Peace corps manual section: Sexual assault

1. PURPOSE

The purpose of this Technical Guideline is to provide PCMOs, and other staff members, with a basic understanding of sexual assault, and guidance for meeting the medical and emotional needs of Volunteers who have been sexually assaulted.

2. DEFINITION

Sexual assault is forcible sexual activity without the consent, and against the will, of the victim. There always is force or the threat of violence involved. A woman submits out of fear; she does not consent. Most important to remember is that while rape or sexual assault is an overtly sexual act, it is properly considered an act of violence with sex used as the weapon.

In some cases, actual penetration does not occur. Nevertheless, for the woman involved, the trauma is the same, and the victim should receive the same support regardless of whether or not penetration occurred. The terms "rape" and "sexual assault" are used interchangeably in this Guideline. Also, the term she for the victim and he for attacker will be used even though homosexual rapes of both men and women do occur.

3. SEXUAL ASSAULT

The trauma and emotional reactions for both the victim of, and the PCMOs or other staff members dealing with, sexual assault are severe. The victim's need for support is obvious, but frequently the individual called upon to provide this support may feel unprepared for the task. Therefore, information is presented in this Guideline to help staff better understand their reactions to the sexual assault victim, and for the PCMO to provide effective and sensitive treatment.

3.1. Cultural Issues. To provide effective treatment of rape victims, we must assess our own reactions to this crime. These reactions are products not only of our own experiences and personalities, but also of the conditioning and reinforcement of our respective cultures.

Anthropologist P. R. Sanday examined the socio-cultural context of rape in a cross-cultural study of 156 tribal societies. Forty-seven percent of the societies studied were classified as "rape free", 35 percent were classified in an intermediate category; and 18 percent were classified as "rape prone". This indicates that sexual assault is not a universal characteristic of human societies. The incidence of rape varies cross-culturally.

"Rape prone" societies are those whose profiles include interpersonal violence, male dominance, and sexual separation. Rape also occurs more often in those societies where the harmony between people and environment has been severely disrupted. In the "rape free" societies, on the other hand, "women are treated with considerable respect, and prestige is attached to female reproductive and productive roles. Interpersonal violence is minimized and a people's attitude regarding the natural environment is one of reverence rather than one of exploitation."

In the United States, many of the attitudes and laws concerning rape are beginning to change from viewing the victim as somehow responsible to viewing this act as a crime. Medical care also is improving. However, most Americans have grown up with conscious or unconscious awareness of many common myths concerning rape. The more common of these, along with facts based on U.S. statistics, are listed below:

- Myth - Sex is the primary motive for rape.

- Fact - Studies show that the major motives for rape are aggression, anger, and hostility, not sex.

- Myth - Rape is an impulse act.

- Fact - The majority of all rapes are planned - both the victim and the place.

- Myth - Rape usually occurs between total strangers.

- Fact - Studies show that in most cases the assailant and the victim are acquaintances, if not friends or relatives. In many cases, the assailant has had prior dealings with the victim, for example, he may be an ex-boyfriend, a neighbor, a friend of a friend, a maintenance man, or a co-worker.

- Myth - Women who are raped are asking for it. Any woman could prevent a rape if she really wanted to since no woman can be raped against her will.

- Fact - In about 87% of all rapes, the rapist either carried a weapon or threatened the victim with death. The primary reaction of almost all women to the attack is fear for their lives. Most women, even if not paralyzed by fear are physically unable to fight off a sexual assault. Submission does not imply a desire to be assaulted.

- Myth - Only young, good looking girls get raped.

- Fact - The average age of victims is between 19 and 26 years old. However, victims have ranged in age from 6 months to 97 years.

- Myth - Mode of dress, such as short skirts, no bra, etc. increase a woman's chance of being raped.

- Fact - Any woman regardless of dress, age or attractiveness may become a rape victim. Rapists are not out for sexual gratification and most are not sexually aroused at the time of the assault.

- Myth - Rape cannot happen to me.

- Fact - Rape can happen to all women, regardless of age, social class, race or personal appearance.

It is important to be aware of these myths and the facts because most Volunteers will have to resolve these attitudes in dealing with themselves, or others, as victims.

Each country carries its own cultural attitudes about rape. It is crucial that both the Medical Officer and any other staff who might deal with the rape victim be aware of both the myths and the realities of their own culture. These include views about "Western woman", such as "all Western women are promiscuous" or "Western women come to our culture because they want to make love with us." As powerful as these cultural myths is the old medical myth that a healthy adult woman cannot be forcibly raped with full penetration of the vagina unless she actively cooperates. This myth does not consider the emotional reactions, such as fear and panic, or logical reactions, such as submissiveness, to protect life. The use of weapons, fists, or threats by the offender are not acknowledged in this myth. Each Peace Corps Volunteer rape victim has reported the fear of being killed at the time of assault. This is the primary reality to keep in mind when preparing to treat a victim of sexual assault. She has just experienced a terrifying sense of helplessness with thoughts of losing her life.

3.2. Motivations for Sexual Violence. To appreciate what the victim experiences, the probable motivations of the offender must be understood. The rapist is commonly portrayed as a lusty man who is the victim of a provocative woman, or he is seen as a sexually frustrated man reacting under the pressure of his pent-up needs, or he is thought to be a demented sex fiend harboring insatiable and perverted desires. The misconception common to these views is that they all assume the offender's behavior is primarily motivated by sexual desire, and that rape is directed toward gratifying only this sexual need. To the contrary, clinical studies of offenders in the United States reveal that rape serves primarily nonsexual needs. It is the sexual expression of power and anger. Forcible sexual assault is motivated more by retaliatory and compensatory motives than by sexual ones. Thus, "rape is a pseudosexual act, complex and multidetermined, but addressing issues of hostility (anger) and control (power) more than passion (sexuality)."

In their work with American sexual offenders, Groth and Birnbaum conclude:

"Rape is always a symptom of some psychological dysfunction, either temporary and transient or chronic and repetitive. It is usually a desperate act that results from an emotionally weak and insecure individual's inability to handle the stresses and demands of his life ...the majority of such offenders are not psychotic - nor are they simply healthy and aggressive young men 'sowing some wild oats.' The rapist is, in fact, a person who has serious psychological difficulties that handicap him in his relationships with other people and that he discharges when he is under stress, through sexual acting out. His most prominent defect is the absence of any close, emotionally intimate relationship with other persons, male or female. He shows little capacity for warmth, trust, compassion or empathy, and his relationships with others are devoid of mutuality, reciprocity, and a genuine sense of sharing.

In trying to understand the dynamics of rape of Peace Corps Volunteers by non-American attackers, we have little information about rapists in the context of other cultures. Anthropological studies indicate that rape is overlooked, tolerated, or even affirmed in some cultures. In addition, the act of cross-cultural rape may include political, racial and/or ideological factors in the retaliatory and compensatory motives described above.

3.3. Patterns of Sexual Violence. To implement preventive measures and treat the victim, the patterns of rape must be understood. Groth and Birnbaum describe three patterns of rape: (1) the anger rape in which sexuality becomes a hostile act; (2) the power rape in which sexuality becomes an expression of conquest; and (3) the sadistic rape, in which anger and power become eroticized. Victimized Peace Corps Volunteers have described all three patterns in their attackers.

Burgess and Holstrom have classified rape based on the assailant's method of attack. The two main styles are: blitz rape (also called stranger rape) in which victims are singled out for a sudden, surprise attack (on the beach, on a street, approaching her home, asleep in her bed) and confidence rape (also called acquaintance rape) in which the assailant gains access to the victim under false pretenses by using deceit, then betrayal, and often violence. This includes examples of many attacks where the attacker is known to the victim. He may be a neighbor, an acquaintance, a date, a friend, or a relative. Many women, including PCVs, have a much harder time reporting confidence rape because they blame themselves for trusting the assailant.

3.4 Coping Mechanisms During Rape. Burgess and Holstrom also have studied the victim's coping behavior at three points relative to the attack: during the early awareness of danger, during the attack itself, and after the attack. This ability to react often depends on the amount of time between the threat of attack and the attack, on the type of attack, and on the type of force or violence used. Initial strategies include verbal tactics, such as conversation, joking or screaming, and physical action, such as struggling, biting or kicking. If these fail, the coping task of the victim is to survive the rape despite the demands forced upon her such as oral, vaginal, and/or anal penetration.

Victims often cope during the rape itself by mentally distancing themselves from the reality of the event. Volunteers have described the whole range of internal defense mechanisms used to cope psychologically with the fear produced by attack: denial ("this isn't happening to me"); disassociation ("I felt like I was at a movie watching it happen to some one else"); suppression ("This will be over in a few minutes; it's not the end of the world"); rationalization ("This poor man, he looks desperate, is this the only way he knows to get sex?"). Not all coping behavior is voluntary and conscious. Some screaming and yelling is involuntary, and victims have also reported physiological responses of choking, gagging, nausea, vomiting, pain, urinating, hyperventilating, and losing consciousness.

The stressful situation is not over for the victim when the actual rape ends. She must alert others to her distress, escape from the assailant, or free herself from where she has been left. Victims always are hopeful that someone will come to their aid, and they may spend time concentrating on how to obtain help. One Volunteer's fear and loneliness were heightened by the fact that passersby did not respond to her cries for help. However, after the attack when she was able to run to a group of workers, she was eventually able to convince them of her need for assistance.

By listening for the coping behaviors of the victim during the attack, the PCMO or other helper can have a therapeutic effect. Identifying the coping behavior tells the victim her behavior functioned as a positive adaptive mechanism to allow her to survive a life-threatening situation. This also helps alleviate some of the guilt suffered by victims who tend to think, "I did not do enough I could have done more." Affirming the coping behavior also reinforces a positive sense of self-esteem and worth. Appreciation of the fact that the victim has successfully managed to survive a life threatening assault is a positive beginning to her long-term process of coping with the aftermath of rape.

3.5. Aftermath of Rape. Following a rape or assault, a woman may experience a whole range of feelings or reactions. These may vary depending on background, personality, race, class, culture, age and her attitudes toward self, body, aggression, and sexuality. These immediate physical and emotional reactions may last for a few days or for a few weeks and usually overlap with the more long-term reactions that follow

3.5.1. Common Emotional Reactions. The following are some of the feelings that are common among rape victims:

- Fear

- fear of being alone

- fear of the assailant returning

- fear of pregnancy or venereal disease

- fear of others finding out, fear of what they will think of her.

- fear of things and places which remind her of the attack.

- fear of men, of dysfunction in future relations with men.

- fear of children being attacked.

- Helplessness

- feeling that her privacy and right to choose have been denied her.

- feeling of loss and emptiness

- feeling unable to change the situation, unable to stop crying or to stop reliving the experience, unable to fight back.

- feeling of having to put herself in others' hands.

- Guilt

- for having "caused the assault

- for not fighting back

- for being "stupid" enough to get into that situation.

- for all the reactions she's having.

- Shame, embarrassment

- feeling degraded, filthy, depersonalized

- feeling everyone looks at her and judges her.

- Betrayal

- feeling wrong for having trusted, been friendly, been open.

- Anger

- at herself for letting it happen

- at the rapist - wanting to kill, castrate, or humiliate him.

- Wanting To Forget It

- to deny it happened

- to not make a fuss over it

- to get on with daily business

- Disruption Of Normal Sex life

- difficulty in expressing affection

- difficulty in trusting men

- experiencing flashbacks of attack

- difficulty allowing the vulnerability that intimacy requires

3.5.2. Common Physical Reactions. Some physical reactions a woman may have in addition to the injuries she may have received are:

- General soreness

- Loss of appetite

- Nightmares

- Tension headaches

- Gynecological and urinary tract problems

- Inability to sleep

- Nausea, stomach pains

- Waking up during the night and being unable to return to sleep

- Fatigue

3.6. Stages of Emotional Reaction. As noted above, the immediate physical and emotional reactions usually overlap the more long-term reactions. The longer term reactions may be classified into three distinct phases. An understanding of these phases has many implications for the treatment of Volunteer victims.

3.6.1. Phase I: Acute Reaction. This first stage, lasting from a few hours to a week, is characterized by feelings of numbness, a state of shock, terror, disgust, a sense of powerlessness, and humiliation. The victim is seen in a disorganized, emotionally active state, weeping, distraught, unable to think clearly or the victim is emotionally contained with only occasional signs of emotional pressure, such as inappropriate smiling and increased motor activity.

Initially, this turmoil of emotions may be too overwhelming for her to be able to single out, identify or recognize. Instead, she feels numb, confused, and is unable to express her feelings clearly. Any apparently calm demeanor should not be mistaken for evidence that the rape did not occur or that she is unaffected by it. Other victims may handle these overwhelming emotions in other ways. They may be hysterical - crying, laughing, screaming. Laughter should not be taken as a sign of levity - it is one reaction to severe anxiety. In these more vocal reactions, the victim may or may not be able to express her feelings clearly, but the emotions are closer to the surface.

3.6.2. Phase II: Outward Adjustment. This second stage, which begins about two weeks after the rape, involves the attempt by the victim to return to normal routines and place the rape in the past. This stage is often characterized by the victim not wanting to discuss the attack.

After the initial shock and chaos of the rape experience has subsided, the victim enters into a period of outward adjustment. At this time she has returned to work or school, and is getting back to the normal routine of her life. She begins to resist talking about the rape, insists that it is in the past, and wants only to forget about it. Although this closure is premature, and all feelings have not yet been expressed or understood, it is in part a healthy defense - a wish to return to normalcy.

3.6.3. Phase III: Integration and Resolution. This third stage may begin anywhere from one month to many years after the rape.

With appropriate support, the victim has found ways to integrate this trauma into her life experience. While, in general, she may have reached her pre-crisis level of functioning, she may have times of feeling again the old unresolved feelings about the rape. Sometimes her previous adjustment is shattered by a reminder of the rape - seeing the assailant in court or on the street, passing the scene of the crime. Unresolved feelings may recur following an unhappy life change such as a divorce, or several months or years of sleepless nights may finally cause the victim to decide to seek help. Prom their experience counseling rape victims, McCombie and Arans report that rape work, like grief work, takes approximately two years to complete, in the psychological sense of integration and resolution.

4. TREATMENT OF SEXUAL ASSAULT VICTIMS

Awareness of the complex feelings evoked in the rape victim leads to the realization that the first people with whom she has contact after the rape can make a dramatic difference in the way she sees herself and the event. If PCMOs and other staff and Volunteers understand this, they are more likely to be able to offer the supportive responses the victim needs.

4.1. Reporting the Assault. In reporting a rape and discussing what happened, the Volunteer will seek out someone she trusts and from whom she expects support. All staff, especially PCMOs, should be capable of fulfilling this role. If the immediate support is being provided by a staff person, other than the PCMO, the Volunteer and/or the support person should seek medical help from the PCMO as soon as possible. In seeking help, the Volunteer is making a statement about her capacity to cope and her willingness to receive help.

It is imperative that all Volunteers report to the Medical Officer all cases of sexual assault due to the pheonomenon of "silent rape reaction." Silent rape reaction (a concept introduced by Burgess and Holmstrom) may be defined as the psychological reaction of rape victims who have not told anyone about their experience, who have not resolved their feelings about the rape, and who are carrying a tremendous emotional burden. These women exhibit symptomatic behavior such as persistent loss of self-confidence and self-esteem, phobic reactions, psychosomatic concerns, social withdrawal, etc.

Many of these Volunteers have significant emotional difficulties. Some of them also had physical problems either not attended to, or inadequately treated by non-Peace Corps physicians. Consequently, they ultimately were medically evacuated to Washington where they saw our counselors. One of our counselors reports that, in the context of counseling about other presenting problems, half of those who had also been rape victims had not reported the assault to Peace Corps staff, including the Medical Officer. Some of the reasons for this reluctance include guilt and self-blame, denial, shame, and the confidentiality problems of the Peace Corps community. The counselor also observed that the women were more likely to report the attack if the assailant was a stranger and if there was bodily injury.

4.2. Immediate Intervention. Given the feelings common to women who are sexually assaulted, it is obvious that both immediate physical and emotional support are imperative. When a Medical Officer, or staff member learns that a Volunteer has been raped, immediate medical care and emotional support, must be provided. The Medical Officer should go to the Volunteer immediately. In the meantime, assure that someone is with the Volunteer until you arrive. Another Volunteer, a host country friend or supervisor, a boy friend, or spouse can provide the necessary companionship until you arrive. If the Volunteer must travel to reach you, she should not travel alone.

The PCMO's responsibility in this initial contact is to attend to the immediate emotional and physical needs of the victim; not to determine whether the patient has been raped. While other staff may have a supportive role in the care of the victim, the PCMO must ensure that the patient receives adequate care as outlined below. This relationship with the PCMO provides the victim with a consistent, predictable, and trustworthy person who will impart acceptance, understanding and respect. This is the first effort at repairing and restoring the victim's integrity so recently invaded and undermined.

The PCMO should:

- Assist the Volunteer in assuring her physical safety

- Provide psychological support and reduce mental stress with a calm, nonjudgmental, warm relationship, help victim identify persons she would find supportive and anything she would find comforting.

- Attend to her physical needs:

- obtain the medical history and observations of physical and mental injury.

- provide warm drink or soup (reassuring physical routine)

- after medical observation and also medical examination, if possible, offer a warm tub bath or shower and a change of clothing (tension reduction, psychological cleansing).

Reduction of anxiety and fear will be demonstrated by a decrease in the victim's behaviors mentioned earlier shaking, trembling, crying, handwringing, as well as by being able to talk about the decreased feelings. Loss of control is an issue for anyone needing emergency care. There is the obvious risk that the feelings of helplessness sustained by the victim during the assault could be compounded by your initial reactions.

Restoring control to the victim begins by honoring her crisis requests.

For the rape victim, having a consistent helper to whom to relate will go far to decrease the confusion inherent in an emergency medical situation, in which every new face may be perceived as a potential rapist. A calm, non-judgmental caring demonstrated by the PCMO will help to diminish the intense anxiety the victim experiences. Then, the victim's ability to understand the treatment and the reasons for it will be considerably increased.

4.2.1. Medical Examination. The medical examination should take place as soon after the rape as possible. The primary purpose of the medical examination is for medical care of the patient. The secondary purpose is for legal actions if the victim wants to pursue those and the medical officer considers those appropriate to pursue in the context of that culture and country.

The patient's physical condition should be stable before any attempt is made at medical evaluation. The history and examination should be pertinent to the medical care of the patient and to the collection of evidence and include:

- Time and date of examination

- Time and date of reported rape

- Incident report, in patient's words, including time, place, circumstances, violence, threats, sex acts, etc.

- Medical history

- Emotional state

- Physical examination, including all signs of external trauma and appearance of patient.

- Pelvic examination, including signs of trauma along with description of pelvic organs.

- Cervical/anal/oral smears and culture for gonorrhea, PAP smear, VDRL, and, if necessary, microscopic exam for sperm identification and motility.

4.2.2. Psychological Evaluation. At all visits, the psychological condition of the victim should be evaluated.

- Provide factual information about the reasons for the examination and various treatments.

- Offer calm acceptance of the victim's range of feelings, and reassurance that these are normal after the trauma of rape.

- Identify the patient's support systems, both formal and informal.

- Offer counseling by a trained person, if available.

- Offer support or counseling to any companion of the victim who may be feeling guilt, anger, and anxiety. If the victim is married, it is essential to offer counseling to the mate.

- Offer medical evacuation for counseling, for recuperation, and for considering early termination, completion of service or for preparing to return to country. (See Paragraph 4.4. below.).

4.2.3. Medical Treatment. All physical injuries should be treated by the PCMO, as appropriate. In addition, the following actions should be taken.

- Prophylaxis for Sexually Transmitted Disease (STD). Many experts recommend routine prophylaxis with appropriate antibiotics against STD in rape victims. Such treatment should prevent both syphilis and gonorrhea, and may be especially appropriate in countries where reliable cultures for gonorrhea and serologies for syphilis do not exist. In addition, this treatment may serve an important reassurance function for the victim. Following are effective therapies (oral therapies are preferred in this situation because of their less traumatic effect):

TETRACYCLINE HCL, 500 mg 4 times a day for 7 days.

OR

AMPICILLIN 3.5 grams orally stat and 1 gram PROBENECID orally at the same time.

Serology for Syphilis (VDRL, RPR) and appropriate cultures for gonorrhea should be obtained one (1) month after therapy to assure adequacy of treatment

- Prophylaxis Against Pregnancy. Overall, the risk of pregnancy resulting from a rape is low (1%). However, the chance increases if the event occurred during the "fertile period" of the menstrual cycle. Obviously, women with an IUD in place or using oral contraceptives have only a remote chance of becoming pregnant. In any case, a pregnancy test should be given at the time of the assault (to rule out previous pregnancy) and 6 weeks later. Use of "morning after" medication (e.g., DES, Premarin, Ovral, etc.) has not been approved in the United States and is, therefore, not recommended.

4.2.4. Emotional Support. Regardless of the victim's behavior she will need immediate emotional support. The PCMO or other staff member should find a quiet, private place and begin to encourge the victim to talk. Listen carefully and notice how she acts. Her body language will give clues to how she feels. The following are suggestions for helping the victim talk about her experience.

- Encourage her to tell you what happened. Start with general questions. Gradually move to more specific ones about the circumstances before, during, and after the assault, the assailant, any conversation that took place, the sexual details, physical and verbal threats, whether there was a struggle, alcohol or drug use (by assailant or victim) and her reactions. Find out about her social network and whether she's been supported or not.

- Understand; do not blame. Blaming and judgmental attitudes will interfere with the helping process. She needs and deserves confirmation that she has been assaulted. Support the fact that she was victimized.

- Share her pain. Let her know she's no longer alone. It will emotionally strengthen her.

- Encourage her to keep talking. Through it she will gain perspective and help herself. If she is not verbal and her style of expression is hard to understand, try to avoid getting frustrated - silence communicates, too. Allow periods of silence.

- Let her cry if she needs to. This is a grieving process. She's been hurt but she's also probably lost a sense of safety and security and thus a way of life. That is a severe loss to some.

- If appropriate, reassure her. She will need to be told it wasn't her fault. Assure her that she can get through this. If she took risks, assure her that she can avoid risks. Clarify and define her feelings. She may not be able to discriminate. Bet her know her feelings are normal in these circumstances.

- Recognize her fear, and respect it. She needs it, especially if threatened. It is realistic. Teach her to be afraid constructively.

- Recognize her rage and help her to respect it. The rage is at being impotent and helpless. It should be directed at the assailant. It will be slow in coming because it is usually constricted. To assist, you may need to express anger at the assailant. Encourage her to express her fantasies of retaliation. The expression of rage in a constructive way gives her a sense of control and power in her life.

- Know that it will take time for her to get over this, but that she can learn to live with it. Tell her this.

- Recognize and support her strength every step of the way (e.g., her coping mechanisms during the assault, her getting help).

4.3. Intermediate and Long-term Care/Recovery. Burgess and Holstrom characterized the first few hours and days following a sexual assault as being a period of disorganization in the victim's life. As indicated in the above paragraphs for her everything has changed. The process of reorganization, then, characterizes the intermediate and long-term periods of recovery from a sexual assault. To assist the victim into this phase, the PCMO should:

- Continue to help her work through the experience by following the guidelines for emotional support listed under the immediate help section. Offer professional counseling, if available.

- Begin to assist her in making her own decisions. She needs to reorganize her own life, starting with the small decisions, such as what to take with her to the capital and where to stay. But she will probably need assistance.

- Gradually begin to discuss options with her.

- should she early terminate and go home?

- should she change sites or countries?

- does she need vacation time to consider what to do next?

- does she want to go to Washington for additional medical or psychological support?

- does she want her family or friends notified?

- is there another Volunteer in the country who could provide companionship and support who should be notified?

4.4. Medical Evacuation. The offer of medical evacuation to Washington is important. Our experience in counseling rape victims indicates that within a few days after their arrival in Washington there appears to be a visible decrease of anxiety and an easing of tension. This may have to do as much with the comfort and familiarity of one's own culture as with the professional help.

The work of Isaiah Zimmerman with American prisoners-of-war, indicates that following violence and emotional trauma, victims do best with a neutral time and space that is a kind of buffer zone between the violence and getting back to families and/or life as usual. He suggests at least one to three weeks for psychologically processing the experience. Most important to this process is immediate reconnection with the positive network in order to disconnect from the traumatizing network.

In terms of Peace Corps, this means that the sense of belonging to the Peace Corps community (reinforced by the PCMO, other staff and Volunteers) can be most therapeutic. The Peace Corps affiliation is healing not only because it offers group identity at a time when the victim's identity is temporarily disorganized, but also it offers the victim "good" people to counter her experience with a "bad" one(s). If she chooses medical evacuation, this reaffiliation process is continued through her contacts with the other medevacs and the medical staff. Several times, rape victims in Washington have had the opportunity to share with other medevacs who were also rape victims and found this sharing most helpful.

In offering medical evacuation, it is important to both encourage the Volunteer to take advantage of this opportunity but also to respect her need for self-determination. One rape victim reported refusing her PCMO's offer of medical evacuation, feeling determined to "tough it out" and carry on with her responsibilities. After about two hours she changed her mind, sensing that she was emotionally and physically exhausted and that she would appreciate counseling in Washington. In her case, the counseling was completed in two weeks, and she chose to return to her country. This is a reminder to offer plenty of time for the victim to make her decision about medical evacuation. While medical evacuation is not essential to recuperation, our experience with rape victims and the work of Dr. Zimmerman, mentioned earlier, indicate that this brief return to one's own culture greatly facilitates the healing and emotional reorganization. Thus, medical evacuation should be encouraged.

4.5. Continuing Service. Whether counseling is provided in country or in Washington, the PCMO also has the responsibility to be aware of the long-term effects of rape if and when the victim chooses to stay or return to country. Considerable care should be taken with her in planning whether to move to different housing and/or a different site. Since it is possible and normal for rape victims to experience periodic anxiety for several months after the trauma, the PCMO or other support person should be available to listen to the Volunteer's feelings, consider with her the realities, and offer reassurance of help in changing the situation. Any trauma carries the potential for an anniversary reaction around the same time the following year.

4.5.1. Intermediate/Long-Term Emotional Reactions. As noted earlier, reactions to sexual assault vary. However, there are a number of common reactions which may recur for weeks or even months after the attack, including:

- A need to change residence in order to ensure personal safety.

- A need for support from family or close friends.

- Difficulty in sleeping, often caused by nightmares recalling the events leading up to the assault.

- Pear that the assailant will return.

- Fear of crowds but also fear of being alone.

- Fear of being either indoors or out-of-doors, depending upon where the rape occurred.

- Fear of sex or lack of sexual desire.

- Periods of depression or anger.

- Feelings of guilt.

- Feelings of being damaged or unclean.

- Feelings of paranoia that others are talking about her or laughing at her.

- Feelings that she can't trust anyone, particularly men.

Once again, the Volunteer should be assured that her feelings normal. She should be encouraged to regain control of her life. As she does so, she should begin to experience a lessening of her fears and begin to accept that the rape has occurred and that it can be placed in perspective along with other bad things that occurred in her life.

4.5.2. Responses of Others - Denial, Blame, or Anxiety. Many of the rape victims we have counseled in Washington have been particularly worried about what to say when they return to country and how to handle the reactions of people who know about their experience. Since we try to resolve this during the medical evacuation, it would be useful for the PCMO to review these decisions with the PCV when she returns. It is assumed that the utmost care has been taken in observing medical confidentiality and that the privacy of the Volunteer has been respected. It is particularly important that all non-medical staff be aware of the confidentiality requirements.

It is helpful to remember that we all react, at some level, with anxiety upon hearing about violence and sexual assault. Knowing about such an event shakes the usual defenses we utilize to feel safe and proceed with undue anxiety in our daily lives. News of an accident or brutal assault makes us realize how close the possibility of such misfortune can be. Thus, one common response is denial, downplaying the trauma, telling the victims things really aren't so bad. Another common response to a victim is to focus on what went wrong, what she might have done differently or what mistakes she made. This is a way of reassuring ourselves that there is a way to prevent violence - that we could avoid such trauma. It is useful for a victim to review her behavior and to understand the circumstances that allowed her to become a target for a disturbed person's brutality. However, rape victims generally are so self-recriminating that they need no encouragement in this process and certainly no additional judgment .

When they are upset or angered by others' responses (such as "it was foolish to jog alone," "you know you are not to walk alone on the street," "why didn't you leave the beach if you thought those men looked suspicious?"), it may be helpful to review the above dynamic with them, explaining that people who respond in such a way probably do not mean to judge as much as they need to deal with their anxiety about the event. Some men who respond with criticism or judgment of the victim may also be dealing with their own anxiety about such aggressive use of sexuality by their gender. On the other hand, men who are able to respond with sensitivity and understanding can have a particularly healing effect on the victim.

Two Volunteer rape victims reported dreams during their medevac counseling with a similar theme. In both dreams, a kind host country national male came to the victim with words of encouragement, reassurance and affection. The dreams seemed to be a mental "undoing" of the rape trauma, an experience of a "good" host country male to counter that with the "bad". They were also signs of the victims' integration of negative experience and the healing provided by a loving response.

5. LEGAL CONSIDERATIONS

Many countries require victims to report the commission of serious crimes involving bodily injury. In such cases, the interests of the country as well as the individual are concerned since the assailant may have attacked others in the past and may do so again in the future. In working with a Volunteer who has been sexually assaulted, such host country requirements should be taken into consideration. PCMOs should, however, clearly differentiate in their discussions with the Volunteer between any such reporting requirements and a further decision to assist the police in the prosecution of the assailant. This latter decision is clearly the choice of the Volunteer. In making it, the Volunteer should be counseled by the PCMO about the following considerations:

- Whether persecution of the assailant may ultimately hurt the victim further by forcing her to publicly relive the incident.

- Whether cultural attitudes toward the victim will make public acknowledgment in a court room setting doubly painful, especially under rigorous cross-examination.

- Whether police and prosecution attitudes may be unsympathetic and even accusatory.

-Whether the victim may be required to remain at her site or in country while a trial takes place, raising questions about her physical and psychological welfare.

In addition, the Volunteer should take into account the fact that the Peace Corps is only authorized to provide legal counsel to Volunteers under limited circumstances. The General Counsel's office has been advised by the Department of Justice that in cases where the Volunteer elects to bring charges against an individual as the result of the commission of a crime, including rape, retention of counsel to assist in such an effort is legally restricted to situations where the impact of prosecution transcends the interests of the individual Volunteers and truly affects the interests of the Peace Corps program. Any attorney whose retention is authorized under these circumstances could only advise the victim prior to her court appearance and assist the prosecution in the preparation of the case. He or she would not under any circumstances be able to appear in court at the trial or in connection with pre-trial matters. Thus, the legal assistance which can be rendered will be very limited. The PCMO should contact GC to obtain authorization in the event such a course is contemplated.

6. ADMINISTRATIVE PROCEDURES

6.1. Reporting - Medical Operations/Washington should be notified immediately of all rapes, via the A-250 Case Card.

6.2. Medevac - If a Washington consultation is indicated, the Office of Medical Services should be contacted as much in advance as possible. In addition to the Volunteer's arrival time, please provide information on the Volunteer's emotional and physical state. Follow normal medical evacuation procedures.

7. TRAINING

7.1. Staff Training. With the help of this guideline, country staff have an opportunity to develop an increased awareness of the effects of sexual assault, identify the attitudes of their own culture(s), and explore their feelings concerning sexual assault. Any persons with special training or interest in crisis counseling should be identified as resources for the PCMO. In addition, the Medical Officer should identify the local physicians and trained counselors, if any, to be used in time of a sexual assault crisis. Perhaps most important is a consensus among staff members about how to preserve medical confidentiality and respect the privacy of the victim, in the midst of the anxiety, anger, and denial that often surface in times of crisis.

7.2. Volunteer Training. Volunteers are warned of the dangers of rape by Medical Services nurses at stagings. In early training and again after about six months in country, sessions for both men and women should be given covering country-specific male/female role expectations and attitudes about Volunteers, including what exceptions are made for them and what is believed about their sexuality and the reasons for their presence in the country. A review of cultural do's and don'ts such as behavior on the street, dress, and areas considered off-limits for women can help trainees understand what might lead to sexual misunderstandings and what things might make them particularly visible targets for an attacker. While it may be useful to have some discussions in separate groups for men and women, it is important to have much of the training in mixed groups so that men as well as women are aware of the special risks for women.

The work of another of our counselors with Volunteers concerning rape prevention indicates that the women learned best from watching host country women role play their behaviors handling verbal, visual, and physical harassment on the street. For many American women, cultural adaptations may require major adjustments in attitude and behavior. They may experience recommendations that limit their personal freedom. Weighing the risks, advantages, and disadvantages of conformity to expectations is a crucial part of training not only for effective service but also for effective health care.

At the same time that cultural adaptation is stressed in order to reduce visibility and aggravation of local mores, it is important not to create another rape myth - that all Volunteer rape victims have been careless or culturally inappropriate. Sexual assault has occurred to women asleep in their homes, on their way home from work, and when walking with friends. Sexual assault can occur wherever violence erupts. Preventive measures only reduce the likelihood of being an obvious target for violence.