Definition of “sexual assault” (noun): illegal sexual contact that usually involves force upon a person without consent or is inflicted upon a person who is incapable of giving consent (as because of age or physical or mental incapacity) or who places the assailant in a position of trust or authority

In recognition of April being Sexual Assault Awareness month, I want to bring light to a subject that I feel passionately about. Due to a generous grant in the county where I currently reside, I have been gifted the opportunity to become a sexual assault forensic examiner (SAFE; also called SANE) to better serve the women and men in my hometown area when they present to the emergency department following a sexual assault. This heinous crime is incredibly under reported due largely to the reality that victims are often not believed. Many people are embarrassed or ashamed following a sexual assault which is further compounded by the fact that so many people are accused of lying or are simply brushed off when they do attempt to report their trauma.

THIS HAS TO STOP.

Want to hear something horrifying? 1 in 5 women will be raped in their lifetime. Truly think about this statistic. Imagine you, your daughter, your best friend, her daughter and your sister…statistically speaking, one of you will be RAPED in your lifetime. Rape is not exclusive to women; 1 in 71 men will be raped in their lifetime. Imagine this life-changing tragedy occurring and then having no one believe you or your loved one when they try to seek justice and treatment. Imagine what trying to heal after something like this happens; now imagine trying to heal while the world calls you a liar.

FACT: 1 in 5 women will be raped in their lifetime

Those are just the stats for being RAPED. A staggering 1 in 3 women will experience some form of physical contact sexual violence in their life. Let me say it louder for the people in back: ONE IN THREE! For men the number is 1 in 6. How is this able to occur in such high numbers? Simply—it’s easy to get away with because we are not a believing society, therefore, sexual assault is under reported. And by “under reported” I mean that rape is THE MOST UNDER REPORTED criminal act: 63% of sexual assaults are never reported. When sexual assault occurs on college campuses, studies show that over 90% of cases are never reported. NINETY PERCENT!!! That is appalling.

FACT: 63% of sexual assaults are never reported

What many people don’t realize is rape rarely happens the way it is most often thought of or portrayed in movies. The majority of people imagine “rape” as a woman walking alone in a mini skirt down a dark alley in the middle of the night when suddenly a stranger emerges from the shadows and attacks her. Right? Although scenarios like this do obviously happen, in 80% of rape cases, the victim knew their perpetrator. A staggering 51.1% of women who have been victims of rape reported the perpetrator being their INTIMATE PARTNER. Additionally, 40.8% of women who have been victims of rape reported the perpetrator being an acquaintance. And apparently nowhere is safe—8% of rapes occur while a victim is AT WORK.

FACT: 80% of rape victims knew their attacker

Although false reporting does happen, it is VERY RARE. Studies have found that the prevalence of false reporting is extremely low – between 2-10% with multiple studies showing an average of 2.1%. This statistic shows why it is so incredibly important to believe victims when they come forward with sexual assault allegations. In the Emergency Department, we can’t prove that a patient is having chest pain; we have to take their word for it. This is the same mentality that should be taken when sexual assault is the presenting complaint. It is not our job as healthcare professionals to decide whether or not the patient is telling the truth—our job is to care for them as best we can [physically and mentally] and often we will be the first person to look the victim in the eye and say “I believe you.” This means everything to a scared patient who just had their control ripped away from them temporarily. Be the first building block in helping them get that feeling of control and security back.

FACT: The prevalence of false rape claims is 2.1%

Although SAFE/SANE nurses do obtain a very detailed report, the focus is centered on specific injuries and sites that are optimal for evidence collection. The task of asking the who/what/when/where questions is left much more to the police. Thankfully, special training in the area of Forensic Experiential Trauma Interviewing (FETI) is becoming more common. The sexual assault victim presents an interesting and sometimes damning phenomenon in the days after the sexual assault takes place. When an assault victim is interviewed immediately after the event happens, they can often react in a manner that seems bizarre or irrational. Furthermore, their ability to remember events in a chronological order is severely impaired so the victim appears to be unreliable or dishonest. The science that backs up why this occurs is much more recognized today and taken into account on the law enforcement side of things.

Let’s get into the science:

For the sake of this article, we will separate the brain into two categories:

1. Prefrontal cortex regulating complex cognition (AKA higher brain function)

2. Limbic system regulating unconscious functions like blood pressure control and breathing

When a person is faced with overwhelming emotions like fear, terror or severe stress, physiological changes occur in the brain impairing higher brain function. The prefrontal cortex is responsible for processing information, making and executing decisions, creating memories, and comparing what is being experienced to what is already known.  These are distinctly human abilities.

The limbic system contains several brain structures that control different processes within the brain. The amygdala processes emotional reactions and memories and is constantly scanning your surrounding for threats. The hypothalamus links the nervous system and the endocrine system. The pituitary gland is the master gland and controls hormones throughout the body. The hippocampus is the memory maker. Therefore, when presented with severe stress/terror/fear, your limbic system takes over and travels through what is called the HPA Axis, also known as the “emotional loop”.

Emotional loop of the Limbic System:

Picture this: Your amygdala is scanning, scanning, scanning looking for any threat that might occur when suddenly, it processes your emotion reaction of fear! Your hypothalamus links this emotional process and tells the boss of your endocrine system: the pituitary gland. The pituitary gland then tells your adrenal glands to release hormones into your body!

This cocktail of hormones includes:

Adrenaline- causes the fight/flight/freeze response. Chances are you’ve really only heard of the fight or flight response that occurs when someone is scared/threatened/etc. New studies show, however, that there is a third option: freeze. This is more scientifically called “tonic immobility” and is an autonomic response in the body meaning you have no conscious control over it. This occurs in up to 50% of sexual assault survivors and is truly terrifying; imagine being attacked and having your body take over your mind resulting in you being unable to speak, respond or move but being completely aware of what is happening to you. This can be compared to sleep paralysis but is an entirely separate phenomenon. This hormonal response that we have NO CONTROL OVER can help to answer the stupid questions commonly asked of survivors: Why didn’t you fight back? Why didn’t you run?

Cortisol- releases energy

Opioids- blocks pain and blunts emotion

Oxytocin- promotes good/positive feelings; also helps to block pain. The release of this hormone is why some survivors act bizarrely immediately after the attack. During interviews and exams, some people laugh hysterically or smile while they are talking. This is difficult for an interviewer to process given the current situation so having a thorough knowledge of the neurobiology of trauma helps those involved to understand why the victim is acting the way they are.

Memory loop of the Limbic System:

So quick refresher—the amygdala is scanning for threats and detects one: que the hypothalamus which links the nervous and endocrine systems and tells the pituitary gland to tell the adrenal glands to release all kinds of hormones. This is the emotional loop. At the same time, the amygdala also alerts the hippocampus which makes memories in 2 steps.

1. Encoding: taking information and tagging it
2. Consolidating: group information and record it

Interestingly, alcohol negatively impacts coding but enhances the sense of smell. The hormones released during times of severe stress/fear/terror/etc. impair memory consolidation making immediate retrieval of specific details very difficult for a victim. Because of the huge flood of hormones, the hippocampus can record memories related to senses, BUT with no chronological sequence. The memories are fragmented, however, accuracy is NOT affected. Sleep can help restore memory consolidation significantly.

The consequences of a traumatic event impact the body in many ways. When the prefrontal cortex is flooded with hormones, complex cognition and decision making is impaired. The effects of these hormones can last for 96 hours and produce many physical symptoms include: headache, insomnia, body aches and irritability. Inhibitory mechanisms are also impaired making the victim susceptible to making bad decisions or behaving abnormally. Clearly, this is not the recipe for producing a traditionally “reliable” witness which also adds to the disbelief of many victims.

This is why the importance of a forensic experiential trauma interview is so important. Interviewers are taught to lead with patience and compassion while normalizing patient’s responses. Ask open ended questions and avoid chronological inquiries initially (Ex. What happened first? Then what happened?). Focus on sensory memories as they are still able to be encoded and consolidated; this is done by asking victims what they are feeling and what they were feeling during the attack. Above all, provide trauma informed care.

Although April is Sexual Assault Awareness month, it is a topic that deserves attention and resources all the time. Annually, rape costs the United States $127 billion—more than physical assault, murder, and drunk driving (including fatalities). The odds of the justice system changing are slim and 98% of rapists will never spend a day behind bars. Therefore, let’s focus our time and energy towards helping the victims of sexual assault feel safe, be able to express themselves and regain control of their lives so they can go on to lead productive, happy, healthy lives. That all starts by gifting victims with a collective message: I believe you.

<3 #metoo

Statistics for this article provided by The National Sexual Violence Resource Center at www.nsvrc.org/statistics

Additional information regarding the Me Too movement can be found here: https://metoomvmt.org/