Male Sexual Assault Victims at Particularly High PTSD Risk

Pauline Anderson

May 19, 2015

TORONTO ― Male asylum seekers who have been sexually assaulted, typically as an act of war or oppression, face unique medical challenges. They have problems sleeping, are easily fatigued, and have difficulty settling into a new life in the United States.

Now it appears they are at particularly high risk for posttraumatic stress disorder (PTSD), with an almost twofold increased risk in comparison with male asylum seekers who have not been sexually assaulted.

Medical professionals play a key role in the application for asylum for these and other refugees, according to Kristina Jones, MD, clinical assistant professor of psychiatry, New York University (NYU) School of Medicine, Bellevue/NYU Program for Survivors of Torture, in New York City.

She and her colleague Brian MacMillan discussed the study and related issues here at the American Psychiatric Association (APA) 2015 Annual Meeting.

Rape: Men Not Legally Protected

The Bellevue/NYU program for torture survivors assists individuals and families escaping political, ethnic, or religious persecution and torture. Launched in 1996, the program provides comprehensive medical, mental health, and social services to asylum seekers and refugees. The program's database now includes 3321 patients.

Today, there are 754 active patients, with the largest group coming from Africa. A recent trend is an increase in gays and lesbians, especially from parts of Africa and Russia, who are seeking asylum as authorities there crack down on homosexuality.

To be granted asylum in the United States, a person's claim of being under threat has to be "consistent and credible," said Dr Jones. She added that the person also has to be a member of a "special group," such that the person has been subject to torture or persecution because of political views, ethnicity, gender, or sexual orientation.

Dr Jones and her colleagues evaluate trauma among asylum seekers and determine whether they meet the definition of torture, which includes cruel or degrading punishment and suffering designed to intimidate, coerce, or punish.

"The difference between torture and regular violence is often that the perpetrators of torture are state-sanctioned actors or police or nongovernment forces," so victims have no recourse.

Many of the asylum seekers she treats are from pockets of Africa where there have been ongoing conflicts or political or religious oppression. In many of these areas, laws do not protect men from rape, or they imply that only women can be victims of rape.

Twice the Risk

"Rape in some countries means insertion of a penis into a vagina," whereas "these men have been raped with sticks, objects, electric prods, or their genitals have been attacked with pepper spray," said Dr Jones.

One man she described is a successful gay financier from Uganda, where the death penalty has been declared for homosexuality. He arrived in her clinic still bleeding from the rectum as a result of the sexual violence he suffered.

Of the 2019 male asylum seekers or refugees in the Bellevue database, 204, or about 10%, have reported sexual assault.

Researchers compared the average scores on the Harvard Trauma questionnaire, which assesses posttraumatic stress symptoms, in those clients with men who were not sexually assaulted. They found that 59% of 99 African males who were sexually assaulted had PTSD. The PTSD rate among the 417 African males not sexually assaulted was 33%.

"Men who were sexually assaulted are 1.92 times more likely to meet criteria for PTSD than those who were not," MacMillan reported.

The total PTSD score on the questionnaire for those reporting sexual assault was 40.79, compared with 36.08 for those not sexually assaulted (P = .003).

"We definitely proved our original hypothesis, which was that sexual assault does dramatically increase the occurrence of PTSD," said MacMillan. "However, given the nature of the data set and the problem itself, there's good reason for us to start investigating this issue from a couple of different angles."

One of those angles would be to determine the role of religious factors as the source of oppression with respect to clinical results, he said.

Physicians for Human Rights

Whether it is religious oppression or some other form of oppression that drives these men to seek asylum, the process they face in the United States is time-consuming. "It may take 1 to 2 years to see a judge," said Dr Jones.

"At that point, the mental health professional becomes critical for the patient to gain asylum. If you go before an asylum judge without any medical reports, the chance of winning asylum is about 30%; if you go with a psychiatric or psychological affidavit from a provider, the chances of winning your asylum case are almost 70%."

She noted that asylum seekers do not have to have PTSD; they only need to show that their symptoms are related to torture.

She urged her audience to consider joining Physicians for Human Rights and completing one psychiatric affidavit per year, which does not take up much time. "If you know about PTSD, you already have the skills to help an asylum seeker."

During a question period, another session speaker, Prof Malcolm Hopwood, professor of psychiatry, University of Melbourne, Australia, wondered whether the researchers had controlled for the overall level of exposure to physical violence.

Dr Jones reported that her clinic had studied head injuries and found that about a third of the patients met criteria for mild traumatic brain injury. "We wondered if that was a substitute marker for severity of torture."

However, as far as she knows, there is no torture severity index.

"It's an important question, because every one of the patients in our sample meets criteria for torture, so by definition, they're horribly traumatized to begin with," and then they also have experienced sexual assault. "We probably should factor out other types of torture and see if the numbers are similar," she said.

In response to another query about use of benzodiazepines in patients with PTSD, Dr Jones said that although these drugs are not approved for PTSD, she uses them to treat sleep problems.

"We treat the symptoms, not the diagnosis," and also recommend psychotherapy.

She stressed that sleep is a huge issue for many torture survivors. "From my experience, if you give these men a benzodiazepine and they just get enough sleep, they feel so much better and then start asking for more treatment and medicine. So for me, it's an invitation and an entrée, and it's critical that I be able to use benzodiazepines. They're a very helpful tool."

American Psychiatric Association (APA) 2015 Annual Meeting. Presented May 18, 2015.

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