Complex PTSD (CPTSD) in Teen Girls after Sexual Assault: Diagnosis and Treatment

Sexual Assault Can Affect Victims for Decades: What Type of Treatment Can Help?

Sexual assault is a crime that affects millions of people in the U.S.

The emotional and psychological consequences of sexual assault can cause severe, lifelong impairment. We’ll discuss these consequences and the details of the impairments below, but it’s important, first, for all members of the general public to understand that sexual assault can affect typical physical, psychological, and emotional development, degrade relationships, reduce cognitive function, and have a negative impact on academic performance, employment, decision-making, self-esteem, social functioning, and overall wellbeing.

We identify the event that leads to this broad host of impairments in the title of this article: sexual assault. The mental health disorder that develops as a result of sexual assault is called post-traumatic stress disorder (PTSD). In cases of sexual assault, many victims develop a variation of PTSD called complex post-traumatic stress disorder (CPTSD), which was defined and added to the International Classification of Diseases, 11^th Revision (ICD-11), by the World Health Organization (WHO) in 2019, and came into effect for use by clinicians in January, 2022.

There’s another thing all members of the general public should understand about sexual assault before we offer clinical definitions, prevalence statistics, and additional data:

Adolescent girls have a higher risk of sexual assault than any other demographic group.

That’s why we write articles like this one. We work with adolescents every day of the year, and we see the consequences of sexual assault in adolescent girls with alarming frequency. We accept girls into our programs for depression, anxiety, behavioral issues, alcohol and drug addiction, and other mental health disorders. While every girl we meet does not have a history of sexual assault, the correlation between girls with mental health issues with severe impairment and girls who are victims of sexual assault is shocking: our goal is to inform anyone reading this article about how we – and they – can help girls who experience this crime recover and rebuild their lives in the face of extreme, painful, and recurring emotional consequences.

[NOTE: We understand sexual assault happens to boys and men, too. However, due to the overwhelmingly disproportionate prevalence of sexual assault among women, and teen girls in particular, we’ll use this time to focus on them.]

First, we’ll define sexual assault, share prevalence statistics, outline the devastating effects these conditions have on adolescent girls, then address PTSD and CPTSD in detail. We’ll talk about evidence-based treatments for PTSD and CPTSD in the last section of this article.

What is Sexual Assault?

The Rape, Abuse, and Incest National Network (RAINN) defines sexual assault as “sexual contact or behavior that occurs without explicit consent of the victim.” They identify several types of sexual assault:

• Rape, i.e. forcible penetration of the victim’s body
• Unwanted fondling or sexual touching
• Forcing a victim to engage in sexual acts
• Forced sexual acts include:
  • Being forced to give or receive oral sex
  • Being forced to penetrate the perpetrator’s body

Now let’s look at the latest statistics on the prevalence of sexual assault in the U.S. We’ll preface this with a figure from a study from 1998, which indicated that at that time, an estimated 17.7 million women had been victims of rape or attempted rape.

Women and Sexual Assault in the U.S.

• 1 out of every 6 women report sexual assault in their lifetime
• 66% of victims of sexual assault or rape are 12-17 years old
• 34% of victims of sexual assault or rape are under age 12
• 82% of victims of sexual assault under the age of 18 are female
• Teen girls age 16-19 are 4 times more likely than the general population to experience rape, attempted rape, or sexual assault

We’ll add another general fact to this series of statistics:

In the U.S., on average, a sexual assault occurs every 68 seconds.

Now let’s look at where sexual assault happens and what victims were doing at the time of the assault.

Sexual Assault: Where Were the Victims and What Were They Doing?

• Where they were:
  • 55% were at home or near home
  • 15% were in the open in a public place
  • 12% were at or near a relative’s home
  • 10% were in an enclosed space such as a parking garage
  • 8% were on school property
• What they were doing:
  • 48% were sleeping or doing something else at home
  • 29% were out doing errands or going to work or school
  • 12% were working
  • 7% were at school
  • 5% were engaged in unidentified activities

We include these last two bullet lists to drive home a critical point and further dispel an old trope that persist to this day: in almost every case of rape or assault, female victims are not at a nightclub dressed in a miniskirt and tight top. In almost every case of rape or sexual assault, the victim is going about their life, minding their own business, and they become the victim of a crime. In other words, the perpetrator is responsible for the crime, not the victim.

Next, we’ll discuss the consequences of sexual assault.

The Long-Term Emotional Effects of Sexual Assault

As we discuss the long-term consequences of sexual assault and the impact it has on teen girls, let’s not forget the horror of the initial act: while every woman or girl has to deal with the fallout of the experience, it’s important to remember that the incident itself is most often terrifying, violent, and often sends victims into a state of emotional and physical shock.

With that said, let’s consider this next set of facts from tj Rape, Abuse, and Incest National Network (RAINN).

Sexual Assault, Women, and Teen Girls: Long-Term Effects

PTSD, Suicide, and Emotional Distress

• 94% of female rape victims experience symptoms of post-traumatic stress disorder (PTSD) within two weeks of the rape
• 30% of female rape victims report symptoms of PTSD persist for at least 9 months after the assault
• 33% of female rape victims report thinking about suicide.
• 13% of female rape victims attempt suicide.
• 70% of rape/sexual assault victims experience moderate to severe distress

Work, School, and Relationships

• 38% of rape victims report school problems
• 37% report problems with family and friends
• 84% of victims of rape by an intimate partner report:
  • Professional issues
  • Moderate to severe emotional distress
  • Increased problem at school
  • Increased problems at work
• 79% of victims of rape by a family member, friend, or acquaintance report:
  • Professional issues
  • Moderate to severe emotional distress
  • Increased problem at school
  • Increased problems at work
• 67% of victims of rape by a stranger report:
  • Professional issues
  • Moderate to severe emotional distress
  • Increased problem at school
  • Increased problems at work

Drugs and Alcohol

• Victims of rape/sexual assault are more likely to use drugs than people who are not victims of rape/sexual assault. Compared to non-victims, they are:
  • 10 times more likely to use any type of drug
  • 6 times more likely to use cocaine
  • 4 times more likely to use marijuana

When we list the long-term consequences of sexual assault, what we really describe are the symptoms of PTSD and CPTSD. As you’ll see in the next section, the psychological, emotional, and social impairments/consequences associated with rape/sexual assault are virtually synonymous with PTSD/CPTSD symptoms.

PTSD and CPTSD: Clinical Definitions

An article called “Complex Post-Traumatic Stress Symptoms In Female Adolescents: The Role Of Emotion Dysregulation In Impairment And Trauma Exposure After An Acute Sexual Assault” published in 2020 addresses the issues central to this article. In the words of the study authors:

“This study aims to determine the frequency and structure of CPTSD, and the relationship of emotion dysregulation with impairment and additional trauma exposure among adolescents who have been sexually assaulted.”

The first thing the study authors do is recognize that sexual assault and rape are severely traumatic events that can disrupt self-organizational capacity and result in the appearance and experience of the core symptoms of PTSD, which include:

• Re-experiencing traumatic memories
• Cognitive avoidance of traumatic reminders
• Behavioral avoidance of traumatic reminders
• Persistent sense of threat, in the absence of actual threat

The second thing the study authors do is define the new diagnosis from the ICD-11 – which we discuss above – known as complex post-traumatic stress disorder (CPTSD). When the following three sets of symptoms appear in an individual when no trauma-related cues are present, they meet clinical criteria for CPTSD.

CPTSD: Symptom Profile

1. Emotion dysregulation:
   • Heightened emotional reactivity
   • Under controlled anger
   • Irritability
   • Temper outbursts
2. Negative self-concept
   • Beliefs about oneself as diminished
   • Defeated
   • Worthless
3. Interpersonal problems
   • Persistent preoccupation or avoidance of social engagement
   • Difficulties in sustaining and managing relationships

As we mention above, those symptoms match the post-assault experience of a vast majority of victims or rape or sexual assault. Researchers concluded that CPTSD is a disorder that predominantly applies to victims of rape, but may also appear in victims of torture, prisoners of war, victims of childhood abuse, and/or victims of kidnapping, slavery, or forced prostitution.

It’s clear: CPTSD occurs in response to the most extreme forms of trauma we know about. Now let’s take a look at the results of the study.

Study Results: Prevalence of CPTSD in Teen Female Rape Victims

To measure the prevalence of CPTSD among teen female victims of sexual assault and/or rape, researchers recruited a total of 134 participants. Here’s the make-up of the study group:

• All female rape/assault victims
• Average age of 15.6 years old
• 51% had received some type of psychiatric help before the study
• 32% reported more than on rape/sexual assault
• 92% of victims reported forced penetration
• 63% were raped by a person they knew

At two time points – one immediately after the assault and one four months after the assault – researchers gathered data on the following three metrics:

1. Presence of CPTSD
2. Further exposure to trauma
3. Level of impairment

Here’s what they found:

• Complex PTSD diagnosis:
  • 59% met criteria for PTSD
  • 40% met criteria for CPTSD
• Further exposure to trauma:
  • After four months:
    • 29% reported additional trauma
    • 9% reported additional sexual trauma
  • Impairment
    • 60% reported at least one symptom of self-organization in each of the three domains:
      • 87% emotion dysregulation
      • 75% negative self-concept
      • 75% interpersonal problems

With this data, the study authors confirm their hypothesis: the set of symptoms reported by teen female victims of sexual assault corresponds with both PTSD and CPTSD. In addition, the study authors indicate that:

“Emotion dysregulation was significantly associated with further exposure to general and to sexual trauma above and beyond core PTSD symptoms, negative self-concept and interpersonal problems.”

What that means is that the trauma of rape, particularly when compounded by additional sexual or general trauma, can exacerbate the symptoms of PTSD and meet the threshold for CPTSD. That information is important both for the families of the victims and the therapists who treat them: it can help families find the appropriate treatment team, and enable that treatment team to use therapeutic techniques proven to help people with PTSD and CPTSD.

That brings us to our final topic: what treatments are effective for PTSD and CPTSD?

Evidence-Based Support for Teen Female Rape Victims

In a paper published in August 2020 called “Systematic Review: Effectiveness Of Psychosocial Interventions On Wellbeing Outcomes For Adolescent Or Adult Victim/Survivors Of Recent Rape Or Sexual Assault,” researcher conducted a thorough review of the current best therapeutic practices for victims of rape or sexual assault.

In total, they found ten studies that analyzed the effectiveness of a wide range of therapeutic interventions. We’ll pull no punches here: the study authors were neither impressed with the strength of the evidence nor the design of the studies they reviewed. Despite spending significant time discussing the relative weaknesses of the studies, they did identify the following treatment interventions that improved symptoms in female rape victims:

• Cognitive behavioral therapy (CBT)
• Eye movement desensitization and reprocessing (EMDR)
• Cognitive processing therapy (CPT)
• Prolonged exposure therapy (PE)
• Systematic Desensitization (SD)
• Brief psychoeducation (PEI)
• Psychological support (PS)

It’s important to note that in the context of this study, all of these interventions occurred in conjunction with CBT. Therefore, the study authors consider them all to CBT-based interventions, and determined they were effective in reducing the following symptoms:

• General PTSD symptoms, including:
  • Avoiding memories
  • Avoiding triggers for memories
  • Constant sense of threat
• Depression
• Fear of subsequent rape/sexual assault
• Sexual function

We’ll address that last bullet point, since it’s something we haven’t mentioned. In many cases, victims of rape or sexual assault experience impaired sexual function, which can manifest in various ways. This study indicates that all of the CBT-based interventions listed above can help reduce symptoms related to this phenomenon.

The Bottom Line: Treatment for Complex PTSD Can Help Reduce Symptoms

Adolescent girls who experience rape or sexual assault can develop PTSD or CPTSD, two mental health disorders that can cause severe, lifelong impairment. As we mention above, the symptoms of PTSD and CPTSD can disrupt almost all areas of life, including family, peer, and romantic relationships, academic achievement, work performance, psychological and emotional health, and overall wellbeing. The disruption can be moderate to severe, with severe impairment limiting function in all practical domains. In addition, anxiety, depression, and alcohol/drug use may also accompany the symptoms of rape-related PTSD or CPTSD.

Evidence in the second study we cite above shows that CBT-based interventions are effective in reducing symptom severity. The most effective approaches included:

• B-CPT: Brief cognitive processing therapy
• Prolonged exposure therapy (PE)
• Brief psychoeducation (PEI)

Researchers indicate that multi-session treatments in these modalities that take place over time show the most success in symptom reduction. For families with teenage girls who have experienced rape or sexual assault, that’s valuable information. These girls are at risk of lifelong disruption, but with appropriate treatment and support, they can learn to manage the symptoms related to their experience, and live in the manner of their choosing, rather than a life dictated by the result of one – or several – traumatic experiences during adolescence.