In 2012, the Centers for Disease Control and Prevention (CDC) reported that nearly one in five women experience sexual assault at some time in their lives (CDC, 2012; McCall-Hosenfeld, Freund, & Liebschutz, 2009). Sexual violence against women is a pervasive public health issue, but fortunately, advancements have been made in the evaluation and treatment of victims and in the prosecution of offenders. In the United States (U.S.) legal changes have occurred in every state, shifting the focus away from victim blame and directing it toward the behavior of the defendant (Clay-Warner & Burt, 2005). Medical evaluations of rape victims have become more patient centered since the advent of sexual assault nurse examiner (SANE) programs (Ledray, Faugno, & Speck, 2001). In addition, DNA analysis has been incorporated into alleged rape investigations, and the usefulness of these analyses continues to improve (Garvin, Fischer, Schnee-Griese, & Jelinski, 2012). However, successful prosecution of assailants continues to be challenging (Ellison & Munro, 2009). One or more nonconsensual sexual act(s) must be proved to have occurred. Lay people empaneled as jurors rely on forensic evidence, witness testimonies, and good judgment to determine the guilt or innocence of the defendant.
Rape myths remain prevalent; one of the harmful consequences is low conviction rates for offenders (Aronowtiz, Lambert, & Davidoff, 2012; Deming, Covan, Swan, & Billings, 2013; Heath, Lynch, Fritch, & Wong, 2013; Rich & Sefrin, 2012; Weiss, 2009). Rape myths were described by Burt in 1980 and defined as stereotypical, prejudicial, or false beliefs about rape, rape victims, and rapists that are generally untrue but widely held (Buddie & Miller, 2001; Weiss, 2009). Rape myths perpetuate and support male upon female sexual violence and serve to justify or deny male sexual aggression against women (Brownmiller, 1975). Societies with a more egalitarian view of contributions by men and women, and with less male dominance, are not as apt to have a rape culture. In contrast, cultures with hostility toward women commonly are noted to have a higher acceptance of rape myths (Livingston, Buddie, Testa, & VanZile-Tamsen, 2004; Suarez & Gadalla, 2010).
In general, U.S. society is willing to treat rape as a crime when it meets the “traditional” or “classic” scenario of a male versus female stranger rape involving a woman who is alone at night and sober. In the traditional scenario, the woman attempts to fight off her attacker with such force that she is injured and then immediately seeks help (Deming et al., 2013). In actuality, most rape victims know their attackers. The CDC reports that female victims of sexual assault identified their assailant as an intimate partner (51.1%) or an acquaintance (40.8%; Black et al., 2011). Victims who have been sexually assaulted by a known perpetrator are less apt to view it as a crime, more likely to excuse and justify the sexual assault, and believe that they are at least partially responsible for the assault. As a result, these victims are less apt to report to police or seek help for themselves (Clay-Warner & Burt, 2005; Deming et al., 2013; Weiss, 2009). Even when the victim appropriately identifies the assault as a crime, family and friends may not be as supportive when the scenario does not conform to social stereotypes (Deming et al., 2013; Sarmiento 2011).
Although men are more apt to endorse rape myths than women, police, prosecutors, clergy, medical providers, and therapists of both sexes have been known to endorse rape myths (Aronowitz et al., 2012; Rich & Sefrin, 2012; Suarez & Gadalla, 2010). Juries participating in mock sexual assault cases displayed tacit acceptance of rape myths when they expected to learn that the victims in the mock trials would fight back against their attacker, experience serious physical injury, report the attack immediately, and appear tearful and distressed when reporting (Ellison & Munro, 2009; Norfolk, 2011). However, when the mock juries were exposed to general expert testimony, the social and psychological information that was provided allowed the jurors to more reasonably evaluate behaviors they otherwise would have found incomprehensible or counterintuitive (Ellison & Munro, 2009).
In every state, expert witness testimony for the purpose of combatting rape myths and educating jurors about the realities of sexual assault either has not been expressly banned or has been supported by legal changes expressly indicating that it is admissible (Ellison & Munro, 2009; Long, 2007; Lonsway, 2005). General expert testimony about the behavior of sexual assault victims is often based on years of professional knowledge rather than formal studies, although there is a significant body of research available (Long, Palmer, & Thome, 2010). When expert witnesses rely on their own experience rather than empirical evidence, defense attorneys sometimes question their experience and credentials (Campbell et al., 2007). Referring to formal research within their own areas of expertise may enhance their effectiveness as educators for jurors and the court (Long, 2007).
The court’s decision to admit expert testimony must be based on whether it has foundational reliability and will help the jury. In the Minnesota Supreme Court, a majority decision ruling was issued in State v. Obeta (2011), stating that, in cases of criminal sexual conduct where consent is an issue, district courts are given discretion to admit expert opinion evidence on the typicality of delayed reporting, lack of physical injuries, and “submissive conduct” by sexual assault victims. This court decision continues to be interpreted in Minnesota courts. The original court decision, State v. Saldana (1982), prohibited the admission of expert testimony on the typical rape-victim behaviors in adult criminal sexual conduct cases.
State v. Obeta (2011) is a significant case, both in Minnesota and throughout the U.S. It set precedence in the state and provides guidance to the courts after 30 years of confusion regarding how, when, and why to use expert testimony in cases of sexual assault regarding victim behaviors, particularly delayed reporting, lack of injuries, and submissive behavior, but can be applied to other victim behaviors as well.
On the basis of outcome and importance of the case, we used the expert witness testimony granted in the Obeta decision to formulate a study in which we present statistical summaries of data obtained from an urban SANE program with emphasis on evaluating the time to seek medical care after a sexual assault, the seriousness of injuries sustained by the victim, and the resistance strategy used by the victim during the assault. In addition to serving as a reference for use by expert witnesses during testimony, the results of this study may also be used in the context of forums presenting sexual assault information to students and the general public.
This was a cross-sectional descriptive study examining the time from assault to arrival at the hospital for evaluation, level of physical and/or anogenital injury, and use of physical resistance during the assault. Data were gathered on female sexual assault victims undergoing examination by a SANE at Regions Hospital in St. Paul, Minnesota.
Institutional Review Board Approval
Before collecting data, approval was obtained from the Health Partners Institute for Education and Research Institutional Review Board.
The study population included all qualified patients presenting to Regions Hospital Emergency Department stating they had been sexually assaulted from January 2011 to December 2012. Inclusion criteria included female gender, age of 13 years or older, presentation to emergency department within 120 hours (5 days) of sexual assault, completed examination by a SANE, and signed consent allowing the chart to be used in scientific studies. Exclusion criteria included declining the SANE examination and patient inability to answer questions because of cognitive difficulties, altered mental status, or lack of memory about the assault. Furthermore, patients who delayed more than 5 days (120 hours) from the end of the assault to their appearance in the emergency department were excluded.
During the study period, Regions Hospital SANE program was staffed by 16 SANEs, all of whom completed training according to the International Association of Forensic Nurses guidelines (International Association of Forensic Nurses, 2013). These nurses also received ongoing training at monthly staff meetings and were offered continuing education at local, state, and national levels. Nine of the 16 SANEs were SANE-A certified. SANEs ranged in experience from 1 to 13 years.
Demographic data were collected for each patient including age, race, and ethnicity. Data were also collected regarding time to seek medical care, documentation of statements indicating active physical resistance, and physical and anogenital injuries as documented by direct physical examination (including colposcopic examination) during the SANE evaluation. Data reported were based on the nurse examiner’s direct observation whenever possible or on patient self-report when information was not directly observable. The nurse examiners collecting the data are trained to be objective and to systematically document information in a standardized format. This study is based entirely on the nurse examiners’ documentation; study investigators did not gather information from other sources such as law enforcement or from direct contact with patients.
Physical injuries were divided into four categories: none, mild, moderate, and severe. Mild physical injuries did not require medical intervention. Language within the SANE report for mild injury included one or more of the following words: swelling, redness, sore muscle, abrasion, scrape, bruise, hematoma, tenderness to palpation without other physical findings, petechiae, and contusion from bite. Victims placed in the moderate physical injury category required medical intervention and had language in the SANE report including one or more of the following: superficial tears/lacerations or sharp force injuries and chipped tooth. Physical injuries requiring medical attention and containing the language; broken bones including arms, hands, and facial bones; traumatic brain injury; deep lacerations or sharp force wounds requiring repair; stab wounds; strangulation; and pregnant with significant blunt abdominal trauma such as thrown down stairs or kicked in the abdomen were considered severe physical injuries. The most severe category was assigned to victims with injuries in several categories.
Anogenital findings were similarly summarized in four categories: none, mild, moderate, and severe. Written narrative of the findings alone was used to categorize the injuries. Mild anogenital injuries did not require medical attention. Language in the SANE report for mild anogenital injures included one or more of the following: bruises, tenderness to touch in anogenital area, redness, and abrasion. Moderate anogenital injuries required medical attention. Language found in the SANE report for this category included superficial tears/sharp force injuries. Severe anogenital injuries required medical attention. Language found in the SANE report prompting placement in this category were deep lacerations/sharp force wounds of the anogenital region requiring repair in the emergency department or the operating room and vaginal bleeding with evidence of a foreign body. The most severe category was assigned to victims with injuries in several categories.
Physical resistance was categorized as no physical resistance throughout the assault, physical resistance only in the second half of the assault, physical resistance only in the first half of the assault, and actively resisting throughout the assault. Absence of active physical resistance included remaining quiet, following commands, tonic immobility, and verbal denial of consent (saying “no”). Language within the SANE reports indicating “no resistance” included wanting the assault to be over, fear for safety, feelings of immobility, and asking the assailant to stop. Language in the SANE report indicating active resistance included forceful verbal denial of consent (screaming for help), forceful attempts to keep clothes on, forceful assault against attacker (kicking, pushing, punching, and biting), and attempts to run away from the attacker. Verbal, physical, or implied (weapon in vicinity) threats that were reported by the victim to the SANE were also recorded.
To determine the time to seek medical care, we calculated the hours from the end of the assault (as reported by the victim) to the victim’s arrival to the emergency department. If the patient did not know when the assault occurred, the data were reported as missing. The presence or absence of a police report before or during the SANE examination was also documented systematically.
Because of the subjective nature of the data and its importance to the article, the absence or presence of active resistance during the assault was examined with great care. Terms were clearly defined in a data dictionary, using objective criteria and listing key words that would indicate active resistance. Each victim’s SANE chart was analyzed by two independent investigators, one man and one woman, who were blinded to each other’s work. The two investigators’s scores were compared; for the 15% of patients where the raters disagreed, a third investigator adjudicated the difference. Most of the disagreements occurred when one rater coded this as “verbal resistance only” and the other rather coded this as “lack of physical resistance throughout the assault.” This occurred in 29% of the cases that were reviewed by a third rater. The final rating was determined by consensus.
Early informal analysis revealed that ratings for physical injuries were highly consistent between the raters. Because of this, formal analysis of interrater reliability for this and similar variables was not deemed necessary. Objective measures that were clearly stated in the SANE report (e.g., time of arrival to the emergency department, race, and age) were collected by a single rater, as these values were recorded directly from the SANE report and would not reveal variance between raters.
Frequency counts and proportions were used for categorical data. Time was divided into categories for inclusion in tables and graphs. Tests for statistically significant relationships between unordered categorical variables relied on Fischer’s exact test and logistic regressions. Relationships involving ordinal variables (e.g., level of injury) were analyzed using multinomial logistic regressions (0 = no injury, 1 = mild injury, 2 = moderate injury, and 3 = severe injury). A small number of patients had incomplete data for one or more questions. These patients were excluded from analyses for those particular questions but were included in other analyses whenever possible. The statistical analysis was completed in SAS 9.2 and 9.3.
Three hundred fifty-nine sexual assault patients were seen at the Regions Hospital Emergency Department between January 2011 and December 2012. Of these, 317 patients met inclusion criteria, and 42 patients were excluded (see Figure 1). Because this article is focused on rape myths related to female victims, the 16 men identified as rape victims were excluded. Nineteen patients were excluded because of inability to answer questions or an incomplete SANE examination, and 7 were excluded for other reasons.
Demographic characteristics and characteristics of the assault are summarized in Table 1. Two hundred thirty-six (75%) study subjects reported the sexual assault to the police before or during the SANE examination. The time between the end of the sexual assault and presentation to the emergency department varied widely, with 78 (26%) presenting in less than 4 hours after the assault and 84 (28%) delaying presentation 1–5 days.
One hundred eighty-five (59%) victims had some form of physical (nonanogenital) injury, with only nine (3%) sustaining severe physical injuries; 134 (43%) patients experienced some form of anogenital injury, with six (2%) classified as severe. Ninety-five (30%) of the victims experienced no injuries of any type. There were 49 victims assaulted by multiple assailants (17%). Individuals assaulted by multiple assailants had twice the risk for physical and anogenital injury compared with those with a single assailant (OR = 2.07, 95% CI [1.12, 3.84], p = 0.02; see Table 2). The risk was also roughly doubled if the assailant made threats (OR = 1.74, 95% CI [1.11, 2.74], p = 0.02). There was a trend toward increased risk for injury if the victim was intoxicated (OR = 1.48, 95% CI [0.96, 2.29], p = 0.08). No statistically significant relationship was seen between level of injuries versus the relationship with the assailant, level of active resistance, or demographic characteristics.
Over half (n = 178, 57%) of the victims did not actively resist during the assault, using the definition outlined above. A quarter (n = 75, 24%) actively resisted during part of the assault, and a fifth (n = 61, 19%) actively resisted throughout the assault. Several potential predictors of the absence of active resistance were considered. Intoxication was the only potential predictor that was statistically significant (OR = 1.76, 95% CI [1.12, 2.77], p = 0.01). Of the 178 victims who did not physically resist throughout the assault, 67% sustained injury (physical and/or anogenital), as compared with 70% of those with some physical resistance and 77% of those who physically resisted throughout (see Table 3). The trend, however, was not statistically significant (p = 0.15 for three-level physical resistance as a predictor of any injury).
Time lags of 12 hours or more from the end of the assault to presentation were seen in 129 (43%) of the subjects. Active resistance was the strongest predictor, with increased resistance associated with lower odds of delay (p = 0.002; see Figure 2). The presence of a threat was also associated with reduced odds of later presentation (OR = 0.61, 95% CI [0.38, 0.99], p = 0.04). Intoxication, relationship with the assailant, and number of assailants were not significant predictors.
The 317 victims studied here had a wide range of experiences regarding injuries, use of active resistance, and time lags from the end of the assault to presentation in the emergency room. Previous studies also support the idea that there is no stereotypical behavior exhibited by victims during or after a rape (CDC, 2012; Ellison & Munro, 2009; Long, 2007; Lonsway, 2005; McCall-Hosenfeld et al., 2009; Tetreault, 1989).
Time from the end of the assault to presentation in the emergency room varies widely, with one fourth of this study’s patients presenting in the first 4 hours, another fourth presenting in 4–12 hours, and nearly half presenting in the emergency room 12 hours or more after the assault.
The myth that rapes will be immediately reported was studied by McCall-Hosenfeld et al. (2009). In their analysis, the median time to presentation for medical care by sexual assault victims was 16 hours. They concluded that victims presented in an “expeditious manner.” It was shown by Millar, Stermac, and Addison (2002) that victims of a stranger rape report more quickly than victims of a known assailant. Millar et al. refuted previously held beliefs that higher socioeconomic, White, and sober women would report more often and quicker than other victims.
The data in this study support varying times to arrival for medical care after a sexual assault. Forty-three percent (43%) of the victims appeared in the emergency department over 12 hours after the assault ended. There is a wide variance in time to presentation, with 26% reporting in less than 4 hours and 28% reporting 1–5 (120 hours) days later. The variability in time to presentation may be partially explained by the dissimilar nature of sexual assaults. For instance, McCall-Hosenfeld et al. (2009) found that severe violence and verbal threats were associated with earlier presentation. Victims of unusually aggressive sexual assaults may have a higher prevalence of moderate-to-severe injuries requiring immediate medical attention and necessitating early presentation to the emergency department. Victims of extremely aggressive sexual assaults may also have a greater feeling of fear causing them to seek safety sooner. Another partial explanation for the variability in time to report may stem from the victim’s emotional state or level of intoxication. McCall-Hosenfeld et al. further noted that the variables of an assault occurring in the home and an assailant known to the victim were each associated with later presentation. Intoxicated victims may feel shame regarding their impaired state and thus prolong reporting the crime. Intoxicated victims may also require time to become sober and fully comprehend the crime. However, this was not supported by Millar et al. (2002).
If a victim is threatened by her assailant with further harm if she reports, she may delay reporting or never report at all.
Sexual assaults where the victim and offender have a previous or current relationship may be excused or justified by the victim. Similarly, the victim may blame herself and be less willing to identify persons she knows, commonly noting not wanting to “get them in trouble,” as motive for this course of action (Weiss, 2009). The victim may also fear the social repercussions if she reports a friend to the police.
It has been shown, overall, that victims of sexual assault are less likely to report incidences to police than victims of other violent crimes (Chen & Ullman, 2010). In our study, 75% of victims who came for a medical/forensic evaluation also reported the incident to police. Others have found reporting rates to vary from as low as 5%–54% (Heath et al., 2013).
Another myth is to expect injury to be found on victims of rape. In our study, 30% of patients experienced no injury, and only 4% experienced severe injury. Anogenital injury has been studied by many researchers (Anderson & Sheridan, 2012; Anderson, Parker, & Bourguignon, 2009; Fraser et al., 1999; Jones, Rossman, Harman, & Alexander, 2003; Larkin, Cosby, Kelly, & Paolinetti, 2012; Lincoln, 2001; Lincoln, Perera, Jacobs, & Ward, 2013; Slaughter, Brown, Crowley, & Peck, 1997; Sommers, 2007). The frequency, location, and total number of injuries have been investigated. All studies showed that rape can occur without genital injury. Location and number of anogenital injuries, when they do occur, have had in some instances a limited ability to differentiate consensual from nonconsensual sexual acts (Anderson & Sheridan, 2012; Larkin et al., 2012, Lincoln, 2001; Lincoln et al., 2013; Sommers, 2007).
The predominant lack of serious injury may be the result of several factors. The tissues of the orifices involved in sexual assault are elastic and do not necessarily sustain injury with penetration (Bowyer & Dalton, 1997; Wells, 2006; White & Mclean, 2006). The penis of a man is susceptible to injury too, so the assailant may exert force by physically restraining the woman resulting in less force needed for penile penetration.
The relationship between the assailant and the victim may play a role in the rate of victim injury. Acquaintances and/or intimate partners have a different emotional investment in the victim than a stranger. The assailant may be less prone to injure the victim if he knows her, and the victim may be less prone to fight back. However, we were unable to detect a statistically significant relationship in our data (p = 0.38).
The number of assailants also plays a role in victim injury. If there are multiple assailants, the sexual assault may be more aggressive and may cause more injury. In our study population, victims with multiple assailants were twice as likely to experience injury or greater injuries. The assailant’s level of aggressiveness during the assault may also dictate physical and anogenital injury. Siegel, Sorenson, Golding, Burnam, and Stein (1989) found that the victim’s resistance strategy matched the assailant’s strategy (Prentky, Burgess, & Carter, 1986; Scott & Beaman, 2004). They also found that assailants who were less aggressive during the assault were correspondingly less likely to personally injure the victim.
Expecting victims to actively resist their attackers is another myth. In this large population, 57% of victims showed no active resistance, and only 19% actively resisted throughout. According to Fusé, Forsyth, Marx, Gallup, and Weaver (2007), approximately one third of sexual assault victims actively resist their attacker by either fighting, fleeing, screaming, convincing them to stop, obtaining outside help, or a combination thereof.
Twenty-four percent of victims in this study shifted between not resisting and actively resisting approaches. Shifts in the victim’s approach may mirror shifts in the assailant’s approach, with the victim possibly matching the level of overt aggression or else being cowed by serious threats or injury. Victims may also choose to not resist, hoping it will reduce the risk for physical or anogenital injury.
Contrarily, the victim’s behavior may shift to the opposite of the assailant’s behavior. This might be a defense mechanism to prevent further injury. For instance, if the victim is resisting the assault, and then the assailant injures her, she may stop resisting to prevent further injury. Although this contradicts the claim that a victim’s behavior matches that of the assailant’s, it does help explain the variability in victim behavior, which is dictated by a multitude of factors.
Tonic immobility may explain some cases of victims not physically resisting. Tonic immobility is a natural state of motor inhibition in response to high-fear situations that often involve threats and/or restraints (Galliano, Noble, Travis, & Puechl, 1993). It is an involuntary body response that results in the body feeling paralyzed or “frozen,” essentially being unable to physically resist or call out for help. Previously, this inability to move or call out was referred to as “rape-induced paralysis” (Marx, Forsyth, Gallup, Fusé, & Lexington, 2008). As many as 37% of rape survivors reported experiencing some paralysis during their sexual assault (Burgess & Holmstrom, 1976). It is important to understand that tonic immobility is both temporary and reversible. The exact time when tonic immobility begins during a sexual assault, and when it ends, varies between victims. In a study conducted by Fusé et al. (2007) of college-age women, 88 had experienced sexual assault. In evaluating these subjects for tonic immobility during their assault, it was found that approximately 42% reported significant immobility and 10%–13% reported extreme immobility. Of note, most subjects reported having known the perpetrator, and only a small number of individuals reported any injury or use of a weapon or restraint during the assault.
Both women with a history of child sexual abuse or adolescent/adult sexual victimization were more likely to experience immobilization than women with no prior history (Gidycz, Van Wynsberghe, & Edwards, 2008).
It has been shown that jurors find it hard to accept tonic immobility in cases where the victim knows the perpetrator even when educated to its existence by an expert witness (Ellison & Munro, 2009). It is confusing to people to learn that the victim is able to clearly recall details of the assault and yet was physically and/or verbally unable to resist. Tonic immobility response by victims is clearly an important area in need of further study and with that education of the public.
There are several limitations to this study. We were able to study only patients presenting for medical care. It is believed that most victims do not seek medical care after a sexual assault (Gartner & MacMillan, 1995). When physical evidence was not available to the examiner, for instance, regarding lag time from assault to presentation or resistance strategies offered by the victim, SANE nurses relied on the victim’s self-report. SANE nurses did not directly ask a victim about their degree of resistance during part or all of the assault. Study investigators had to glean this information from SANE examiners’ notes, thus subjecting them to interpretation error. To address this risk, we used two independent chart abstractors and third investigator servicing as an adjudicator. Final decisions were made by consensus. The examining nurse’s written findings of physical and anogenital injury were taken at face value without review of photographs to corroborate findings.
Three rape myths that are not intuitive to the general public, who may be serving on a jury, are that victims report their sexual assault immediately after the assault, they experience physical injury during the assault, and they aggressively fight off their assailant. Our study, which was based on the 317 documented SANE examinations at the Regions Hospital in 2011–2012, debunks these myths. Victims in our case series had a wide range of lag times from the end of the assault to presentation in the emergency room. Moderate and severe physical or anogenital injuries were rare, and only a minority of victims resisted physically throughout the entire assault.
Studies have linked SANE testimony with greater conviction rates and increased provictim sentiment among jurors (Campbell, Patterson, & Bybee, 2012; Campbell, Patterson, & Lichty, 2005; Canaff, 2009; Ledray & Barry, 1991; Ledray et al., 2001; Wasarhaley, Simcic, & Golding, 2012).
Many professionals in addition to SANEs can qualify and testify as experts to the behavior of sexual assault victims (Long et al., 2010). They include medical providers, victim advocates, and therapists as well as members of law enforcement and academia (Long et al., 2010). All expert witnesses can benefit from access to rigorously done statistical analyses that underscore their personal observations and demonstrate their objectivity (Long, 2007; Tetreault, 1989). Referring to formal research may enhance their effectiveness as educators for jurors and the court, within the boundaries of their expertise (Long, 2007).
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