Case Study 2
Ms. M, a 62-year-old widow, was hospitalized following a cerebral vascular accident (CVA) affecting her right hand and speech. She was discharged home to receive in-home physical therapy treatments. The therapist told her to lie on her right side, on the couch, behind which was her pet parrot, Arthur.
Ms. M's sweat shirt was removed and the therapist began to rub her shoulder. He unfastened her bra and moved it to the side. Ms. M tried to cover her breasts with a pillow. The therapist said, "Come on now. How old are you? I'm a professional. You're a grown up lady." He repeated these statements in a soft voice as he began touching her body. Periodically he would ask her if she had any feeling or sensation in various parts of her body including her breasts and stomach. He asked if she could feel the area over the stomach bruising from the heparin injections. He touched her pubic area, pulling her pubic hairs and asking if she had any sensation. He then instructed Ms. M to insert her finger into her vagina to see if she could feel anything. She was upset and frightened and told him that her "vagina did not have a stroke." The therapist then inserted his fingers into her vagina pushing hard on her pubic area. Ms. M said she couldn't seem to move and suddenly something brought her out of the therapist's control: her bird fell from his perch making a loud sound. Ms. M yanked with her good hand to pull up her pants. The therapist assisted her up from the couch, helped her dress, and completed some paperwork. As he left he said, "Come on, you need a hug." He also informed her he would finish his little test when he saw her next.
Ms. M was in shock. She asked herself: "Did this really happen?" She got in the shower and just let the water run over her; she felt dirty. She called her son-in-law at his office and also drove to a neighbor to tell what happened. When she later told another neighbor, who was also a police officer, she was advised to call the police department and file a report, which she did. A sexual assault forensic examination revealed no vaginal trauma. She was counseled by rape crisis professionals and discharged.
Ms. M, disabled by her CVA and the victim of a confidence style rape, suffered compounded rape trauma, a subtype of chronic PTSD. This assault on a disabled patient may be classified as a subordinate assault in the Crime Classification Manual (Douglas, Burgess, Burgess, & Ressler, 1992) and the offender may be classified as a power-reassurance rapist. In compounded rape trauma, victims have a pre-existing physical problem that compounds the effect of the assault in Ms. M's case, symptoms of a CVA. The impact of a rape on a stroke patient has to do with many factors including the nature of the act, how the victim thinks about the offender, how the trust was severed, and presentation of symptoms.
Rape trauma in an elder increases the challenge for recovery; it can lead to further physical, cognitive, and psychological deterioration of a victim. Older rape victims, with the slowing of their ability to process information, suffer because they are unable to put traumatic memories out of their mind, as a younger victim can do. In compounded rape trauma, the symptoms of the primary disorder are filtered through the rape symptoms. In this case, the primary symptoms of the stroke (speech difficulty and semi-paralysis) filter through the rape-related symptoms of the anxiety, fear, withdrawal, and anger. Ms. M suffered a second stroke 6 months later in July 2001.
The following symptoms of rape trauma were gleaned from a clinician's notes and interviews of Ms. M. She had crying spells, was upset and agitated. There were mood changes of anger and crying, withdrawal, flashbacks, difficulty sleeping, decreased interest, feelings of worthlessness, and depressed mood. She was diagnosed with Post-Traumatic Stress Disorder (PTSD). She became increasingly anxious when the perpetrator was released on house arrest. She believed he sat in front of her house wearing a disguise. She also would see his face in her mirror. Her therapist worked on helping to distinguish this misperception.
She was referred for a second opinion because she was not improving. The therapist diagnosed her with both PTSD and major depressive disorder. She was referred to her primary physician who started her on an antidepressant and anti-anxiety medication.
It is important to differentiate those symptoms Ms. M experienced that were rape related and those that were stroke related. The rape-related symptoms were directly attributable to the digital rape attack and include the mood swings, especially the crying, the fears of professional care, her fear of his (or his relatives) returning to harm her, and her avoidance of thoughts and reminders of the rape. The rape aggravated her stroke-related symptoms that included left-sided weakness and some immobility. The prognosis for improved functional status needed further evaluation. Counseling and other resources such as exercise with a personal trainer, education, and pharmacotherapy were recommended.
J Foren Nurs. 2006;2(3):113-120. © 2006 International Association of Forensic Nurses
Cite this: Information Processing of Sexual Abuse in Elders - Medscape - Oct 01, 2006.