Nancy Downing, PhD, RN, SANE-A, CP-SANE, associate professor in the Forensic Nursing Program at the Texas A&M College of Nursing, is part of an interdisciplinary team researching how hormones may affect the development of post-traumatic stress disorder (PTSD) after sexual assault.
Christina Sumners: Welcome to Science Sound Off, I’m Christina Sumners.
Tim Schnettler: And I’m her co-host, Tim Schnettler.
Nancy Downing: Thank you for having me.
Christina Sumners: We’re here today to talk about sexual assault and mental health; I know you’re doing research on PTSD after sexual assault, but before we get into that, maybe just tell us a little bit about your experience as a sexual assault nurse examiner.
Nancy Downing: Sure, so I think it’s not a surprise to most people to understand that sexual assault is potentially very traumatic for people and that mental health outcomes following sexual assault could be quite significant and interfere with day to day functioning. So my objective with my research and my practice is to help promote optimal mental health outcomes, following sexual assault. I’ve been a sexual assault nurse examiner since 2004, and I came to it through my work as a medical psychiatric nurse, immediately recognizing that connection between that traumatic experience and long-term mental health outcomes. And short-term mental health outcomes that can severely impact people’s functioning quality of life.
Christina Sumners: So just from the practice side of it, let’s talk about that for a minute. What do you, what can you do during an exam, after somebody’s been sexually assaulted, in order to help put them on the path to healing?
Nancy Downing: Sure, that is actually a really important function of what we do, how we’re trained, educated as sexual assault nurse examiners; it’s called trauma-informed care. So, that is care that takes into account that a person has experienced a traumatic event, and therefore the way we talk with them, the way we provide choices and control during the exam, is really critical to how they’re going to function, how they’re going to respond. It can really have long-term impacts on their mental health. So it can be making sure that we explain everything we do before we do it, asking permission to touch them before we touch them, providing them choices, they can decline anything that we offer them. They, we’re very careful about the language that we use. We avoid any implications of victim-blaming. We, which is another reason why we explain, really carefully, that we’re, I’m going to ask you some questions now, and here is why I’m asking them. Rather than just asking questions that could be confusing and make them feel like I’m, that we are blaming them. So providing safety, restoring control, choices, all of those are really important elements of how we let a survivor feel as though they have more control, because they’re just in a situation where control is taken away from them.
Christina Sumners: So giving it back to them.
Nancy Downing: Yes.
Tim Schnettler: Yeah, and you mentioned just letting them know the questions that you’re going to ask them and stuff, is it also they’ve been through a traumatic experience and you don’t wanna make it any worse on them, and don’t want to make them feel like it was their fault. Is there that aspect of it as well?
Nancy Downing: Absolutely, because research indicates that people have a lot of self-blame, and there’s a lot of so-called rape myths in our culture, in society, in which people are blamed for their victimization. So we need to really be making sure that we’re avoiding any further harm that could come from implicating their culpability in that traumatic event.
Tim Schnettler: Obviously, when people think of an event like this, it’s usually more on the female side, but there are male victims, as well. Is there a way that you have to deal differently with a male victim versus a female victim?
Nancy Downing: Right, that is really important, and something that I work hard to educate our students and our forensic nursing program, that males are often forgotten in a lot of these discussions. It does happen to males, too. At different rates than with women, but we really don’t know as much about the male experience. They’re less likely to come in for an exam. They’re less likely to report to law enforcement. The little bit of data we do have indicates that the way they cope might be different. But the same sorts of self-blame, depression, anxiety, post-traumatic stress disorder, also can happen for them, definitely.
Christina Sumners: So you mentioned post-traumatic stress disorder. That’s the focus of some of your current research?
Nancy Downing: Correct, so, for a long time, we’ve been aware of the association between sexual assault and post-traumatic stress disorder. So much so that the American psychiatric association includes sexual assaults as the only specifically identified traumatic event that meets criterion for development of PTSD. So, it’s very highly recognized as a risk factor for the development of PTSD. As much as 82 percent of people will meet criteria one month post sexual assault, for PTSD symptoms. So it’s really a high, high rate.
Christina Sumners: That is a really high rate. So what are some ways you’re looking at that we could potentially lower that number?
Nancy Downing: Right, so right now we still need to understand more about what the specific risk factors are for PTSD development, specific to sexual assault. We know it’s a traumatic event that people experience, as highly threatening to their personal bodily integrity, and that really is the factor that is associated most highly with PTSD. A lot of people minimize sexual assault. They think it’s just sex that maybe was unwanted, but it’s just sex, so what’s the big deal? Why does it cause such long-term mental health problems for people, as well as physical health problems, too, I will add. But the reality is, that’s not how the brain experiences it. And a lot of people who have been victims, or survivors, whatever they prefer to call themselves, following sexual assault, have difficulty explaining to others, but also to themselves, how threatened they felt during their sexual assault. And they feel like they’re going crazy. They feel like their symptoms are, are a sign of being insane because they’re experiencing flashbacks, intrusive memories, they’re unable to get over it, they’re isolating themselves, they’re unable to sleep, they have nightmares. Their whole lives are disrupted and they feel like they’re going crazy; what I hope that they will understand from my work is that the brain is making these changes, it’s unconscious, they don’t have control over it, and there are very specific interventions that need to occur to help them get better.
Christina Sumners: So what are some of these interventions? Have they been well-studied, or are you still working on determining some of the best approaches?
Nancy Downing: A lot of the research, most of the research, is done with people who have chronic PTSD. Combat veterans are one large group, but also sexual assault survivors, accident victims, people who have experienced catastrophic weather events, like hurricanes, survivors of disasters and terrorism. And so they’re looking at some of those interventions for chronic PTSD, like cognitive behavioral therapy, exposure and extinction therapies are all shown to be effective at reducing symptoms and bettering functioning quality of life. What makes my area of research unique is that we’re able to intervene following the traumatic event, so the traumatic event happened, we can’t prevent that, but we’re getting them at the acute aftermath, before they’ve really gone on to develop the diagnosis, because it can’t be diagnosed until you’ve had symptoms for one month, so it’s possible that we’re going to be able to intervene and prevent PTSD development, if we know what to do. So we don’t really know yet what to do. There’s been a few things that have been tried. Debriefing has been shown to not be effective. So for a while, they thought debriefing with people after the traumatic event, they’ve done this with terrorists and disasters, and that has not shown to be effective, but it may be that debriefing and talking about the experience without having some sort of cognitive restructuring in there, or other sorts of interventions, is not helpful. We don’t really know enough about what would be helpful, in this acute period, so we have this, some people call it this magic window, and I’m a believer in the magic window, because that’s what I have to work with. And so I’m hopeful that there are things we can do to prevent that long-term impact.
Tim Schnettler: You mentioned that magic window and I was thinking about time, the time element in all of this. Obviously, I mean, you have some survivors that come out right away, but then there’s some that hold it in and don’t come out until maybe a year or two later. How important is the time aspect in all of this?
Nancy Downing: Time is so important, so I’m glad you bring that up, because right, we know disclosure of sexual assault is very, very low, especially to providers who can perhaps treat it. And we also know that even for people who do come in for a medical forensic exam, follow up is really low. Especially for mental health. And one of the reasons for that is actually part of the conditions; so, one of the symptoms of post-traumatic stress disorder and acute stress disorder, which happens in the immediate aftermath, is avoidance of thinking about the trauma. Avoidance of thinking about distressing thoughts related to it, avoidance of sights or sounds or places or people that remind them of it. And it can seem like these are deliberative, but again, these are things that are in the brain. They’re unconscious, they’re occurring without conscious control and so it’s hard for people to access help when they’re avoiding thinking about the trauma. So timing is critical. Another element that we’re looking at is sleep. Because what this really comes down to is fear memory being consolidated in the very primitive parts of the brain that just happen unconsciously in response to trauma, that are really helping promote a lot of the symptomology. So, sleep is an element of that fear memory consolidation. We know that sleep is associated with memory consolidation, and it’s also, fear learning is also a part of learning. So, if we can somehow figure out how to promote sleep that’s going to make PTSD symptomology better, that’s a potential target right there. So, but people come in for an exam, like you say, they don’t necessarily come in right away, they don’t come in, having the same amounts of sleep, or the same amounts of time. There’s even people who are perhaps dissociating, mentally, so they’re not even prepared to admit to themselves or to recognize what happened to them. So there’s a lot of reasons people don’t come in for help. So unfortunately, it’s going to be difficult to help the people who don’t come in and access help.
Tim Schnettler: So how do you educate the public that if something has happened that time is such a critical element? I mean, how do you reinforce that?
Nancy Downing: That’s one of the messages we really need to work on, is I think from some of my own research that I’m looking at, a lot of people assume that coming in for a medical forensic exam following a sexual assault is really part of the law enforcement reporting process. Because there’s been a lot of media attention based on the sexual assault evidence and the kits, right, so they think of it as: I’m going in to get evidence collected. They don’t necessarily think about the health impact. And I really want people to look at it as a health issue. I’m a nurse, I’m there to help them with the health aspects. Because I’m there at the time and there’s evidence, and it’s on their bodies, I’m well-prepared and educated to collect that evidence, in fact, the evidence we collect has been demonstrated to be superior to people who don’t have that background and education, but it’s not my primary focus. Because unfortunately, very few cases move through the legal system; a lot of that is because the victims don’t want to pursue that because of the emotional distress that it causes. So if we can address some of that emotional distress, it’s possible we could even help them feel more comfortable moving through the legal process, which we could argue we want that to happen, because that’s one good way to prevent other people from being victimized, but my ultimate goal as a nurse is to help improve the health outcomes and the mental health outcome is part of that.
Christina Sumners: So there are some tactics that we can use, that we know work for helping survivors of sexual assault, but what is some of your current research doing to help find out other possible ways?
Nancy Downing: Well, one area of research that I think is so fascinating is the contribution of female hormones to the development of PTSD. So some of the clues that we have about PTSD risk include that women have higher rates of PTSD, regardless of the trauma type. So that was one clue that there’s something unique about women, and it usually comes down to hormones, because we know males and females have different endogenous hormone production. So, some interesting preliminary data that have come out of this search include the finding that women who were taking oral contraception before they presented for a sexual assault exam, and women who were given emergency contraception during a sexual assault exam had lower PTSD symptoms on one of the PTSD symptom sub-scales, than women who didn’t have hormonal contraception. So there’s something about that hormonal contraception that is changing their endogenous hormone production, and perhaps interfering, and perhaps interfering with that hormonal contribution to development of PTSD symptoms. So one of the things we’re looking at in a lab setting, with healthy women who have not been sexually assaulted, is what is the impact of having emergency contraception on some of their fear memory learning, and then some of their fear extinction learning? So, it’s a really interesting lab experiment that is less ethically problematic, because we’re not working with patients who have been sexually assaulted, and hopefully we’ll have some very interesting results. It’s in progress now; this is one of the (Texas A&M University) president’s research initiative T3 grants that funded our research. It’s myself and Dr. Amorie MacNamara, and Dr. Mary Mahur, at the Department of Psychology.
Christina Sumners: So these T3 grants, they bring together people from different colleges, different disciplines. What do each of you bring to the table to help make this research accessible?
Nancy Downing: Yeah, interdisciplinary research is so important because we do bring different talents. I, as a sexual assault nurse examiner, and I’m working directly with these patients, I see the impact on them, but I don’t know how to run a classical fear conditioning experiment. So, I found Dr. MacNamara, and I presented this proposal to her. Because she has a fear conditioning lab that uses well-established fear conditioning paradigms, and I asked her if she’d be interested in partnering on this, because of my interest in seeing what are emergency contraceptions doing to fear learning that could potentially impact real victims, because we give them during a sexual assault exam, we give them emergency contraception. I want to know: am I helping them, or am I hurting them? So, she was very interested in that. The hormonal contributions to PTSD is starting to be a well, a more well-studied area. It’s really been neglected for a long time, even though the contributions, even though women have higher rates of PTSD, they were really not looking at some of the endogenous differences between males and females, which to me seems ludicrous, but we’re on it now. So we’re helping to untangle this.
Christina Sumners: So these hormones the emergency contraception and the birth control pills, is this estrogen, is it progesterone, what do you think is the agent?
Nancy Downing: So one of the exciting pieces of preliminary data that we’ve found in the literature was that women who were at the mid-luteal phase of the menstrual cycle, so that’s the phase of the menstrual cycle when progesterone levels are highest. Those women were found to have higher rates of PTSD, than women who were in the lower progesterone phase of their cycle when they experience sexual assault. So for me, that is so intriguing, because we are giving emergency contraception that is supposed to make that progesterone, ah, level decline, so that we’re preventing ovulation and preventing implantation of a pregnancy that could have ensued because of the assault. So we’re giving a progesterone, so the plan B is a progesterone, Levonorgestrel, that’s the generic. And that is a higher dose of progesterone than in a usual emergency contraception pill, and so that’s why it’s presumed to be effective in preventing pregnancy, so in giving this progesterone, are we then simulating a high progesterone effect, and then making PTSD symptoms worse? Or what we also find is that these progesterone medications, they compete at the receptor site, and so the endogenous progesterone levels are lower, so therefore that’s what is conferring that, perhaps protection against PTSD. So, really we’re looking at what it’s doing for that fear learning. So the other medication though, we more commonly give now, is Ulipristal. So that is an emergency contraception that is a synthetic form of progesterone. So we’re not sure what that one’s going to do yet, but since that’s the one we are now giving more commonly, we’re going to look at that in another phase of this T3. Right now, we’re comparing Plan B and placebo. We’re trying to decide what’s the best phase of the menstrual cycle to give Ulipristal to. Because right now, we’re taking women at the levels where their normal progesterone and estrogen levels are really low, and then seeing if that, or that, Plan B is increasing the levels, or keeping them the same, or how it is working on that fear consolidation mechanism.
Christina Sumners: Because it might be somehow blocking the body’s natural progesterone, and therefore…
Nancy Downing: Right, we don’t exactly know. It’s kind of distressing that even the pharmacologists don’t really know how many of the medications we take and know are effective really work. We’re looking at it from obviously a different kind of protective mechanism than its intended use, but it’s very, very intriguing. Bottom line for me: I’m the clinician of the three that’s working directly with this population, so I need to know, are we helping, are we hurting, how could we be helping more? And does the point of the menstrual cycle that they come in for their assault make a difference in how I might treat them?
Tim Schnettler: You mentioned the lack of research in this area, and you mentioned that PTSD is common in women, and why has there been such a lack of research in this area? Is it because PTSD is traditionally thought of the military, and soldiers, and is that the reason why we don’t see as much research in this area?
Nancy Downing: I think that’s definitely part of it, that it has been traditionally associated with combat veterans, which we now know there are female combat veterans, and also a lot of science is difficult to explore in females because of the complexity of the female hormones. And research on women with the potential to get pregnant, and I think there’s been a lot of avoidance of sort of muddying the data, because of some of those factors, but obviously it’s important, since they are 50, at least, percent of the population and at higher risk for PTSD, so we’re now finding ways to really fully examine that.
Christina Sumners: So your research is focusing on women who are cycling, who are of reproductive age, and they, I want to say when they come in, they’re not going to be on any sort of hormonal birth control, though?
Nancy Downing: Very good, yes, we make sure that they are not on hormonal contraception currently, regularly cycling, in the early part of their menstrual cycle, so their levels are more equivalent to males, so typically males make a tiny bit of endogenous progesterone and, ah, males typically make a tiny amount of endogenous progesterone and estrogen, just like women make a small amount of testosterone. But the levels are similar for men and women in that early part of the menstrual cycle, and then women have this increase of estrogen, followed by an increase of progesterone, and then the differences are sometimes a magnitude of 30 times difference in those levels of progesterone. So that could be one reason PTSD rates are higher in women.
Christina Sumners: So you started recruiting participants for the study. What will they be doing, once, if you can tell me? I don’t want to ruin the experiment.
Nancy Downing: Right, so what is a classical fear conditioning paradigm in a person? So what we do is we take something that’s a really harmless stimuli, but it’s annoying. So we’re just inducing a really, a mild electric shock to their wrist, and we’re pairing that with certain colored light that appears on a lantern on a screen. So they’re watching a computer screen, and when this lantern has a specific color of light, that’s paired with this really mild electric shock to their wrist, and they’ve chosen the comfort level ahead of time for that shock. And this is actually a classical conditioning paradigm that’s been conducted in labs all over the world. It’s been well-validated and it’s safe, and we have IRP approval, and all the necessary things are in place for safety. But the very interesting thing about it is that when you’re pairing that electric shock with that one colored light, even though the participant might not necessarily even be aware that those two things are being paired, a part of their brain, the very primitive part of their brain called the amygdala, is very aware that that’s what’s going on, and we can measure that by using EEG. The participants will wear a cap that has electrodes all over it, and we’re measuring that very sensitively. We’re also measuring their eye-blink reaction, and their skin conductance; do they start to sweat a little bit when they have that pair? So, it’s really actually easy to train the amygdala, which is our fear learning part of our brains, to anticipate that fear. It’s very robust, and we can measure it and so we do that, and then we randomize people to either receive a placebo or the emergency contraception and then they come back the next day and they do what’s called an extinction learning paradigm. So here we’re uncoupling that light with the shock. So they’ll see the same colored light, but they won’t get shocked, and again, the amygdala just does this automatically. It’s outside the conscious control of the participant, and it’s really easy to extinguish that really mild fear. It’s not the kind of fear that’s gonna translate into their everyday life and they’re gonna go outside and see a street lamp and freak out. This is just easily extinguished, but how they hold on to that fear memory learning might be different between the people who got the placebo and the people who got the emergency contraception. So that’s what we’re looking at: what’s the brain doing? And I think that that can be really helpful to survivors, to know that the brain is doing these things unconsciously, without their conscious control. So what’s happening to people after a trauma like sexual assault that makes them fearful, makes them have flashbacks, nightmares, intrusive thoughts, feel like they need to avoid things, traumatic memories, their emotion dysregulation, their mood dysregulation, their inability to function, what’s happening is outside their conscious control. They’re not going crazy. These are highly conserved, mechanisms that have been in place since humans were on this planet, that are intended to protect us from things that could be threatening to our bodily integrity. So, it takes a lot of very specialized interventions to uncouple those fears, and that’s what therapy is supposed to do.
Christina Sumners: What would you like survivors of sexual assault and the people in their lives to know?
Nancy Downing: I think it’s really important for survivors and their family to understand that these, again, are symptoms that they don’t have conscious control over. That most people will spontaneously recover from PTSD, given enough time, that natural uncoupling of the circumstances around their assault and that fear learning will just occur naturally, for many people, without extensive therapy. There’s about 10 percent of people who will go on to develop chronic PTSD following sexual assault, and those people really need more intensive therapy. Intensive therapy could be helpful for all survivors, however, to help make that process quicker and avoid some of the other things that can happen to people after sexual assault. The maladaptive coping mechanisms that we also see. So, it’s really important, I think, for family and friends and loved ones and survivors to know they’re not going crazy. These are things that are happening automatically and unconsciously, and that therapy can really help. Including medication and cognitive behavioral therapy and other kinds of extinguishing therapies that can help prevent some of the long-term sequelae. It’s also important for juries to understand. So we wanna educate people about why victims might behave in certain ways, why they didn’t report right away, why they perhaps didn’t cooperate with law enforcement, because every time they’re talking about their assault, it’s emotionally triggering for them. So, it’s important to understand some of those behaviors that seem counterintuitive following sexual assault that are really quite understandable, once you understand how PTSD works.
Christina Sumners: Well, I think that’s a great message to end on, that there are resources out there, and ways to help survivors. Thank you so much for being with us today.
Nancy Downing: Thank you so much for having me.
Christina Sumners: And thank you all for listening, and we will see you next time.