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The unacknowledged trauma epidemic

Sexual violence haunts survivors long after the event. Are health services equipped to cope?

By Zoë Grünewald

Eighteen months after a stranger subjected Lucia Osborne-Crowley to a violent sexual assault at the age of 15, she started experiencing severe abdominal pain. Following ten gruelling years of surgical procedures and tests, the Australian writer and journalist was eventually diagnosed with endometriosis and Crohn’s disease.

Around this time, she opened up to her doctor about the rape. In her book, My Body Keeps Your Secrets, Osborne-Crowley describes the disclosure as a “house of cards” that “began to fall, slowly at first and then very, very quickly”. Her doctor promptly linked her symptoms to the sexual assault, and she began physiological treatment with psychological therapy.

“I really think this is something we as a society need to understand a lot better,” she tells Spotlight, “this differentiation between psychological symptoms of trauma and the physical symptoms of trauma are such a fine line, because they interact with each other.”

In recent years, society has been confronted by just how common sexual violence is. The “Me Too” movement, from 2017 on, and the Everyone’s Invited revelations by schoolgirls around the UK last year, triggered a public conversation about the culture of silence and shame around sexual assault, abuse and harassment, the majority of victims of which are women.

The exact extent of sexual violence in the UK is hard to gauge. According to the Crime Survey for England and Wales as many as one in four women will experience rape or a serious sexual assault in their lives. A harrowing report from Ofsted in June 2021 estimated that as many as 90 per cent of girls had experienced some form of sexual harassment. By the time women reach the age of 24 that figure is as high as 97 per cent.

The traumatic effects of sexual violence are often misunderstood. The NHS’s Strategic Direction for Sexual Assault and Abuse Services acknowledges the “damage and devastation” that sexual violence can cause, but makes scant reference to the more complex physical and emotional symptoms of resulting trauma.

But, as Osborne-Crowley’s story highlights, unacknowledged trauma can present in complex ways. Markus Reuber is a professor of clinical neurology at Sheffield Teaching Hospitals NHS Foundation Trust, and a world-leading expert in non-epileptic attack disorder (NEAD). He focuses on the link between physical symptoms that present to neurologists, such as non-epileptic seizures, and the mental health causes of these symptoms.

“We are increasingly aware of physiological links between a lot of traumatic experience and health consequences in later life,” says Reuber.

Somatisation – a term that encompasses functional neurological disorder – is the conversion of psychological concerns, such as trauma, into physical symptoms. It is not mentioned in the NHS strategy, much to the dismay of Reuber, nor is the difficulty of discussing traumatic events.

Suppressing memories of trauma is often the only way to live with them. A 1994 paper published in the Journal of Consulting and Clinical Psychology demonstrated how common it is for people to repress sexual abuse. In a study where women were sexually abused as children, 38 per cent of the survivors had forgotten their abuse two decades on.

The denial of a memory does not mean that the body has forgotten the abuse, however. Reuber explains: “Long-term effects on how the body and brain respond to their environment may be caused by experiences that cannot be recalled. Trauma can be ‘stored’ in the body in different ways – for instance, in the brain’s basic level of arousal, persistent activation of the body’s immune system, changes in how the brain’s endocrine system responds to stressful events, and which bits of the genetic code in the cells of our body are activated.”

Aimee Morgan-Boon, a specialist psychotherapist in neurology based in Sheffield, works with patients who have functional neurological disorder, a condition “whereby the patient has neurological symptoms, and what appears to be organic illness, but it’s not caused by any disease”. Instead, difficulties with emotional processing interrupt messages the brain is receiving from or sending to the body, and may result in symptoms such as seizures, physical pain, paralysis and impaired vision. Often, Morgan-Boon tells Spotlight, this condition is caused by trauma – and most of those patients are women with sexual trauma.

“It’s very difficult to quantify because so much of it is unspoken and undisclosed… in my work, it feels like the vast majority of women that I see have experienced sexual violence,” says Morgan-Boon.

Often her patients have no memory of a traumatic incident, but Morgan-Boon is trained to spot the kind of symptoms that may be indicative of somatisation. “This kind of dissociative response is a reflection of what happens during sexual trauma. Because it’s intolerable to the psyche on many levels, people kind of switch off… there’s a part of self that holds that traumatic memory and the person isn’t necessarily consciously aware of it.”

She emphasises that sometimes the patient may never recover the traumatic memory, but that treatment is still possible. “The very fact that they’re having that kind of attack suggests that they are not able to tolerate the memory… but work can build up their tolerance to experiencing emotion, to the point they can regulate it,” she says.

Morgan-Boon explains that for some patients their memory never returns. “If it doesn’t, then that’s the way it needs to be,” she says.

Marian Peacock, a lecturer in public health at the University of Sheffield, worked as a clinical practitioner for 16 years in a mental health counselling service where she saw how “widespread experiences of sexual abuse and sexual violence were among women”. She developed the kind of interview techniques that are helpful for getting patients to open up in situations where they either can’t acknowledge their trauma or won’t.

Much of Peacock’s research has highlighted the “enormous social gradient” around trauma, especially “a link between poverty and the incidence of sexual abuse, particularly among girls”. Peacock believes that shame and stigmatisation are also factors in women’s acknowledgement of trauma.

“You don’t necessarily see things as traumatic, and that’s putting it bluntly… there’s so much crap in your life and the lives of those around you, it seems normal,” she says.

Morgan-Boon concurs: “Sometimes they don’t identify it as trauma or abuse, particularly where they’ve grown up in a culture where violence from men towards women is experienced as the norm.”

This social disparity can play out between the patient and doctor. Due to this correlation between socio-economic circumstances and trauma, conflict can emerge between the middle-class, highly educated practitioner and a socially disadvantaged and sick patient.

One doctor, who wished to remain anonymous, explained that he had to caution his staff in South Yorkshire for using the phrase “normal for Barnsley”, when referring to patients who had functional neurological disorder.

Peacock points to a 2007 study in the Journal of General Internal Medicine, by psychologist Peter Salmon, which showed that some GPs actively disengaged from patients with chronic pain. In the paper, one GP describes patients as “pestering” and “dependent”. Reuber has come across practitioners resorting to pejoratives when referring to somatisers, such as using the term “pseudo-seizures”, implying the disorder is made up and the patient unreliable.

And he emphasises that if a patient is presenting with physical pain, it is rare that a GP would associate this with trauma. As Peacock explains: “There isn’t the training – people don’t know about it, and even if there was the training, people don’t know what do with [the patients]. Where do you send people?”

Even when trauma is suspected, eliciting admissions of past trauma is hard, especially when patients are not aware of it themselves. “Do you give people a questionnaire? Do you interview them? Do you interview them twice? Do you give them time to reflect?” asks Reuber.

Peacock and Reuber believe that the NHS, in its current form, is poorly equipped to deal with the issue. For Peacock, there are obvious resourcing and funding issues, but the issue also highlights the difficulty of accessing mental health services without a diagnosis. “

It has to be a diagnosis of a [psychiatric] thing, an illness or an event… We can’t seem to find a way of legitimising and validating the aftermath of suffering without giving it some medical name, and a medical name is a prerequisite to accessing services,” she says.

Reuber emphasises that even with a diagnosis, trauma services in the UK are “non-existent”.

“If you wrote to all the CCGs [clinical commissioning groups] in the country and asked them do you have a trauma service, they would almost invariably say ‘yes we do’. But the reality of it is that trauma services are completely inadequate”, he says.

Spotlight understands that the NHS is developing new support services for those living with complex trauma as a result of sexual assault and abuse, which will launch within the next two years. The Department of Health and Social Care is also investing £2.3bn into mental health services as part of the NHS Long Term Plan, while the new Health and Care Bill and this year’s upcoming Women’s Health Strategy will include support for victims of violence and abuse.

Often, Peacock says, patients “don’t want to hear a psychological explanation”. This can act as another barrier to treatment. “They want to be told they’ve got a physical condition that can be treated and will be seen as legitimate,” she says. People with functional neurological symptoms have “incredibly difficult lives of both physical suffering and largely speaking, emotional dismissal”, and when functional neurological disorder is suggested, many patients hear that they are “faking it”.

“It’s a very hard thing to convey to people in a way that doesn’t make them feel that what you’ve just said to them is it’s all in their head,” she adds.

Osborne-Crowley wishes she had known more about the relationship between the mind and body. She sees a role for schools in teaching this to ensure “much earlier interventions” so that someone like her “doesn’t have to be living with chronic trauma symptoms for ten years”.

“We need to start thinking about health and bodies when we’re really little, to stop splitting mind and body”, says Peacock. “That has to fundamentally change right across society, because all we do is shovel that problem into GP surgeries and expect GPs to resolve it.”

As with any health issue, of course, prevention is better than cure. Sexual violence is a product of patriarchy, says Morgan-Boon. Men need to be taught that this “behaviour is not OK, and it has long-lasting impacts on women”.

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