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Reasonable responses to unreasonable behaviour?: medical and sociological perspectives on the aftermaths of sexual violence - Liz Kelly, CWASU, London Metropolitan University
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Reasonable responses to unreasonable behaviour?: medical and sociological perspectives on the aftermaths of sexual violence - Liz Kelly, CWASU, London Metropolitan University


Reasonable responses to unreasonable behaviour?: medical and sociological perspectives on the aftermaths of sexual violence - Liz Kelly, CWASU, London Metropolitan University

Reasonable responses to unreasonable behaviour?: medical and sociological perspectives on the aftermaths of sexual violence - Liz Kelly, CWASU, London Metropolitan University

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  • Effect - implies individual psychology Impacts and consequences include wider circumstances including the responses of others (Kelly, 1988) Trauma concept – medical model Greek word means injury. Modern usage began with Freud – symptoms as traumatic effect, traced back to irritation of the genitals – 1896 - Where trauma originally denoted a physical wound, within the fields of psychoanalysis and psychology, any inspection or treatment of the traumatic wound shifts the main emphasis from somatic to psychic topologies. TAKEN ON CULTURAL DIMENSIONS Empowerment - rebuilding self recognition of strengths and abilities MEANINGS – social analysis or individual level Harm – HR discourse Social suffering – from Bordieu and developed by Veena Das in anthropology, that life is, social and individual, and much suffering is created, experienced and coped with socially
  • 2007 study in east London up to 75% of women reported shame following sexual assault (Vidal and Petrak, 2007) Jan Jordan -women opted out of previously enjoyed social and recreational activities. 16 studies demonstrate equal psychological distress regardless of relationship with perpetrator (Frazier and Seales 1997) – however additional factors of betrayal etc not measurable? Sudan – rape survivors’ biggest fear is stigma and social isolation (Amnesty, 2004) Equation of childhood and innocence – sexualised children are knowing and therefore stigmatised (Kitzinger 1997) ‘ In the experience’ or ‘in the social context’?
  • Ann Burgess professor or MH nursing, Lynda Holmstrom a sociologist – started a RC at a hospital. Documented responses of women they saw. Model still widely cited today. Used to introduce to CJ system the impacts of SV – help jurors understand immediate and subsequent responses can vary. HOWEVER has also been used by defence – if she did not show symptoms of RTS – one case 1982 victim ordered to undergo MH examination – 1989 another case defendant entered evidence to argue that she did not show evidence of RTS so no rape occurred. Have to locate syndromes and disorders in context of US private health insurance regime - if can show impacts can argue for counselling, but at same time becomes a normative framing
  • Square the need for a diagnosis in a US context with a more social model
  • Popular and expert discourses (Hengehold, 2000) may conflict – what happens when disclosures become co-opted into discourses? Louise Armstrong talked about CSA survivors on US TV framed in infantilised terms, teddy bears, girlish voices. Paula Reavey’s work shows what happens when women survivors of CSA in adulthood draw on discourses of abuse ‘effects’ and make links between problems experiencing now and past abuse unproblematically. Invisible perps. Weakness and deficit model not about strengths and abilities – resistance/coping Ethnocentrism - these meanings may not be psychological or medical but may be spiritual, cultural, or political. By imposing this Western trauma framework on other populations, psychological practitioners have largely ignored the role that culture plays in issues of distress and mental health, instead focusing on interpreting the suffering of people by means of pre-determined psychiatric categories and PTSD symptom checklists.   Salvadoran women and calor (Jenkins, 1999, cited in Wasco, 2003) Ataques de nervios – attack of nerves, shouting, crying, trembling and aggression – Latina women (Bryant- Davis et al, 2009) Chest pains (China), burning on soles of feet (Sri Lanka), ants in head (Nigeria) – Ussher (2010)
  • Bonnie Burstow suggests rid ourselves of medical language such as recovery, symptoms, diagnosis but whether or not keep concept of trauma more complex. Symptoms often survival skills Part of everyday language and theorises not as disorder but reaction to a wound - despite ethnocentrism idea of connection with wounds speaks to people across cultures – people feel distress because they have been wounded
  • The meaning of ‘victim’ product of social relations, culture and language Victimhood discourse part of the fashionable conservative critique in the 1990s of PC – but adopted by many who regard themselves as critical Post-structuralists – language constructs reality/meaning Little recognition of critical engagement of feminists with language Interesting which words and concepts deemed ’worthy’ of filling with new meanings
  • Dissociation – separate thinking, feeling self from the physical body switching off, pretending it’s not happening, watching from the ceiling Med/psych perspective focuses on dissociation as a mental health disorder sexual abuse signifies to women that bodies can be appropriated by others for their sexual gratification, reinforcing both a sense of personal powerlessness, and (dis)embodiment,
  • Social suffering been mainly applied to political violence – that experienced by communities, but some of this is SV – but could extend to SV and see women as a group affected by adversity
  • Fry (2007) merging of DV and SV, SV is less served O’Sullivan and Carlton (2001) compared 8 independent SV services, with 8 integrated SV/DV: independent SV had more inclusive definitions, worked with young people, paid more attention to diversity, and undertook outreach and community education Conclusion re integrations – if it is an SV service expanding is more positive, marriages of convenience with DV less so If are going to combine SV service should have autonomy – control of budgets and staff so that can focus on the needs of their service users


  • 1. Reasonable responses to unreasonable behaviour?: medical and sociological perspectives on the aftermaths of sexual violence Liz Kelly CWASU June 2011
  • 2. Overview
    • Pick up on theme of tensions between sociological and medical framings, definitions and contexts
    • Two key questions
    • How are ways of understanding the impact of sexual violence mediated by medical/therapeutic discourses and social contexts?
    • Are there alternative sociological framings which offer opportunities for new thinking in health policy and for practitioners?
  • 3. Starting points 1
    • Most victim-survivors do not make an official report or disclose to health sector – but they do tell someone and seek support
      • Often delay contacting formal agencies
    • The responses of informal network members and professionals either compound impacts or alleviate them, be a gateway into further support or a barrier
    • Other keynotes all focus on DV/IPV, this one on SV
    • Health – unlike in some other countries has been a reluctant partner in responses to VAW
  • 4. Starting points 2: Language in discourse
    • Medical/psychological
      • Effect
      • Trauma
      • Healing
      • Recovery
      • Syndromes
      • /disorders
    • Sociological
      • Impacts and consequences
      • Empowerment
      • Embodiment
      • Meaning
      • Resistance
      • Harm
      • Social suffering
    • Multiple narratives – stories of harm but also coping/survival
  • 5. Wider context
    • Policy shift at national and some local levels
      • integrated approach to violence against women and girls (VAWG) begun by Labour government in Nov 2009, rooted in gender inequality and human rights
      • Approach and framing re-affirmed by coalition govt
    • Neo-liberalism and new public management
        • Measurement, ‘evidence’ based
        • Fits with a health research models, but ongoing debates about what counts as evidence
        • Variations in funding base – drug companies and health provider funding, versus small budgets for social science
        • Valorisation of quantitative, controlled trials
        • When do women’s voices and lives count?
  • 6. Evidence on sexual violence and mental health
      • Short term impacts
        • Shock, fear, anxiety, withdrawal, distrust
      • Longer term
        • Depression, self-harm, eating disorders, sleep disturbance, self-blame, self-medication/substance misuse, panic attacks, flashbacks, fear and anxiety, shame and self-blame
    • Sense of safety in the world is undone – shrinks women’s space for action (Jordan, 2008)
    • Negative social reactions associated with poorer psychological outcomes (Ullman 1996, Filipas and Ullman 2001, Banyard et al, 2002)
    • Higher rates of mental health impacts than physical violence (McFarlane et al, 2005)
    • SV in childhood – penetrative and repeated assaults are associated with more severe/disabling mental health impacts
  • 7. The trauma framing
  • 8. Rape Trauma Syndrome (RTS)
    • Burgess and Holmstrom (1972) – 146 women – attending hospital post assault
    • Marks the early recognition of rape as social problem, its effects and the need for crisis intervention
    • Trauma model based on their research
      • Acute phase (initial impact and immediate effects)
    • - expressed reaction
    • - controlled reaction
      • Disorganisation phase (re-experience assault)
      • Reorganisation phase
    • - emotional legacies
    • - disruptions to lifestyle
    • - establish new routines and capacities
    • Later writings highlight ‘compounded reaction’ – that recent assault amplifies any past or current histories of psychological, psychiatric difficulties
  • 9. Post Traumatic Stress Disorder (PTSD)
    • Superseded RTS as a model
    • Developed following experiences of Vietnam War veterans
    • Describes a cluster of symptoms observed in the aftermath of trauma – entered DSM III in 1980
      • ‘ Experienced an event outside of the range of usual human experience and would be markedly distressing to anyone ‘(added 1987)
      • Amended DSM IV (1994) - event that involves actual or threatened death or serious injury or threat to physical self or others; responses include intense fear, helplessness or horror
    • Widely used to measure impact of sexual violence in research
      • many studies find changes in PTSD at intervals following assault
      • evidence base limited to assaults disclosed to formal agency
      • Interventions focus on alleviation of ‘symptoms’, ‘recovery’
  • 10. Judith Herman – Trauma and Recovery (1992)
    • Combines psychological and sociological
      • Links the trauma of sexual violence with social devaluation of women and children, both cause and consequence of SV
    • Identified changes in arousal, emotion, memory, and cognition
    • Challenges the use of psychiatric diagnoses of women, especially personality disorders
    • ‘ Complex post-traumatic stress disorder’ – to accommodate that changes self (not just sel;f-worth/self-esteem) and ‘being in the world’
    • Need to find meaning in order to ‘recover’
    • Activism as strategy that helps some women
  • 11. Critiques of trauma model
    • Problematising ‘recovery’ (Kelly et al, 1996; Reavey & Warner, 2001) – is not an illness but a life changing event
    • Contested concept – can validate as ‘real problem’, open pathways to therapeutic support and become part of everyday vocabulary (Ussher, 2010) BUT as diagnostic label fails to recognise the social context
      • No recognition of that being part of a social group is relevant –to the violence and its meanings – gender/class/ethnicity/disability
      • ‘ language of psychology rather than the language of survivors’ (Humphreys & Joseph, 2004: 566)
    • Embedded in clinical psychology - but most victim-survivors do not access this, use grass roots specialised services
    • Has become a narrative with ‘master status’ (Frank, 1995) – against which all accounts are judge - ‘trauma talk’ to be recognised
    • Loss of survival and resistance
    • Ethnocentric in the framework – distress expressed differently across cultures
  • 12. Feminist engagements
    • Have used strategically (Burstow, 2003)
      • Contributed to the development of trauma discourse
      • Attempt to add social location into
      • Viewing sexual violence as ‘outside of usual human experience’ is to challenge its normalisation, and to introduce women’s lives into ‘human experience’
    • HOWEVER, the underlying assumption is that social life is safe is belied by prevalence studies on the extent of sexual violence
    • Part of feminist argument has been that violence is everyday, mundane and world is not safe
    • If apply PTSD formulaically then women’s continued anxiety and fear appears irrational and to be lessoned
    • Can the concept of trauma be used in non-medicalised way?
  • 13.
    • Because I do not like to think that the man who raped me infected me with a mental illness, I resist calling the effects of overwhelming terror an illness. I claim my sanity, and view my response as human, even appropriate and dignified
    • Nancy Venable Raine (1999)
  • 14. Sociological framings
  • 15. Stigma, spoiled identities
    • Goffman (1963) 'the process by which the reaction of others spoils normal identity'.
      • rape is inherently dishonouring, amplified where culture/faith places high value on women’s honour, and silences (Gill, 2009)
        • Contexts where hymen repair considered necessary treatment, eg Palestine (Shalboub-Kevorkian, 1999:164) and recent discussions in Libya
      • Implications for telling others – have to manage their responses – emotion work (Hochschild, 1983)
      • Responses of others – positive: listening and believing emotional support, practical support
      • - difficult/negative: blame; taking control; distraction; treating differently; egocentric reactions
    • Time of Silence and Time of Telling (Carlson, 2009)
    • Complexity of silence (Crisp, 2010; Singh et al, 2010)
  • 16. Feminist version: Victimism
    • Redefining rape, demanding recognition of women’s victimisation has led to the creation of a new status - the victim.... Creating the role and status of the victim is the practice I call victimism. A woman who has been sexually assaulted finds she can only be understood if she takes on the role of the victim, she is assigned victim status and then seen only in terms of what has happened to her…. It creates a framework for others to know her not as a person, but as a victim, someone to whom violence has been done.
    • Victimism is an objectification which establishes new standards for defining experience, those standards dismiss any question of will, and deny that the woman even whilst enduring sexual violence is a living, changing, growing, interactive person…. It denies the reality of women’s circumstances and the very real human efforts they make to cope with those circumstances…. Surviving is the other side of being a victim. It involves will, action, initiative. Any woman caught in sexual violence must make moment-by moment decisions about her survival. (Kathleen Barry, 1979, p38-9)
  • 17. The relational self
    • I develop and defend a view of the self as fundamentally relational – capable of being undone by violence. But also of being remade in connection to others … (Brison 2002)
    • Sexual violence as violation of the body and social relationships (Koss, 2006)
      • Interrupts capacity for trusting relationships
      • Requires a rebuilding of the self in a changed context
    • PTSD underplays the role of re-connecting to social networks (Humphreys & Joseph, 2004)
    • Positioning as a victim
      • can lead to feeling ‘tainted’ and defined by men’s violence
      • victim as passive and a gendered concept (Reavey & Warner, 2001)
  • 18. The ‘v’ words
    • Victimisation
      • Material reality – extent of violence/abuse
    • To be made a victim
      • Powers of violence and abuse as control
      • Corodes confidence and erodes agency
      • Further harms through responses of others –shame and stigma
    • To be a victim
      • To name ones experience
      • Legal status
    • Victimhood
      • As a chosen identity
      • A critique of feminist analysis – ‘victim feminists/feminism’
    Child and Woman Abuse Studies Unit
  • 19. (Dis)embodiment
    • Implications of violating boundaries - disrupts
    • control over body and relationship with body
    • Coping during assaults: dissociation and leaving the body emotionally when it is impossible to leave physically
    • Body as ‘crime scene’
    • Self as embodied – ‘ Nothing can be your body if there is no you ” (Church 1997) – struggling to ‘get the self back’ (Jordan, 2008)
    • Sexual and physical abuse is experienced through the body and survivors of sexual abuse often describe a disconnection or dissociation such that the ‘true’ self can describe incidents of abuse from a physical and emotional distance. The child’s sense of believing ‘this isn’t happening to me’ may go on to develop into a profound alienation from the life of the body (Scott 2001:177)
    • Dissociation as disorder or an attempt to manage the unbearable and linked to social/cultural views of women and their bodies?
  • 20. Resistance, Harm and Social Suffering
    • Resistance seldom asked about in research or practice
      • Different to resilience, which emphasises aspects of personality and behaviour that mitigate impacts
      • Physical/cognitive/emotional resistance (Kelly, 1988; Jordan, 2005)
        • withholding a part of self
        • retaining a sense of control
    • Discussing can enable women to positively reassess (Jordan, 2008)
      • often discount themselves as ‘unsuccessful’ but remembering and reframing helps shift self-blame
    • Harm/s as alternative to effects/impacts, comes from a human rights perspective, and adopted by some criminologists ‘social harm’ (Dorling et al, 2008)
    • ‘ Social suffering’ from Bordieu (1999) and developed by Veena Das (2001), links the social, cultural and individual – the burdens of violence in everyday lives
  • 22. Specialist services
    • Rebecca Campbell (2008) : where there is no specialist provision many victim-survivors experience ‘secondary victimisation’: the majority of reported cases are not prosecuted; many do not receive complete medical care, and most do not have access to quality support services
    • Unacknowledged sexual violence can compound impacts over time – need to provide safe spaces that enable naming,
    • Minority women and lesbians are less likely to access support, so outreach and appropriate responses necessary
    • Most significant in positive coping – perceived control over process and body (Frazier et al, 2004)
      • Practice of FMEs in SARCs
    • What enables women to access and receive support - ‘normalisation’, validation, respect and dignity’ (Campbell, 2008 )
  • 23. Specialist services 2
    • Services that women deem most helpful in 3 countries
    • were specialist SV services and RCCs in particular
    • (Fry, 2007; Kingi and Jordan, 2009; Lievore, 2005)
      • Ongoing project (Ullman and Townsend , 2007) with 1000 victim-survivors: 16% accessed RCCs, 79.3% found it helpful, higher than any of the 10 formal and informal sources of support being studied.
    • Patterson (2009) RCCs most responsive to victim-survivors and attempt to offer the most holsitic services
    • Under-resourcing of sexual violence services noted in recent US research (Macy et al, 2010) and in the Australian Plan to Reduce VAW (2009)
      • Means do not have capacity to meet needs (p75), reach certain communities
      • As disclosures and reporting of VAW increases, the gap between demand and needs being met will only grow… the first door should be the right door ( p75, 79).
    • Westminster and GLA invested in expanding RCCs, but cuts in public expenditure mean will remain fragile eg history of provision in Liverpool
  • 24. What women think
    • Support for specialist women’s organisations in WNC focus groups (2010, including A Bitter Pill to Swallow to inform the Alberti review) even though not asked
      • Value – safety, holistic support, when and for as along as need it, and empowerment approach
    • We need more appropriate services for vulnerable women ... The Havens [SARCs in London] only accept people within one year. Some times it can take many years to come forward. You feel you are on your own if there are no services to support you (p87)
    • The second time round when I was raped again I went to the Haven, they were fantastic, they made me tea, took my statement, gave me clean clothes, let me have a shower.... the doctor that examined me was perfect, brilliant, she was female (p85)
  • 25. Food for thought
    • I’ve had really bad experiences with psychiatrists. I’ve been
    • suicidal and I’d been trying to tell them about some of the domestic violence I had suffered – I hadn’t even got to my sexual abuse as a child. and the psychiatrist said to me ‘well you’re good at picking them aren’t you... it is alright for your husband to want sex’... and then diagnosed me with OCD (p87)
    • I don’t want to be given drugs and be locked up in wards just because I have been abused. I want human responses to human distress which recognises my experience as a woman is often different from men (p88)
    • I’m a mental health patient, when I go to the psychiatric hospital I am abused by the staff. There’s a lot of homophobia ... I got attacked in hospital and that staff didn’t take any notice. One nurse said to me ‘you’re butch , you can defend yourself (p89-90)
    • I would rather be raped again than enter the mental health system. when I was sectioned I was put in a mixed ward which included sex offenders. I was threatened with shards of glass; the psychiatrist did not believe me.. Trust and most importantly consent were completely absent, it was totally disempowering... I would never, ever disclose if I went back (p90)
  • 26. RCCs: The whole place self
    • From Fiona Elvines MA dissertation,
    • drawn from an interview with SERRIC
    • The approach is standing alongside and working with
      • to rebuild a self fragmented by violence
      • active participants in exploring what violence meant and means for their whole selves – not just a story of abuse, a collection of effects
    • ‘ Relational self’
      • Women only has significance here – who women can relate to/with
      • Create new meanings ‘in conversation’
    • Empowerment means extending women’s space for action, including the power to speak out, resist, be part of a collective movement against sexual violence and for women’s equality
  • 27. Basis for progress and dialogue?
    • Good outcomes from the perspective of victim-survivors (drawn from RAE for Stern review)
      • being believed and acknowledged
      • access to information and options
      • complete medical care
      • feeling in control of what happens to their body and case
      • access to specialist services
      • practical and emotional support
      • access to female practitioners
    • Implications for health sector
      • Audit own responses using these as indicators
      • Recognition of the model sdeveloped in Rape Crisis Centres, and subsequently SARCs
  • 28. Susan Brison
    • I develop and defend a view of the self as fundamentally relational – capable of being undone by violence, but also of being remade in connection with others… [the] tension between living to tell and telling to live, that is between getting (and keeping) the story right in order to bear witness and being able to rewrite the story in ways that enable the survivor to go on with her life (pxi-ii) [Aftermath, 2002]