I was both sad and angry when I heard recent statistics about the incidence of a specific crime in this country. According to FBI data, murders in 2004 decreased for the first time in 5 years, and the number of violent crimes, including aggravated assaults and robberies, fell by 1.2%.1 Property crimes also dropped in 2004, by 1.1%.1 However, the number of rapes has increased for 3 of the past 4 years—in all, by 0.8%.1
This last statistic reminded me of a shocking story a close friend told me over 20 years ago. She was awakened in the middle of the night by a man standing by the side of her bed. She struggled, but her attacker's threats of bodily harm made it clear that she should not resist further. After raping her, he left his terrorized victim and disappeared into the night.
What has stayed with me through the years is not so much my friend's description of the event, although I found it horrifying, but that she seemed so ordinary. In fact, she seemed just like me. She was young and hard working, had a family and friends, and lived on Main Street, USA, in a small New England town. How was it possible that she became a rape victim? Two decades later, I realized that I could use my memory of this traumatic event to help my PA colleagues learn more about rape, its victims, and its tragic aftermath.
Rape victims and the health care system
Rape is a violent crime that has both short- and long-term effects on the victim. At least some victims seek medical help. According to one study, sexual assault survivors' visits to their physicians increase by 18% the year of the assault, 56% the year after, and 31% the second year after the assault.2
Overall, 31.5% of women who reported being raped as adults suffered some type of physical injury during the attack. More than one third (35.6%) of those received medical care; 81.9% of all medical care received by rape victims occurred in hospitals.3
PAs in emergency medicine are the most likely to evaluate rape victims in the acute care setting and may
be more knowledgeable about rape. However, research has shown that women who have experienced violence are more likely to turn to their primary care provider for help than to mental health professionals, police officers, or lawyers.4,5 Those in primary care will often be the first—and often the only—health care provider to evaluate the woman for trauma.4
Unfortunately, primary care clinicians may be unable to provide help. A recent study examined the extent to which a random sample of 250 primary care practices in Virginia were prepared to provide care to victims of sexual violence. Many practices refused to participate, saying that they did “not have any rape victims” in their patient panel. More than 80% did not have staff trained to assist victims; two thirds had no relationship with the community rape crisis center.6
Primary care providers, like Americans in general, need to know the facts about rape. Distinguishing the facts from the many myths we hold about rape is essential to providing good care for victims of sexual assault.
Myth: Rape doesn't happen very often
Shockingly, the US Department of Justice says that every 2 1/2 minutes, somewhere in America, someone is sexually assaulted.7 In 2002 and 2003, there were an average of 223,280 rapes, attempted rapes, or sexual assaults. Rape can happen to people of all ages, races, and socioeconomic groups. Assailants often choose victims who seem most vulnerable to attack: older persons, children, and those who are physically or emotionally disabled.
Myth: Rape is an act of sex
Nothing is further from the truth. Rape is an act of violence—often a life-threatening one. Men rape to express anger and to dominate. Rape is about power and control. Most rapes are committed by persons known to the victim.8 Most convicted rapists are married or have an available sex partner; rape is not an act of uncontrollable passion but rather a criminal act in which sex is used as a weapon. Studies show that 75% percent of all assaults are planned in advance: 58% when one assailant is involved, 83% for two assailants, and 90% in gang rape involving three or more perpetrators.9 The mythology of rape is that it is committed by strangers in dark alleys and parking lots. In reality, however, more than 33% of rapes occur after the assailant has forced his way into a home, and more than half of rapes occur in a residence.10 In my friend's case, the rapist was a married acquaintance who lived across the street.
Myth: Women incite men to rape
This is one of the most damaging myths about rape and probably the most difficult to dispel. Some people believe that rape cannot occur without some cooperation from the victim.10 Others believe that assault happens to careless women who are “asking for it” by the way they dress or the places they visit. In some cases, such as my friend's, the woman does not resist because she fears for her life, and so she is not physically hurt. Serious physical injury does not have to occur, however, to make a rape real.11 Seventy percent of rape victims reported no physical injury, 24% had minor physical injuries, and 4% sustained serious injuries.11 However, 49% describe being fearful of serious injury or death during the rape.11
Submission is not the same as cooperation, and to argue that it is shifts the blame from the perpetrator to the victim. If a victim chooses to cooperate in response to an attacker's threats, her cooperation should not be construed as consent. Sexual assault is just that—assault—and no one “deserves” to be raped.
Myth: Rapes are usually reported
In reality, rape is probably one of the most underreported crimes. Researchers estimate that 50% to 90% of rapes go unreported.10 According to the 2003 National Criminal Victimization Study, 61% of rapes/sexual assaults are not reported to the police.7 There are a variety of reasons why this is so. The victim may fear that the assailant will retaliate against her or her family, or she may feel too humiliated by what happened to go to the police. Female victims often have trouble telling male family members, friends, and boyfriends about an assault.
As for the number of false reports, the most quoted statistic is 2%, popularized in Susan Brownmiller's 1975 book Against Our Will.12 According to FBI Uniform Crime Reports, fewer than 5% of reports of rapes are false—the same percentage as for other felonies.13
Myth: Most rapists are convicted
Prosecuting rape is a long and tortuous process. Fewer than half of those arrested for rape are convicted; 54% of all rape prosecutions end in either dismissal or acquittal.2 If the rape is reported to police, the chances are 50.8% that an arrest will be made. If an arrest is made, the chance of prosecution is 80%. If the case is prosecuted, the chance of a felony conviction is 58%. If there is a
felony conviction, the chance that the rapist will spend time in jail is 69%. So even in the 39% of attacks that are reported to police, the chances are only 16.3% that the rapist will end up in prison. When unreported rapes are factored in, only about 6% of rapists—1 out of every 16— will ever spend a day in jail. The other 15 will walk free.2
When a rape victim decides to press charges, the police and district attorney decide whether the evidence is sufficient to make the rape case worth prosecuting. If they determine that the evidence is insufficient, outsiders often assume—wrongly—that this means the charges are false. Pressing civil rather than criminal charges may increase a rape survivor's chances of receiving some justice, such as financial restitution for emotional distress. Most civil cases are settled out of court.13 In my friend's case, her assailant was arrested and, 18 months after the rape, the case went to jury trial. At the last minute, a plea bargain resulted in the assailant's receiving a 15-year sentence, of which he served 9 years.
Myth: You don't know anyone who has been raped
Despite my friend's experience, I still find it hard to imagine someone I know being a victim of rape. It is hard to shed the “it happens to other people” mentality. But after writing this editorial, I have a better understanding of why PAs should know the facts so they can appropriately evaluate and care for rape victims. Given the statistics, you probably know someone who has been raped. You may just not know who it is.
REFERENCES
1. Freidan T. FBI: Violent crime rate declines again. October 17, 2005. Available at: http://www.cnn.com/2005/LAW/10/17/crime.rate/. Accessed October 27, 2005.
2. Sexual assault statistics. Men against sexual assault at the University of Rochester. Available at: http://sa.rochester.edu/masa/stats.php. Accessed October 27, 2005.
3. Tjaden P, Thoennes N. Prevalence, Incidence, and Consequences of Violence Against Women: Findings From the National Violence Against Women Survey. National Institute of Justice, Centers for Disease Control and Prevention. Research in Brief. Available at: http://www.ojp.usdoj.gov/nij/pubs-sum/172837.htm. Accessed October 27, 2005.
4. Koss MP, Woodruff WJ, Koss PG. Relation of criminal victimization to health perceptions among women medical patients. Journal of Clinical and Consulting Psychology. 1990;58(2):147-152. Available at http://content.apa.org/journals/ccp/58/2/147. Accessed October 27, 2005.
5. Mehta P, Dandrea LA. The battered woman. Am Fam Physician. 1988;37:193-199.
6. Plichta SB, Vandecar T, Tiraphat MS, Houseman C. Rape victims: are primary care practices prepared? Paper presented at: American Public Health Association 133rd Annual Meeting & Exposition; December 12, 2005; Philadelphia, Pa. Available at: http://apha.confex.com/apha/133am/techprogram/session_15613.htm. Accessed October 27, 2005.
7. Catalano SM. Criminal victimization, 2003. Bureau of Justice Statistics. National Crime Victimization Study. September 2004. Available at: http://www.rainn.org/docs/statistics/cv03.pdf. Accessed October 26, 2005.
8. Standing Together Against Rape. Anchorage, Alaska. Available at: http://www.star.ak.org/Library/files/rmr.htm. Accessed October 27, 2005.
9. Rape Victim Advocates. Dispelling the myths. Available at: http://www.rapevictimadvocates.org/myths.html. Accessed October 27, 2005.
10. Common myths about sexual assault. Project Horizon. Available at: http://organizations.rockbridge.net/projecthorizon/sacommonmyths.htm. Accessed October 26, 2005.
11. Pratt K. Rape in America. A Report to the Nation. Arlington, Va: National Victim Center; 1992.
12. Brownmiller S. Against Our Will: Men, Women, and Rape. New York, NY: Simon & Schuster, 1975. Available at: http://www.susanbrownmiller.com/html/against_our_will.html. Accessed October 27, 2005.
13. Sexual violence statistics. STAAR (Students Together Against Acquaintance Rape). University of Pennsylvania. 1997. Available at: http://dolphin.upenn.edu/~staar/manual/stats.html. Accessed October 27, 2005.