In the Public Interest by Child Abuse Survivors and their Advocates in their Pursuit of Justice, Recognition, Recovery and Redress.
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Article Category: 2007 January
Description:
Article originally prepared on : 13 January 2007
Jill Astbury
Published by the Australian Institute of Family Studies.
ISBN 0 642 39547 0, ISSN 1833-7864 (online), ISSN 1833-7856 (print)
ACSSA Coordinator: Dr Zoë Morrison
Jill Astburyis the Research Professor in the School of Psychology at VictoriaUniversity. Her research focuses on the links between human rightsviolations and a range of health outcomes. In particular, she isinterested in the impact of all forms of gender-based violence onwomen's mental and reproductive health.
Publicationsfrom the Australian Centre for the Study of Sexual Assault (ACSSA) areavailable from the Australian Institute of Family Studies (AIFS). Ifyou would like to receive future publications as they are releasedplease register your details for the ACSSA mailing list.
Thefull version of this paper can be downloaded in pdf format or accessedas html below. To view or download individual sections of the paperclick on the relevant link in Contents.
Download Services for victim/survivors of sexual assault - ACSSA Issues No. 6 December 2006 (PDF 640 KB)
Littleresearch has been done on the services that currently exist forvictim/survivors of sexual assault. Yet high quality services canminimise the harm experienced by the victim/survivor. This papersummarises the international and national literature that exists onsexual assault services. It focuses on the needs of victim/survivors,on existing interventions, and data on the services that currentlyprovide these interventions.
Servicesfor victim/survivors of sexual assault form an essential component ofthe effort to provide an adequate response to sexual violence inAustralia. High quality sexual assault services can minimise all formsof harm experienced by the victim/survivor, including long-termphysical and psychological harm, many of which are likely to compoundin the absence of an appropriate and timely response. Furthermore, itis being increasingly recognised that there is a need to strengthen thequality of existing services that support and provide care to women andgirls who have experienced sexual violence (World Health Organization[WHO], 2004).
However, there has been little research onthe services that currently exist for victim/survivors of sexualassault. Both in Australia and internationally, very little researchhas been carried out to assess either the effectiveness of specialistsexual assault services, or the ability of generalist health servicesin meeting the perceived needs of victim/survivors. Indeed, theAustralian Bureau of Statistics ([ABS], 2004) identified the evaluationof programs that seek to respond to sexual assault as one of the threehighest priority areas for new research and data collection in thefield.
This paper begins to address this gap by providinga summary of the international and national literature that exists onsexual assault services. The paper focuses on three key areas. Firstly,the perceived needs of victim/survivors are identified. Secondly,literature on the existing interventions that are perceived to addressthese needs, and data on their effectiveness are reviewed. Currently,most of these interventions are therapeutic or counsellinginterventions. Finally, data on the services that currently providethese interventions, with patterns of service usage, barriers to usingthese services, and the characteristics of these services thatvictim/survivors find particularly valuable are identified. The paperwill end by making some recommendations for primary health careproviders working with victim/survivors of sexual assault.
Thepaper employs a gendered, health and human rights perspective and an'ecological framework' to inform the overall aim of investigatingcurrent intervention programs for victim/survivors of sexual assault. Amultilevel ecological perspective informed by a gender and human rightsperspective is considered the most appropriate model for understandinginterpersonal violence including sexual violence (Krug, Dahlberg,Mercy, Zwi, & Lozano, 2002). The ecological framework recognisesthe multifaceted nature of sexual violence and encourages explorationof the relationship between individual and contextual factors. Sexualviolence is seen as the product of multiple levels of influence onbehaviour from the level of the individual, to relationships, communityand society.
The general term 'sexual violence' will beused interchangeably with the specific terms used in the variousresearch papers and reports cited throughout the paper. 'Survivors'will include both adult survivors of childhood sexual assault (infancyto 17 years of age), who are frequent users of counselling services inCentres Against Sexual Assault and their equivalants, as well assurvivors of adult sexual assault. The most common reason survivorscontact CASAs is to access counselling services (National Associationof Services Against Sexual Assault [NASASV], 2000)
Sexualviolence is a human rights issue. Sexual violence violates the notionthat victims are full human beings 'born free and equal in dignity andrights'. Among other rights violations, sexual violence transgressesthe right of victim/survivors to enjoy the highest attainable standardof physical and mental health (Astbury, 2005). Health service providerstherefore have a particular responsibility to identify, understand andameliorate the harmful health effects of sexual violence.
Beforediscussing the adverse outcomes of sexual assault, the prevalence ofsexual assault, and barriers to reporting and disclosurevictim/survivors face are discussed. This is in order to providebackground conveying the scope of the issues needing to be addressed byservices providers.
Thetrue prevalence of the many forms of sexual violence against girls andwomen is not known. Available data are drawn from different populationsusing a variety of measures of sexual violence and data accuracy isaffected by non reporting (Lievore, 2003). A full discussion ofunderreporting and non disclosure can be found in the ACSSA BriefingPaper by Neame and Heenan (2003).
Prevalence rates differfor women and men. In Australia, it is thought that more than one inthree women, compared with one in six men reported having unwantedsexual experiences in childhood (Najman, Dunne, Purdie, Boyle, &Coxeter, 2005) and just over 21% of adult women, compared with lessthan 5% of men experience sexual coercion (de Visser, Smith, Rissel,Richters, & Grulich, 2003). Similar gender disparities in rates ofsexual violence are found in recorded crime statistics where more than80% of all sexual assault victims are female (ABS, 2003) and serviceuse data, where 85% of services are provided to girls and women(NASASV, 2000). Young girls are most vulnerable. Recorded crimestatistics reveal that girls between 10 and 14 years of age experiencethe highest rate of sexual assault (462 per 100,000) (ABS, 2003).
Findingsfrom the International Violence Against Women Survey (IVAWS) indicatethat sexual violence is three times more common among Indigenous womenthan other Australian women. Women from non-English speakingbackgrounds in this study reported similar rates to those in thegeneral population. Estimates of lifetime prevalence of sexual violencein national, community based surveys range from 16% in the Women'sSafety Survey to 34% in the IVAWS (Mouzos & Makkai, 2004).
Reportingand disclosure of sexual violence represents an important opportunityfor victim/survivors to receive assistance from service providers andbegin the process of recovery. However, numerous barriers to reportingand disclosure operate at both the personal level and at the level ofthe criminal justice system. Furthermore, victims who have beensexually assaulted by someone they know well, particularly an intimatepartner, may not even name what has happened to them as a crime and arefar less likely to report than victims who have been sexually assaultedby a stranger. Barriers to reporting and disclosure thus may also bebarriers to victim/survivors accessing the specialist services theymight require.
Lievore (2005) argued that the process ofsilencing women about sexual violence occurs from the macro level ofsocial discourses and representations, including discourses aroundwomen's lack of entitlement to sexual autonomy or stereotypical mediarepresentations of 'real rape', through to the micro level ofinterpersonal interactions. Her study of women's help-seeking decisionsand service responses to sexual assault found that a quarter of thewomen interviewed either did not or could not name what they hadexperienced as sexual assault. Yet, even if an experience is unnamed itcan still exert a profound impact. All these women experiencedpsychological and physical consequences, ranging from depression andsuicide attempts to poor health and eating disorders. At the same time,when an experience of sexual violence remains unnamed, delays inaccessing services may occur and victim/survivors may not link negativepersonal, health and social outcomes that appear over time with pastviolence.
Lievore (2003) cited a number of personal barriers to disclosure including:
Barriers at the level of the justice system include:
Thebarriers identified by Lievore (2005) have a personal and socialdimension and provide a map of the psychological terrain likely to beinhabited by many survivors. All are capable of engendering emotionaldistress in addition to that generated by the sexual assault. In thisway, these barriers may complicate and compound the psychosocial burdenalready carried by survivors. This burden is the one with which serviceproviders must grapple when they work with victim/survivors and developinterventions to meet their needs.
In addition to thesematters, sexual violence is associated with both immediate andlong-term effects. Service providers must be able to identify andrespond appropriately to these effects if victim/survivors are toreceive meaningful assistance. Most research on these effects has beenconducted in the US: a brief review follows.
Immediateeffects include shock, fear and feelings of helplessness. Illusionsregarding personal safety and being invulnerable in the world areshattered, and levels of psychological distress are very high in thefirst few weeks after the sexual assault but abate over the longer term(Koss et al., 1994). Victims can experience a range of physicalinjuries and damage to the urethra, vagina and anus and are atincreased risk of contracting sexually transmissible infectionsincluding HIV/AIDS. Fears of contracting HIV and/or becoming pregnantas a result of sexual assault are pervasive (Holmes, Resnick,Kilpatrick, & Best, 1996; Resnick, Acierno, & Kilpatrick, 1997).
Sexualviolence, whether this occurs in childhood or adult life, is associatedwith a plethora of poor, long-term, physical health outcomes. Thesephysical health problems include sexual and reproductive healthproblems, pain syndromes, eating disorders (especially bulimianervosa), and gastro intestinal problems (Krakow et al., 2002;Leserman, Li, Drossman, & Hu, 1998).
Mental healthproblems such as major depression, generalised anxiety, panic, phobias,symptoms of traumatic stress and suicidal thoughts and actions arecommon. These can co-occur with reduced self-esteem and a damaged senseof gender identity.
Relationships can also sufferdepending on how well or badly those closest to the victim such as apartner, family or friends are able to understand the impact of thesexual assault and how they respond to its disclosure (Coker et al.,2002; Fleming, Mullen, Sibthorpe, & Bammer, 1999; Koss, 1993;McMahon, Goodwin, & Stringer, 2000; Resnick et al., 1997). Beingbetter informed about the psychological effects of sexual violencewould greatly assist family and friends of survivors to feel moreconfident in providing support and understanding.
Womenwho have been sexually victimised as children face increased risks ofsubsequent rape and domestic violence in adult life and experience evenhigher rates of adverse health outcomes (Fleming et al., 1999).
Ofall the traumatic stressors researched so far including naturaldisasters such as earthquakes, hurricanes and tsunamis, it is the 'manmade' trauma of sexual violence that most strongly predicts thesubsequent development of post-traumatic stress disorder (PTSD) (Bruceet al., 2001; Kessler, Sonnega, Bromet, Hughes, & Nelson, 1995).Women who have experienced sexual violence constitute the singlelargest group of people suffering from PTSD (Calhoun & Resnick,1993). Rape victims are six times more likely to develop PTSD at somepoint in their lives than non victimised women (Kessler et al., 1995;Kilpatrick, Edmunds, & Seymour, 1992). Women's risk of developingPTSD following exposure to trauma has been found to be approximatelytwo-fold higher than men's. Women's PTSD also tends to last longer.This parallels the gender difference found for depression, with whichPTSD frequently co-occurs (Breslau et al. 1998).
Feministresearchers have criticised the use of the psychiatric diagnosis ofPTSD as the main way of understanding and responding to thepsychological distress and the meaning of sexual violence for women.Both Edna Foa and her colleagues (Foa, Cashman, Jaycox, & Perry,1997) and Judith Herman (1992) have argued that the assumptions and thesymptoms that define the diagnosis of PTSD do not accurately reflectthe range of traumatic experiences and traumatic effects experienced bysurvivors of sexual violence and whose PTSD is of a more complex typethan that experienced by survivors of discrete traumatic events.
Likeall psychiatric diagnoses, PTSD relies on the individualising andpathologising language of 'psychiatric symptoms' and represents thevictim of sexual violence as the bearer of a psychiatric disorder. Byfocusing on the victim/survivors as a person with a mental illnessneeding treatment, attention is deflected from the social causation ofrape and the generalised oppression of women. Moreover, theconcentration on a set of decontextualised and medicalised set ofproblematic symptoms inherent in the diagnosis of PTSD also shiftsattention from survivors' psychological concerns including the impactof sexual violence on their sense of themselves, their lives, theirrelationships, their sense of safety in the world and their overallhealth and wellbeing.
Sexually victimised women whodevelop PTSD are significantly more likely than those who do not, tohave to contend with a number of other co-occurring or co-morbidpsychological difficulties that may persist for many years (Kessler etal., 1995). Survivors who develop PTSD can be impacted by this bothduring the day when they experience intrusive thoughts and distressingrecollections of the violence, and at night when nightmares and othersleep disturbances may be the norm rather than the exception (Choquet,Darves-Bornoz, Ledoux, Manfredi, & Hassler, 1997; Krakow et al.,2000; Krakow et al., 2002; Roberts, 1996). A number of the womeninterviewed in Lievore's (2005) study commented on being unable tosleep, not sleeping properly and having nightmares.
Nightmaresare listed within the symptom cluster describing 're-experiencingsymptoms' and difficulty getting to sleep and staying asleep are listedwithin the symptom cluster describing 'arousal symptoms'. One US studyfound that survivors with PTSD recalled having more than fivenightmares per week on average (Krakow et al., 2002). Sleep problemsaffect the daytime functioning of those who experience them and impairfunctioning at work, diminish quality of life and are associated with ahigher risk of accidents and increased health care costs (Roth, 2005).Prescribed medications for sleep problems include anxiolytics andhypnotics but over-the-counter medications, alcohol or other drugs areoften used to self-treat (Roth, 2005).
Health providershave a unique opportunity to identify a history of sexual violence,diagnose psychological disorders and provide accurate and meaningfulresponses to survivors' sleep and other violence related healthproblems. Research to date suggests that few take this opportunity. Astudy of more than 3000 women attending general practitioners inVictoria found that only 9% of women who had experienced sexual abusehad ever disclosed this to their general practitioner, primarilybecause the practitioner had never asked about a history ofvictimisation (Mazza, Dennerstein, & Ryan, 1996). Yet recentAustralian research (Vos et al., 2006) demonstrates that intimatepartner violence including sexual violence is the single largest riskfactor for ill health (primarily poor mental health) for Victorianwomen aged between 15 and 45 years.
Avictim/survivor's negative experiences regarding the assault with thoseclosest to them (family members, friends), and with the criminaljustice sytem and health service providers (including counsellors) cancontribute to what has been termed 'secondary victimisation'. Suchvictimisation is likely to exacerbate existing psychological distress(as outlined above) and delay recovery from the initial trauma(Campbell & Raja, 1999).
Secondary victimisation byservice providers is a major preventible form of harm to the survivorand its elimination should be a priority for all professionals workingwith victim/survivors of sexual violence. Both the initial sexualassault and secondary traumatisation can initiate or reinforce harmfulhealth behaviours including smoking, heavy alcohol and illicit drug useand reliance on prescribed and non prescribed medication. Thesebehaviours are independently associated with poor mental and physicalhealth (Resnick et al., 1997).
Patterns of utilisation ofdifferent forms of health care reveal some interesting variations.Overall, sexually victimised women have increased rates of utilisationof medical services compared with non-victimised women. However, theyhave lower rates of using mental health, services for victims andpreventive health care (Jewkes, Sen, & Garcia-Moreno, 2002; Koss,Koss, & Woodruff, 1991; Springs & Friedrich, 1992).
Tobe meaningful, contemporary sexual assault interventions must respondto survivors' needs and concerns. At the present time, the evidencebase on this and other aspects of sexual violence is incomplete.Currently available interventions may not be the most appropriate onesto respond to survivors' needs.
In Australia, thepressing need to deliver services has understandably taken priorityover evaluation of those services. As already mentioned, research onexisting interventions and different approaches to working withsurvivors is lacking. Some sexual assault service workers may also havephilosophical reservations about psychological research if this isperceived to 'label' and psychopathologise victim/ survivors. A smallamount of research exists on service users and their perceptions ofsexual assault services. This will be discussed below, but first thelargely US research on mental health interventions for survivors willbe reported.
Themain focus of mental health interventions for victim/survivors has beenon the treatment of the mental health consequences of sexual violenceincluding guilt, shame, anxiety, depression, hypervigilance, anger,mood swings and social discomfort (Campbell, 2001; Foa, Rothbaum,Riggs, & Murdock, 1991; Trowell et al., 2002; Vaa, Egna, &Sexton, 2002). Some of these consequences equate with symptoms of PTSD(Foa et al., 1991; Lubin, Loris, Burt, & Johnson, 1998). However,as mentioned previously, victims of sexual assault may experience formsof psychological distress that do not meet criteria for the diagnosisof psychological disorders such as intense feelings of shame,existential insecurity and self blame. Alternatively, they may presentwith symptoms that do meet criteria for disorders such as depression,anxiety and dissociative disorders. These conditions may also co-existwith symptoms of PTSD (Lubin et al., 1998; Nishith, Nixon, &Resick, 2005; Vaa et al., 2002). The literature identifies two mainpsychotherapeutic approaches in relation to the treatment of victims ofsexual assault: cognitive behavioural therapy and feminist (or group)therapy.
Cognitivetherapies include cognitive behaviour therapy, rational emotive therapyand cognitive processing therapy. All share the assumption thatpsychological distress and behavioural dysfunction can be produced byinaccurate and dysfunctional thinking. The goal of therapy therefore,is to change psychological distress by challenging and changing thedistorted cognitions which give rise to it. Clients are taught, in avariety of ways to "recognize, observe, and monitor their own thoughtsand assumptions, especially their negative automatic thoughts" (Corey,2005, p. 285).
Cognitive behavioural therapy (CBT).CBT involves a number of different techniques, such as exposure totraumatic memories, cognitive restructuring and eye movementdesensitisation and reprocessing (Bradley, Greene, Russ, Duttra, &Westen, 2005).
Prolonged exposure therapy. Underthe cognitive behavioural framework, Foa and Rauch (2004) evaluated theoutcomes of prolonged exposure therapy on its own as well as thecombination of prolonged exposure and cognitive restructuringtherapies. Prolonged exposure requires the client to confront traumaticmemories repeatedly (through imaginal exposure) as well as confrontingtrauma related situations which are usually avoided (in vivo exposure)(Foa & Rauch, 2004). The goal of this type of therapy is to presentthe client with information that invalidates PTSD-related cognitions.
Cognitive restructuring therapy.Cognitive-restructuring targets the negative cognitions associated witha traumatic event. The aim of this therapy is to actively engage theclient in challenging negative automatic thoughts in order to alterPTSD related cognitions. Foa and Rauch (2004) found that prolongedexposure therapy was effective in reducing PTSD related symptoms invictims of sexual assault; however the addition of cognitiverestructuring did not enhance the outcome of therapy.
Other therapeutic services that address PTSD.Therapeutic services to prevent sexual assault victims fromexperiencing chronic symptoms of PTSD and depression have also beenexplored. Resick and Schnicke (1992) used cognitive processing therapyinvolving education, exposure and cognitive components in a 12-weekprogram using a pre-test post-test design. Women who received theprogram compared with a wait list (control) group showed significantimprovement on measures of PTSD and depression and this improvement wasmaintained for six months. Foa, Hearst-Ikeda, and Perry (1995)developed a brief cognitive behavioural program for recent victims ofsexual assault. The program involved education about common reactionsto sexual assault, breathing and relaxation training, prolongedexposure therapy and cognitive restructuring therapy. Immediatelyfollowing the program, women who received the brief therapy were lesslikely to meet the criteria for PTSD than those who did not receive thetherapy. Five and a half months after the end of treatment, women whohad experienced the therapy maintained low levels of PTSDsymptomatology and were also significantly less depressed than thosewho had not.
The efficacy of cognitive-behaviouraltechniques in comparison to solution-focused counselling wasinvestigated by Foa et al. (1991) for the treatment of PTSD in victimsof rape. Participants were assigned to either stress inoculationtraining, prolonged exposure therapy, supportive counselling or awaiting list group (control group). Stress inoculation traininginvolved education about coping strategies, breathing and relaxationexercises, cognitive restructuring and role playing to prescribe newmodels of behaviour. Prolonged exposure involved asking the client toimagine the rape event repeatedly within the session, and outside thesession to expose herself to feared or avoided situations that werejudged by both the client and the therapist to be safe. Supportivecounselling was governed by a solution-focused framework in which theclient was asked to report and generate strategies to deal withproblems in a highly supportive environment.
Each of thetherapeutic procedures was effective in reducing PTSD symptoms,immediately after the treatment and at follow up. However, the timingof the effect differed between the two therapeutic approaches. Theclients who received stress inoculation training showed moreimprovement in PTSD symptoms immediately after treatment than thosereceiving supportive counselling or those on the waiting list. Bycontrast the clients who received prolonged exposure therapy showed thelowest levels of PTSD symptoms at follow up more than three monthslater.
Interventions that address victim blaming and feelings of guilt.Victim blaming and feelings of guilt are commonly reported by sexualassault survivors and have become a focus of psychotherapeuticintervention in their own right (Campbell et al., 1999). Trauma-relatedguilt has been associated with the etiology of depression in victims ofsexual assault (Andrews, 1995; Gladstone et al., 2004). Nishith et al.(2005) compared the effectiveness of cognitive processing therapy andprolonged exposure on female rape victims. Cognitive processing therapywas equally effective in treating women with 'pure' PTSD or PTSDtogether with major depressive disorder and significantly moreeffective than prolonged exposure in reducing guilt cognitions relatedto the trauma.
Interventions that address sleep difficulties.As noted earlier, chronic nightmares and other sleep difficulties occurfrequently in clients with PTSD but have not been a major focus oftreatment to date. Krakow et al. (2001) treated chronic nightmares infemale sexual assault victims using imagery rehearsal therapy andcognitive restructuring. This treatment decreased chronic nightmares,improved sleep quality and decreased PTSD symptom severity. Anotherpositive outcome was that the clients' experiences in therapy weregeneralised to and helpful with other areas of maladaptive functioningsuch as negative and obsessive thinking.
Eye movement desensitisation and reprocessing therapy.Eye Movement Desensitisation and Reprocessing (EMDR) is anothercomponent of cognitive behavioural therapy that has been used quiteextensively in traumatised populations (Shapiro, 1989). During EMDR theclient is asked to move their eyes rapidly from side to side whileimagining an aspect of their trauma experience; such as a visual image,negative cognition, negative emotion or physical sensation (Wilson,Becker, & Tinker, 1995). This process is repeated until the clienthas altered self-cognitions in a positive manner and has becomedesensitised to disturbing aspects of their trauma experience. Wilsonet al. (1995) found that psychologically traumatised individuals,including sexual assault victims, showed reductions in their traumarelated issues and anxiety and increases in positive self-cognitions.These results were maintained at three-month follow-up and EMDR wasshown to be effective regardless of type of trauma experienced by theclient.
Feministtherapy stresses the importance of considering the social and culturalcontext, including gender-based oppression, in understanding the causesand nature of women's psychological difficulties. In this way, feministtherapy contrasts with traditional psychotherapies that attributeproblematic behaviours and emotions to intrapsychic causes, have atendency to blame the sufferer for her own distress and ignore the roleof sociocultural factors and how women are treated in society ingendering psychological disorder (Astbury, 1996).
Thereis ample empirical evidence linking material disadvantage, the inferiorsociopolitical position of women, the rights violations and exposure tosexual and other forms of gender-based violence women experience totheir higher rates of certain psychological disorders including PTSD,depression and eating disorders (for review see Astbury & Cabral,2000).
The goal of feminist therapy with a victim ofsexual violence is to help her understand that such violence is asocietal problem not just an individual problem and that sexualviolence is reinforced by gender-based differences in privilege andpower that play out within interpersonal relationships. Feministtherapies also focus on survivors' difficulties with guilt andself-blame in the long term, not merely the alleviation ofpsychological symptoms in the short term (Campbell, 2001).
Thefindings of an early study (Hutchinson & McDaniel, 1986) suggestedfeminist therapy was, indeed, more successful in reducing survivors'levels of guilt and self blame than traditional counselling. A morerecent study (Morgan, 2000) with survivors of childhood sexual abusealso demonstrated that survivors who participated in feminist therapyhad greater improvements in depression, social adjustment, self-blameand post traumatic stress than their counterparts in the control group.Most therapeutic services in the United States use a combination of CBTand feminist therapy according to Campbell (2001).
Vaa etal. (2002) used a multimodal group therapy treatment approach withadult survivors of child sexual abuse and recent adult victims ofsexual assault. The therapy ran in five phases each with its ownspecified goal including developing a sense of group identity andsocial support, re-experiencing and working through trauma, learningassertiveness, experiencing oneself as a victim and regaining controlover one's life, evaluating present circumstances and developing futuregoals. Of the 50 women who participated in the program, 38 wereinvolved in long-term follow-up some four-and-a-half years later. Thosewho improved immediately after the treatment were likely to retain thisimprovement at follow up. Women who were older at the time of treatmentand initially showed improvement in psychological symptoms were mostlikely to lose these gains by the time of follow up. Betterpost-treatment outcome was found in younger women, who had fewerpresenting symptoms at the start of the therapeutic program and hadreceived no previous treatment.
Another group model usinga feminist approach was evaluated by Lubin et al. (1998) with a femalesample of multiply traumatised women. The therapy waspsychoeducationally based and was conducted in three phases. Thetherapy:
Resultsindicated that this form of therapy was consistently effective inreducing PTSD symptoms and other forms of psychiatric distress,regardless of the type of trauma experienced. Moreover, theseimprovements were maintained at six-month follow-up. The researcherssuggest that group therapy does not need to be limited by focusingstrictly on individualised emotional and interpersonal issues as a morestructured, psychoeducational format may contribute to more success insymptom reduction and overall outcome.
Very littleliterature exists on therapeutic frameworks beyond the cognitivebehavioural and feminist approaches. Bowling and Weiland (2002)recently conducted a study utilising a family systems framework inorder to test its efficacy in treating victims of sexual assault whencompared to traditional individual therapy. The clients receivingfamily systems therapy showed greater improvement in depressivesymptoms than individual therapy clients, however reductions in PTSDsymptoms were at the same level for both types of treatment. Familyfunctioning was not affected by either type of therapy.
Littleresearch has been conducted into therapeutic approaches orinterventions with survivors in Australia and what there is tends to bedescriptive in nature. No studies could be identified in the Australianliterature that focused on the reduction of symptoms linked to specificpsychological disorders using experimental or quasi-experimentaldesigns. Some of the research that has been conducted does identifywhat survivors perceive to be emotionally helpful versus unhelpfulabout the services they have accessed. Before discussing this, abackground to the sexual assault services sector in Australia isprovided.
Effortsto draw public attention to the importance of violence in the lives andhealth of Australian women were critically connected to second wavefeminism (Weeks, 1994). Violence against women was made a priority areafor focus at the first Women's Liberation Conference held in Melbournein 1970. The first Rape Crisis Centres were established in Sydney andMelbourne in 1974. The Melbourne Rape Crisis Centre was run by WomenAgainst Rape at the Women's Liberation Centre in Melbourne with medicalservices provided by the Melbourne Women's Health Collective inCollingwood. The Queen Victoria Hospital started providinggynecological check-ups and counselling to recent victims of sexualassault in 1977 and the Geelong Rape Crisis Centre was started in 1978.These early services came into being as a direct result of activism bygrassroots women's health groups who shared a passionate interest inwhat was then called 'women's liberation'.
The firstservices were run as collectives and relied on the work of highlycommitted volunteers. They were informed philosophically by feministanalyses of society that attributed sexual violence to a patriarchalsocial order. Women who gave their time to run the early services wereinitially loath to consider government funding because of the beliefthat such funding would have unpalatable strings attached, encouragecooption, weaken women's control over services and dilute their agendaof radical social change and emphasis on the prevention of sexualviolence (Broom, 1991; Hewitt & Worth, n.d.; Weeks, 1994). Malecontrol of social institutions such as the criminal justice system andthe low rate of conviction of men for crimes of sexual violence wereseen to illustrate the way in which patriarchy served the interests ofmen while denying legitimacy to the interests and concerns of women andblocking women's access to justice, power and resources.
Thenumber of funded services increased after the Whitlam Government cameto power in 1972. Its platform of social change was more compatiblewith the philosophical views espoused by the feminists who had set upthe first women's health and sexual violence services. A seminalpublication that further galvanised women's activism around rape was Against our will: Men, women and rapeby Susan Brownmiller published in 1975. The first funded Sexual AssaultCentre, at Melbourne's Queen Victoria Medical Centre, began in 1979. Itwas not until the late 1980s that a significant number ofgovernment-funded Centres Against Sexual Assault (CASAs) and otherCentres that shared the same philosophy of service provision (but havesomewhat different names) began to be set up throughout Australia.
Some118 sexual violence services were identified as potential participantsby the National Association of Services against Sexual Violence(NASASV) by the time the National Data Collection Project on theseservices and their clients was undertaken by NASASV in 2000. Theseservices continue to be informed by feminist notions of practice andsituate the crime of sexual violence as an abuse of rights,particularly the rights of women and children (NASASV, 2000).
Researchon Australian sexual assault services and on 'mainstream' healthservices that see the vast majority of sexually victimised women isextremely limited, and presented here below.
Themain source of information on services for survivors comes from theNational Data Collection Project undertaken in 2000 by the NationalAssociation of Services against Sexual Violence. These services, inkeeping with their feminist principles and rights based perspective,prioritise service users' rights to informed consent, information,confidentiality and respectful responses. Many place a priority onviolence prevention programs and campaigns and aim to "enhancecommunity understanding of sexual violence against women and childrenby countering myths with current and comprehensive data" (NASASV, 2000,p. 1).
The objective of the Project was to gaininformation from all 118 services identified as eligible to participatebut unfortunately only 37 services nationwide returned completeevaluation data. This resulted in a participation rate of just over31%. Nevertheless during the three-week period of data collection inApril-May 2000, more than 4,000 contacts with services were recordedand provide a valuable snapshot of services against sexual violence.Most service users (85%) were female and the largest single group (62%)were victim/survivors of sexual assault, followed by professionals(17%). More than half of the contacts were made in person (2,039)followed by phone contacts (1,760) while a small number of people (49)contacted services through writing. Counselling was the most commonlyrequested service (1,918) followed by information (1,451) and crisissupport (639). No information was collected on the length of timeservice users spent in counselling.
Morethan 27% of those who contacted sexual assault services were in the agegroup, 20-29 years, and they comprised the largest group of survivorsto contact the services followed by those in the 30-39 age group (22%).The study does not provide data on whether all those who contactedservices received the type of service they were seeking.
Around3.5% of service users identified as Indigenous while in the Australianpopulation overall, Indigenous Australians make up only 2%. It would bea mistake, however, to conclude that Indigenous people are high usersof sexual violence services. Indigenous Australians as a group aresignificantly younger than other Australians and younger age is a riskfactor for sexual assault. For example, in 2001, the proportion ofIndigenous people under 15 years of age was 39% compared with 20% ofnon-Indigenous persons and the median age of Australia's Indigenouspopulation was 20 years, some 16 years younger than the median age forthe non-Indigenous population (36 years) (ABS, 2005).
Around20% of service users indicated that they had a disability of some sort.The largest group (n = 350) however did not specify the nature of theirdisability. Of those who did specify, a mental health disability wasthe most common (n = 270).
Childsexual assault was the most common form of sexual assault for whichservices, presumably counselling, was requested. More than 1,100victim/survivors had sought services for this form of assault duringthe study. This was followed by rape, for which services were sought byslightly less than 600 victim/survivors.
Sexual assaultsmainly occurred in the victim's home (46%) with a further 18% occurringin the perpetrator's home. Twelve per cent of assaults were perpetratedby multiple offenders and most offenders (10%) were known to thevictim, with the majority being male (79%).
Inline with previous research, the vast majority of victim/survivors knewthe person who assaulted them. Given the large number of service usersseeking assistance with issues related to child sexual assault, it isnot surprising that the largest group of perpetrators identified wereparents. They were followed by friends and acquaintances, other familymembers, trusted adults and step-parents. Ninety six per cent of singleperpetrator assaults were reported as male. The majority of offenderswere aged between 16 and 49 years.
Themain source of evidence on service users decision making around helpseeking and survivors perceptions, views, and experiences of sexualassault services, is Denise Lievore's (2005) study No longer silent: A study of women's help seeking decisions and service responses to sexual assault.
Thisqualitative study focused on service users who had experienced adultsexual assault and consisted of two components. The first examinedsocial and personal factors that influenced victim/survivors' decisionsto seek help from a variety of sources including sexual assaultservices. It involved semi-structured interviews with 36 femalesurvivors recruited through sexual assault services across Australia.Service users' views were complemented by 65 sexual assault counsellorsrepresenting 23 services. The second component involved consulting with55 sexual assault workers regarding their perceptions of the efficacyof coordinated service provision, their experiences of collaboratingwith criminal justice and forensic medical personnel and theirrecommendations for improving service delivery. We discuss the findingsof this study here, including the context of other research on serviceprovision from overseas.
Thestudy revealed how sexual assault had affected and disrupted everydimension of survivors' lives. Victim/survivors faced making decisionsabout a range of important life issues, not just the decision aboutwhether to report sexual assault. Help-seeking decisions involvedmultiple decision points and were affected by survivors' relationshipswith people from different social contexts and their reactions todisclosures about sexual assault.
The quality of supportsurvivors received was variable within both formal and informal sourcesof assistance. Of the formal helping agencies, sexual assaultcounsellors were the most highly valued. Medical, mental healthservices and services provided by other organisations were judged asless empathetic and less helpful. Among informal support networks,survivors were more likely to disclose to friends and to find them morehelpful than family members. Even when friends or family members wantedto be helpful and supportive, they were often unsure about how toprovide this or what to say. Women who lacked informal sources ofsupport and had poor mental or physical health were particularlyvulnerable to violence and its effects.
Overseas studieshave also found that social support is a critical mediator of mentalhealth outcomes. In a study of more than 300 survivors Ullman andFilipas (2001) found that women with lower education, whose assaultswere characterised by greater threat to life and who received morenegative social reactions on disclosing adult sexual assault, had moresevere symptoms of PTSD. Conversely, survivors who had someone believetheir account of what happened or were allowed to talk about theassault and considered these reactions to be healing had fewer physicaland emotional health problems (Campbell, Ahrens, Sefl, Wasco, &Barnes, 2001). Social support also moderates long-term mental healthoutcomes (Murthi & Espelage, 2005).
Ofthe 36 service users interviewed in Lievore's study, slightly more thanthree quarters knew their perpetrator and slightly fewer than half ofthe women first disclosed the sexual assault to a friend. Of theremainder, five had disclosed to strangers including neighbours orpassers-by. Disclosure to police or a doctor was less common thandisclosure to family members, a counsellor or a psychologist. Threepatterns of disclosure were identified. These were: unsoliciteddisclosures (n = 25); solicited disclosures (n = 7); and disclosure in the context of being rescued (n = 4).
Thefirst disclosure of sexual violence was not always a planned action ora conscious decision with a clear objective in mind. Time to disclosureranged from immediately after the sexual assault to decades after itsoccurrence. Disclosure and help-seeking were largely determined by thecontext of the sexual assault and/or the social context that madedisclosure possible. Other people's confirmation that a serious crimehad occurred coupled with an offer of support was instrumental inpersuading many survivors to report to police. Unlike the majority ofsurvivors, most of the participants in Lievore's study reported theoffence to police. Only six of the 36 women did not report to police.Of the women who did report, 17 reported on their own behalf and 13 hadreports made for them by other people. Despite the high percentage ofwomen who reported to police, most reported concerns or negativeperceptions about becoming involved in the criminal justice process.
Commonthreads in the narratives of the participants around their needs at thetime of disclosure included the need for safety and protection,emotional or medical help in crisis whether this was months or yearsafter the assault, emotional support and being believed by someone whowas sympathetic, not being blamed, making sense of what had happenedand having their experiences validated. Needs specifically related tothe time when the sexual assault occurred included medical help andpractical help such as getting to the police or accessing advice onavailable options.
It is believed by many researchers andpractitioners that in order to be able to deal with and overcome thetrauma of sexual assault, it is necessary to name unwanted sexualexperiences as sexual assault. A quarter of the women interviewed didnot or could not do so even though all of these women had experiencedserious psychological and physical consequences, ranging fromdepression and suicide attempts to poor health and eating disorders.
Lievore(2005) commented that this finding is consistent with previous researchabout the naming of sexual assault. For example, one early study (Koss& Gidycz, 1985) found that 43% of women who said 'yes' to questionsabout sexual assaults that met the legal definition of rape, answered'no' to the question, 'Have you ever been raped?' Part of thedifficulty in naming sexual assault may derive from the fact that theefforts, cognitive and emotional, that women make to cope with andcontain the distress associated with sexual violence, may also minimiseperceptions of its severity. Kelly's (1998) argument cited by Lievoreis somewhat different although not necessarily incompatible with thisand centres on the silencing of women by dominant male discourses thatlimit what "is deemed unacceptable (sexual behaviour) to the mostextreme, gross and public forms" (Kelly, 1988). Lievore (2005)contended that "this process of silencing occurs from the macro levelof social discourses and representations, including discourses aroundwomen's lack of entitlement to sexual autonomy or stereotypical mediarepresentations of 'real rape' through to the micro level ofinterpersonal interactions" (p. 32).
As noted earlier,participants rated sexual assault counsellors as their most valuedsource of support but at the same time all participants were recruitedthrough sexual assault services suggesting the possibility of selectionbias. A few women in Lievore's study did express dissatisfaction withthese services but most made highly favourable comments about theircounsellor/advocates including "fundamental to my recovery", "mylifeline", "amazing" and "my lifesaver".
Sexual assaultservices provide a context that functions as an antidote to the cultureof censorship and silence that victims can experience in the widersociety. Participants' comments underline how psychologically powerfulit was to be able to talk and freely express their emotions about whathad happened to them and to be believed.
The following comments were from participants in Lievore's (2005) study:
This benefit also characterised group work, where the ability to talkwith other women was combined with having a sense of belonging at atime when most women's capacity to trust had been violated and theyfelt profoundly isolated.Ineeded to talk to just get stuff off my chest, I needed to cry, becauseI held it in, even with my best friend. (Annabelle, p. 67)
I let everything out and that helped put things in perspective. (Alison, p. 67)
It was helpful to talk about anything and everything to the counsellors. (Michelle, p. 67)
I enjoyed group therapy,it was really good meeting women in the same situation. They were asclose as I had to friends. I didn't want friends because I didn't trustpeople. (Kate, p. 68)
Besidesgroup therapy, women valued many other types of activities thatoccurred in groups such as art therapy and yoga as well as being givenbrochures on relaxation, tips on how to sleep, information onself-defence and anger management, being able to borrow books onrelevant subjects such as relationships and abuse and receivingpractical assistance such as help with letters about compensation.These and other activities 'value-add' to standard therapeuticapproaches. Moreover, techniques for stress management, weight control,smoking cessation and increasing physical exercise have proven benefitsto mood, depression and anxiety levels (Resnick et al., 1997). Sharinginformation on these techniques with victim/survivors can contribute tothe overall goal of healing, namely, by helping to restore power andcontrol to the victimised woman over her life and health.
Thisapproach accords with Herman's (1992) view that violent victimisationis damaging psychologically primarily because it robs the victim of asense of power and control and is congruent with the feminist,rights-based philosophy of sexual assault services.
Lievore's(2005) study revealed that many of the elements perceived byparticipants to contribute to the "helpfulness" of services, satisfiedsurvivors' needs for psychological safety. Being able to speak freelyto counsellors who understood the effects of sexual violence, wereunderstanding, compassionate and non judgemental, provided emotionalsupport, information, a sense of belonging and ran a service that wasaccessible at all times, were all thought to be important in "puttingthings in perspective" and "getting through the process" (p. 67).
Amanda, another participant from Lievore's (2005) study, said:
It'shelpful being able to pour your heart out in confidential surroundings,where you're safe and it's okay to ask about your fears. (p. 67)
Theestablishment of safety represents the first stage in the healingprocess when feelings of being unsafe extend to the externalenvironment, the perpetrator and women's sense of being unsafe in theirown bodies (Herman, 1992). Stage two involves remembrance and mourningand the third stage relates to reconnection with ordinary life. Herman(1992) cautions that stages "are an attempt to impose simplicity andorder upon a process that is inherently turbulent and complex" (p.155). Nevertheless, the idea of stages has utility for sexual assaultworkers and other health professionals in suggesting the likelypreoccupations and needs of victim/survivors at different points in thehealing process. Unfortunately, it is not possible to examine theresponses of the participants in Lievore's (2005) study regarding whatthey found helpful in service provision according to Herman's model ofstages, due to insufficient data.
Research on thehelp-seeking patterns of adult survivors of child sexual abuse andtheir perceptions of what has been helpful versus unhelpful in theirattempts to seek meaningful assistance is needed to complement theresearch undertaken by Lievore with survivors of adult sexual assault.For example, while the research with survivors of adult sexual assaultindicated that most women believed that their needs on initialdisclosure had been met, it is not known whether the same would be truefor survivors of child sexual assault. The greater vulnerability ofchildren, their higher likelihood of experiencing protracted periods ofabuse at the hands of adults in positions of trust and their difficultyin accessing services, all suggest that their experiences of disclosuremight be more problematic than is the case with adult survivors.
Thesexual assault workers consulted in Lievore's study endorsed a model ofservice provision that incorporated a coordinated response to sexualassault involving interagency collaboration between all agencies withwhom victims of sexual assault might have contact including criminaljustice agencies, forensic services, health and sexual assaultservices. For a detailed overview of health sector and interagencyprotocols, see the detailed overview by Olle (2005) in a previous ACSSAIssues paper.
The ideal of full interagency collaborationhas not yet been achieved. Of the 14 sexual assault centres consultedin Lievore's (2005) study, only nine were covered by interagencyprotocols. Workers in the centres were generally optimistic thatprogress was being made but a number commented on the sources oftension that can arise between personnel working in different agenciesand carrying out different and sometimes contradictory roles. Furtherresearch is needed to explore how the existing barriers to the fullimplementation of integrated service models can best be dismantled.
As one worker in Lievore's (2005) study put it:
Theprocess often works well and when it does it's great, but there areglitches, which are mainly to do with different roles and attitudes. Weprovide support, advocate for the victim/survivor, have an attitude ofbelief and are focused on client wellbeing. We define a recent sexualassault as occurring within the last two weeks. We go through thesurvivor's options face to face: we explain about reporting; that shecan contact police if she wants to, or just meet with them; we'll gowith her to the crisis care unit. This can conflict with the role ofother services. The police are focused on investigating the crime andcollecting evidence. They talk about the 'alleged' offender and definea recent sexual assault as up to 72 hours. They might not attend thecrisis care unit. The police look at it from the view of courtprocesses and the paper work involved. So there's a different language,a different belief system (p. 137).
Workersmade several recommendations for promoting organisational change andimproving social responses to sexual assault. They recommendeddismantling barriers to accessing sexual assault services, increasingsupport for sexual assault centres and specialised service providers,providing specialised training for all systems dealing withmarginalised groups and collecting reliable statistical data on sexualassault among women with disabilities and from Indigenous andnon-English speaking backgrounds. For a full discussion of sexualassault workers' views on service provision, see Chapter 14 ofLievore's (2005) report.
Most participants in Lievore'sstudy held sexual assault services in high regard. Further research isneeded to identify the precise mental health outcomes associated withthe feminist, rights based approach to counselling used by theseservices.
Theonly attempt to describe a therapeutic approach used within a sexualassault service that could be located was a small pilot study on SharedCounselling undertaken in 2005 by CASA House in Melbourne. Sharedcounselling provides an alternative to one-to-one counselling,decentres the therapist and uses outsider witnesses who engage eachother in conversations about what is heard in counselling. By using anarrative, feminist perspective, the shared counselling approachreflected a commitment to "validate women's voices and their stories inthe face of inequality" (White, 1995).
Three women, allof whom were survivors of child sexual assault, participated in theprogram and were interviewed pre-counselling, at six weeks and aftercompletion of the program. At the final evaluation, two women gaveshared counselling the maximum rating of five and the third gave it arating of four. The experience of not being alone, hearing the storiesof others and seeing how these resonated in their own lives were allhighly valued.
One participant described how sharedcounselling made her "feel special and strong enough to be at ease"(White, 1995, p. 6). For another, identifying the grief she felt helpedher to understand "where" she was in herself. Another came to the newbelief that there was, after all, a place in the world for her. Thewomen changed how they felt about themselves. Day to day life becameless of a struggle. Moments of strength and clarity occurred,relationships and sleep improved and there was "less noise andconfusion in my head" and less anger. Sexual assault was no longer seenas being their fault.
The shared counselling approachappears to support existential changes that empowered the women to feelon more solid ground within themselves and as such differs quitemarkedly from the symptom reduction approach that characterise most ofthe interventions described earlier. A much larger study of the impactof shared counselling is needed.
TheNSW Rape Crisis Centre established a new service, Rape Crisis Online,in December 2005. The service provides a person-to-person, on-line,real-time information and support service for anyone who has beensexually assaulted and is the first of its kind. Targeted at youngpeople, the service responds to the finding that many survivors ofsexual assault report that the most difficult thing after the assault,is telling what has happened for the first time. Advantages of thisapproach as a first contact with services include survivors being ableto access help from a quiet, private location, being able to type wordsrather than say them and being able to access instant support andinformation backed up by a website (NSW Rape Crisis Centre, 2005).
Informationon the first seven months of operation provided by Jacqueline Burke,Counselling Coordinator at the NSW Rape Crisis Centre, indicates that atotal of 149 online contacts were made by 93 individual people to RapeCrisis Online up to July 31, 2006. Around a third had never spoken toanyone before about the violence. The majority (64%) were aged between16 and 34 years, with approximately 30% from rural NSW. Callers wereencouraged to make contact with the NSW Rape Crisis Centre and over athird made subsequent telephone contact. For those who did not want tomake contact, counsellors suggested other options.
Inline with Lievore's (2005) finding, 30% of callers did not talkdirectly about being assaulted but asked questions such as "if someonedid … to me, is that sexual assault?". The language and content of mostof these calls indicated that the authors were young and wanting helpbut were unsure of the outcome of 'telling'. Of the callers who spokedirectly of sexual violence, 30% had been assaulted in the past sevendays and 50% had been assaulted six months or more ago. Overall, 40%had been sexually assaulted as adults, 30% had been assaulted when theywere children and a few had been gang raped. On line contacts followedthe same pattern as telephone contacts with 68% of calls being receivedbetween 3 pm and 11 pm.
Thevast majority of women who experience violence including sexualviolence do not access formal support agencies such as sexual assaultcentres. In the most recent analysis of a large scale Australian studyof violence against women, Mouzos and Makkai (2004) found only 16% ofwomen who experienced intimate partner violence and only 9% of thosewho experienced non-partner violence subsequently contacted an agency.Furthermore, while the limited evidence on formal sexual assaultservices indicates that users regard them highly, no research has yetbeen conducted in Australia to determine how survivors of sexualviolence regard the quality of care and support they receive fromprimary health care providers.
Given that the majority ofsurvivors access primary health care services rather than specialistsexual assault services, it is imperative that primary health careproviders are equipped to enquire about and respond appropriately todisclosures of sexual violence, to detect negative health outcomesincluding adverse psychological outcomes and to conduct consultationsand examinations so as to minimise secondary trauma.
Allhealth care professionals who see female clients need to keep in mindthat up to a third of them are likely to have experienced some form ofsexual violence over their lifetime.
Primaryhealth care providers have been trained to develop expertise in thediagnosis and treatment of ill health and to act as authority figuresin relation to their clients. As such, they become accustomed todevising treatment plans, giving advice and expecting clients to adhereto those plans and advice.
Increasing patient compliancemay be desirable in other spheres of health care but it should not be agoal when working with victimised girls or women. Indeed it is likelyto be highly counterproductive because it mimics the controllingbehaviour of the perpetrator and reinforces the woman's sense ofpowerlessness and lack of agency. Health care workers must strive to beas unlike the perpetrator as possible in all their interactions withvictimised women. A non-directive, woman-centred therapeutic approachis indicated.
Unlike sexual assault counselling andadvocacy services where no physical examinations are carried out,primary care providers routinely engage in a range of physicalexaminations that have the potential to cause secondary traumatisation.
Secondarytraumatisation is most likely to occur in situations that share some ormany of the same features as previous episodes of violence. Intimategynecological examinations are a case in point.
Anyclinical examination or procedure that places women in a helpless,powerless or humiliating position where it is impossible for them toexercise control or express preferences or participate in decisionswhich impact on their emotional wellbeing and/or physical integrity anddignity, will serve as strong reminders of the violence endured outsidethe consulting room.
A history of trauma and violentvictimisation can transform what health care providers might consider'ordinary' or 'everyday' procedures into formidable challenges tovictimised women's abilities to cope physically and psychologically.
Primaryhealth care providers need to reconsider the traumatic potential of arange of procedures from a client centred perspective and ask thefollowing questions:
Some procedures such as Paptesting and other intimate gynecological examinations that occurroutinely in pregnancy and labour or in testing for sexuallytransmitted infections are likely to trigger reminders of past violenceand to provoke the same physical and psychological responses as theoriginal violence. Apart from a small pilot study on the Pap testingexperiences of survivors carried out at CASA House (Carlson, 2002), noAustralian research to date has been funded to investigate thiscritical aspect of service provision for victim/survivors.
USresearch on gynecological care, however, indicates thatvictim/survivors of sexual violence find gynecological examinationsmore distressing than other women. Survivors are more likely thannon-abused controls to rate their gynecological care experiencesnegatively and during a gynecological examination report more traumalike responses including overwhelming emotions, intrusive or unwantedthoughts, memories, body memories and feelings of detachment from theirbodies as well as more shame, fear and anxiety than other women. Mostwomen (82%) had never been asked about a history of sexual violence bya gynecological care provider (Robohm & Buttenheim, 1996).Similarly, Smith and Smith (1999) reported that survivors of childhoodsexual abuse reported higher levels of anxiety during a gynecologicalexamination than non-abused women. The traumatic stress followingsexual violence is thus evidenced in the trauma like responses ofvictimised women to gynecological examinations and may explain why somefind Pap tests unbearable (Farley, Golding, & Minkoff, 2002). Atraumatic experience of the Pap smear procedure could significantlydelay the length of time to subsequent screening or prevent it fromoccurring altogether. This needs to be investigated further.
Primaryhealth care that is responsive to the needs of survivors has animportant role in supporting the empowerment of survivors as opposed toreinforcing their disempowerment. It is only in the presence of atrustworthy ally that a survivor is likely to feel comfortable intelling her story or as Herman (1992) puts it, being able to "speak ofthe unspeakable".
The establishment of trust is thereforecritical. A strategy to achieve this includes ensuring that alldiscussions about sexual violence occur in a safe and private place. Anumber of WHO documents on violence against women stress the importanceof prioritising women's safety in any encounter they might have withresearchers or clinicians (WHO, 1999; WHO, 2004). This might besummarised as: "Ask alone and ask safely".
If there isany likelihood of interruption during the discussion that could violateconfidentiality, warn of this possibility in advance and agree on achange in the topic of conversation (WHO, 1999).
Toprovide psychological support, both the words and actions of the healthcare provider must demonstrate to the victimised girl or woman (who hastaken the risk of trusting that provider with her disclosure ofviolence) that the provider:
Thenotion of stages in healing from sexual violence may be 'a convenientfiction' (Herman, 1992) but it is this convenience that most recommendsit. When listening to women talk about their concerns andpreoccupations about sexual violence and its effects, primary healthcare workers are likely to be able to respond more meaningfully if theyunderstand the different stages and their associated concerns andpsychological tasks.
Sexualviolence is a multidimensional problem. In attempting to worksensitively and effectively with survivors in a way that contributes tothem regaining control over their lives following the devastation ofsexual assault, it is salutary to keep in mind that no single factorexplains such violence and equally, no single person can overcome it.Just as sexual violence results from the complex interplay ofindividual, relationship, social and cultural and environmentalfactors, so, too, its solution must also involve all those who have theopportunity to reduce such violence and eliminate its preventable harmsby working together, where possible, to build synergistic relationships.
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