Rape-Related PTSD: Issues and Interventions

Rape is a crime that is defined as an unwanted sexual act that results in oral, vaginal, or anal penetration.¹ Generally speaking, there are 2 major types of rape. Forcible rape involves unwanted sexual penetration obtained by the use of force or threat of force. Drug- or alcohol-facilitated rape occurs when the victim is passed out or highly intoxicated because of voluntary or involuntary consumption of alcohol or drugs. Rape can happen to boys and men as well as to girls and women,² but this article will focus primarily on women.

Before describing data on rape prevalence, it is important to address some common stereotypes so that mental health professionals will have an accurate understanding about the true nature and scope of rape.

• First, contrary to stereotype, rape is not an experience that only happens to adult women. Data from carefully conducted epidemiological studies suggest that more than half of women who have been raped were first raped before age 18.^3-5
• Second, contrary to stereotype, many women who have been raped have been raped more than once^3,5,6; women who seek treatment for a recent rape may have been raped in childhood or in adolescence.
• Third, although the stereotype is that most perpetrators are strangers, the data indicate that perpetrators are much more likely to be someone the victim knows well.^3-5
• Fourth, although many people expect victims of rape to have sustained serious physical injuries, the reality is that most rape victims sustain either minor or no physical injuries, perhaps because most of them are fearful that the perpetrator will kill or seriously injure them if they resist.^3-5

Many rape victims themselves believe these stereotypes and think of rape as something that only happens to adult women, is committed only by strangers, and that always involves excessive levels of physical force. This means that proper case finding and screening must make use of procedures that counteract these stereotypes.

There is substantial evidence that rape is a major problem for women in the United States. The best epidemiological studies indicate that the lifetime prevalence of forcible rape (ie, the proportion of women who have been raped) is between 12.6% and 16.1%.^3-5 One recent national survey⁴ found that 18% of a national probability sample of women in the United States had been victims of at least 1 forcible rape (16.1%) or drug- or alcohol-facilitated rape (5.4%). Based on 2005 US Census data, this means that an estimated 20.2 million women have been raped. This same study found that the past-year prevalence (ie, the proportion of the sample who had been raped within the past year) was 0.94%, or an estimated 1.1 million women.

Recent lifetime prevalence estimates of forcible rape are higher than those obtained in the early 1990s using similar methodology³ and suggest that the prevalence of rape in the United States has increased over the past 2 decades. Furthermore, past-year prevalence estimates for forcible rape are comparable to those reported in the early 1990s, raising doubts about claims that the annual incidence of rape is decreasing.

Of particular relevance to the topic of this article, data from a large probability sample of psychiatric patients with serious mental illnesses found that the lifetime prevalence and past-year prevalence of rape was substantially higher in female patients than the estimates just reviewed.⁷ This suggests that a history of rape victimization is not uncommon in patients with psychiatric disorders.

This article addresses 3 major topics, including screening and case finding, assessment of posttraumatic stress disorder (PTSD) and other rape-related problems, and treatment issues. With regard to treatment approaches, early intervention is briefly addressed but the main emphasis is on treatment of PTSD and other problems in women who are not recent rape victims, since those with less recent assault history are more likely to be seen by mental health practitioners.

Rape and other forms of sexual assault have broad-reaching effects on many levels, including basic needs, functional impairment, physical health, and mental health. Although chronic psychopathology does not develop in most rape or sexual assault victims, these forms of traumatic victimization are associated with a higher prevalence of PTSD than are other types of traumatic events. For example, the National Women's Study,⁸ an epidemiological survey of 4008 women, found the lifetime prevalence of PTSD resulting from rape and sexual assault to be 32% and 30.8%, respectively, compared with a prevalence of 9.4% caused by non- crime-related trauma (eg, motor vehicle accident).

Population-based studies indicate that about 1 in 9 women have met criteria for PTSD at some point during their lifetime.^8,9 In real population numbers, these estimates equate to about 11 million women in the United States. Other common mental health consequences of rape are major depression and alcohol or drug abuse.^8,10 In this article, we focus on PTSD because it has been the most extensively researched area of the treatment literature in this population.