JN_THESIS_Final

Running Head: COMPENSATING HEALTH FOR RAPE SURVIVORS 1
Compensating heath recovery for rape survivors
Jancy Nightingale
Elizabethtown college

COMPENSATING HEALTH OF RAPE SURVIVORS 2
Abstract
This paper explores the possibility of recognizing rape as a health issue, so survivors may
be compensated through health insurance, rather than having to file a police report to
qualify for victim compensation. The paper examines the current state of systems to demonstrate
the need for rape to be treated and compensated as a health issue. Long-term health
consequences of rape are brought to light, to better understand what symptoms survivors
experience indefinitely. Research on rape survivors’ interactions with legal, medical and social
agencies (Greeson & Campbell, 2011) is discussed. Survivors subject themselves to these
agencies to seek healing and justice, but result in negative experiences and no justice. Evans
(2014) provides a comprehensive view of the victim compensation system in America, and the
intricacies that stunt the process from truly helping those who need it. Due to the ineffectiveness
of the criminal justice system and the immediate need for medical care, providing coverage for
physical and mental injuries sustained from rape would significantly assist with the healing
process.

Compensating heath recovery for rape survivors
“No other physical encounter between human beings carries such a disparate potential for
good or evil” (Vartan, 2014). Rape brings about deeper traumatic effects more than any other
event, and 1 in 5 women experience it, with half raped by an acquaintance (Tuerkheimer, 2014,
p. 1453). Social conversations and legislative efforts towards stopping this violence overshadow
the long-term health consequences victims must bear mentally, physically and financially.
Despite regulation passed at the federal level attempting to alleviate financial costs, there are still
loop-holes in implementation on the state-level. Rape is treated as a crime, and though some
debate it should be treated as a civil matter, due to the human rights component, the health of
survivors has been overlooked. Rape should be recognized as a health issue, so survivors may
be compensated through health insurance, rather than having to file a police report to
qualify for victim compensation. This paper will examine the physical and mental health
consequences suffered by survivors, the challenges of the criminal justice system, and complex
victim compensation system.
Definitions
Using the department of justice’s definition, rape is defined as, “the penetration, no
matter how slight, of the vagina or anus with any body part or object, or oral penetration by a sex
organ of another person, without the consent of the victim” (Tannura, 2014).
Compensation in this context is full coverage through health insurance premiums to eliminate
co-pays and deductibles, and cover care for both physical and mental health. The care is optional,
but readily available to rape victims who have been examined by appropriate medical personnel.
Victim or Survivor are the interchangeable terms for those who have been raped.

Background: Rape reform in America
Initial social conversation about rape was sparked by feminist activist groups. In 1927,
rape was defined in the United States Department of Justice as, “the carnal knowledge of a
female forcibly and against her will” (Tannura, 2014, p. 248) limiting the definition to violence
against women and remaining vague overall. This definition was not altered until 2012.
Several decades after the initial definition, statutes introduced in the 1970s recognized rape as a
crime, but required victims to have proof of attempted resistance to the violence, allowed sexual
history to be shared in court to create reasonable doubt about victims’ accusations, and
absolutely required corroboration (Bachman & Paternoster, 1993, p. 559). These laws laid the
foundation for sub-conscious victim-blaming within the judicial system as well as society. Since
victims attempting the system were subjected to second assault tactics of being faulted for their
rape, feminist sparked another round of conversation.
Violence Against Women Act
Four years of activism and congressional hearings produced the Violence Against
Women Act (VAWA) in 1994, a victory cited as, “a historic stand and hopeful step toward free
and safe lives of women in this nation as equal citizens of this nation”(Anderson, 2013, p. 224).
The Act threw out the dated statutes, so victims no longer had burden of proof to prove
resistance, produce evidence and their sexual history could no longer be legitimately used to
create doubt. The excitement generated from the Violence Against Women Act surrounded the
human rights component, meaning this legislation was a symbol of the government recognizing
rape and sexual assault as a violation of human rights that needed to be stopped. Over time, the
Violence Against Women Act was reauthorized twice, in 2003 and 2013 each time with added

provisions intending to alleviate out-of-pocket costs for rape survivors and eventually cover
initial medical exams following the trauma, which typically cost over $1,000 (Andrews, 2014).
Despite media coverage and enthusiasm of the activist community surrounding of Violence
Against Women Act, few states adopted the model and passed the measures (Anderson, 2013, p.
239-40).
Center for Disease Control contribution
In conjunction to the creation of the Violence Against Women Act, the Center for
Disease Control (CDC) was granted ‘congressional appropriation’ to their Department of
Violence Prevention (DVP), which took a holistic approach to stopping rape and other vicious
acts. “(The Department of Violence Prevention’s) work focuses on primary prevention, or
preventing violence before it occurs, and it emphasizes reducing rates of sexual violence at the
population level rather than focusing solely on the health or safety of the individual” (Degue et.
al., 2012, p. 1211). Though the approach of stopping a problem before it can occur was valiant, it
was similar to the idea of putting all efforts go toward cancer prevention, and neglecting
treatment of cancer patients currently infected. That optimism overlooks the reality of those
surviving with the health issues. The Department of Violence Prevention’s objective was to
prevent violence before it happened, but that idealistic goal does not properly address existing
health issues brought onto survivors. How can violence be prevented, when the systems
supposedly set up to protect survivors re-victimize them?
Despite these attempts to combat rape and positive shifts in social perception of rape
were evident, they had yet to be ‘translated into significant performance changes in the criminal
justice system’ (Bachman & Paternoster, 1993, p. 574). Over twenty years after the Violence

Against Women Act and Center for Disease Control’s violence prevention program, the social
conversation about stigma and system complexities for rape survivors is practically identical.
Health of the survivors was not prioritized, but some discoveries show how the combination of
health issues and mistreatment from systems are not conducive to proper healing.
Health care and concerns for rape survivors
Of an estimated 300,000 to 700,000 sexual assault victims annually, 40,000 visit the
emergency room for immediate treatment, but a small portion receive proper care. (Kwence,
2012, p 16). A survey from 2008 indicated that 9.6% of 117 participating hospitals emergency
departments provided the following recommended medical care: “Acute medical care, history
and physical examination, acute and long-term rape crisis counseling, prophylactic and
therapeutic management for HIV or other sexually transmitted infection, and provision of
emergency contraception, with appropriate counseling” (Kwence, 2012, p 16).
From immediate treatment after an attack to therapy sessions years later, rape survivors earn
their name from the trauma they endure short and long-term. Immediate medical treatments can
get mixed up with the forensic exam, or rape kit, which is needed if a police report is filed.
Though victims should at least receive medical treatments, gaps in the system prevent an
estimate 40 to 80% from receiving the basic preventative medicines for pregnancies and sexually
transmitted diseases (Greeson & Campbell, 2011, p 582, & Kwence, 2012). If a victim does
receive medical treatment, it can potentially cross over into an invasive forensic exam, they do
not need to be subjected to if they did not file a police report. “By defining post-rape care for
victims as the forensic exam, victims who do not want contact with police may be forced to
choose between accessing high quality medical care and enduring a law enforcement response
they do not want and that may be hostile toward them” (Corrigan, 2013, p 943). Additionally,

differing state definitions of what the forensic exam entails results in financial consequences for
the victim (Andrews, 2014). Various studies demonstrate that assault and rape correlate with
poor health, with women who had been raped being ‘at three time’s greater risk of reporting poor
health’ (Amstadter et. al., 2011, p 203, 208).
Physical health side effects and trauma transition
Sexually transmitted infections are an immediate concern for survivors’ physical health,
since they have a 26.3% chance of contracting a disease (Kwence, 2012, p 19). Hepatitis B,
chlamydia, trichomonas, gonorrhea, and the human immunodeficiency virus (HIV) are some
examples of infections that with immediately administered prophylactic treatment, are
preventable and should be available to all survivors at first response (Kwence, 2012, p 19).
Long-term effects of rape negatively affects key body systems, including the
reproductive, musculoskeletal and cardiovascular systems (Amstadter et. al., 2011, p. 202).
Reproductive issues are related to menstruation, chronic pelvic pain, sexual dysfunction and
dyspareunia which is painful intercourse and the most common symptom among rape victims
(Vartan, 2014). Cortisol levels in survivors were raised, which can ‘have permanent effects on
the brain’, be particularly dangerous during stressful periods, and correlated with feelings of
shame (Vartan, 2014).
The transition through rape trauma, which was defined in the 1960s, demonstrates the cross-over
of physical symptoms that can transition to mental issues. The assault itself and ‘acute crisis
reaction’ are reflective of the physical side effects then the remaining phases of ‘outward
adjustment’ and ‘resolution and integration’ demonstrate mental manifestation (Tannura, 2014, p
249).

Mental health side effects and costs
Anxiety, depression and post-traumatic stress disorder (PTSD) are the most common
mental side effects resulted from rape, with approximately one in three rape survivors affected
with post-traumatic stress disorder (Tannura, 2014, p 252), which can stay with victims long
after the assault occurs. In a study of women in their late 80s, who experienced sexual trauma
and non-sexual trauma during World War II, the women who experienced sexual trauma during
the war displayed deep symptoms of post-traumatic stress disorder compared to those who
encountered non-sexual trauma, demonstrating the powerful effect of those acts, more than 60
years later. “Not only does this study point to the different (and more severe) mental health
outcomes of those who have been raped, but it emphasizes the possible longevity of these
untreated traumas” (Vartan, 2014).
When some seek treatment for their post-traumatic stress disorder, despite low-cost options
available, many end up paying out-of-pocket to receive quality care, making it one of the more
costly disorders to treat. Since types and longevity of treatments vary from person to person, the
estimated annual costs for individual treatment to be $4,100, and, an individual being treated for
four years may pay upwards of $10,000 (Hill, 2014). An overlooked cost factor is loss of
productivity, which is lost time at work and wages. That estimated annual cost jumps to $7,000
when combining lost time from employment and treatment (Hill, 2014).
Though costs incurred from medical treatment of rape survivors are intended to be covered
through the Violence Against Women Act and some health insurances, variation in laws and
regulation at the state level create inconsistencies in treatment.

State-level cost complexities
States and territories in the United States have varying definitions of rape and in some
cases, it is interchangeable with assault (Tannura, 2014). This discrepancy trickles down into
how survivors receive and in some cases, are charged for medical treatments. Though many
states do offer complimentary medical exams, “a hodgepodge of state rules means that some
victims may still be charged for medical services related to rape, including prevention and
treatment of pregnancy or sexually transmitted infections” (Andrews, 2014).
Regarding potential health insurance coverage, a study from 2012 discovered that 15 of
50 states have legislation for use of health insurance to cover rape injuries (Andrews, 2014).
Currently, states can ask for claims on rape treatments to be submitted, but the victim should not
be required to make deductible payments or co-payments. However, a bigger discrepancy on the
state-level is the erratic practice of some health insurers receiving bills for forensic medical
exams, a cost that should be covered by the Department of Justice, while other states do not send
a bill (Andrews, 2014). With all of these health issues rising up, currently survivors only have
the judicial system presented to them as a two-step solution, but the complexities within the
system continue the concerns of stigma getting in the way of justice and full recovery. Charging
survivors for the forensic exam is an example of differential treatment of rape victims compared
to victims of other crimes, and only skims the surface of the unsupportive system.
Initial complexities in judicial system discourage many from seeking justice
“Women who are raped continue to be embarrassed. Doubted, and abused by the legal
organizations that process them, a pattern referred to as a ‘second assault.’ From research and the
media…..we know that some legal officials mistreat rape victims and refuse to pursue legal cases

against rapists or do so reluctantly and ineffectively” (Corrigan, 2013, p 924). Rape survivors are
told to cooperate with police and comply with the system, but it takes both parties for an
investigation to be conducted successfully. Dated statutes from the 1970s have left behind an
unfortunate mentality in some police forces, where disbelief and treating the victims as ‘guilty
until proven innocent’ hinder rape survivors from seeking justice and victim compensation.
“Survivors are frequently denied the very assistance they seek,” with most cases never
prosecuted and approximately 12% convict the perpetrator (Greeson & Campbell, 2011, p 582).
Police stigma
“Rape survivors are victimized by rapists as well as by the social systems to which they
turn for assistance” (Greeson & Campbell, 2011, p 583). Some survivors have been turned away
by the police, with the excuse presented being their story was unbelievable and unable to be
investigated. Along with the disbelief is mistrust of victims due to a perpetuate myth that hurts
rape survivor’s abilities to report and seek justice. False allegation stigma is not fair to statistics,
since most rapes aren’t even reported (Belknap, 2010, 1335-6). Mixed with high profile stories
and ineffective rape shield laws, police stigma towards rape victims is aggravated instead of
reduced (Belknap, 2010, p. 1338-41).
Greeson and Campbell (2011) conducted research on rape survivors and their interactions with
justice system, as well as social and medical, finding survivors attempted three actions:
compliance, noncompliance, and defiance. Examining these studies, survivors were expected to
comply with systems, but even with their compliance, they still did not get positive results
(Greeson & Campbell, 2011, p 584).

Compliance was an action taken by some survivors interviewed, even when they did not want to
be interviewed or have a forensic exam performed. In one complex case, a survivor reported
being assaulted by her partner, though they had consensual sex earlier that day. Though the
assault did not involve penetration, both police and social workers pushed her to get a forensic
exam, which she questioned the intention, but ultimately submitted to (Greeson & Campbell,
2011, p 589).
In an example of noncompliance, a woman reported being raped by her ex-husband. The
ex-husband was interviewed and insinuated she was framing him and had search results to prove
it. A detective asked the women to turn over her computer, but she rightfully refused to surrender
her computer since they wished to use search history against her, and she knew the computer was
accessible by more than one person, so it would not be legitimate evidence (Greeson &
Campbell, 2011, p 588-9). Survivors turn to noncompliance out of self-protection, especially
when they sense harm from the system (Greeson & Campbell, 2011, p 589).
Dismissal based on substances usage
Police have dismissed rape testimonies on ground that alcohol and other substances may
cause a misinterpretation of events. Common misperception is that intoxicated victims or
witnesses have false recounts. Though many studies demonstrate the negative effects of alcohol
on memory, alcohol myopia is the sensation where certain memory cues remain intact. Certain
aspects of testimonies are recounted accurately despite the influence. Palmer, Flowe, Takarangi
and Humphries (2013) surveyed witnesses from 289 rape cases, 169 assault cases and 181
robbery cases, with 69% of total cases taken to court, and 130 cases had at least one intoxicated
witness (p 56).

Findings indicate that intoxicated witnesses and suspects regularly show up in criminal
investigations, and in suspect identification, both types of witness’ could be asked to identify
from a live line up. In this study, intoxicated witnesses identified 91% correctly, while sober
witnesses identified 87% accurately (Palmer, Flowe, Takarangi & Humphries, 2013, p. 57-58).
“Field research about intoxicated witnesses is important because witness testimony is often
central to the resolution of criminal cases. Police officers report that witnesses usually or almost
always provide the major leads in an investigation” (Palmer, Flowe, Takarangi & Humphries,
2013, p 55).
MisusedResources
Sexual assault nurse practitioners (SANE) were developed so trained medical personnel
could obtain evidence and maintain proper bedside manner for these trauma patients, but
treatment does not necessarily mean the patient filed a police report (Corrigan, 2013, p 928,
938). Regardless of the good intentions behind the position’s development, police misinterpreted
the purpose of sexual assault nurse practitioners, assuming only those nurses could perform
forensic exams or just the basic care. In some cases, victims traveled out of their way to receive
care from a sexual assault nurse practitioner, though they may not seek that level of care, or
police screened their stories and recommended them to nurses based on the credibility of their
testimony (Corrigan, 2013, p 934-6). “Until the systemic hostility and suspicion of law
enforcement personnel regarding rape allegations is confronted, even well-meaning innovations
such as SANE programs may simply provide more justifications for high rates of attrition in
sexual assault criminal case processing” (Corrigan, 2013, p 945).

Adding to the attrition is the fact that DNA can often go untested. More storage for DNA
samples was seen as a solution to solving crimes through evidence, but the idea has backfired
since most DNA gets stored in the spacious banks, never to be retrieved for testing (Sallomi,
2013). For rape victims, DNA is retrieved through an invasive exam. Since their body is the
crime scene, medical personnel must swab crevices and parts of the body where the perpetrator
left their mark and be photographed. If the evidence recovered from that exam goes unprocessed,
survivors are essentially re-victimized and their case goes unsolved (Corrigan, 2013, p 940).
If the survivors survive complying with police through the long-winded system, then they
could qualify for existing victim compensation. The victim compensation system is positioned as
an available resource, but as indicated earlier, a survivor must get past police stigma, file a report
in a timely manner, cooperate during the investigation, and have a legitimate case, as defined by
the justice system. Then they may take next steps.
Current Victim Compensation System
Funding for the compensation program comes from the federal level, but distribution
varies state-by-state. The Victims Of Crime Act (VOCA) makes it a fixed spending program, and
contributes to 37% of each states’ fund (Evans, 2014, p.4). An exception where federal
compensation could occur would involve an U.S. citizen, traveling abroad, is the victim of an act
of terrorism (Evans, 2015, p. 3).
Available compensation covers a small range of damages from lost wages to medical care
and mental health services, typically with violent offenses that resulted in harm to the victim
(Evans, 2014, p. 3). Though states have varying application standards, if accepted, all states
cover medical, mental health and lost wages. Though the compensation program would cover

health needs of victims, the requirements for the timing of the police report create a challenge
(Evans, 2014, p 5-7).
Requirements for application include the following:
 Crimes must be reported within specified timeframes, as short as 72 hours, 5 days, or in
some states, there’s no time limit. The application for compensation must be completed
within 1-2 years of the police report. Some states permit 3-5 years for the application.
 Cooperation of the victims with police and legal during investigation and prosecution of
the offender. The victim cannon be a participant in the crime (Evans, 2014, p 5).
Despite a compensation program in place, “underutilization” and “administrative
complexities” hurt the process of helping victims and families fully recover. Approximately half
of all applicants are granted compensation (Evans, 2014, p 8), though many lose the opportunity
simply by not filing a police report, but may seek alternative options through assistance
programs (p 10).
Rape is distinct from sexual assault, but in some instances, the two are blended. According to
stats from 2012, over 13,000 claims were paid out combined over $16 million for sexual assault.
Rape may have been combined with “assault” since the amount for sexual exams is more than
the indicated previously (Evans, 2014, p 8).
The processing time for applications can be lengthy for victims who may need to cover out-of-
pocket expenses sooner than later (Evans, 2014, p 12), but the compensation system is placed on
a pedestal, yet rape victims who may be unable to file a police report, or have to face
uncooperative systems do not have an opportunity to apply for a fifty-fifty chance of receiving
compensation for medical treatment, and other costs.

Summary
A great discrepancy still exists regarding what resources are available to survivors and
what is truly helpful to their needs (Anderson, 2013, p. 225). Rape survivors are directed to
systems, specifically the justice system, yet deep rooted stigma and mishandled interrogations
and evidence leave survivors exasperated and turn to themselves for support. In 2011, a Toronto
police stated that women should ‘avoid dressing like sluts’ to avoid being raped, prompting the
finding of the women’s movement, Slut Walk, which “situates itself where anti-rape and pro-sex
norms converge” (Tuerkheimer, 2014, p 1455). These movements of advocacy and education
have uncovered more untold stories to help begin some sort of healing process. In the classroom
settings teaching rape trauma, more survivors were discovered showing how prevalent rape is,
but bypasses the system, and has many suffering in silence (Tannura, 2014, p 255).
Though social acknowledgement of these stories has assisted in a healing process
(Vartan, 2014), guaranteeing coverage of treatment through all health insurance acknowledges
the immediate needs of the survivors, without forcing them into another potential second assault.
The sexual assault nurse examiner is a great start for ensuring victims receive quality health care,
and though there are instances of misunderstanding the resource, more beneficial resources have
been developed through the nurse. Some communities have taken the next step of creating sexual
assault response teams (SARTs) using “a multidisciplinary approach, strive to meet the sexual
assault victim's many needs” (Kwence, 2012, p 16). Other areas, particularly rural places, have
established video-conferencing as a treatment tool for survivors with mental issues of depression
and post-traumatic stress disorder to maintain a much-needed connection with the survivor to aid
with healing (Kwence, 2012, p. 20). Having health insurance absolutely cover treatments can
take away the burden of the guessing game of what type of treatment is available whether

pregnancy prevention is needed or years of therapy to cope with post-traumatic stress disorder.
Sexual assault nurse examiners and response teams can be the initial point of contact for victims
seeking treatment and be approved in the health system by those medical personnel so a form of
regulation exists. Since victim compensation through the criminal justice system is practically
unattainable for many rape survivors, prioritizing their health and providing that coverage
through adjusted premiums is a more thoughtful approach.
Inclusion through health care premiums is a small proposal that may not address other
issues that arise, such as lost wages, but its progress for survivors to provide an avenue for
proper healing, instead of relying on themselves and other broken survivors through advocacy.
Sharing stories and taking a stand is part of the healing process. With coverage from health
insurance, and over time, a shift in perception from the police, rape survivors can receive proper
treatment to take stronger stands for their cause and end the stigma.
“Despite experiences of victimization and oppression, survivors also demonstrate great resilience
in the face of adversity and actively seek to shape their own experiences” (Greeson & Campbell,
2011, p 594).

References
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