Psychiatric Evaluation of Victims and Offenders of Sexual Assault in View of Current Laws.

Sexual violence may be a vital reason not only for physical but also for psychological distress and anguish for women and children. Primarily women and girls suffer from sexual violence but boys may also be victim of sexual abuse.[1] Adult men specifically in jails or custody along with sexual minorities such as transgender may additionally be prone to sexual violence. There are many forms of sexual assaults and the perpetrators may be an unknown person or government/private servant or a closely known person; as per the available data perpetrators in sexual violence cases are commonly a known person.

The relevant Indian laws which may be considered in context are; IPC section 375- definition of Rape,[2] Section 376- Punishment for Rape,[2] Section 228(a)- Disclosure of victim’s identity is punishable offense, Section 366A and 366B – Export or import of girls for prostitution is punishable. Others are “ Sexual harassment of women at their workplace” (Prevention act) 2003, CrPC Sec 357C – No hospital can refuse the admission of victim of child sexual abuse, IPC 166 B – No hospital can deny treatment of a rape victim. As per the protection of children from sexual offences (POCSO)[3] act section 27, if victim is female child or adolescent the medical examination is to be done by a lady doctor.

In every case of sexual assault or violence, examination is done for any physical disabilities, mental illness, and pregnancy, HIV, or other sexually transmitted diseases. Calling a mental health professional to provide mental health care has two purposes; (i) Provide mental health support (ii) Assessment of mental health issues or morbidities if any.

Health professionals have dual role of treating and facilitating evidence collection for justice.[1]

While assessment always ensure–

Safety

Privacy and Confidentiality: No reports to media or other personnel

Identity not to be disclosed to media

Therapeutic care: Must be ethical, humane, and compassionate (Respect for autonomy – the right of the patient to take decision – including giving or refusing consent for any examination or filing a legal suit.) The survivor should be assured that she will receive adequate treatment and her treatment will not be affected

Beneficence: Therapist must act in patient’s best interest. To facilitate informed decision, the survivor should be told about her legal rights, facility of referral, and what other resources are available for her.

First line support as follows should be provided to victim, by doctor or other competent health personnel available:

Hear the victim nonjudgmentally, validate feelings, and be supportive

In response to victims concerns try to provide optimum, best available support and care without intruding

Be careful listener while obtaining sexual violence history and avoid pressurizing victim to talk about incidence (if interpreters are involved pay special attention and care while talking about sensitive topics). History must be taken in sensitive manner and appropriate response should be provided.

As such, there is no classical response after suffering sexual violence and there are no classical victim characteristics. The approach for assessment is from general to specific questions.

Facilitation and explaining a medical procedure

To start with the victim should be prepared for conduction of internal medical examination

Victim should be told about the stages and the manner of medical examination along with the purpose of examination.

Facilitating survivors to express their feelings

Victims diverse emotions to be identified

Expression of feelings by victim should be facilitated

Victim should be encouraged to avail crisis counseling

To prevent self-harm or suicide, safety assessment should be done and safety plan should be made accordingly

Make family members and friends as part of the recovery plan.

Victims may have varied emotional response to sexual violence[456]–

Rape trauma syndrome (stress response pattern of a person who has experienced sexual violence). In Acute phase (from violence to approximately 2–3 weeks) may present as crying, wailing, grinning and chuckling, calm and composed, or a blunt affect. Once victim is in safe environment, victim may feel humiliation, degradation, fluctuation in mood swings, guilt, shame, may even blame to self, defenselessness, hopelessness, anger, revenge, and fear of another assault.[7] Long-term phase (2–3 weeks after the event) reaction depends on surrounding situations, lifestyle of survivor, survivor’s age, characteristic personality traits, and available social support. Long term may present as problems at workplace, home, or educational institutes (school/college), specific phobias, sexual dysfunctions, and/or mental health morbidities i.e.,

Posttraumatic stress disorder

Anxiety

Social phobias

Depression

Inclination or increase in substance use or abuse

Suicidal thoughts or behavior.

In long term

Fatigue

Headache of long duration

Sleep disturbances

Frequent nausea

Eating disorders

Dysmenorrhea

Sexual problems.

The trauma experienced by sexual violence may be overcome by getting help of available crisis counselors. The survivor must be made understand by mental health provider that

“Rape” is nothing to do with honor; it is breach of bodily integrity

Assault is not act of lust rather it is a miss use of power

Give positive messages like “for this incidence you are not responsible,” “the type of cloth you wear does not matter”

This will help the survivor to reject self-blame feelings as offender should feel ashamed of his action and would enable to regain the survivor’s self-confidence.

WHEN VICTIM IS CHILD (AGE <18 YEARS)

In the case of a girl child, medical examination is to be done by woman doctor

Consent should be taken from parents or guardians (Separate consent should be taken for the (1) Medical examination for treatment purpose (2) Sample collection for clinical and forensic examination. (3) Medical treatment. (4) Police intimation (POCSO)

It should be informed consent: Purpose, expected risk, side effects and benefits, and time taken. Furthermore, it should be in form, language, and manner which are understood by child/parent/guardian

Examination or assessment should be done in the child trusted persons presence which maybe parents, relatives, or social workers. If such trusted person is not available the assessment should be done in the presence of a hospital nominated female

Since each child have different personality, temperament, social context, and circumstances, thus child may perceive and responds psychologically differently with similar kind of abuse

While assessing a child, first objective is to know the nature of abuse, i.e. Contact/Noncontact, penetrative/non penetrative abuse, also need to understand preabuse emotional state and postabuse emotional and behavioral issues

History taking: Creative play methods, storytelling, dolls, and body charts can be used to facilitate history taking.

WHEN VICTIM IS MALE

Sexual violence forms from which males commonly suffers are:

Receptive oral sex

Receptive sodomy (Anal sex)

Perpetrator forces for his masturbation

Victim’s Forced masturbation.

Most male victims of sexual violence avoid reporting of such cases to the police due to extreme feeling of awkwardness, which makes sexual violence against men underreported.

Psychological and physical response to sexual violence by male victims is similar to response by women, such as

Anxiety, Fear

Anger

Depression

Suicidal behavior

Relationship issues

Sexual dysfunctions

Males may also experience “Rape trauma Syndrome” and are mainly concerned about masculinity, sexuality, opinion of others (considered as homosexual), and unable to prevent rape.

ASSESSMENT OF OFFENDERS OF SEXUAL ASSAULT

Psychiatrists are often called for the assessment of offenders of sexual assault, as most offenders take a defense of mental health issues for the crime of sexual assault.[7]

Good history is important aspect in the psychiatric evaluation of offenders, which includes; early life experiences, education, occupation, psychosexual history, social relationships, previous forensic history, offense analysis, previous and current psychiatric issues, and personality (Antisocial).[89] There can be some Do’s and Don’t while doing assessment which are summarized in Table 1.

Table 1

Do’s and Don’t

DO’s	Don’ts
Take consent	Incomplete examination and reports should not be sent as final
Maintain privacy and confidentiality	Not to be judgmental
Act in patient’s best interest	Do not pressurize victim to talk rather encourage to express feelings
Safety assessment and plan
Provide appropriate information and care
Thorough assessment and examination

A psychological assessment should also be performed for better understanding of psychological characteristics of an offender and making risk assessment of future offending behavior of offender. Appropriate risk assessment scale can be used among several types of available scales.

Most rapists are not mentally disordered. However, offenders should be assessed for:[101112]

- Neurobiological impairments or organic brain damage

- Schizophrenia or related psychoses-abnormal sexual behavior may be due to psychosis itself or indirectly to disinhibition.

-Mania or hypomania; disinhibition may lead to such offenses.

- Paraphilia– Such as pedophilia (sex with underage children), sadomasochism, and exhibitionism.

- Intimacy/attachment problems-early life adversities such as sexual abuse, physical abuse, and dysfunctional family relations, which are likely to affect their capacities for secure attachments and developing healthy adult relationships.

- Drug abuse

- Cognitive distortions; Cognitive distortions are fallacies in cognitions which are used by the offender to rationalize and minimize the perceptions and judgments made by them to justify their abusive behavior.

Suggested scales or tools which can be used are

For Screening purpose MINI – Mini international neuropsychiatric interview

For Depression, HDRS – Hamilton depression rating scale

For Anxiety, HAM-A– Hamilton anxiety rating scale

4. For PTSD, CAPS– 5 Clinician – Administered PTSD scale for DSM-5.

For Psychotic symptoms, BPRS – Brief psychiatric rating scale

For Personality assessment, MCMI – Millon clinical multiaxial inventory and FES– Family environment scale

For assessment in children CDRS – R (Children’s Depression rating scales) and

SCARED (Screen for Child anxiety-related disorders).

REPORTING

Reporting of assessment should include following information

Demographic details

Identification

Assessment done on order or request of

In presence of (in case of minor)

Positive findings

Psychological or other test reports

Further test advised

Treatment advised

Follow-up.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.