Psychopathology, perceived social support, and coping in survivors of adult sexual assault: A cross-sectional hospital-based study.

BACKGROUND: Adult sexual assault (ASA) is often associated with negative mental health consequences. The psychological needs of ASA survivors are overlooked while the legal and social needs focused on.
METHODOLOGY: It is a cross-sectional study. The ASA survivors who came for medical evaluation were included in the study after obtaining consent. Fifty ASA survivors were interviewed for the study. Psychopathology, perceived social support, and coping mechanisms were assessed during interview using especially designed semi-structured pro forma.
RESULTS: The mean age of participants was 25.6 ± 7.2 years. Forty-one of 50 survivors suffered from major depressive disorder or posttraumatic stress disorder or both with 33 expressing suicidal ideas. Maximum social support was perceived from family and least from significant others such as health-care workers, police, and judiciary. Problem solving and expressive action are associated with better perceived social support by family as well as friends.
CONCLUSION: Depression and suicidal ideas among majority the survivors of ASA highlight the mental devastation the sexual assault causes to a woman. Although family is primary social support to them, health-care workers and law enforcement officials are not perceived as supportive toward the survivors. Routine mental health assistance and empathetic approach by all parties involved in the management of survivors are needed in these cases. Copyright:

INTRODUCTION

Nonconsensual sexual advances towards women are known and documented through the history, however, rarely studied from survivor's point of view. Sexual assault includes anything from touching another person's body in a sexual way without the person's consent to forced sexual intercourse-oral and anal sexual acts, child molestation, fondling, and attempted rape.[1] The victims of adult sexual assault (ASA) are better referred as survivors of sexual assault due to better narrative significance of it pertaining to overcoming of the severe trauma of sexual assault.[2] ASA survivors commonly experience psychological sequelae similar to posttraumatic stress disorder (PTSD), depression, anxiety as well as sleep disorders[34] and increases risk of eating disorder, substance use disorders and suicide attempt.[45] The most deterioration in mental health tend to occur in the immediate months of assault. With time subjective appraisal of event decreases which contributes to recovery. At the end of 3 months it contributes significantly lower to PTSD.[6]

Disbelief of the survivor and the commonly reported perception that the survivor provoked the rape lead to secondary victimization of the survivor at the hands of family and friends, as well as the health-care services, police and judicial services.[789] Any negative responses or attitudes by close social support structures, or the feeling that one lacks social support, have a disproportionate effect on the mental health aftermath of rape.[10] Positive support by formal providers of support (e.g., first responders, including police, fire fighters, medical or mental health service providers, and other emergency personnel) may differ in characteristic behavior and differentially impact adjustment compared to informal sources.[11]

This investigation is first step to gain scientific insight into the mind of the survivors of ASA from India. We aim to study the psychopathology, perceived social support and coping mechanism in ASA survivors in urban center India.

METHODOLOGY

The study protocol was presented to institutional ethics committee and was approved before commencement of study. Incidence of ASA in India was 6.3 per lakh of woman population in year 2016.[12] Based on the prevalence, a conservative estimate of 50 participant recruitment for the study was set between April 2015 and March 2016.

The ASA survivors brought for medical evaluation by law officials during the said period were screened for selection criteria of the study. Those fulfilling the criteria were briefed about the study, assured confidentiality and written informed consent was obtained from willing participants before commencing the interview. All the survivors were informed about their right to abandon interview or withdraw from the study anytime they wanted. Interviews were conducted in a separate chamber in the presence of a female staff member of psychiatry department or female caregiver of the survivor as per the discretion of the survivor. Confidentiality was maintained using unique identifiers and name of the survivors were not noted in case record form to avoid identification of the survivors. The survivors of the study were psycho-educated about the psychopathology and mental healthcare options were explained to each one of them.

The protocol for management and participants with psychopathology diagnosed during interview was to have a consultation with qualified psychiatrist at the institute. The participants were treated by a team of psychiatrist, psychologist and social worker from the psychiatry department of the institute with all the necessary infrastructures to manage any psychiatric emergency. The details of management were not documented or analyzed for the study.

Selection criteria: The operational definition of ASA survivor was framed as “any adult woman who reported history of one or more incidence of sexual assault on her”. The survivors with any chronic and debilitating medical illness or suboptimal intelligence were excluded from the study. ASA survivors who had history of sexual assault more than 3 months before interview were also excluded from the study.

Participant assessment: Survivors consenting for study were given an appointment of their convenience and were further interviewed for data collection by PP and SVJ. The psychiatric morbidity was assessed using Mini-International Neuropsychiatric Interview (MINI), English version 5.0.0.[13] This version of MINI can be made copies of and used for research in publicly owned hospitals. The perceived social support was assessed using Multidimensional Scale for Perceived Social Support (MSPSS). It assesses the support under three categories, family, friends, and Significant others.[14] For our study, we suggested Significant others as health care workers and law enforcement officials for participants to rate. Scale was translated to Marathi and back translated for use in study. Mechanism of Coping Scale (MOCS) was used for assessing coping across five mechanisms: Escape avoidance, Fatalism, Expressive action, Problem solving, and Passivity.[15]

Statistical Package for Social Sciences (SPSS, Inc., Chicago, Illinois, USA) version 18.0 was used for data entry and statistical analysis. The categorical variables like diagnosis were summarized as proportions. Quantitative variables, i.e., perceived social support and coping mechanism were summarized as median (interquartile range). Correlations between perceived social support and coping mechanisms were done using Spearman's rank correlation. In this study, a level of significance (α) of <0.05 (two-tailed) was taken to consider a result statistically significant.

RESULTS

The mean age of the sample was 25.6 ± 7.2 years with 29 of the participants younger than 25 years of age. Majority (62%) of our participants were never married and 70% were educated not more than 12th standard. Thirty of the participants belonged to lower socioeconomic status and 14 and 6 were from middle and upper socioeconomic status, respectively. Psychiatric morbidity was present in 41 of 50 participants with 30 diagnosed as major depressive disorder (MDD), 6 suffered from PTSD and 5 had both, MDD as well as PTSD. Suicidal ideas were reported by 33 participants.

The median perceived social support from family was highest among MSPSS subscales. Expressive action and problem-solving had the highest median among MOCS subscales [Table 1]. The correlation between coping mechanism and perceived social support is presented in Table 2.

Table 1

Perceived social support and coping in study population

Parameter	Subscale	Median (interquartile range)
Perceived social support	Family	26.00 (19.00-28.00)
	Friends	4.00 (4.00-19.25)
	Significant others	4.00 (4.00-11.25)
Coping mechanisms	Escape Avoidance	0.60 (0.40-1.00)
	Fatalism	0.80 (0.30-1.20)
	Expressive action	1.00 (0.50-1.30)
	Problem solving	1.00 (0.55-1.80)
	Passivity	0.80 (0.50-1.35)

Table 2

Correlation between perceived social support with coping mechanisms

	Escape avoidance	Fatalism	Expressive action	Problem solving	Passivity
Family
Spearman’s rho	0.242	−0.279	0.301	0.379	−0.351
P	0.090	0.050*	0.033*	0.007*	0.013*
Friends
Spearman’s rho	0.175	0.012	0.337	0.308	−0.134
P	0.225	0.935	0.017*	0.030*	0.353
Significant others
Spearman’s rho	0.201	−0.245	0.139	0.044	−0.076
P	0.162	0.087	0.334	0.764	0.601

*P<0.05

DISCUSSION

Rape is one of the most severe traumas for a woman. The psychiatric morbidity in survivors of sexual assault is reported to be very high. Various psychiatric morbidities reported in survivors of ASA are PTSD (17%–65%), depression (13%–51%), generalized anxiety (12%–40%), alcohol dependence (13%–49%).[3] Although most survivors experience some symptom reduction by 3 months' postassault, many effects, including fear, anxiety, depression, posttraumatic stress, decreased self-esteem, social difficulties, and sexual dysfunction may continue at significant levels for a number of years thereafter.[16] In our study, the most common psychiatric disorder which survivor of sexual assault suffered was MDD followed by PTSD, while majority of survivors of sexual assault reported suicidality. The psychiatric comorbidity of survivors has multiple implications not only into their personal life but social and legal context as well. The survivors were pursuing legal battle for justice and them being suffering mental illness makes it more difficult for them to put up with the rigors of a protracted court trial. Therefore, the mental health of the survivor needs a prompt addressal. Considering the high psychiatric morbidity in this population it is justifiable that survivors be screened for psychiatric morbidities and indicated psychiatric intervention be advised by the specialist in mental health.

ASA is associated with increased risk of suicidal behavior in women. Depression, younger age, and self-blame are the factors more likely to be triggering the suicidal thought in ASA survivors.[17] Suicidality was not only expressed by most survivors with MDD and PTSD, but also in certain cases, where there was no other diagnosis could be made. The survivors were overwhelmed with despair to the extent that they wanted to give up on their life. The suicidality in ASA survivor is known to be associated with sleep disorders and sleep fragmentations.[18]

Social support has been identified as a critical factor affecting sexual assault survivors' recovery process. Positive reactions by social support system include emotional support, validation, informational support, and tangible aid. Potentially helpful social reactions such as believing the survivor may enhance recovery, whereas harmful reactions like victim blame may harm recovery. Negative social reactions of being treated differently, having someone take control, and distraction were all related to poorer recovery and mental health outcome.[19] Survivor from our study sample perceived maximum social support by family and least by significant others such as health-care professionals and police personnel. Bhattacharya suggests that attitude by male as well as female police personnel in India is negatively biased towards ASA survivors.[20] Similarly, people who have been sexually assaulted often seek medical help but may not disclose the assault which suggest as medical fraternity not perceived as objective.[21] Indian social fabric still holds significant involvement of family in individual's life and instances of broken families are less as compared to their western counterparts. This reflects in family being perceived as a significant social support by typical Indian, and therefore by survivors of sexual assault from India.

Maladaptive coping partially mediates the effects of other traumas, self-blame, and perceived control over recovery on both PTSD symptoms and recovery.[22] Although seemingly counterintuitive, coping and social support also have been examined in models that include the concept of positive changes following sexual assault. Positive changes refer to improvements in self, strengthened relationships, positive life philosophy or spirituality and stronger sense of empathy.[23] Regardless of ethnic differences, the literature has suggested that higher levels of psychological well-being are experienced by sexual assault survivors who use greater amounts of positive religious coping, i.e., a variety of methods that help individuals feel close to God, see meaning in life, and feel spiritually connected to others.[24] Coping strategies such as positive distancing is negatively associated with PTSD in survivors of sexual assault.[25]

Fatalism and passivity are known to be associated with negative mental health outcomes.[2627] The problem focused copings such as expressive action and problem solving are known to be associated with better outcome.[28] The problem focused coping mechanisms are associated with better perception of the social support from their friends and family adding to a better mental health outcome. The therapy work during the recovery process should take into account the predominant coping mechanisms and by encouraging better psychosocial support by friends, family, and significant others. Especially the sensitization of law officers, healthcare personnel can positively impact the mental health outcomes in survivors of ASA.

CONCLUSION

Sexual assault is a significant trauma with devastating behavioral and psychological after effects such as depression and suicidality. Therefore, medical team assessing the survivor must consist of a mental health professional. The trust of the survivors must be gained by law officials and health care professionals involved to help them better. The management should be individualized due to plurality of factors affecting survivors such as social support, coping to name a few. Mental health professionals and policy makers should take steps to ensure sensitization of fraternity for a more receptive approach to mental health needs of ASA survivors.

Limitation

The sample size of the study is small and consists only of survivors visiting hospital for evaluation. In addition, the correlation between the coping mechanisms and perceived social support are fair and requires a larger size to conclusively accept or reject the association. The psychiatric morbidity reported may not be extrapolated to cases that are not reported due to multiple complex reasons which may include mental health variables of the survivors. This study also does not investigate the sexual assault in detail such as whether single or serial assaults, single or multiple perpetrators, and associated violence which can be a prominent confounding factors for psychopathology. The follow-up study of survivors during the legal trial or following a year may help put the mental health needs in better perspective to fund the dedicated mental health services for the survivors.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.