WE ARE

  NOT POWERLESS

My Personal Experience

            Addiction. What is it? For me, it is an all-consuming black hole and supernova that implodes and explodes my humanity simultaneously. I have struggled with addiction for the majority of my adult life and despite the fact that I have used and/or tried many different drugs over the last several years and never became an “addict”, there is one exception, alcohol. It has been my poison of choice for the last 7+ years.

Trauma

            Before delving any further into this paper, it is necessary to understand what trauma is and how it affects an individual. According to the Office of Behavioral Healthcare Equity at the Substance Abuse and Mental Health Services Administration, trauma is broadly defined as a stress that “causes physical or emotional harm from which you cannot remove yourself”. Trauma, in any form (physical, sexual, etc.) changes a person for the rest of their lives. Additionally, (Sack, 2012), reports that trauma in childhood is associated with later drug addiction, overeating, compulsive sexual behavior and various other addictions.

            Furthermore, trauma is subjective, such that, it can only be defined in an individual's mind. What is seen as “very traumatic” for one individual may be seen as “less traumatic” by another. Therefore, it is impossible to understand the experience of another individual's trauma, without experiencing it for yourself.

Substance Use/Spectrum Disorders

            With the release of the 5th version of the Diagnostic Statistical Manual (DSM-V) by the American Psychological Association (APA) in 2013, the concept of mental health disorders existing on a “spectrum” was introduced. Such that, every individual who experiences a mental health disorder, does so to varying degrees of severity. Additionally, the concept of a “spectrum disorder” makes for a more flexible diagnosis and enables mental health practitioners to create treatment plans for the individual and not just a “one size fits all” approach (Integrated Approach to Diagnosis and Classifications." DSM-5, 2013).

            In concerns to addiction, before the publication of the DSM-V, “substance-dependence” and “substance-abuse” disorders were considered to be two similar but separate disorders. In the DSM-V these two disorders have been combined and are now referred to as a substance-use disorder (SUD), to note the spectrum that addiction lies upon (Substance-Related and Addictive Disorders, 2013). In regards to alcoholism,  people may think of the “stereotypical” alcoholic who drinks heavily every night when they get home from work. However, because substance use disorders exist on a spectrum, several different substance use patterns exist that qualify an individual for a diagnosis of a SUD. In light of this fact, many people do not know that binge drinking is a form of alcoholism and therefore a SUD. According to the National Institute for Alcohol Abuse and Alcoholism (NIAAA), binge drinking is defined as a pattern of drinking that brings blood alcohol concentration (BAC) levels to 0.08 g/dL (.08% of your blood is composed of alcohol). A BAC level of 0.08 can be achieved by consuming 5 alcoholic drinks in the span of 2 hours for men, and 4 alcoholic drinks in the same timespan for women (Drinking Levels Defined. n.d).

            I first started drinking at the age of 17. I did not drink every night. In fact, I drank maybe once every 2 months. But when I did drink, it was in extreme excess. In other words, I was a binge drinker. This pattern continued for almost 3 years until my sexual assault (SA) occurred. Following my SA two significant things changed concerning my SUD; (1) my drinking patterns changed and; (2) I developed PTSD. In terms of drinking patterns, I stopped binge drinking and began to drink heavily every day in an attempt to cope with the negative emotions that I was experiencing, and my development of PTSD is significant as combined with a substance use disorder, I developed what is known as a dual diagnosis.

Dual Diagnosis

            A dual diagnosis occurs when an individual develops more than one mental health disorder (e.g. substance use disorder and PTSD) at the same time. Recovery in terms of a single diagnosis is in and of itself a rather lengthy and daunting task for any individual. However, with a dual diagnosis there are two sets of problems that interconnect and in order for recovery to take place both issues must be dealt with.

            In a discussion concerning the dual diagnosis of trauma (e.g. sexual assault) and a SUD (Sack, 2012) states that recovery is a particularly complicated process. Specifically, when an individual uses a substance as a coping mechanism for their trauma and develops a SUD two things must happen for recovery to take place; (1) the trauma needs to be dealt with and; (2) new coping mechanisms must be adopted. Therefore, a dual diagnosis requires a dual recovery plan. Unfortunately, this is much easier said than done.

Post Traumatic Stress Disorder (PTSD)

            My battle in overcoming addiction was further exacerbated by my PTSD; as the associated symptoms (flashbanks, increased anxiety) were a significant contributor to my desire to drink. In a study looking at the effects of PTSD on substance use, (Peirce, Kindbom, Waesche, Yuscavage, & Brooner, 2008) report that PTSD was in general unrelated to a substance use diagnosis or severity, but note that subjects with PTSD appear to face an increased risk of alcohol dependence. Furthermore, (Galatzer-Levy, Nickerson, Litz, & Marmar, 2012) report that men, in particular, appear to face an increased risk of developing a SUD following the development of PTSD.

            When I went to Iowa City in the Fall of 2012, I was sober for about 4 months. However, this was short lived as in the Spring semester I once again, started to binge drink. This pattern continued for over 2.5 years, and in that time my tolerance vastly increased and therefore so did the amount of alcohol I drank every night.

            The year of 2015 was especially difficult for me. Aside from creating my website, and being contacted by hundreds of other survivors, I was also processing my own trauma, working full time, attending school full time and in a relationship with a co-addict. In order to cope with all of this I began consuming at least a fifth of Fireball whiskey a night in addition to developing a severe addiction to stimulants. In June of 2015 I had a massive mental and emotional breakdown, I came to work drunk, self-injured and was subsequently taken to a detox facility where I stayed for 3 days. In July of 2015 I attempted to admit myself into a mental health facility due to the severe depression and suicidal ideations I had recently been experiencing. However, because of the fact that I was not suicidal at that moment in time, they refused to admit me. For the next 6 months I battled both depression and addiction. I lacked any and all motivation or drive for life. I was getting into trouble at work, I stopped going to the gym, and my grades suffered terribly; however, by the end of December 2015 I decided that I had enough. I no longer recognized the man staring back at me in the mirror. I was miserable, and I realized that I couldn't keep living like that, so I made the decision to become sober. The last several months of my life have been far from perfect, as I quickly learned that recovery from addiction is a process, and not an instantaneous fix.

            Despite the fact that I have struggled with a substance use disorder for the majority of my adult life, I know now that my addiction was exacerbated by my SA. From my own research and in conversations with fellow survivors, I have found that I am not unique in my experience with addiction. Therefore, I have decided to write a review of the existing scientific literature concerning SA and subsequent addiction. I hope that in reading this you will gain a greater understanding of the many negative side effects that can occur after SA.

Addiction and Interrelated Factors Among Sexual Assault Survivors

Introduction 

            Research has shown that survivor substance use following SA is a rather frequent occurrence. Furthermore, survivor substance use is also associated with re-victimization, such that, substance use following SA may put a survivor at an increased risk for subsequent SA. In light of the immense toll that both sexual assault and substance use have on the individual and society in terms of: (1) personal well-being; (2) loss of social relationships; (3) lost wages and; (4) the expense of rehabilitation or detox facilities, further study of the interconnection between these two factors is warranted. This review will discuss: (1) why survivors often develop SUDs following their SA; (2) the prevalence of SUD’s among male and female sexual assault survivors; (3) risks associated with substance use; (4) the negative impact that substance use may have on the disclosure of SA and; (5) the resources that are necessary for a survivor's recovery from SA and a SUD.

Etiology/Side Effects

            Miranda, Meyerson, Long, Marx and Simpson, (2002), purport that substance use following sexual assault is an attempt on the part of the survivor to “self-medicate”. Specifically, survivors may use alcohol and/or other drugs as a means of relieving themselves from the painful emotions and memories that they are experiencing. In addition, survivors may use substances to: (1) increase feelings of relaxation or control and; (2) reduce chronic anxiety and/or suicidal thinking (Sack, 2012). Unfortunately, self-medication is not without negative consequences, as individuals with substance use disorders may experience difficulties in regulating affect (emotional expression), self-esteem, relationships and self-care (Khantzian, 1997). Furthermore, (Khantzian, 1997) reports that individuals with SUDs experience extreme emotional dysregulation (e.g. emotionally overwhelmed or not feeling at all).                        

Risks/Prevalence

            Much research has been done on the risks associated with SUDs in both men and women. Howard, Griffin, & Boekeloo, (2008), conducted a study of the prevalence and risks of alcohol related SA among undergraduate students, and note the impact that both gender and alcohol use have on the occurrence of SA. Specifically, females reported a higher prevalence of alcohol-related SA (20.4%) compared to males (6.6%).1 Additionally, women who report binge drinking and other alcohol-related violence faced an increased risk of alcohol-related SA. In comparison, only alcohol-related violence was associated with alcohol-related SA among males in this study. Finally, the authors state that alcohol-related SA is associated with other risk factors and note the importance of accounting for these risk factors in future research.

            In a study looking at sexual abuse and alcoholism, (Sack, 2012), reports that the rate of sexual abuse in the general population is around 6%, and notes that the rates of sexual abuse found in alcoholics are significantly higher (12% for men and 49% for women). Sack, (2012), reports that in addition to facing an increased risk of sexual abuse, alcoholics also face a higher risk of experiencing negative long-term consequences such as, depression, anxiety and suicide later in life. Specifically, survivors of sexual abuse are 3 times more likely to suffer from depression, 6 times more likely to suffer from PTSD, 13 times more likely to abuse alcohol and 26 times more likely to abuse drugs compared to those that have not been sexually abused (“Substance Abuse”, n.d.). However, it is important to note that (Bullock & Beckson, 2011) assert that it is likely that the prevalence of male SA is higher than reported by current literature, and attribute this underreporting to the stigma surrounding male SA

            Current research reports that males in particular, appear to face an increased risk of developing SUD’s following SA. In a study concerning male survivors, substance use and sexual functioning (Turchik, 2012) reports that male SA is related to increased alcohol consumption on a weekly basis and increased problematic drinking behaviors. Furthermore, their results showed that male SA is also associated with an increase risky sexual behavior and difficulties in regards to sexual functioning.

            It is important to discuss the impact that substance use may have on the re-victimization of survivors. Such that, substance use following SA may put a survivor at increased risk of experiencing subsequent SA. Ullman, Najdowski, & Filipas, (2009) conducted a study which looked at: (1) child sexual abuse; (2) PTSD and; (3) substance abuse in an attempt to discern which factors increase an individual's risk for sexual re-victimization. Their results showed that: (1) child sexual abuse was associated with increased symptoms of PTSD in adult SA survivors; (2) PTSD numbing symptoms directly predicted re-victimization and; (3) PTSD symptoms of avoidance, arousal, and re-experiencing were related to problem drinking which increased a survivor's chances of sexual re-victimization.

            Given these results it would appear that past SA, PTSD symptoms, and SUDs interconnect to increase a survivor's likelihood of experiencing a future SA. While there are many resources available for a survivor following SA, these results highlight the need for the community to make an effort to: (1) increase awareness of these resources and; (2) make an effort to establish more accessible intervention programs in regards to drug and alcohol counseling and mental health therapy for SA survivors.

Rape Culture

            Minimal statistics exist concerning the prevalence of substance use at the time of the crime being committed in regards to the perpetrator. This gap in the existing research concerning SA may be attributed to “victim blaming” portion of the rape culture that currently exists in our society. Messina-Dysert, (2016) defines rape culture as a culture in which “sexual violence is common and widespread.” Furthermore, (Messina-Dysert, 2016) states that in a rape culture “sexual violence is encouraged and condoned by prevailing [social] norms and attitudes.”

Gender Roles, Rape Myths & Victim-Blaming

            In a review of the impact that gender roles may have on the attribution of blame in the event of a SA (Grubb & Turner, 2012) report that rape myths are created and perpetuated by our current culture and gender roles. Therefore, it would appear that gender roles, rape myths and victim-blaming are three separate, yet interconnected factors. Thus, in order to understand the combined impact of these three factors, it is necessary to first understand the impact of each separately.

Gender roles. Gender roles are assigned to both men and women at a very early age. They not only impact how individuals behave, but how we view both ourselves and others as well. Specifically, gender roles are a set of beliefs of how males and females are to behave. More specifically, men are socialized to be dominant, and hyperactive sexually, whereas women are expected to be more passive and hypoactive sexually. Thus, creating a double standard when it comes to the sexual activity of men and women. Such that, if a male has multiple sexual partners he is viewed as masculine and a “stud”. Conversely, when female is sexually active with multiple partners she is viewed as promiscuous and/or a “whore”.

Rape myths. Burt, (1980) describes rape myths as “prejudicial, stereotyped, or false beliefs about rape, rape victims and rapists”. Examples of rape myths include, “male SA means losing your masculinity” and “women can resist a rapist if they want to”. Additionally, (Grubb, & Turner, 2012) argue that the traditional gender roles found within a patriarchal society create and perpetuate rape myths, thereby instilling them on both the individual and societal level, and note that the dual ingraining of rape myths makes them: (1) difficult to recognize and; (2) even harder to eradicate.

            In addition, the widespread acceptance of rape myths create a hostile environment for survivors, and may serve as a barrier to the disclosure of SA for both men and women (Sable, Danis, Mauzy, & Gallagher, 2006). Heath, Lynch, Fritch, & Wong, (2013) support this finding and report that the acceptance of rape myths within the criminal justice system may serve as a barrier for a survivor in the prosecution of their perpetrator, and (Greeson, Campbell, & Fehler-Cabral, 2014) assert that a negative experience in disclosure of SA to the police may: (1) negatively affect a survivor's emotional well-being and; (2) decrease the involvement of a survivor in a criminal investigation.

Victim blaming. The current rape culture gives rise to several different negative consequences for a survivor following their SA. One particularly harmful consequence is the phenomenon of “victim-blaming”. Such that, an individual may hold a survivor responsible for the occurrence of their SA. Ullman, & Hagene, (2014) report that blaming the survivor is associated with reduced feelings of control over their recovery and is associated with poorer recovery outcomes overall.  Examples of victim-blaming include, “She was asking for it because she was dressed provocatively” or “Men should fight back against their assailant” (Edwards, Turchik, Dardis, Reynolds, & Gidycz, 2011).

            In summarization, gender roles, rape myths, and blaming the survivor for the occurrence of their SA conjoin to create an adverse environment for a survivor’s recovery process. Such that, the current gender roles create unrealistic expectations as to how men and women should behave. In turn, these unrealistic expectations create different false beliefs about how a survivor should react in the case of SA. Lastly, these false beliefs are the origin of blaming the survivor for their experience. In consideration of the aforementioned factors, further education for the general public concerning the negative impact that these factors may have on a survivor's’ disclosure as well as recovery process is necessary. 

Social Reactions

            In a study among college students, (Untied, Orchowski, Mastroleo, & Gidycz, 2012) explore the effects that substance use by both the survivor and perpetrator may have on the disclosure of SA. Participants were given hypothetical scenarios of SA and were instructed to report on both the responsibility of the survivor and perpetrator, the extent to which the scenario could be considered SA/rape, and their likelihood of providing positive or negative support to the survivor at the time of disclosure. Their results showed that compared to women, men were: (1) more likely to give more negative and less positive reactions; (2) less likely to view the scenario as rape and; (3) ascribed less perpetrator responsibility.

            Furthermore, the researchers report that when the survivor was drinking, participants attributed greater responsibility to the survivor and less responsibility to the perpetrator for the SA occurrence. In addition, participants reported that they would provide less emotional support to the survivor when the perpetrator was the only one under the influence of alcohol, compared to when both the survivor and perpetrator were intoxicated (Untied, Orchowski, Mastroleo, & Gidycz, 2012). These results indicate that substance use by the survivor and/or perpetrator may have a significantly detrimental impact in regards to how disclosure of SA is perceived.

Perpetrator Substance Use

            The findings of (Untied et al., 2012) are significant as (Krahé, & Berger, 2013) report that almost 75% of survivors and 70% of the perpetrators were intoxicated at the time the SA occurred. Similarly, in another study which looked at SA risks among gay and bisexual men the researchers report that 67% of perpetrators in their study consumed alcohol prior to the occurrence of the SA (Hequembourg, Parks, Collins, and Hughes, 2015). Additionally, (Koss, Gidycz, & Wisniewski, 1987) report that perpetrator substance use is associated with increased SA severity. Such that, when a perpetrator is under the influence a survivor’s risk of serious physical injury increases.

Self-Blame

            It is not uncommon for a survivor to blame themselves for the occurrence of their SA. Unfortunately, self-blame may serve as a barrier to disclosure for survivors, and self-blame is just one of the many false beliefs that a survivor may face following their SA (Logan et al., 2005; Edwards et al., 2011). In fact, two different types of self-blame exist in the field of sexual assault recovery: (1) behavioral self-blame (BSB) or blaming the SA on the survivor's own behavior and; (2) characterological self-blame (CSB) or blaming the SA on the survivor's own character. Both types of self-blame have been associated with poorer recovery outcomes. However, the effects of CSB are stronger, due to the fact that CSB is an attack on the survivor’s character and is therefore more difficult to overcome (Breitenbecher, 2006).

Negative Social Reactions

            Wyatt, Newcomb, & Notgrass, (1990) assert that negative social reactions are associated with higher levels of self-blame in a survivor. Additionally, (Ullman, 2010) reports that negative social reactions may increase a survivor's likelihood of developing mental health issues, such as depression and/or PTSD. Furthermore, higher levels of survivor self-blame are also associated with an increased risk of sexual re-victimization (Miller, Markman, & Handley, 2007).

            Current research shows that negative social reactions and survivor self-blame appear to be connected in a complex manner; therefore it is important to look at the effects of these two factors in combination with one another. Sigurvinsdottir and Ullman, (2015) attempt to discern the impact that these two factors may have on a survivor’s alcohol use following SA, and report that (1) CSB, but not BSB mediates the relationship between negative social reactions and problem drinking and; (2) positive social reactions are correlated with decreased levels of CSB and BSB. Specifically, problem drinking may be increased by negative social reactions if a survivor has higher levels of CSB, and positive social reactions appear to decrease the overall levels of self-blame in a survivor. Additionally, the authors note that greater education among the public in regards to positive and negative social reactions is necessary so that people can better respond to the disclosure of SA.  

Medical & Mental Health Services

            In a discussion concerning public health policy (Mercy, Rosenberg, Powell, Broome, & Roper, 1993), state that a public health approach treats any form of violence as health issues because there are significant physical and psychological injuries in addition to other long-term impacts resulting from the violence. Basile, & Smith, (2011) support the use of a public health approach and report that SA has negative impacts on a survivor’s: (1) physical, psychological and sexual health; (2) relationships; (3) social roles (e.g. husband, wife, employee) and; (4) economic well-being (e.g. missed work, lost wages, medical expenses). Furthermore, the authors assert that all of these areas must be addressed in order for a survivor to recover from their SA. In light of this review it appears that a survivor may need: (1) medical care; (2) mental health therapy; (3) social support and/or; (4) economic assistance in the aftermath of their SA.

            While there are many services available for a survivor following SA, many social barriers to these resources exist. Some of these barriers may include a survivor’s ethnicity, socioeconomic status (SES), shame, self-blame and/or the fear of not being believed (Amstadter, Mccauley, Ruggiero, Resnick, & Kilpatrick, 2008; Logan, 2005). Additionally, a significant barrier unique to men in regards to accessing medical and mental health services following SA is the stigma that surrounds male SA in our society (Turchik, Mclean, Rafie, Hoyt, Rosen, & Kimerling, 2013). From this research, it appears that many barriers exist for a survivor to access the resources necessary for recovery; therefore, the remainder of this review will explore these barriers and attempt to provide possible solutions for their removal.

            In a study of ethnic minority women survivors in the United States, (Alvidrez, Shumway,  Morazes, & Boccellari, 2011) report that despite the fact that mental health services were offered at no cost, Black and Latino women were less likely than Caucasian women to utilize these services in the year following the assault. In addition, the researchers note that ethnic matching did have an effect in their study. Such that, the survivor and therapist be of the same ethnic group. However, the authors also report that these differences are not entirely explained through differences in access and note that further research concerning barriers for ethnic minorities is warranted.

            In a national survey of female survivors regarding the utilization of medical care and/or mental health therapy following SA, (Amstadter et al., 2008) report that 40% of survivors do not seek professional mental health therapy for their emotional problems. Moreover, the authors report that ever seeking help following SA was associated with (1) being white; (2) being married and; (3) having PTSD. The researchers also note the impact that SES and ethnicity had in their study. Such that, women of a low SES and/or ethnic minority were less likely to seek medical and mental health services following SA. In a review of public health centers (Sasso, & Byck, 2010) advocate for an increase in federal funding and further use of a sliding-scale payment plan in order to provide services for those individuals of a low SES.

            In a study concerning internal cognitive barriers (Logan, 2005) report that: (1) the establishment of peer groups for survivors; (2) counseling and education for friends and family members of the survivor; (3) further education concerning SA among both the general public and within the medical and criminal justice systems and; (4) the establishment of more stringent laws against perpetrators are necessary to: (1) reduce the stigma that survivors are confronted with; (2) reduce feelings of isolation, self-blame and shame; (3) make the prosecution easier for the survivor, not the perpetrator and; (4) prevent “re-victimization by the system.” That is, to prevent the survivor from becoming re-traumatized by their SA throughout the judicial process. In addition the researchers assert that future research should focus on how these barriers simultaneously differ and overlap by different types of services (e.g. mental health, medical, criminal justice). In conclusion, these findings indicate that much work remains to be done in regards to removing the barriers that prevent survivors from obtaining justice and a measure of closure in their experience.

Discussion 

            Current research asserts that substance use is a way for the survivor to cope with psychological and emotional distress following SA, and appears to affect men and women in slightly different ways. Women appear to face an increased risk of an alcohol-related SA in comparison to men. In regards to drinking patterns, women who report binge drinking following SA face an increased risk of re-victimization and other types of alcohol-related violence. In comparison, men appear to face an increased risk of alcohol-related violence in addition to an increase in weekly alcohol consumption, problematic drinking behaviors and difficulties in sexual functioning.

            Moreover, substance use may be exacerbated by different factors, such as prior trauma and symptoms of PTSD. Specifically, (Ullman et al., 2011) report that the PTSD symptoms of avoidance, arousal and re-experiencing were related to problem drinking which increase a survivor's chances of sexual re-victimization. In addition, long term substance use increases a survivor's chances of experiencing negative long-term consequences such as, depression, anxiety and suicide later in life. Little research exists in regards to perpetrator substance use at the time of SA. However, perpetrator substance use may increase the severity of the SA.

            In addition, gender roles, victim-blaming and rape myths appear to be intimately connected with one another. Specifically, gender roles shape our behavior, and affect how we perceive ourselves and others. Current gender roles purport that males are to be “aggressive, assertive and the sexual initiators”, and women are to be “passive, hypoactive sexually, and submissive to men”. These unrealistic social expectations of how men and women should behave lead to the creation of rape myths, such as “women want to be raped” and “men can’t control their sexual desires”. These, in turn, often create a hostile environment for both male and female survivors. Because men are to be “sexually aggressive” and women are to be “sexually submissive”, male SA is often equated with a male survivor’s “loss of masculinity” and female SA is often met with contempt in the false belief that “they wanted it”. Ultimately, both male and female rape myths may lead to the minimization and/or dismissal of a survivor's’ experience.

            Additionally, substance use may also negatively impact (1) how disclosure of SA is perceived and; (2) the amount of support that is given to a survivor following SA. Such that, greater responsibility may be attributed to the survivor and less responsibility to the perpetrator for the SA occurrence and less emotional support may be given to the survivor when the perpetrator was the only one intoxicated at the time of the SA. Additionally, men appear to be less supportive and may attribute greater responsibility for the SA to the survivor rather than the perpetrator.

            Many myths and false beliefs concerning SA exist in our society which creates a difficult and sometimes hostile environment for the survivor following SA. These rape myths contribute to “victim-blaming” and the minimization of a survivor's experience. Furthermore, the acceptance of rape myths within the criminal justice system may serve as a barrier to disclosure for the survivor.

            Moreover, negative social reactions and survivor self-blame appear to be intimately connected to one another. Such that, a negative reaction to the disclosure of SA may increase the levels of self-blame that a survivor experiences. Furthermore, negative social reactions may also increase a survivor's risk of experiencing mental health disorders, such as depression, and/or increase symptoms of PTSD.

            Many barriers exist to accessing medical and mental health services following a SA. Some of these barriers appear to exist along the lines of race, class, gender and sexual orientation. Similarly, some barriers arise from the acceptance of rape myths and miseducation among the public. Furthermore, other barriers arise from the general population’s unsurety of how to respond to disclosure of SA. Altogether, it is evident that further education in our society in regards to rape myths, SA, SUD’s and how to best support a survivor following their SA is necessary.

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