What I Wish I Knew About Sexual Assault

By: Joseph Maa

[Trigger warning] This topic may be sensitive to some readers.

I don’t know how to respond when a friend tells me: “I’ve been sexually assaulted.”

I don’t want to believe that people have been conditioned to accept sexual assault as perfectly normal, a phenomena of daily life, and a systemic problem that can’t be changed. My article is intended to inform you of a few things I didn’t know about sexual assault. It is not my story to tell, but it is my responsibility to write, and to share a few problems with the idea of sexual assault.

You indicated your crotch
And told me
To take responsibility
For what I’d started
But what of my responsibility
To myself?
I threw that away
To be responsible
for your pleasure

Figure 1: A poem written a while back and sent to me by a friend

This all started with this poem, sent to me a few days prior, a singular account of sexual assault. Let me tell you that there’s no worse feeling than being given a second-hand report of sexual assault as it unfolds. Your stomach curls, and your mind settles into a haze of raw anger and helplessness. I’ve never considered myself an overly emotional person, but I saw red, those few days ago, the day a brave soul had the confidence to confide in me and share a story of fear, anger, contempt, and finally acceptance.

Screen Shot 2017-04-09 at 11.37.04 AM.png
Figure 2: Seeing red after listening to her narrative. [1]

Firstly, I don’t have the qualifications to talk about in the case a situation like this. If you are looking for resources, my friend Kylie feels comfortable being reached out to as a first stop in the event that sexual assault does occur after this article is written.

Secondly, what I do feel comfortable with is analyzing and breaking down problems. In doing so, I hope to contribute a cogent breakdown of a small part comprising a larger issue as it stands. As a result, this article will be a review of this paper: [2] by Kaitlin Wilson.

This paper was written in response to the rising prevalence of PTSD among assault survivors in Canada, far above international averages. For that reason, Wilson wrote this paper implying that current therapy for sexual assault should be strongly reconsidered. In doing so, she delves into some of the biological pathology as well as psychological methods of treatment. The few critical ideas to take away with you from her paper are:

  1. The dysregulation of the Hypothalamic-Pituitary-Axis
  2. The shortcomings of current pharmacotherapies
  3. SARTE, an example of a sexual assault response team done better
  4. Perceived positive regard, early social support, and psychotherapy treatments along with education is important to recovery.
Screen Shot 2017-04-09 at 11.39.01 AM.png
Figure 3: Note that the recipient, in this case the survivor, has to perceive the positive regard and this is independent of the giver’s intentions. [3]

Furthermore, I also reached out to the author of Pop Psychology and PhD in Experimental Psychology, Jesse Marczyk, whose sensationalist blog actually contains pertinent analysis of recent findings directly applicable to understanding of the survivor’s mindset. His review of the article ultimately boils down to the fact that survivors of sexual assaults tend to assign more blame to themselves moreso than friends and family whom knew the sexual assault had occurred. [4]

Screen Shot 2017-04-09 at 11.42.01 AM.png
Figure 4: While important, survivors of sexual assault tend to attribute more of the blame to themselves than did 3rd parties.

One of the earliest conclusions that I reached shocked me.  The simple prevalence of sexual assault incidents across the US and Canada was almost irrationally high. In her paper, Wilson cited 21% of students at the University of Alberta to have experienced at least one unwanted sexual advance. [5]

Normally statistics can be exaggerated, but as I kept looking at different websites, I realized the lower bound of sexual assault never dropped below 10%. [6][7] This alarming frequency paired with the fact that sexual assault has directly affected someone that I know, was my personal impetus for this article. Furthermore, while critics may address non-responder bias to surveys as a reason for the high percentages, the studies that I looked at ultimately covered different periods of the past 30 years, and were also achieved independently. [6] [8]

Screen Shot 2017-04-09 at 11.46.06 AM
Figure 5: The fact that college women are at three times higher risk of sexual assault is indication that there is a need to directly address the problem head-on, just like how you’ll read Edmonton does so later on. [9]

Thus, I firmly believe that this problem is more pervasive than the general public would make it out to be, and ultimately problematic for both survivors and their immediate social circles. So, without further ado, let’s get into the paper.

Sexual assault and posttraumatic stress disorder: A review of the biological, psychological and sociological factors and treatments:

Introduction:

With the purpose of defining sexual assault more clearly, Wilson first laid out her definitions:

  1. Sexual assault: any form of sexual contact without voluntary consent and violates a person’s sense of autonomy, control and mastery over their body.
  2. PTSD: a disorder that develops in some people who have experienced a shocking, scary, or dangerous event. [10]

After defining the problem, Wilson clarifies that in Canada, it was estimated that 50% of women experienced PTSD after sexual assault. She goes on to say, “The alarmingly high rate of PTSD in survivors of sexual assault is a strong indication that the current therapies for rape victims are inadequate and in need of improvement.” This ultimately was her impetus for writing the review.

1. The Dysregulation of the Hypothalamic-Pituitary-Axis:

Screen Shot 2017-04-09 at 11.17.57 AM.png
Figure 6: The Hypothalamic- Pituitary-Axis. Notice that the adrenal cortex is not the kidneys themselves, but the organ on top of them.[11]

Wilson addresses the fact that the Hypothalamic-Pituitary-Axis, heretofore referred to as the HPA, is messed up (dysregulated) in individuals with PTSD. Normally, the body creates Corticotropin-Releasing-Hormone (CRH) in the hypothalamus, which stimulates the anterior pituitary to release Adrenocorticotropin-Releasing-Hormone (ACTH) which subsequently releases cortisol from the adrenal glands, organs that look like little hats on top of the kidneys. Ultimately, cortisol is the main hormone responsible for stress. Finally, cortisol produces the stress response, and as it is released, signals back to the hypothalamus to stop producing CRH.

However in survivors with PTSD, too much CRH is released, leading to an adaptive decrease in the number of receptors in the anterior pituitary, as well as decreased negative regulatory control of cortisol, leading to over-activation of the HPA [11], which also possibly leads to further dysregulation of the mesocorticolimbic dopaminergic system, which could lead to an inappropriate fear response and persistent mild depression. [12] This is the same limbic system that governs emotion, behavior, motivation, and long-term memory.

2. The shortcomings of current pharmacotherapies:

Again, Wilson chose to first define the goals of the current pharmacotherapies before addressing their shortcomings. Her perception of the goals were:

  1. To reduce core symptoms: anxiety and flashbacks
  2. To improve stress resilience
  3. To improve quality of life
  4. To reduce disability and comorbidity (concurrence of two diseases)

As well as the HPA dysregulation described above, the serotonergic, adrenergic, and glutamergic systems are also disrupted by PTSD. [13] These disruptions contribute to a reduction in the size of the hippocampus, a region of the brain important for memory, and this pathology sets precedent for treatment with Selective Serotonin Reuptake Inhibitors. (SSRIs) While SSRIs have been used commonly with depression, researchers finally recognized that it might have use for treatment of PTSD after a paper was written in 2004 that showed a 5% hippocampal increase in patients with PTSD after treatment with Paroxetine, an SSRI . [14]

Screen Shot 2017-04-09 at 3.36.06 PM.png
Figure 7: It’s not right without a few chemical structures. This is fluvoxamine. You can see the amine group at the top of the picture [15]

Furthermore, the immune system is considered to be co-regulated with inflammatory diseases, e.g. HPA dysregulation. In a study with female patients with a history of childhood abuse, Fluvoxamine, a different SSRI was shown to decrease the hyperresponsiveness of the HPA axis within the first 6 weeks. [16]

Moreover, the glutamergic system also experiences dysregulation, evidenced by a sharp increase in activation of GABA- receptors, which is thought to be due to a release of benzodiazepines by the body. [17] Thus, benzodiazepine-inhibitor drugs like flumazenil may have efficacy in controlling anxiety and flashbacks. However, a review in the Journal of American Medicine Association mostly showed SSRI’s to be the only medication that has shown empirical evidence for it’s use. [18]

3. SARTE, an example of a sexual assault response team done better

Since 1999, the Edmonton Capital Health Authority has run the Sexual Assault Response Team of Edmonton (SARTE). Nurses well-versed in the procedures explain the treatment thoroughly and work with assisting patients through interactions with law enforcement. Previously Edmonton, was considered the “sexual assault capital of Canada”. [19]

The link previously is written by a survivor of sexual assault specifically from Edmonton, who personally utilized SARTE after her sexual assault. The key takeaway was that the city recognized a problem had manifested itself for too long, and took preventative actions. On college campuses, similar actions could alleviate problems caused by sexual assault, especially if students knew that law enforcement and nurses were working together professionally to identify perpetrators.

Screen Shot 2017-04-09 at 3.39.27 PM.png
Figure 8: It’s surprising that Wilson talks about the prevalence of PTSD after sexual assault, but doesn’t attempt to address the numbers. This is from a single website [20]

4.

Perceived positive regard, early social support, and psychotherapy treatments along with education is important to recovery.

Perceived positive regard, early social support, and psychotherapy treatments along with education is important to recovery.

These four factors are imperative to recovery. Because over half of survivors choose not to tell anyone about their experiences, PTSD in survivors can be negatively impacted. This paper here says that reduction in self-blame, a process that is initiated by the survivor, had improved recovery. [21] Additionally, this process  could be supplemented by psychotherapy, as well as group therapy.

For instance, Eye Movement Desensitization and Reprocessing (EMDR) is a psychotherapy that emphasizes remembering traumatic memories while simultaneously attempting to solve visual tasks. For anybody like me who gets distracted easily, this makes it very difficult to maintain concentration, and is thought to allow survivors process their trauma more wholesomely.

Screen Shot 2017-04-09 at 3.53.16 PM.png
Figure 9: Supposed reduction in brain activity after EMDR treatment [22]

While it is controversial whether the eye movements are responsible for recovery, it is considered an evidence based cognitive behavioral therapy. In an EMDR study by Rothbaum, only 10% of EMDR participants experienced PTSD post-treatment.  [23] Although, a critic might point out that the cohort consisted of only 18 participants, in conjunction with other treatments, EMDR may have efficacy as a protocol to assist those seeking recovery and to empower those looking for more resources to regain back their lives. [24]

Regarding trauma debriefing after an incident, a single study found that debriefing paradoxically may have contributed to the onset of PTSD. While studies like these are normally have a small number of participants, further research has to be done into seemingly well-intentioned protocols that are in place for law enforcement. [24]

Conclusions:

Here are the four points that we went over in this long article:

  1. The dysregulation of the Hypothalamic-Pituitary-Axis
  2. The shortcomings of current pharmacotherapies
  3. SARTE, an example of a sexual assault response team done better
  4. Perceived positive regard, early social support, and psychotherapy treatments along with education is important to recovery.

In my opinion, the topic of sexual assault on college campuses is understated. Too often, campuses brush aside the recurrent problem of sexual assault in favor of flimsy and weak programs that do not condemn the perpetrators.

While this article was focused on recovery, I believe that are merits to assembly of groups like SARTE to combat the persistent spectre of sexual assault on college campuses. Ultimately, there is still much work to be done and hopefully you can take away a better idea of the underlying problems with sexual assault.

Your friend,

Joseph Maa

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