PROTOCOL: Interventions to reduce distress in adult victims of sexual violence and rape

Estimates of the incidence and prevalence of rape and other forms of sexual assault vary depending on how terms are defined, what types of sexual assaults are included, the time frame during which the data are collected, sampling methods used, age and gender of the population studied, and the location of the sample (Acierno, Resnick & Kilpatrick, 1997). Further, as few countries have undertaken studies that comprehensively document the prevalence of rape and sexual assault, worldwide incidence is difficult to determine (British Council, 2006). In the United Kingdom, Painter (1991), reported that 1 in 4 women experienced rape or attempted rape. A national random sample of 6,926 women in Sweden found that 1 in 6, or 16% of the respondents, had experienced sexual violence by a former husband or cohabitant and that 1 in 4, or 25% of the respondents, had been subject to sexual violence by a man outside a relationship (Lundgren, Heimer, Westerstrand & Kalliokoski, 2002). In a similar study in Ghana, Coker-Appiah and Cusack (1999) randomly sampled 2,069 women and adolescent girls and found that 1 in 3, or 33% of the respondents, had been touched against their will and that 1 in 5, or 21% of the respondents, had been raped. In the United States, a population-based study of 1,769 women in Virginia discovered that the lifetime prevalence of sexual assault was 27.6% and the prevalence of rape was 17.8%. In a survey of households in Los Angeles, the lifetime prevalence of sexual assault was 13.2% (16.7% for women and 9.4% for men; Burnham et al., 1988). A similar study in Northeastern United States, reported a lifetime prevalence of sexual assault of 7.3% for women and 1.3% for men (Norris, 1992). A national random sample of women found that 12.7% reported a history of rape and 14.3% reported other forms of sexual assault (Resnick et al., 1993). Other US studies have focused on college populations. Koss, Gidcyz and Widniewski (1987) found in their survey of 6,000 students from 32 colleges, that 50% of the respondents indicated having experienced some form of sexual violence after age 14 and 27.5% reported having been raped (Koss, Gidycz & Wisniewski, 1987). In a subsequent study with 2,700 college women, 15% reported rape and 12% reported attempted rape since age 14 (Koss & Dinero, 1989). Gross and colleagues (2006) reported that 27% of a sample of college women had experienced some form of unwanted sexual contact (ranging from kissing and petting to intercourse) since entering college. Thus, while estimates vary, sexual assault affects a non-trivial percentage of the population. Distress often occurs after a person has been exposed to a traumatic event such as sexual assault. Resick (1983) for example found that victims of rape exhibited more depressive symptoms, more fear and anxiety, more problems with social and work adjustment, and more problems with sexual functioning than did a control group of non-victims. The increased prevalence of Post-Traumatic Stress Disorder (PTSD) in victims of rape is well documented. PTSD has been reported to affect between 9 and 15 percent of the general population and almost 50 percent of individuals who have been raped (Treadwell & Foa, 2004). As the negative effects of sexual assault have become better recognized, there is increasing attention to the possibility that psychosocial interventions may reduce suffering and limit distress. There are now several treatments modalities available for victims of rape and sexual assault including: pharmacology; behavioural techniques such as flooding, systematic desensitization, eye movement desensitization and retraining (EMDR); cognitive behavioural therapy; cognitive therapy; relaxation; rational-emotive therapy; group therapy; hypnosis; family/couple therapy; existential therapy; humanistic approaches; and psychodynamic therapy. A critical review of this literature reveals many articles based on clinical impressions, but few studies measuring outcomes of treatment. Due to the well documented negative consequences of sexual assault such as posttraumatic stress disorder (PTSD), and secondary depression (Resnick, Acierno, Holmes, Kilpatrick, & Jager, 2006), it is imperative that effective and efficient treatment options for these victims are identified (Rothbaum, Astin & Mosteller, 2005). One of the issues in evaluating post-traumatic stress interventions is the degree to which symptoms spontaneously remit. For instance, Rothbaum, Foa, Riggs, Murdock and Walsh (1992) reported that, while 94% of the 95 rape victims in their study met the criteria for PTSD at one week post-rape, this reduced to 47% at 94 days post-rape. Once the three month marker occurs, it has been suggested that symptoms of PTSD become relatively persistent. While there are hundreds of original reports describing the effectiveness of treatments for individuals who have been exposed to traumatic events, the vast majority are not empirically based studies (Solomon & Johnson, 2002). Yet, the natural diminishing of symptoms of PTSD requires that controlled studies be considered when discussing efficacy. Stein, Ipser and Seedat's (2006) systematic review of pharmacotherapy for PTSD is the only systematic review to examine the reduction of distress for victims of rape. The reviewers concluded that while medication treatments can be effective in treating PTSD, there continues to be a need for more effective strategies. However, in this review victims of sexual violence were grouped with other populations of trauma sufferers, and no specific data synthesis was reported regarding those who had been victims of rape. Within the psychotherapy literature, there have been several non-systematic reviews of treatment for rape and sexual assault (Falsetti, 1997; Foa, Rothbaum & Steketee, 1993; Foa & Rothbaum, 1998). Other reviews have examined the reduction of distress in populations experiencing symptomology of PTSD but these reviews were not specific to adult victims of rape and sexual assault. Bisson and Andrew (2007), for example, completed a Cochrane Review of psychological treatments to reduce symptoms of post traumatic stress disorder (PTSD). Although they found evidence that individual Trauma-focused cognitive behavioural therapy/exposure therapy (TFCBT), eye movement desensitisation and reprocessing (EMDR), stress management and group TFCBT were effective in the treatment of PTSD, the authors made no restriction on the basis of severity of PTSD symptoms or type of traumatic event. Instead, their study population included war veterans, female assault (mainly sexual assault) survivors, refugees and police officers, and mixed groups of individuals who had experienced a variety of traumatic events including road traffic accidents, assaults, bereavement and industrial accidents. Likewise, Sherman (1998) completed a meta-analysis of controlled and clinical trials of psychotherapeutic treatments for posttraumatic stress disorder (PTSD) and included samples of combat veterans from the Vietnam and Lebanon Wars, crime-related victims, and severe bereavement sufferers and victims of rape. Sherman examined cognitive, and psychodynamic treatments, in group and individual settings and found the overall impact of psychotherapy on PTSD and psychiatric symptomatology was significant (d = .52, r = .25) with a non-zero, 95% confidence interval suggesting that the true effect lies between .39 and .68, however no data were available specifically for those who were victims of rape. It is important to evaluate treatments specifically for victims rape because although there may appear to be similarity of response to different trauma including rape, accidents and disasters (Rothbaum, Ninan & Thomas, 1996), there is evidence that trauma associated with rape may be different than other forms of trauma in part due to the strong element of self-blame, the higher incidence of concurrent depression and the increased risk of suicide (Connor, Jonathan & Davidson, 1997; Kimerling, Ouimette & Wolfe, 2002). Using a representative sample to assess the differential risks of PTSD across types of trauma exposure, Breslau, Davis, Andreski and Peterson (1991) reported that the incidence of PTSD was highest after rape (49%, SE=12.2) followed by other forms of sexual assault (23%, SE=10.8). The incidence of PTSD after being shot or stabbed was 15% (SE=13.7), a serious car accident was 2.3% (SE=1.3), other kinds of serious accidents was 16.8% (SE=6.2) and following natural disaster was 3.8(SE= 3.0). Given the high risk of PTSD following rape and other forms of sexual assault, there have been a growing number of treatment programs that specifically target victims of rape and other forms of sexual assault. While treatment modalities may not be explicitly feminist, due to the gendered nature of a majority of sexual assault their implementation is often influenced by feminist frameworks and feminist theory. Feminist frameworks pay heed to re-establishing appropriate boundaries in relationships, beginning with the therapeutic relationship, promoting self-determination in the victimized person, and empowerment of the victim to move from victim to survivor. Feminist informed approaches view sexual victimization as a crime against the self and highlight the contributions of a society that condones violence (Bass & Davies, 1992; Myers Avis, 1992; Solomon, 1992). Feminist therapeutic approaches emphasize integrating the social causes of rape into the client's world-view and reducing self-blame and guilt following sexual assault (Enns, 1993; Koss & Harvey, 1991). The goal of such analysis is to help the victim understand that such violence is a societal not individual (Enns, 1993). Although of feminist may different of treatment there is a of in a treatment in this systematic review as a and The of of therapy to victims in from sexual assault and rape are based on the psychodynamic and the cognitive to the psychodynamic traumatic events into and to and the the of self that is and in to and a to and requires of a of self and with 1997; & approaches are the for with trauma in forms sexual assault and rape. is the in which there is the available the literature on & studies 1997; & and clinical & 2006). of on how traumatic events and of and the this occurs, become and the individual is to and the and on of and & 1993; & of treatment a of specific approaches including or Stress and and are based on the that cognitive a significant in the severity and outcomes of PTSD symptoms after sexual assault & 1997; Foa, & Rothbaum, Koss & & Foa, 2002). on the of and cognitive associated with the traumatic which will to and In general these approaches systematic to traumatic and cognitive of these events Riggs, & and and therapy including rape and and reduction techniques & Foa & Rothbaum, & Johnson, 1998). treatments for victims of rape and sexual assault, have been with other types of such as psychodynamic or has been found to be effective in reducing symptoms of PTSD Rothbaum, Riggs, & and Harvey, and Resick 1992; Rothbaum and Foa, has focused on which of treatment be more effective than Foa and colleagues (1991), for instance, and treatment found that while was the effective treatment in reducing PTSD symptomatology after was found to be effective treatment at was to or a in terms of other of anxiety, or It that such approaches treatment by to stress and while the and et al., 1991). However, the evidence to this has been For instance, Foa et (1999) and a of and with a and found that three reduced symptoms of PTSD and depression to the control to general better than or the for PTSD and depression were similar for the three groups across a effect for the reduction in PTSD severity and depression were reported for the treatment. The was in the number and of that in this than the group and the group et al., The authors that this a as to the did not the therapy of cognitive therapy and in the form of and the traumatic event et al., 1993; Resick & 1992). Resick et (1992) that that of the events, and and be more effective in symptoms than the but not regarding which are rape victims & 1992). the of the authors examined in a group in the treatment of PTSD & 1992). The indicated that was effective in symptoms in a majority of in to the in significant in PTSD and depressive symptomatology to the when in a group Resick et a controlled with and a attention victims of rape with to symptoms of PTSD and The authors made not to cognitive in the or to or behavioural in the et 2002). The indicated that and were in treating PTSD in this sample of rape victims to the were found to be effective in treating depressive was found to be to in guilt desensitization and reprocessing has attention the have been mixed and have been a of groups to assess & & et al., et al., studies have been with sample and few studies have been with the victims of sexual assault. Although several that the has not been well (Rothbaum, Astin & similar to (Rothbaum, 1997). For instance, during the is to of traumatic while on a such as or (Rothbaum, 2005). As it has been suggested that PTSD is due to to the trauma and may be in this reprocessing Steketee, & Rothbaum, Rothbaum, 2005). 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