While rates of sexual trauma in women are disturbingly high—with National Victim Center statistics showing that one in three women experiences a lifetime sexual assault—the roots of the physical and emotional pain these women endure may often go undetected by professionals, said psychiatrist Marian Butterfield, M.D., M.P.H.

According to Butterfield, who is director of the Women’s Mental Health Center at the Durham Veterans Affairs Medical Center at Duke University, the reason that these women’s problems go undetected is that the assaults may be underreported by victims seeking help at mental health, primary care, and addiction centers. "Our colleagues in primary care see a lot of these women before they come to us, and often they don’t come in complaining of a trauma history, but with multiple somatic complaints," stated Butterfield at APA’s Institute on Psychiatric Services in Philadelphia in October.

Even in the U.S. military, where rigid codes of conduct are strictly enforced, there is a significant amount of victimization of women. In the summer 1998 issue of the Journal of the American Medical Women’s Association, Butterfield and her colleagues reported that 22 percent of women veterans at the Durham VAMC had been raped, while another 26 percent had experienced battering. One-third of the rapes and 20 percent of the battering occurred during the women’s military service.

Butterfield, who treats women veterans with sexual trauma at the VAMC, has learned to recognize the physical and mental symptoms linked with sexual trauma, which enables her to treat the veterans effectively.

Physical symptoms can include pelvic pain, irritable bowel syndrome, migraines, and obesity, while correlated psychiatric conditions are just as varied. "Major depressive disorder, alcohol and drug abuse and dependence, panic disorder, borderline personality disorder, posttraumatic stress disorder, and obsessive-compulsive disorder can all be associated with sexual trauma," Butterfield said. She added that almost half of women who have been raped develop PTSD.

However, Butterfield emphasized, screening for sexual trauma is the only way to be certain that it has occurred. "Most patients don’t bring it up, and clinicians need to ask." Butterfield uses "normalizing statements" in her approach. "When I initially evaluate a patient, I say something like, ‘Many women have suffered from a sexual trauma such as rape or incest during their lifetimes. Has anything like that ever happened to you?’"

Once the clinician establishes that the patient has experienced rape, incest, or other sexual abuse, a sexual trauma history must be taken. To take a successful history, key questions need to be addressed to the patient. Butterfield advised that the clinician determine the age of the patient when the traumatic event occurred, the gender of the perpetrator, the relationship of the perpetrator to the victim, the duration of the trauma, and the effect of the event on the life of the patient.

After the trauma history has been completed, treatment begins. In Butterfield’s view, goals for the treatment of the sexual trauma should include improvements in general functioning and at work, as well as helping the patient to regulate self-esteem, affect, and her capacity for self-actualization. Said Butterfield, "It is also important to free the patient to be able to evolve more adaptive coping mechanisms to deal with later life issues such as aging and loss."

Butterfield usually takes an empathic approach with her patients, reiterating that the traumatic event is over, if this is the case. "I will say something like, ‘I’m sorry that happened. It is good that you survived the trauma and are here now. The memory of the trauma is what is disturbing now,’" said Butterfield.

She targets treatment toward the women’s specific disorders. For example, if the woman with a history of sexual trauma has borderline personality disorder or complex PTSD, Butterfield may use dialectic behavioral therapy (DBT). DBT targets problem behaviors such as self-mutilation or binge eating—which she noted are attempts to cope with the patient’s overwhelming emotions—and helps the patient develop constructive behaviors to cope with these symptoms. Butterfield has found that in particular, two types of cognitive-behavioral therapy are helpful for PTSD. One type involves exposure procedures, in which the patient is exposed to some of the triggers that may be reminders of the sexual trauma; another type is anxiety-management procedures, in which breathing and relaxation training play a role. Medications such as antipsychotics and antidepressants should also be used to ease PTSD symptoms, Butterfield said.

"SSRIs are emerging as the treatment of choice for the anxiety and affective symptoms of PTSD, and for borderline personality disorder SSRIs are also helpful with impulsivity, affective instability, and chronic suicidality."

Education and referral, Butterfield emphasized, should be part of the treatment plan. "Review with the patients that sexual trauma is common," she advised, "and talk about the stigma issues that come up with this type of trauma."