Q: With all the recent press about the sexual abuse by the Olympics’ gymnastics doctor, and the #MeToo movement reacting to all the high-profile cases with celebrities and well-known men in powerful positions, is this becoming a bigger medical issue?

A: Rape is the nonconsensual penetration of the vagina, anus or mouth by a body part (typically penis, finger or tongue) or object. ‘Nonconsensual’ can be physically forced (including threatening or intimidating behavior), due to the victim being under the influence of drugs/alcohol (so they are not able to consent), or because the victim is coerced. Coercion includes verbal pressure (such as word choice/tone/cadence, lies or manipulation), emotional abuse (for example controlling or jealous behavior) or other means. Sexual assault includes rape and any other unwanted sexual act, whether physical (such as being touched, kissed, groped, etc.) or other (for example verbal harassment, stalking, exhibitionism, etc.).

Sexual abuse is, unfortunately, NOT new. Increased awareness of sexual abuse has been a long time coming, and is a trend that must continue if we are to successfully address this issue. There have been some setbacks, such as in the political arena where men in powerful positions were still either elected or received a lot of votes despite overt evidence (for example recordings of their own words) of their sexual abuse.

The statistics on sexual abuse are horrifying:

Each year over one percent of children are newly subjected to some form of sexual abuse, eventually exposing 20-25 percent of girls and 5-10 percent of boys to this trauma. Over one in five college women and over 5 percent of college men are sexually assaulted during their undergraduate years, and over 10 percent of undergraduate women are raped. In thirty percent of undergraduate relationships there is some form of violence from an intimate partner. Almost 20 percent of women have been raped in their lifetime. Technology may be making things worse; almost 15 percent of kids using the internet have received unwanted sexual solicitations, including requests for or receiving sexual photos, as well as solicitation for real-world contacts.

Yet only a fraction of all these cases are reported to authorities. For example, less than 20 percent of college sexual assaults are reported to the school, and under 5 percent are reported to the police. Less than 20 percent of adult women who are raped report it to the police. The reasons for this underreporting are many, including:

Feeling embarrassed or ashamed Worrying that reporting will make it even more emotionally difficult for them and/or nothing will be done anyway Thinking the incident was not ‘serious enough’ to report Thinking that they somehow contributed to or allowed the assault to happen (by being intoxicated, allowing kissing or other contact even though they said no when things went further than they wanted, not ‘fighting back hard enough’, etc.) Worrying that they will be blamed for being attacked Being in denial and/or feeling overwhelmed.

When sexual abuse it perpetrated by a medical professional such as a doctor or dentist, the intimidation, confusion and doubt experienced by the victim causes them to continue to seek care from this perpetrator over 25 percent of the time, with another 25 percent simply deciding to avoid seeking any care at all.

The same factors that minimize reporting of sexual abuse contribute to only a small percent of victims receiving appropriate medical care.  When victims of sexual assault do come to medical attention, it is very common that their presenting complaints are non-specific and do not directly call out the underlying cause.  For example, victims of abuse may be referred because of changes in their own behavior:

In children this may manifest as acting out, exhibiting age-inappropriate sexual behavior, having non-specific somatic complaints of pain (or other symptoms), having other social issues, and/or depression (including suicidal thoughts and even actions). In adults (including college age victims) there is a 6 times higher incidence of PTSD, a three times likelihood of a major depressive episode, 20 times the risk of abusing drugs and a 10 times increase in alcohol abuse.

The ramifications of sexual assault are severe, complex and long lasting, often affecting the victim their entire life. In addition to the psycho-social support that sexual abuse victims need, there are other medical conditions that need to be considered, such as the potential of acquiring a sexually transmitted disease.

Much more needs to be done to address this way too common problem.

—We must educate all boys and all girls about this issue:

Specifically addressing what is and is not acceptable behavior Educating them about ways to prevent becoming a victim (such as increasing their situational awareness)
Addressing concerns about reporting (encouraging anonymous reporting is one technique being utilized on some campuses); if something doesn’t seem right it needs to be reported (such as ‘if it doesn’t seem right, make it right by reporting it’). We talk about reporting terrorism (‘if you see something, say something’), and yet with sexual abuse being so much more prevalent (the number of victims is many orders of magnitude higher), the level of awareness of the need to report this issue is unacceptably limited. By increasing the understanding of what consensual sex really is, and ensuring they understand the consequences of their actions. Our colleges and universities must do better; recent changes by our federal government decreasing protections for college students are inexcusable. Peer support techniques should also be taught. This should include teaching preventative measures (for example by being a dedicated friend and arriving and leaving a party together, and keeping an eye on each other throughout the party) and teaching how to be supportive of a victim (helping them get to a safe place, encouraging them to seek medical care, ensuring them it was not their fault, listening, and helping them address the many other concerns they may have).

—We must ensure there are well-trained and dedicated professionals available to help the victim and address legal issues. 
—‘Rape culture’, where the victim is blamed, is made to feel afraid to report the assault, and/or excuses are made to explain or excuse the perpetrator’s behavior, contributes to the problem. Giving sexual abusers who happen to be in power a ‘Mulligan’ for their behavior, or writing off their despicable behavior as ‘locker-room talk’, perpetuates this rape culture.

Many countries (including the United States) have mandatory reporting requirements for cases of suspected childhood sexual abuse. Yet the recent cases where serial abusers were able to continue their abuse of more and more victims (as in the Olympics’ gymnastics doctor) demonstrate that the execution of this required reporting, as well as the follow up by authorities, is woefully inadequate.

We need to change the culture that allows this evil to exist. We need to advocate for education about this issue for our children’s protection. We all need to become part of the solution.

Jeff Hersh, Ph.D., M.D., can be reached at DrHersh@juno.com