
ciates at the time of the incident, exhibits dissociative symptoms immediately afterwards, or both39,40;
the victim is unable to move as a result of their own nervous system response,28 or some external
restraint41; the victim is very young42 or very old43 at the time of the incident; the victim has previ-
ously experienced psychological trauma,44 has prior psychiatric history, or both; the victim is in an
environment of captivity at the time of the rape.45
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’
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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, tear-
fulness, 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.46
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,47 many of the more persistent
psychological symptoms observed in survivors of rape are now recognised as being compatible with
a diagnosis of PTSD.48
Research indicates that most women recover from the acute effects of the attack at between 3 and 4
months. For example, Rothbaum et al.49 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. Kil-
patrick et al.50 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 classi-
fication 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-TR48): (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,51 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 benzodiaze-
pines, 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, diffi-
culties with social adjustment and sexual functioning. Kilpatrick et al.52 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.52 found that 33% of rape victims compared with 8% non-victims had ever
32 F. Mason, Z. Lodrick / Best Practice & Research Clinical Obstetrics and Gynaecology 27 (2013) 27–37

contemplated suicide, whereas 13% of rape victims compared with only 1% of non-victims had made
a suicide attempt.
Burgess and Holmstrom47 found 78% of their sample (n ¼ 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.

Legal implications

When a victim of rape discloses their experience, it is important, and one determinant of the
victim’s future psychological well-being,53,54 that the person receiving the disclosure has an
understanding of potential psychological reactions to sexual assault and its aftermath. If the
victim has chosen to disclose to the police and thus become a complainant, they are likely to
encounter throughout the criminal justice system individuals who will make judgements based
on their own, sometimes ignorant, belief systems. Attitudes might affect questioning, evidential
acquisition, victim response, decisions about proceeding, and jurors deliberations. Beliefs held,
when myth rather than reality, may have a crucial role to play in the victim’s well-being, and
achieving justice.
Neurobiological phenomena occurring at the time of the incident, as described earlier, can affect the
survivor’s ability to give a coherent, consistent account of their experiences, and yet any perceived
‘inconsistencies’ in the victims’ account may be viewed as evidence that they are lying. Ironically, given
what we know of the significant effect trauma has on brain functioning, and ultimately on recall,
perhaps the opposite should be true (i.e. that the difficulty of a victim to give a coherent narrative of an
assault should be deemed to increase their credibility rather than decrease it). Post-trauma symptoms
themselves will also potentially affect recall and consistency. Indeed, the inability to recall an impor-
tant aspect of the event is a characteristic symptom of PTSD, as is avoidance of thoughts that are
associated with the trauma. Victims experience feelings of shame and self-blame,55 and this may lead
them to give an incomplete or inaccurate account of the circumstances surrounding the rape. Cultural
and religious considerations may also have a significant effect on the victims’ ability to disclose the full
details of their experience.
The survivor will often experience an increase in somatic complaints, such as headaches, muscle
tension, and stomach upsets, and research has demonstrated that rape survivors visit their doctors
more frequently for such complaints. It may be hard for the individual who has been assaulted to do
anything that reminds them of the circumstances of the assault, and simple tasks may become
impossible. They may be unable to go to certain areas and may avoid social contact. Home security
may be enhanced, and they may be unable to confide in those who love them most. Their ability to
access and benefit from support may, therefore, be limited. These factors may lead complainants to
seem avoidant, and that avoidance may be wrongly interpreted as indicating that their account was
false. The presentation of individuals who are so profoundly affected by the trauma that they appear
detached, numb and disconnected, may be misinterpreted, and their complaint taken less seriously
as a result.

Late reporting

The timing of reporting has historically influenced conviction rates, and it is important to under-
stand why women may not report immediately. One study has shown that, if the woman made
a complaint within 24 h of the rape occurring, and the suspect was subsequently charged, there was
a 73% chance of conviction. Women who made a complaint between 24 h and 3 months after the rape,
however, saw the conviction rate drop to 38%.56
Complainants are usually aware that, in reporting a rape, they face the risk of not being believed, of
being blamed, and of having their behaviour exposed and scrutinised. Many will feel ashamed. For
some, the shock, disbelief, and denial that frequently characterise post-trauma response will prevent
them from being able to define what has occurred in a timely enough manner to facilitate immediate
complaint. Others will need time to consider their experience and to define it, because few rapes fall
 F. Mason, Z. Lodrick / Best Practice & Research Clinical Obstetrics and Gynaecology 27 (2013) 27–37 33

into the category that we might label ‘stereotypical’ and, as such, victims may fail to recognise
immediately that their experience was that of rape (despite the fact that what occurred falls squarely
within the legal definition of such). Women may fail to report immediately for simple, practical
reasons; they may have childcare responsibilities and little social support, they may not have transport,
or they may have to remain in the home with the perpetrator.

Re-traumatisation

If a complainant, especially if they have developed PTSD, is required to confront their trau-
matic experience during the history-taking necessary for the sexual offence examination, police
interview and courtroom testimonies will thwart characteristic efforts at avoidance and
predictably results in the resurgence of intrusive ideation and increased autonomic nervous
system (ANS) arousal. The wish to avoid such distress may lead complainants to avoid court by
retracting or altering their account, or not disclosing the full extent of their experiences. On the
other hand, it may only be during times of high ANS arousal that the complainant seems able to
access the traumatic memories in detail, and therein lies the danger of significant re-
traumatisation during interview, court appearance, or both. It requires a well-trained, sensitive
and skilled doctor, interviewer, or legal counsel to facilitate the balance necessary for the victim
to be allowed the time and support needed to disclose the level of detail necessary to meet the
demands of the judicial system while ensuring the victim does not experience intolerable levels
of ANS activation.
If the victim is not sufficiently, and actively, supported to manage their ANS response, to that which
they are disclosing, there is a real danger that their higher brain functions will become overwhelmed
and the archaic structures of the brain that govern survival will become dominant (as they did at the
time of the assault). Thus, the victim will likely become ‘compliant’ and ‘passive’, answering questions
in the way they believe the interviewer wants them answered as opposed to stating what actually
occurred. Arguably, a victim in such a state cannot give their informed consent to the interview or
sexual offense examination.
It is likely that individuals with heightened ANS arousal will be able to readily access implicit
material (which is not usually accessible in a less activated state) and, for this reason, it is sometimes
considered desirable. Material accessed in such an activated state, however, is unlikely to be
explicitly recallable by the victim. This will result in a victim having disclosed to the doctor or police
interviewer details that they do not consciously remember, and will almost certainly result in
inconsistencies between the accounts they will give as their complaint proceeds through the criminal
justice system.
It is also the very process d replaying of ANS activation present at the time of the incident during
recall of the incident d that gives rise to the phenomena of revictimisation44 experienced so alarm-
ingly often by survivors of sexual violation. It hardly needs stating that, to reduce the likelihood of
a victim of sexual crime becoming a repeat victim of sexual crime, is a priority. To minimise that
likelihood, everyone who interacts with the victim after rape must be mindful not to do anything that
intends to recreate the ANS high-arousal pattern that the rape itself would have elicited. In other
words, victims must always be supported to remain very much in touch with the ‘here and now’ reality
while recalling the ‘there and then’ (but not happening now) experience.28

Inconsistencies and lies

As mentioned previously, trauma can lead to extremes of retention and forgetting. Terrifying
experiences may be remembered with extreme vividness, or may be totally inaccessible. Amnesia, for
all or part of a traumatic experience, is not uncommon. As mentioned earlier, the victim may dissociate
when faced with overwhelming threat, and will then be unable to integrate the totality of their
experience into consciousness. This, in turn, will hamper their ability to provide a detailed, temporally
accurate statement.
Victims may, of course, also consciously alter parts of their account, so as to avoid shame,
humiliation or possible consequences of their actions. Thus, the woman who has, for example
34 F. Mason, Z. Lodrick / Best Practice & Research Clinical Obstetrics and Gynaecology 27 (2013) 27–37

taken illicit substances, may fabricate elements of their account so as to avoid having to
disclose their illegal activity. Unless dealt with, such deception may create a false impression
in court, in that the victim will be seen as lying in all aspects of the account that they
gave.

The trial

Research supports the assumption that jurors are not familiar with typical reactions of rape
survivors57 and hold a number of attributional beliefs about the complainant’s responsibility. Jurors
tend to identify with a complainant (or defendant), and may have trouble understanding how that
person could have felt or acted any differently to how they themselves would have felt or acted in the
same situation and, yet, their judgement in this regard will be flawed, unless they understand the
issues described.
Ellison and Munro58 conducted a study in which volunteers observed one of nine mini-rape
trial reconstructions and were asked to deliberate as a group towards a verdict. These delibera-
tions were analysed to further understand what goes on behind the closed doors of the jury room
in rape trials and explore the effect of complainant conduct during and post-assault on credibility.
Many jurors were influenced by expectations about the instinct to fight back, the compulsion to
report immediately, and the inability to control one’s emotions. Many jurors harboured unrealistic
expectations about the association of sexual assault and physical injury. Jurors who received
educational guidance were less likely to consider the fact of a 3-day delay before reporting or
a calm demeanour as necessarily problematic. The authors concluded that concerns about the
limits of current public understanding about what constitutes a normal reaction to sexual vic-
timisation seem to be merited.

Treatment

Treatment for clinically significant psychopathology is essential, and the general practitioner
has an important role in identifying those who require formal treatment and ensuring active
follow up. Clear guidance for the management of PTSD has now been published,59 and indicates
that all PTSD suffers should be offered a course of trauma-focused psychological treatment
(cognitive–behavioural therapy or eye movement desensitisation and reprocessing). These
treatments should normally be provided on an individual outpatient basis, and should be offered
regardless of the time that has elapsed since the trauma. For PTSD suffers who have no or only
limited improvement with such treatment, healthcare professionals should consider an alterna-
tive form of trauma-focused psychological treatment, the augmentation of psychological treat-
ment with a course of pharmacological treatment, or both. The use of antidepressant medication
is particularly indicated where depressive symptoms are prominent. Given hyperarousal, short-
term use of hypnotics and anxiolytics may be of benefit in the immediate aftermath of a rape,
but should not be continued for a prolonged period. Treatment requirements may be more
complex in individuals with a history of repeat traumatisation, when referral to an appropriate
specialist centre should be considered.

Conclusion

Rape and serious sexual assaults are serious crimes with far-reaching consequences, but are under-
reported to the police owing to a variety of complex factors. Regardless of whether the perpetrator was
a stranger or known to the victim, women can experience profound psychological consequences of this
trauma. This can include developing mental illnesses such as depression and PTSD, which require
appropriate treatment. A better knowledge of the neurobiological and psychological processes
involved will allow professionals and the public to understand women’s reactions to rape. An attempt
to dispel societal myths may, in turn, lead to an increase in reporting of rapes and improved conviction
rates.
 F. Mason, Z. Lodrick / Best Practice & Research Clinical Obstetrics and Gynaecology 27 (2013) 27–37 35

Practice points

 Vulnerable women are more likely to be targeted by sex offenders and are more likely to be
subject to repeat victimisation.
 When faced with a perceived threat, the human system broadly responds in one (or more) of
five predictable ways: ‘fight, flight and freeze’ and ‘friend’ and ‘flop’.
 Memories of traumatic experiences are more likely to be stored predominantly as implicit
memory.
 Immediate emotional responses will vary between individuals after rape, and should be
viewed as a normal reaction to an abnormal event.
 Symptoms may include symptoms of anxiety, depression or PTSD, and a wide array of
psychosomatic complaints.
 Clear guidance for the management of PTSD indicates that all PTSD sufferers should be
offered a course of trauma-focused psychological treatment (cognitive–behavioural therapy
or eye-movement desensitisation and reprocessing).
 The use of antidepressant medication is particularly indicated where depressive symptoms
are prominent.

Research agenda

 Effect of myths and stereotypes on recovery.

 Effect of myths and stereotypes on the criminal justice process.
 Effectiveness of early interventions on preventing chronicity.
 Effective treatments for victims of repeat traumatisation.
 How to ensure ‘best practice’ in court.

Conflict of interest

None declared.

Acknowledgements

The authors would like to thank Dr Clare Oakley for her helpful comments on this chapter.

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