Health practitioners on frontline of realities of sexual assault

SEXUAL assault and child sexual assault are far more common than our community has been prepared to acknowledge, and it is critical that health practitioners are there to listen, hear, believe and validate the lived experiences of their patients.

The 2016 Australian Bureau of Statistics Personal Safety Survey established that almost 2 million Australian adults had experienced at least one sexual assault since the age of 15 years. They are most common in the home and family, where secrecy, ready access and dependence on the perpetrator often mean that it continues unabated.

We have long used euphemisms to describe these crimes and to minimise their perceived impact. The terms rape and incest are more accurate but used less commonly.

While sexual assault is more common among women, girls, transgender and non-binary people, boys and men are also victims. This is often unacknowledged and the stigma for men and boys, including gender norms and pervasive shame, makes speaking out very challenging. While perpetrators are most often men and young men, they can also be women and girls. The Royal Commission into Institutional Responses to Child Sexual Abuse revealed more victims were male. Sexual assault is common in prisons and as a tool of war as it often is an abuse of power and coercive control.

Contrary to what most people believe, sexual assault is most often perpetrated by a person the victim knows. These are serious crimes – abuses of power, betrayals of trust and violations of personal boundaries. They are often also secret crimes, in which victims are often blamed and perpetrators given the benefit of the doubt. Sexual assault is generally about power and coercion. It is not about having sex but rather about sex being weaponised. Sexual assault is poorly understood in terms of the acts which constitute it. It is not only about penetration or vaginal penetration but forced sexual acts of diverse forms, all of which can have a profound impact on the victim.

Power imbalances and the blurring of workplace boundaries create the dynamics in which the need for consent is annihilated, accountability absent, and cover-up, victim blaming, secrecy and lies common. There has been much stigma in our society around sexual assault, which feeds into the self-blame victims often experience. Retaliation against people speaking out against sexual harassment and victimisation in the workplace has been common. Myths around sexual assault contribute to victim blaming and a social fabric in which sexual assault becomes tacitly excusable.

Issues of consent are poorly understood. A person who is sleeping, intoxicated, cognitively impacted or incapacitated or a young child, without the language or level of development, cannot give consent. In these situations, the person is not able to say “no” but nor can they say “yes” or give consent. Sex is not a right because another person wants it. It cannot be assumed or snatched. It requires active and definitive permission. Non-consensual penetrative sex is rape.

Belief is a vexed issue. Sexual assault is a crime in which there are usually no witnesses. Yet research establishes that false reports of sexual assault are rare. Many sexual assaults go unreported or stay undisclosed for a long time. This can mean a lack of physical evidence and a questioning of the motives of the alleged victim in not coming forward immediately. Delayed reporting makes sense. If the person was a child, dependent on the perpetrator, and with no one to trust, they have often been threatened into silence and groomed into compliance. Some victims, as adults, are sexually assaulted by partners, spouses, ex-partners or friends, adding another layer of shame, confusion and disbelief.

There have been a number of high profile abusers – for example, Jeffrey Epstein, Harvey Weinstein – where we have seen many victims coming forward, with each new person speaking out “giving permission” for others. It has been a time of the Me Too, End Rape on Campus, Let Her speak and Enough is Enough campaigns in which we are seeing significant social change through coordinated movements for change. Speaking out against power, hierarchy, influence, societal judgement and internal shame and self-blame takes incredible courage. It often invites a barrage of commentary about the victim’s appearance, clothes, partying or behaviour. No circumstances ever give anyone the right to rape another person.

People rarely make claims of rape or sexual assault to attract attention and notoriety. Being a victim is a fraught path, eliciting victim blaming, ostracism and derision, with the consequences of shattering families, destroying friendships, eroding self-esteem, and affecting mental and physical health. Many victims blame themselves for not fighting back and stopping the assault. But in situations of terror the body often goes into freeze mode, unable to move or speak let alone fight or flee. Very often people’s experiences are minimised, both by themselves but also by others. “It wasn’t that bad.” “Others had it worse.” “It was only once.” Sexual assault is always significant and can affect victims over the short, medium and long term. Many victims develop post-traumatic stress disorder after a single sexual assault: avoiding situations, being anxious and jumpy, experiencing flashbacks and nightmares, difficulty sleeping, losing pleasure and connection, and becoming isolated.

We have repeatedly seen the human cost of sexual assault with victims taking their own lives or using coping strategies (eg, self-harming, substance misuse, gambling, overwork, eating disorders) to try and numb their pain and distress. Many victims and survivors struggle in their daily lives, having their education disrupted; experiencing difficulty in finding and staying in work; being depressed; having panic attacks, mental distress and mental health issues; and struggling with their physical wellbeing as well. People experiencing repeated sexual assaults, especially in childhood, can have profound impacts over time.

Not being believed, being publicly humiliated, decimated in legal proceedings, and marginalised in society all make recovery so much harder. While recovery is possible, many victims and survivors struggle to trust enough and be safe enough or have the resources to seek help and support to help them heal. Therapy and counselling can help many victims to cope and feel less overwhelmed and fearful. However, therapy is not for everyone. There are many paths to recovery; for example, eye movement desensitisation and reprocessing (EMDR), meditation, mindfulness, art therapy, or drumming. Recovery can take time, but the support of friends and family is also critical. Being believed is bottom line and having a society that is more compassionate is the first step to reducing the stigma that sabotages healing and costs lives.

It is important for GPs to be aware of how common sexual assault is and to be alert to recognising its signs. Recent sexual assault and historical sexual assault in particular are often associated with medically unexplained symptoms as well as mental health impacts. It is important for GPs to learn how to safely and respectfully speak about trauma and seek information from people presenting every day. It is critical for GPs to be there to listen, hear and believe and to validate the experiences of their patient if that person chooses to disclose a sexual assault. It is about empathic support and finding out what it is that person needs in the present, and working with them to find pathways to support over time. Know that as their GP, you are someone they can trust to walk alongside them on their journey and refer as appropriate to specialist services depending on their needs.

Dr Cathy Kezelman AM is President of the Blue Knot Foundation. Blue Knot Foundation www.blueknot.org.au is the National Centre of Excellence for Complex Trauma. It empowers recovery for the more than 5 million Australian adults living with the impacts of complex trauma (repeated interpersonal trauma as a child, young person or adult).

National sexual assault support

Blue Knot Foundation: For adults with experiences of childhood trauma including child sexual abuse. Operates 9am-5pm Monday-Sunday.
Phone: 1300 657 380

1800 RESPECT: National sexual assault, domestic family violence counselling service. Operates 24 hours/7 days a week.
Phone: 1800 737 732

Bravehearts: For those wanting information or support relating to child sexual assault and exploitation. Operates 8:30am to 4:30pm Monday to Friday.
Phone: 1800 272 831

IF YOU ARE IN IMMEDIATE DANGER, PLEASE CALL 000

The statements or opinions expressed in this article reflect the views of the authors and do not represent the official policy of the AMA, the MJA or InSight+ unless so stated.