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November 25, 2015

Alcohol abuse, sexual assault: Consider trauma-informed approach, physician urges

“There are very few violence virgins on college campuses. By the time students come to us on college campuses, many of them have already experienced or witnessed domestic violence — whether it’s their parents hurting each other, or dating violence and sexual violence,” said Elizabeth Miller, a faculty member in pediatrics and a physician in the Division of Adolescent and Young Adult Medicine at Children’s Hospital.

Miller challenged her audience to consider a trauma-informed approach in addressing the intertwined issues of alcohol and campus sexual assault at the “Reducing Dangerous and Underage Drinking: Innovative Strategies for the Millennial Generation” conference,  which drew staff from nearby universities for sessions focused on alcohol prevention, education, response and community support.

“I think this may in fact be the place in which we need to start thinking about where alcohol fits in,” Miller said in a keynote address at the Nov. 10 event in the William Pitt Union.

Citing stark national statistics, Miller asked her audience to think about these issues “in the context of exposure to violence that so many young people —the students we care for, students we serve — have experienced.”

• One in four women and one in five adolescent girls have experienced violence in the context of intimate relationships.

• One in six young men has had an abusive sexual experience before age 18; one in seven has experienced severe intimate partner violence.

• Most female victims of completed rape experienced their first rape before age 25. Almost half were raped before age 18, more than a quarter between ages 11 and 17, and 10 percent at or before the age of 10.

• Men and women who have experienced childhood sexual abuse are twice as likely to attempt suicide.

• Children who have experienced rape or attempted rape in their adolescent years are almost 14 times more likely to experience rape or attempted rape in their first year of college.

• In addition, sexual assault impacts academic achievement. Women who have experienced sexual assault during their first semester of college tend to have lower GPAs throughout their academic career.

“You will hear, when people start to talk about alcohol and sexual violence, that what we just have to address is young adult promiscuity on college campuses — without really understanding the ways in which young people’s experiences of their sexuality have been profoundly impacted by the ways in which they have been hurt as children,” said Miller, who is testing in student health centers a counseling intervention strategy aimed at reducing sexual violence.

Women of all ages are at risk but interpersonal violence peaks in young adulthood. Young adults have the greatest risk of nonfatal partner violence and the highest rates of rape, sexual assault and stalking.

They also have some of the worst health profiles, Miller said: sexually transmitted diseases, including HIV; unintended pregnancies; and mental health problems including substance use and suicide.

“In terms of neuroscience of adolescent and young adult development we know that there is still a lot of developing to be done for the young adults that we serve on campus,” she said, positing that some of these health issues are rooted in society’s tendency “to push young people out of the nest at the age of 18, saying ‘Good luck with that’ and then put them on college campuses and say to college administrators, ‘Good luck with that.’”

Freshmen — whose familiar support systems from high school have been disrupted — are at particular risk, and often targeted.

The role of alcohol

Studies vary, but find that 50-70 percent of campus sexual assaults are associated with intoxication — either of the victim, the perpetrator or both.

By attributing sexual violence to alcohol consumption, “we inadvertently blame victims and forgive perpetrators for poor judgment rather than recognizing that these are intentional violent acts,” Miller said. Alcohol often is intentionally used to subdue victims, she said. “More often than not perpetrators of campus sexual assault know good and well that there is not consent, and in fact that is really sort of part of the sexual conquest.”

It’s no secret that alcohol is the No. 1 date-rape drug, but the link is a co-occurrence, not a cause, Miller maintained.

“I offer to you to ponder, to think about the possibility, that in fact prior exposure to violence is part of what is driving this co-occurrence of heavy drinking and binge drinking along with sexual violence,” Miller said.

Increasing reporting

Despite all the conversations on college campuses, when sexual violence occurs, “very, very few college women will tell anybody,” Miller said, citing a 2000 study that found only 5 percent of attempted or completed rapes against college women are reported to law enforcement.

“My hope is that with all the changes that have happened on campuses, that we are going to see significantly more people coming forward and talking about their experiences,” she said.

“What we do know is when health center providers talk to women about abuse, they’re much more likely to seek care: That can include talking to an advocate, to a counselor or, in the case of partner violence, a protection order or calling a hotline,” Miller said.

Health center providers “are incredibly powerful,” yet few campus sexual assault task forces include representatives from student health services, she said.

Student health center-based intervention

Miller currently is testing in 22 college campus student health centers — including many in western Pennsylvania — an intervention based on universal education.

“People who work in student health and wellness are incredibly passionate and love their students,” Miller said. “It is really in that context we’re being able to do this prevention work.”

It’s normal for students to visit their campus health center, and providers build relationships with students over time. Those centers can become a gateway for connecting students with advocates and counselors.

“What we’re able to do in health centers is establish trust and take that trust and transfer it right over: ‘I know these phenomenal people in counseling.’ ‘I know these amazing people at Pittsburgh Action Against Rape and they’re so great and they’ll come and talk to you any time.’ And so that ‘warm referral’ piece is a critical piece of what campus health centers are able to do,” she said.

“It’s very, very difficult for young adults to actually waltz into a clinic saying ‘Hi, I’ve experienced sexual assault and I need to see a counselor.’ More often than not, it’s going to be ‘I’m not sleeping well,’ ‘I’m not eating well,’ ‘I’m not doing well in my classes,’ ‘My stomach hurts,’” Miller said.

Miller’s GIFTSS (Giving Information For Trauma Support and Safety) intervention aims to make it easier for providers to initiate what can be a difficult conversation by using an educational card to break the ice.

The simple combination of a clinician, a card and a conversation can be very impactful, Miller said. “We’re doing universal education — we’re talking to all students: young men, young women, regardless of gender expression or sexual orientation. We are talking to everybody,” she said.

“It turns out that health care providers do universal education really well: ‘I really want everyone to have this information and did you know that these kinds of things can affect your health too,’” Miller said. “So we provide that education, use an educational card, talk about some harm-reduction strategies, and offer referrals.”

The approach is simple and takes about 30 seconds: “‘We’re giving this card to all of our patients so they know how to get help for themselves or so they can help others.’ It normalizes the conversation and it’s a universal intervention. It benefits all patients, even those who have not experienced partner violence or sexual violence,” Miller said.

“It signals that the student health center is there for anticipatory guidance; encourages students to share this information with their friends; includes resources for students on how to help a friend; and provides messages on bystander intervention,” Miller said.

In addition to referral information, the card includes a section on understanding consent and the role of alcohol, reinforcing the message that when a person is drunk they can’t consent to sex.

Another section of the card offers strategies for being a positive “upstander” who can intervene on behalf of friends. And safety planning and harm reduction are addressed: using the buddy system; safety apps such as Circle of 6; or having a designated driver, for instance.

A different approach

“This is very, very different from the approach typically taken at many health centers, not just student health, which is kind of a checklist approach” of yes/no questions, Miller said. “What is key about this approach is that disclosure is not the goal.”

Instead, the aim is to ensure that every young person leaves with information about resources and with the seed planted that health services is a confidential place they can go to talk and get connected to help, she said.

In tests in other health care settings, “Young people who’ve received the intervention are much more likely to know where resources are,” she said. They’re likely to share the information with friends or family. “And they really appreciate the opportunity to receive this information and discuss relationship issues with somebody.”

In addition, although disclosure isn’t the goal, one adolescent health care study of the approach showed disclosure tripled.

“This educational approach tends to promote much more conversation,” she said.

—Kimberly K. Barlow         

Filed under: Feature,Volume 48 Issue 7

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