One of the great fears that a lot of people seem to have about rape is:

If we believe more rape victims, then what if I get accused of rape?

There's some good news.

Firstly, unless you have some underlying severe personality disorder, the likelihood that you will go on to rape someone is incredibly low. As explained in my previous post, almost all rapists have some underlying psychiatric diagnosis, and most of those diagnoses are severe personality disorders. People with psychotic illnesses such as schizophrenia or with intellectual or cognitive disorders are fairly unlikely to harm others, even though they do make up a small proportion of those who assault or rape people.

Secondly, we have the likelihood that someone will make a false rape accusation against you. Fortunately, only 5% or 1/20 rape accusations are false. When you consider that 1/4 of women (and 1/6 of men) are raped in their lifetimes and only 1/6 of all rapes are even reported in the first place, this gives you only 1/480 or so women and probably less than 1/720 men given less likely to report rapes who would make a false rape accusation. And that's assuming that people who make false rape accusations only make one of those. The more they make on average, the rarer these people are. Over a lifetime we only tend to know and interact with 500-1000 people, including distant acquaintances. Which leaves us with the most likely outcome being that we might know one or two false rape accusers, and probably won't even know about the accusation they made. On the other hand, 21% of the people we know have been or will be raped or sexually assaulted, which is a horrifying statistic.

So no, it is not very likely that you will get falsely accused of rape. In fact it is exceedingly unlikely. With this in mind, we can go back to the real issues at hand: preventing and punishing rape and supporting and helping rape victims.

Just to be clear, here are some infographics for everyone, because these days no article is complete without infographics. EDIT: one of the infographics has been edited for clarity, to include references and for greater accuracy. The reason for not including female perpetrators and under-reporting of male rapes to the police are due to a lack of available data, not because these issues don't exist. Female perpetrators are very much under-reported and sadly very few male victims (of both male or female perpetrators) go to the police.

Additionally, I posted my infographic on imgur so I could share it with a friend before I posted here, and decided to see what would happen if I posted it to their gallery. The results were... telling and somewhat predictable.

References:

• Finkelhor, D., Hotaling, G., Lewis, I., & Smith, C. (1990). Sexual abuse in a national survey of adult men and women: Prevalence, characteristics, and risk factors. Child abuse & neglect, 14(1), 19-28.
• Tjaden, P., & Thoennes, N. (2000). Full report of the prevalence, incidence, and consequences of violence against women: findngs from the National Violence Against Women Survey. Washington, DC: United States Department of Justice, 71.
• Mouzos, J., & Makkai, T. (2004). Women’s experiences of male violence: findings from the Australian component of the International Violence Against Women Survey (IVAWS). No.: ISBN 0-642-53842-5, 162
• Lisak, D., & Miller, P. M. (2002). Repeat rape and multiple offending among undetected rapists. Violence and victims, 17(1), 73-84..
• Lonsway, K. A., Archambault, J., & Lisak, D. (2009). False reports: Moving beyond the issue to successfully investigate and prosecute non-stranger sexual assault. The Voice, 3(1), 1-11.

Introduction

While analogous, there are many differences between the way in which community and individual health are practiced. In this short essay, I will outline some of these differences.

Definitions

The World Health Organisation in 1946 defined health as:

“A state of complete physical, mental and social well-being and not merely the absence of disease.”(World Health Organization, 1946)

This definition uses a biopsychosocial and inclusive model of health and can equally be applied to individuals as to communities, although the health of the individual is implied.

The NPHP in Australia defined public health in 1997 as:

 “the organised response by society to protect and promote health and prevent illness, injury and disability.”(National Public Health Partnership, 1997)

This encapsulates the modern, multidisciplinary approach to public health.

Ethical Differences

In treating patients, healthcare practitioners generally use “principles” and deontological frameworks such as beneficence, non-malfeasance, equity and fairness. One strives to improve a person’s health without harming them, in a fair and just manner. In particular we advocate for an individual patient when engaging with other stakeholders rather than necessarily making a decision that takes other individuals into account- responsibility for community health is usually handed over to public health agencies and administrative bodies. However in community health, measures such as disability-adjusted life years (DALY) are used to allocate resources & design interventions in a utilitarian manner as the aim is the greatest good for the greatest number.

This distinction however is not altogether clear-cut. While traditionally, utilitarianism is cited as the underlying ethical principle in community health and a deontological framework the underlying ethical principle for individual treatment, there is evidence that a mixture of models is what is used in practice.(Fortes & Zoboli, 2002; Hedner & Hansson, 1988)

In addition, sometimes these two methods clash. Surgical intervention for an individual with many complex medical problems may in fact be very expensive and improve community outcomes only slightly in comparison with inexpensive population measures such as vaccination programs. A 2001 study of American publicly-insured elderly patients estimated that the 5% of the population of elderly people who were in their last year of life contributed roughly 30% of the medical expenditure, 6 times the expenditure when compared with their surviving counterparts (Hogan, Lunney, Gabel, & Lynn, 2001).

Measuring Health

Health status of an individual can be assessed in several ways. Health practitioners assess symptoms, signs and the results of diagnostic tests. Medical and psychosocial wellbeing can be evaluated qualitatively during a consultation as well as using various quantitative tools designed to, for example, evaluate risk of depression, functional score or pain scores. Further investigations can also be used to measure health via methods such as blood tests, radiology, pathology, exercise tolerance and other physical components.

In comparison, analysis and measurement of community health is less straightforward and is conducted on a larger scale. Health surveys are analogous to using qualitative and quantitative tools applied to many representative individuals rather than a single individual. Incidence and prevalence of disease conditions may be collected via disease & death registers, hospital & general practitioner databases (eg coding discharge summaries after inpatient stays), surveillance systems where data is compulsorily submitted to a central authority such as for notifiable illnesses. Demographic data, economic and educational data that are continuously measured also give information as to social determinants of health.(Baum, 2003; Canadian Public Health Association, 1986; Lin, Chaplin, Robinson, Fawkes, & Smith, 2007)

Health Interventions

Health interventions for individuals are generally more focussed on secondary and tertiary prevention, ie treatment of risk factors & disease states that already exist rather than prevention in healthy individuals. An example would be that of someone who presents to their healthcare practitioner with ischaemic chest pain. While risk factor reduction such as diabetic control, cessation of smoking and initiation of an exercise regimen may all be appropriate, the initial response will be targeted to treatment of the underlying cause of chest pain and its psychosocial effects. The “history of presenting complaint” is the focus of what we often do.

In contrast, much of community intervention is primary prevention. Legislation and regulation, health promotion and education, screening, vaccination, treatment of risk factors, environmental management, socioeconomic and education policy are some of the many ways in which public health interventions are practiced. There is a “bigger picture” approach that emphasises prevention and often requires a co-ordinated and multidisciplinary approach to the health of the system.(Baum, 2003; Canadian Public Health Association, 1986; Lin et al., 2007)

Conclusion

Public health is not just individual health on a bigger scale. While the healthcare of individuals is increasingly holistic, public health necessarily has a “bigger system” perspective involving not just healthcare workers and departments but also legal, economic and educational systems.

The focus is on prevention, surveillance and maintenance of wellbeing rather than on treatment of ill-health.

Bibliography

Baum, F. (2003). The new public health. Oxford University Press. Retrieved from http://www.cabdirect.org/abstracts/20043034459.html

Canadian Public Health Association, W. (1986). Ottawa charter for health promotion. Ottawa: Canada.

Fortes, P. a. C., & Zoboli, E. L. C. P. (2002). A study on the ethics of microallocation of scarce resources in health care. Journal of Medical Ethics, 28(4), 266–269. doi:10.1136/jme.28.4.266

Hedner, T., & Hansson, L. (1988). A Utilitarian or Deontological Approach Toward Primary Prevention of Cardiovascular Disease? Acta Medica Scandinavica, 224(4), 293–302. doi:10.1111/j.0954-6820.1988.tb19587.x

Hogan, C., Lunney, J., Gabel, J., & Lynn, J. (2001). Medicare Beneficiaries’ Costs Of Care In The Last Year Of Life. Health Affairs, 20(4), 188–195. doi:10.1377/hlthaff.20.4.188

Lin, V., Chaplin, S., Robinson, P. M., Fawkes, S. A., & Smith, J. (2007). Public health practice in Australia: the organised effort. Retrieved from http://arrow.latrobe.edu.au:8080/vital/access/manager/Repository/latrobe:24280

National Public Health Partnership. (1997). Memorandum of Understanding. National Public Health Partnership.

World Health Organization. (1946). www. who. int/bulletin/archives/80 (12) 981. pdf WHO definition of Health. In Preamble to the Constitution of the World Health Organization as adopted by the International Health Conference, New York (pp. 19–22).

Introduction

I am a doctor who has worked in hospital settings of varying sizes including the Western Sydney Local Health District which is home to the largest urban Aboriginal population. However, I have not worked in a community setting or in a dedicated Aboriginal or Torres Strait Islander medical service. Prior to my medical training I completed my education in New Zealand, where welfare of the indigenous people of New Zealand was compulsory in our curriculum, which informs some of my pre-existing beliefs surrounding Indigenous Health in Australia.

My previous exposure in the area of indigenous health in Australia- as a medical student, doctor and member of the general community- had led me to the belief that there were very large disparities between the health of Aboriginal and Torres Strait Islander Peoples and the health of the general population. Statistical measures of health and wellbeing such as life expectancy, maternal and infant mortality and death rates to my understanding were comparable to developing world conditions, as were morbidity and mortality from chronic health conditions such as diabetes, cardiovascular disease, renal disease, infectious diseases and liver disease.

Similarly, from both reading and through my observations as a medical practitioner, my views and beliefs of the underlying reasons for the gross health inequalities came from both a biomedical as well as a biopsychosocial model of health incorporating social determinants of health. Socioeconomic inequality, mental health issues, dietary, overcrowding and environmental factors, streptococcal and staphylococcal colonisation, high smoking rates were some of the many risks that stood out to me as relevant to the poor outcomes in comparison with the general population.

This I viewed in the context of historical segregation, dehumanisation (via the Flora and Fauna & Aborigines Acts) and assimilation policies, political, institutional and media racism as well as the ongoing racism and discrimination that I had seen both in the workplace by colleagues and in the wider community.

However, although I felt that I had a some ideas and knowledge about why a large health disparity exists, I did not feel that my understanding was particularly complex or equipped to answer questions of how best to address this disparity. I also felt that without either formal education or direct experience of the complexities of the situation, I was unlikely to be able to interpret statistics such as why a large disparity existed in mortality from liver disease despite a similar chronic alcohol abuse rate to the general population.

Having now consumed subject readings and participated in the intensive workshops, have a more nuanced, evidence based and complex perspective on indigenous health issues.

Defining Health

Understanding of health requires adequate definitions and evidence.

A concept I have become familiar with is the WHO definition of Health:

“Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity” (World Health Organization, 1946)

This is a holistic concept which encompasses biopsychosocial understandings of wellbeing rather than just a biomedical understanding of disease.

The definition of Aboriginal Health in the National Aboriginal Health Strategy (1989) shares similar concepts but also includes community and cultural understandings of wellbeing:

“’Aboriginal health’ means not just the physical well-being of an individual but refers to the social, emotional and cultural well-being of the whole Community in which each individual is able to achieve their full potential as a human being, thereby bringing about the total well-being of their Community. It is a whole-of-life view and includes the cyclical concept of life-death-life.

Health care services should strive to achieve the state where every individual is able to achieve their full potential as a human being and this bring about the total well-being of their community.”(National Aboriginal Health Strategy Working Group, 1989)

The concept of cultural loss as a risk factor in mental health is also mentioned in Hunter (2002) and the health of the environment in Kingsley, Townsend, Phillips, & Aldous (2009).

Thus, my view of Indigenous Health and health in general has expanded to include not just the biomedical and biopsychosocial concepts of health but also cultural and community concepts and the life-cycle as important for wellbeing.

Historical Context

Pre-Colonial Era

Franklin & White (1991) note that prior to the colonisation of Australia by European settlers in 1788, that “the average Aborigine, in fact, enjoyed better health than the average Englishman” . The Aboriginal population and semi-nomadic hunter-gatherer culture was certainly ancient, settlement having occurred at least 50,000 years prior to colonisation (Franklin & White, 1991 p. 1). Life expectancy was estimated at roughly 40 (Abbie, 1969), significantly greater than the corresponding life expectancy of the mid-30s in England at the same time (Mokyr, 1993) and comparable to life expectancy in England in 1900 (Kinsella, 1992).

Even allowing for the health problems and epidemiology of crowded urban living, this longevity surprised me. Unfortunately, although both Abbie (1969) is widely cited, I was unable to find many other objective estimates of Aboriginal life expectancy prior to colonisation.

Colonisation

Franklin & White (1991) and Saggers & Gray (1991) both outline the history of post-colonial Indigenous Affairs in various major stages.

Firstly, the early contact & colonisation era, in which European settlers indulged in brutal treatment of local people- as competitors for land, or as employees- despite Indigenous Australians having rights as British subjects, and despite official government statements regarding their welfare. Australia was not considered to be inhabited or owned prior to colonisation despite its inhabitants. Infectious diseases, some still major contributors to Indigenous burden of disease were introduced, either accidentally or intentionally. The result was a significant decline in health. (Franklin & White, 1991)

Following this, a period of “segregation” and “protection”, initiated by missionaries and the British colonial government with the stated aim of improving the health and welfare of Indigenous Australians via forced resettlement, with the expectation that eventually they would either be “assimilated” into lower echelons of European-Australian society or die out as a race. “Assimilation” also encompassed the removal of “half-caste” children from their families during the Stolen Generation. These policies were economically beneficial due to minimisation of clashes between settlers and Indigenous peoples, employment of otherwise unemployable people to “look after” Indigenous people, reduced social welfare and infrastructure costs and generation of a compliant, dependent, underpaid workforce of Indigenous people (Franklin & White, 1991; Saggers & Gray, 1991).

Within this context, it struck me that several familiar themes emerged which are still evident in the political discourse surrounding Indigenous health and affairs:

• Discordance between official government policy and actual behaviour
• Indigenous dispossession, maltreatment and disempowerment at the expense of economic profit
• Persistent stereotypes dating back to the early colonial era
• Assumptions of European cultural norms as “superior” and “healthier”
• Dissent with discriminatory policy & behaviour from Indigenous and non-Indigenous Australians leading progressive change
• If one is to believe that government actions are benign and follow the official policy, then one (incorrect) line of reasoning is to disbelieve the reality of mistreatment and instead to state that Indigenous people are responsible for their own ill-health as they have failed despite benign government intervention.

While I did know that there was historical context, I was surprised and shocked to find how eerily similar the arguments of past generations were to beliefs I hear expressed by some politicians, healthcare workers and educated people now.

Post World War Two Australia & the Modern Era

Following greater community exposure to the plight of Indigenous Australians and greater empowerment of Indigenous Australians during World War Two, more progressive policies and changes were implemented. In 1967 was the referendum which recognised Indigenous Australians as citizens with equal rights.

“Self Determination” was the next broad policy direction, with community-run Aboriginal and Torres Strait Islander Peoples organisations receiving funding and autonomy for provision of Aboriginal health services to run in parallel with “mainstream” services.

Unfortunately, partially due to the structure of federal and state governments in healthcare in Australia as well as changes of government, there was frequent restructuring of government and community organisations with dilution of responsibility and funding and erosion of community autonomy.(I. Anderson & Sanders, 1996; I. Anderson, 1997)

The Howard Federal Government in 2004 abolished the Aboriginal and Torres Strait Islander Commission (ATSIC) and took control of Indigenous health funding,  a process labelled “mainstreaming” due to diversion from community organisations to “mainstream” organisations.

I was unaware of the context of complex bureaucratic restructuring, waste and gradual erosion of self-determination in the recent history of Indigenous health provision. Certainly in the light of the historical context of cultural loss, assimilationist policies, racist stereotypes and the cultural and community definitions of Aboriginal health, I now perceive a significant set of barriers and an additional risk factor.

Evidence Base

Data & Measures of Healthcare

Quality statistical data on health outcomes and interventions for Indigenous Australians is limited. Multiple reasons have been identified including but not limited to:

• Incomplete or incorrect identification of Indigenous status in research
• Lack of studies into Indigenous health and health outcomes
• Reduced participation in studies

(I. Anderson et al., 2007; Madden & Pulver, 2009)

Demographics show that Indigenous Australians are younger overall, have higher birth rates and tend to live in much more remote settings, have lower education and birth weight and much lower health funding.  The statistical evidence that exists paints a picture of gross health disparity with poor outcomes on many key measures including life expectancy and maternal & child mortality. Chronic illness represents the biggest contributor to morbidity and mortality. Most alarmingly given the high rate of diabetes, the rate of smoking is double that of the general population at 45%. (Nettleton, Napolitano, & Stephens, 2007; Ring & Brown, 2002)

Interventions and Future Directions

The approach that has been devised by multiple working groups and endorsed by Indigenous health organisations is that of partnership, shared responsibility, greater funding and research and collaboration.(I. P. Anderson, 2006; I. Anderson, 1997; Australia, 2007; Chapman, 2010; National Aboriginal Health Strategy Working Group, 1989; Thomson, 2003; “Time To Remove the Barriers Preventing Indigenous Australians Getting Equal Access To Quality Health Care,” n.d.)

This holistic and inclusive and culturally appropriate model of intervention is compatible with the Aborignal definition of health and I was very encouraged to find a concrete set of possible interventions which were possible at multiple levels of government and health.

Bibliography

Abbie, A. A. (1969). The Original Australians. Muller. Retrieved from http://www.aiatsis.gov.au/library/documents/Arrente_Aranda_Published_Apr2011.pdf

Anderson, I. (1997). The National Aboriginal Health Strategy. Health Policy in Australia, 119–135.

Anderson, I., Crengle, S., Kamaka, M. L., Chen, T.-H., Palafox, N., & Jackson-Pulver, L. (2007). Indigenous health 1: indigenous health in Australia, New Zealand, and the Pacific. The Lancet, 367, 1775–85.

Anderson, I. P. (2006). Mutual obligation, shared responsibility agreements & indigenous health strategy. Australia and New Zealand Health Policy, 3(1), 10. doi:10.1186/1743-8462-3-10

Anderson, I., & Sanders, W. (1996). Aboriginal health and institutional reform within Australian federalism. Australian National University, Centre for Aboriginal Ecomonic Policy Research. Retrieved from http://caepr.anu.edu.au/sites/default/files/Publications/DP/1996_DP117.pdf

Australia, O. (2007). Close the gap: Solutions to the Indigenous health crisis facing Australia. Oxfam Australia.

Chapman, N. (2010). Partnership Position Paper. Close the Gap Steering Committee for Indigenous Health Equality.

Franklin, M.-A., & White, I. (1991). Chapter 1: The History and Politics of Aboriginal Health. In J. Reid & P. Trompf (Eds.), The health of aboriginal Australia (pp. 1–33). Houghton Mifflin Harcourt P.

Hunter, E. (2002). “Best intentions” lives on: untoward health outcomes of some contemporary initiatives in Indigenous affairs. The Australian and New Zealand journal of psychiatry, 36(5), 575–584.

Kinsella, K. G. (1992). Changes in life expectancy 1900-1990. The American Journal of Clinical Nutrition, 55(6), 1196S–1202S.

Madden, R. C., & Pulver, L. R. (2009). Aboriginal and Torres Strait Islander population: more than reported. Australian Actuarial Journal, 15(2), 181.

Mokyr, J. (1993). Technological Progress and the Decline of European Mortality. The American Economic Review, 83(2), 324–330. doi:10.2307/2117685

National Aboriginal Health Strategy Working Group. (1989). A national Aboriginal health strategy. Canberra: AGPS.

Nettleton, C., Napolitano, D. A., & Stephens, C. (2007). An overview of current knowledge of the social determinants of Indigenous health. In Symposium on the social determinants of Indigenous health, Adelaide. Retrieved from http://new.paho.org/hq./index.php?gid=12421&option=com_docman&task=doc_view

Ring, I. T., & Brown, N. (2002). Indigenous health: chronically inadequate responses to damning statistics. Medical Journal of Australia, 177(11/12), 629–632.

Saggers, S., & Gray, D. (1991). Chapter 9: Policy and Practice in Aboriginal Health. In J. Reid & P. Trompf (Eds.), The health of aboriginal Australia (pp. 381–394). Houghton Mifflin Harcourt P.

Thomson, N. (2003). Responding to our’spectacular failure’. Retrieved from http://ro.ecu.edu.au/ecuworks/3437/

Time To Remove the Barriers Preventing Indigenous Australians Getting Equal Access To Quality Health Care. (n.d.). Australian Medical Association. Retrieved March 24, 2013, from https://ama.com.au/node/2699

World Health Organization. (1946). www. who. int/bulletin/archives/80 (12) 981. pdf WHO definition of Health. In Preamble to the Constitution of the World Health Organization as adopted by the International Health Conference, New York (pp. 19–22).

“Yotti” Kingsley, J., Townsend, M., Phillips, R., & Aldous, D. (2009). “If the land is healthy … it makes the people healthy”: The relationship between caring for Country and health for the Yorta Yorta Nation, Boonwurrung and Bangerang Tribes. Health & Place, 15(1), 291–299. doi:10.1016/j.healthplace.2008.05.009

Since the former Australian government introduced a tax incentive for private health insurance (or should I say, a tax disincentive for not having it), a lot of people now have some degree of private health insurance.

Most people are, however, somewhat confused at what this actually entitles to them- which is understandable given that it's actually quite confusing.

The bottom line is that although there are now private hospitals that have ICU facilities and emergency departments, they really are set up for low-risk elective admissions, while public hospitals are much, much better at handling sick, complex emergency patients. Public hospitals are geared towards prioritising the sickest patients first (thus why waiting lists for non-urgent things are long). Private hospitals are businesses and are geared towards servicing things that are low-risk and high-gain, such as elective surgery or people who aren't that sick.

There are also often costs that are not obvious to those who aren't familiar with the healthcare system and how it works. The public health system is free. The private health system is not. If you are having an operation or procedure, you will have to pay whoever is doing the procedure (surgeon, dentist, gastroenterologist, cardiologist etc) as well as the anaesthetist and the hospital.

What private health insurance entitles you to:

• Usually some or all of your money back if you have an admission or procedure or consultation at a private hospital (as long as it's been long enough since diagnosis, etc). The amount varies considerably from plan to plan and is often capped at a certain amount. There is also often an excess payment for making a claim.
• "Private in Public" status at a public hospital which usually includes the ability to choose your own specialist, have procedures done by your choice of specialist (if they agree) and extra funding is given to the hospital by your insurer.
• If you have at least "Basic Plus" cover or similar, you can usually get covered 2/3 of the cost of dental care, physiotherapy, other allied health services, massage, acupuncture, other alternative healthcare practitioners. This is of course based on reasonable costs- if your practitioner overcharges you or the "reasonable cost" is actually unrealistic then you may not have the whole 2/3 covered.
• Elective (non-urgent, non-emergency) procedures will usually be performed much faster in the private sector. Good examples include varicose vein surgery, tonsillectomy, tendon repair, carpal tunnel release and arthroscopy.
• Transfer to the public system if you cannot afford the private service or run out of money (depending on resources available)

What private health insurance does not entitle you to:

• A single room. Single rooms are usually reserved for infectious, dying or delirious patients.
• Coverage of costs beyond what your plan covers or beyond what the insurance company deems a reasonable cost- there may be a price gap which you would have to pay out of your own pocket.
• Shorter waiting times for emergency procedures in a public hospital. Emergency procedures are prioritised according to urgency of the case. If you have an abscess on your thigh or a cut on your finger, your operation will be delayed if someone comes in from a car crash or is about to die of dead bowel or a woman in the middle of childbirth has a threat to the safety of the baby.
• Automatic transfer to a private hospital if you are unhappy with your treatment in the public hospital. Being admitted to a private hospital requires that your medical condition suitable for the private hospital, that a specialist is willing to look after you there and that there is a bed available for you.
• Inappropriate medical treatment, procedures or tests just because you think they are a good idea. Ultimately all doctors have to adhere to ethical conduct and the Hippocratic Oath, which forbids doing things that are harmful or unnecessary. Being in the private sector does not mean that you are only a customer. You are still a patient, and your doctor is obliged to act in your best interests.

What private hospitals & insurance are good for:

• Elective, low-risk surgery and procedures
• Simple problems and short admissions
• Covering dental care and allied healthcare
• Rehab- physical & otherwise

What private hospitals are not good for:

• Emergencies, critically unwell and complex patients- in the public system there is always a doctor on site and transfer to intensive care or theatre is prioritised for sick patients. Not always the case in a private hospital where there may not be a doctor on site at night time. Additionally, if your stay is complicated in any way, you may end up with large out of pocket costs.
• Trauma. For exactly the same reason. If you fall off a roof, are in a car accident or get stabbed, you are much, much better off in a public hospital where they routinely deal with trauma, sick patients and have the staff to take you for emergency procedures if required.
• Heart attacks, strokes, liver failure, cancer, hepatitis, cyanide poisoning, etc... I think you get the point.

If you choose to go ahead with doing something in the private hospital setting, I'd advise the following:

• Make sure that you know exactly what you are covered for. The insurance company should be able to advise you in advance if you're contemplating an admission under the private system.
• If it comes to having an operation, make sure you get a quote from 1) the person doing the procedure 2) the anaesthetist and 3) the hospital and then go to your insurer to find out what you are actually covered for. A lot of people get stung by the cost of the anaesthetic for the reason that they assume that it's part of the cost or that there will be no gap. In reality a lot of insurers do not pay a lot of money to the anaesthetist, while the anaesthetist actually pays a lot in indemnity insurance due to risk. The gap can be in the hundreds of dollars if not more.
• Discuss the cost of the procedure, the anaesthetic and the hospital with the person doing the procedure if you can't afford it. They may negotiate a different set up or doing it via the public system. Certainly they can't help you if they don't know that you are going to have financial problems.
• Public hospitals have a liaison person assigned to deal with "private in public" admissions. They can usually tell you a fair bit about what you are and are not covered for and entitled to. At the very least they can tell you who to talk to.

Whew. Hope this helps!

Not a particularly controversial post as the evidence is quite clear.

First: here is a review article from the American Journal of Obstetrics & Gynaecology 2009 going through the various studies on flu vaccine safety in pregnancy.

The conclusion is that influenza is pretty dangerous in pregnancy, while the influenza vaccine is pretty safe. Additionally, no long term side effects from the small dose of thimerosal which is a mercury based preservative.

Thimerosal free vaccines are available.

Second: here is an earlier review article from The Lancet Infectious Diseases 2008

Once again, conclusion is that benefit outweighs risk. As this was prior to the large prospective double blind randomised controlled trial in 2008, there was not enough data at the writing of that article regarding the flu vaccine and safety in pregnancy.

Finally here is the New England Journal of Medicine 2008 prospective double blind RCT that seals the deal with enough evidence- 340 patients.

Today's topic is that of domestic abuse and intimate partner violence (IPV). I am limiting this to abuse that occurs between those in an intimate/romantic/sexual relationship, as the topic of family violence and childhood abuse is beyond the scope of this article. There are of course parallels between the IPV and child abuse literature and both are focussed on the results of the abuse as the defining feature rather than a focus primarily on abusive acts. However the key difference is that while adult abuse is directed towards a presumably psychologically developed individual, child abuse is directed at a developing individual. Thus the range of behaviours considered abusive is overlapping but not completely comparable- examples include neglectful behaviour in child abuse.

First things first

Abusive relationships can involve emotional/psychological abuse, physical abuse and sexual abuse. Often these things can co-exist in fact: Emotional and psychological abuse can be difficult to detect to the outsider- resulting in low detection rates and low rates of complaints. Psychological abuse is better recognised in the child-abuse literature than in the IP literature. This can involve very varied tactics such as:

1. Threats to physical health: physical threats, damage to property
2. Control of physical freedoms: isolation and restriction of partner access to others, preventing partner from physically leaving, not letting partner sleep or fulfil basic human needs
3. General destabilisation of partner identity/perception of reality: convincing partner that they are responsible for and deserve abuse, threats of suicide, threats of abandonment, humiliation and ridicule, verbal abuse and criticism, forcing partner to beg for things, making partner believe they are crazy
4. Controlling behaviour: morbid jealousy and suspiciousness, threats of abandonment, emotional and sexual withholding and blackmail, excessive checking up on partner, following, stalking
5. Ineptitude: failure to live up to expected roles, clingy and needy behaviours, rigid gender role ideas

(Follingstad, DeHart 2000 - in order of decreasing severity of abuse) Additionally certain other more innocuous behaviours have been identified as being correllated with psychological and physical abuse- such as excessively physical behaviour in public, suicide threats and other behaviours. While psychological abuse may be perceived as less harmful, in actual fact it has been shown to have a similar or in some cases higher negative psychological impact on the victim of the abuse- perhaps due to the brainwashing, controlling, psychological and less easy to identify nature of psychological abuse. (Follingstad & DeHart 2000 "Defining Psychological Abuse of Husbands towards Wives" (Journal of Interpersonal Violence), Marshall L.L. "Physical and Psychological Abuse" (The Dark Side of Interpersonal Communication eds Cupach & Spitzberg) 1994, Engels & Moisan "The Psychological Maltreatment Inventory" (Psychological Reports) 1994) In addition, psychological abuse is also a predictor of long-term physical abuse. Physical abuse includes battering, slapping, punching, biting and otherwise physically assaulting a partner. Sexual abuse runs the gamut from coercive sexual assault to severe repetitive rape.

The Abuser

Let me trot out the old line: Domestic abuse is common. In particular, Intimate Partner Violence (sexual and physical abuse) has a lifetime prevalence of victimisation in Australia of 16-20% among females and 4-9% among males. (Roberts et al (1996), Robbe et al (1996), Krahe, Bieneck, Moller (2005) "Understanding gender and intimate partner violence from an international perspective" (Sex roles: A Journal of Research)) Once again as in other behaviour such as stalking, abuse has been reported to be perpetrated with comparable frequency by females as males. The range of behaviour and the physical threat is different, however- females are more likely use psychological forms of abuse and are less likely to inflict grievous bodily harm when physically abusing (perhaps reflected in the lower rate of male physical victimisation). There is, as ever, significant overlap. As in the previous articles, we will discuss various psychiatric syndromes and motivations behind the abuse.

Abusive Personalities

In the IPV literature, there is a common trend for between 2-4 typologies of abusers to be identified. Generally speaking, there is a clear distinction made between the occasionally violent, mostly normal personality offender and the far more violent, personality disordered abuser. Attachment styles as pictured above are a way of conceptualising relationships. Those who have good self-esteem and see others as good are likely to form positive, secure relationships. Those who have poor self-esteem but see others as good are likely to be anxious and preoccupied about their worthiness in the relationship and thus preoccupied with thoughts and fears of abandonment- much like those with Borderline Personality Disorder. Those however with good self-esteem but who view others with suspiciousness or look down on others tend to have a "dismissing" attachment style- they look down upon their partners and tend to be colder and less responsive towards their emotional needs, thus making them comparable to those with Paranoid and Psychopathic/Narcissistic traits. Finally we have the "fearful" attachment style- that of those with poor self-esteem and who view others with suspiciousness or fear. This style is characterised by avoidance of intimacy due to fear of rejection. Thus one would expect that the "secure" and "fearful" attachers would be least likely to be abusive- they would either be content with no reason to abuse or too scared to enter a relationship in the first place. The "pre-occupied"/borderline attachers may lash out due to their insecurities and fear of rejection while the "dismissing"/antisocial/paranoid attachers may lash out due to seeing their partner as inferior or bad. Ehrensaft et al. (2006) find in their large longitudinal study that all personality disorder clusters are positively correlated with abusiveness. All clusters were moderately associated with each other- it was more likely for someone to exhibit other personality disorder traits if they had a personality disorder already. Cluster A and B were the most correlated with abusiveness. In particular, a combination of jealous, suspicious, paranoid (cluster A) and emotionally volatile, impulsive, unpredictable (cluster B) behaviour was found to be strongly correlated with abuse. After accounting for cluster A and B traits, however, the remaining compltely independent cluster C traits were actually found to be protective against abusiveness- perhaps because those who are fearful of others are also less likely to be aggressive towards them. Dutton (2007) in his book "The Abusive Personality" on the other hand notes 3 main typologies. There is the impulsive, brooding, cyclically loving, clingy, needy and abusive violent, angry, jealous type- most likely to score very highly on measures of borderline personality traits. Described as "Jekyll & Hyde", a person who seems like a perfect partner, then starts brooding and getting more and more volatile until he/she finally lashes out violently. This is followed by gifts and other behaviour to make up for the bad behaviour. There is the coldly calculating extremely violent (antisocial/psychopathic) type who controls, is constantly angry, batters severely and often uses instruments such as weapons, chairs, frying pans, what comes to hand to inflict severe violence. Finally there are those who are passive, avoidant and often quite dependent- those who, due to their overcontrolled nature bottle up all of their negative emotions and anger until they finally explode in a bout of rare rage, sometimes with lethal consequences. There are some parallels between this model, attachment theory and Ehrensaft's model. Dutton also speaks of 2 types of co-existing traits- combined violent and borderline traits and combined passive and borderline traits. These combinations tend to be associated with greater violence and adverse outcomes. Holtzworth-Munroe et al have the most complex model following a 3 year longitudinal study of 102 couples recruited from the community who had had an incident of IPV. By far the largest category of couples (55%) scored close to normal on personality testing, with very low scores on measures of both psychopathy and borderline traits. These they denoted FO or "Family Only" Batterers. They had some passive personality traits (but not enough to qualify for a diagnosis of personality disorder). They were the least likely to have suffered physical or sexual abuse as a child and least likely to suffer from substance abuse disorders. They were the most loving, securely attached and remorseful and had the most liberal political and gender ideas. They also committed the lowest level of violence and only reported occasional violence vs family with no violence outside the family. They also had the most stable relationships. They could be considered to  be securely attached. Next there was a category known as BD or "Borderline/Dysphoric". These had high scores on the Borderline Personality Organisation Questionnaire and reported low mood, self-esteem and the lowest relationship satisfaction of all groups. They were also the most jealous of all three groups, being morbidly jealous as a group. They tended to visualise their partner as part of their self-identity rather than another individual. Additionally they saw themselves at times as a "knight in shining armour" or "rescuer" of their spouse. They were needy and clingy and desired their partner to be dependent on them. Their relationships had intermediate stability. They could be considered to have preoccupied attachment. The most aggressive and violent category was the GVA, "Generally Violent Abuser" category. These abusers scored very highly on the Hare Psychopathy Self-Report Questionnaire measure of psychopathy. They were very likely to commit many acts of violence outside the family setting, have friends/peers with misogynistic/violent/criminal attitudes and to have significant alcohol and substance abuse problems. They were also the group who had experienced the highest rate of and most severe child abuse. They were emotionally void, felt the least love and tended to see their partner as an object rather than fellow human. They also tended to blame their victims, have the most conservative gender roles. They had the most unstable relationships with by far the majority experiencing repeated separations and many having had their partner file for divorce after 3 years. Lastly there was the LLA "Low Level Aggression" category. They were like a much less severe form of the GVA category. They had moderate scores on psychopathy and were intermediate on all measures between the GVA and FO categories. Interestingly although there were psychologiical differences found between the BD, GVA and LLA categories, these differences were not found to be statistically significant. The authors posited that this may mean that these categories have a great deal of overlap and may in fact be subtypes of the same psychological phenomenon, the cluster B/paranoid violent type. Also there were no significant differences between FO abusers and the general population- a finding which warrants further investigation as to how they differ from non-abusers.

Discussion

All groups in the Holtzworth-Munroe study showed a reduction in violence as reported by both the abuser and victim over time- a finding which flew in the face of conventional wisdom. It is unknown at this stage whether this finding will be replicated and whether there was self-selection bias evident. This does however correlate with the finding that personality disorder scores in individuals and incidence in the community decrease slowly with age after a peak in the early 20s, reflecting greater maturity and moderation of undesirable traits with time. All studies found a strong correlation between child abuse (including physical punishment, neglect, more severe physical abuse, sexual abuse) and future IPV. This alone should be argument enough to oppose the use of physical force against children and to oppose sexual abuse of minors. There is also a dichotomy found in all studies between normal/passive occasional abusers and the cluster B (+/- A) impulsive/jealous/borderline/antisocial routinely violent abusers- often with a jealous subtype identified. The major weakness in these typologies is the lack of an explanatory model for the personality changes and future abuse as well as perhaps being simplistic in their formulations. On a population level this all makes sense- how about on an individual basis? It is also noted that co-abuse is common. How does this factor into models of abuse? There is a multifactorial Bayes network that has been produced to show risk factors to predict sexual offending. A similar sort of network may be what is needed in this area. I offer the following two theoretical flowcharts in lieu: As you see, there is one pathway for those with normal personality but low assertiveness and high partner dissonance. The other pathway depicts the evolution of the borderline and the psychopathic abuser via triggers and innate ideas about self and others. Further research must of course be done! Additionally, once again I must emphasise that these typologies and mechanisms suggest intervention strategies depending on underlying psychological pathology. The "normal" offender may benefit from assertiveness training and relationship counselling and other forms of psychotherapy. The "borderline" offender needs more intense psychotherapy and therapy directed towards the style of problem-solving and attachment style. The "psychopathic" offender of course  requires better problem solving strategies as well as behavioural controls and a large degree of monitoring in the community.

Overview

Generally speaking, we can split psychiatric diagnoses in the following way:

1. Axis I: major psychiatric disorders such as schizophrenia, depression, anxiety, autism, substance abuse disorders, attention deficit disorder, delirium
2. Axis II: disorders of personality
3. Axis III: medical (read: biological) diagnoses which contribute psychologically, such as thyroid disorders, cancers, etc
4. Axis IV: psychosocial support network
5. Axis V: global assessment of function score (0-100, 0 = death, 100 = fully functional)

What is a disorder of personality? How can you have a disordered personality as such? Simply put, a personality disorder occurs when someone has:

• A stable, ongoing pattern of behaviour, thoughts, emotions and social function (since adolescence or early adulthood)
• That differs markedly from the cultural norm
• Causes significant social/occupational/functional impairment or distress
• And is not better accounted for by another mental, medical disorder or substance use

So, that asshole who antagonises every client without fail and gets constant complaints about him? The 30 year old drama queen (male or female) who is always full of gossip and never seems particularly sincere? The suspicious weird old lady down the street who everyone is convinced is a witch? That guy at work who always lets everyone walk all over him? That needy, intense woman who stalks her exes? These are examples of potential personality problems. It is their personality, the exaggerated nature of their behaviour, emotions, thoughts, interactions that is at fault. This is not to say that personality is not something which has a great deal of normal individual variation. All the above four features need to be fulfilled for this to be a personality disorder. Simple eccentricity, oddness, quirkiness or other differences are not a disorder- for something to be a personality disorder it needs to cause some sort of ongoing functional impairment or distress. Nor does it mean that someone with a personality disorder is incapable of future functionality because it is their intrinsic personality which is problematic- it is certainly quite possible for someone to moderate their behaviour, thoughts, emotions.

"Everyone has a personality with character traits such as stinginess, generosity, arrogance and independence. But when these traits are rigid and self-defeating, they may interfere with functioning and even lead to psychiatric symptoms. Personality traits are formed by early adulthood, persist throughout life and affect every aspect of day to day behavior. Individuals with personality disorders often blame others for their problems."

-BehaveNet.com In addition, they may find some difficulties with their attachment styles.

The Clusters

Cluster A

Cluster A can be considered the "aloof, suspicious" group. They have in common propensities to some of the "negative" symptoms of schizophrenia - ie social withdrawal, suspiciousness, flattened emotions etc.

Paranoid Personality Disorder

This personality disorder is exactly what it says on the packet; it is characterised by an excessively suspicious, paranoid nature. People who suffer from this tend to be constantly questioning others' motives and see others as a threat. They are preoccupied with ideas of lack of loyalty and others' trustworthiness. They also bear grudges strongly and tend to take offence easily as they believe others to be attacking them.

Schizotypal Personality Disorder

Schizotypal personality disorder is what can almost be considered to be part way on the spectrum of schizophrenia itself (though much milder). In fact, family members of people with schizophrenia and related disorders are much more likely to have this personality disorder. It is a disorder which is in fact characterised by the less paranoid and more, well, odd features of schizophrenia - albeit without being floridly psychotic. This includes- eccentric behaviour, speech and ideas, belief in magical and superstitious things, paranoia, social anxiety and a withdrawn nature, flattened emotions.

Schizoid Personality Disorder

These people tend to be socially uninterested and somewhat indifferent. They do not really miss the lack of social closeness with others, nor the variety of experiences. Praise and criticism does not really affect them. They seem somewhat aloof, but not because of nervousness, just because of a very solitary nature.

Cluster B

Cluster B personality traits are characterised by extroverted, emotionally unstable and often anxious and/or aggressive behaviour. In addition, there are often distortions of self-esteem, self-identity and impaired empathy.

Psychopathy

Psychopathy is a disorder which was previously included in the DSM in place of the rather contentious and amorphous Antisocial Personality Disorder. There are said to be two major trait factors involved in psychopathy. Factor 1, "Aggressive Narcissism", connotes the selfish, remorseless, callous, charming, grandiose, shallow, flirtatious traits. Factor 2, "Socially Deviant Lifestyle" connotes the emotionally unstable, antisocial, violent, deviant, impulsive, parasitic, delinquent, stimulation-seeking traits. Thus, psychopaths lack empathy, are emotionally labile and generally superficially charming, very manipulative and guilt-free; they are impulsive, irresponsible, uncontrolled, hedonists. This category overlaps with both Narcissistic, histrionic personality disorders and Antisocial personality disorder.

Narcissistic Personality Disorder

Once again, the narcissist is what the label says. They are egocentric and believe they are self-important, unique, special and worthy of special treatment and rewards. They are obsessed with fantasies of power, success, beauty; they are manipulative, lack empathy, are arrogant and fluctuate between envy and the belief that everyone wants to be just like them.

Histrionic Personality Disorder

Histrionic means what most people think of as "hysterical"- these are what most would term the "drama queen". Attention-seeking, flirtatious, shallow, dramatic, with swinging moods and a bit, well, intense. Larger than life, and quite full-on.

Antisocial Personality Disorder, Conduct Disorder

Antisocial Personality disorder encompasses 2 main types of traits- the psychopathic traits as defined above as well as criminality. Needful to this diagnosis is also the diagnosis of Conduct Disorder, the juvenile equivalent of this disorder. Conduct Disorder has several categories of behaviour: aggression to people and animals; destruction of property; lying/theft; serious violations of parental rules.

Borderline Personality Disorder

Borderline personality disorder is a very overrepresented category of person who presents to hospitals, in particular to emergency departments. These people are strange cookies, and it is very likely you have met at least one- it is a fairly common disorder with an incidence of roughly 2%. BPD involves very unstable relationships, self-image, emotions and very impulsive behaviour. They are clingy and needy as they are constantly in fear of being abandoned. They alternately idolise and demonise people, often rapidly. They have little sense of who they are and think of themselves often as an empty void. They very often self-harm, threaten and attempt suicide - often as a response to their extreme anxiety. Their moods swing violently; they are often uncontrollably angry and sad. They do impulsive things, including self-destructive sexual relationships, gambling, spending. Under extreme circumstances they can become paranoid or even have anxiety related dissociation.

Cluster C

These are the anxious personality disorders. People who have always been a bit nervous. One can think of these disorders almost as the over-controlled, introverted counterparts to the Cluster B disorders.

Avoidant Personality Disorder

These people are inhibited, inadequate and over-sensitive to criticism and have poor self-esteem. In an attempt to avoid censure, rejection, embarrassment, they avoid social contact, relationships, any sort of risk. They believe themselves to be inferior, unappealling, inept, unloveable. They are shy.

Dependent Personality Disorder

Dependency in this case comes from a need to be taken care of, inability to make one's own decisions and fear of being left alone. There is difficulty making decisions without reassurance, advice; a need for others to take responsibility; inability to start things without others' support; neediness, passivity and submissive behaviour due to fear of rejection if they are assertive; fear of being alone and need for a constant relationship.

Obsessive-Compulsive Personality Disorder

OCPD is what the lay person may think of as an obsessive-compulsive person. Someone who is anally retentive, obsessed with organisation, perfection, lists, rules, work, productivity, morality. They are rigid, perfectionistic, can be miserly and sometimes even hoard things.

Passive-Aggressive Personality

This is sometimes included as part of Cluster C. Passive-aggressive people are unassertive and have difficulty expressing anger. As a result, they are resentful, sullen and express their anger through passive forms such as inviting criticism, performing poorly, being obstructive.

Not Otherwise Specified

Yes, they meet the criteria for a personality disorder but it does not fall neatly into a category, or is undefined by the above clusters. While people may fit easily into a personality disorder category, it is sometimes more useful to conceive of personalities as containing personality traits, cluster traits or similar.

What is Rape

Sexual assault (including rape as sub-category) is a common crime in Australia affecting 0.3-0.7% of the total population per year and affecting close to 20% of 18-24 year old women in the past 12 months(!) Only 15% of sexual assaults are reported to the police. Let us define rape. This is difficult as can be evidenced by a quick google search for definitions of rape. Let us go with the following for now:

"Rape is defined as forced, manipulated or coerced sexual intercourse (or other sexual act) against the will of the victim. If the act occurs while the victim is unconscious, asleep or otherwise unable to communicate unwillingness, it is still considered rape."

(As per Massacheusetts law)

What is Stalking

Stalking too is a common phenomenon, affecting some 23% of people throughout their lifetime, and with rates of 32% amongst people aged 18-35. There are various definitions of stalking in legal and academic literature. The nature of the behaviours and the intent are controversial areas- if the intent is romantic in nature, is it stalking? Similarly, if it is a seemingly innocent gesture but is repeated and done in such a way to cause (reasonable) fear, is it stalking? Consensus however is reached when it comes to the effect on the victim: it is necessary that the conduct causes the victim to fear for his/her safety. Thus I use the following definition:

"Stalking refers to a course of conduct by which one person repeatedly inflicts on another unwanted intrusions to such an extent that the recipient fears for his or her safety."

(Purcell, Pathé, Mullen 2004)

Who Rapes, Stalks- and Why?

Many models have been proposed for rape, stalking, sexual murder and sexual assault, striving to represent the diversity of motive and execution evident in the crime.

Summary of Convicted Rapists

Not all rapists (I must point out once again) are psychopathic- fully half are non-psychopathic. >95% of reported rapes have a male perpetrator. However female rapists are likely very underrepresented due to sociocultural factors and attitudes. It is also to be noted that rapists carry a recidivism rate (for all crimes) of roughly 50%- the highest rate for violent offenders; convicted paedophiles carry a rate of between 10-50% depending on study and subcategorisation, which includes both child rapists as well as those attracted to children.

Summary of Convicted Stalkers

Stalking has only recently entered the popular lexicon despite reports of stalking behaviours since at least the 1800s; it became a common term only some time in the 1980's, as a response to celebrity stalkers. This became more generalised to harrassment and predatory behaviour towards non-famous victims. In contrast with rape, the gender split with perpetrators is roughly 50/50. Once again, this difference may represent greater social acceptability for people to report female stalkers than female rapists. Various studies of stalkers have also shown that concurrent psychiatric problems (whether psychosis, mood disorder or personality related) were almost universal in this group.

The FBI Model of Violent Crime

The FBI have a model which divides rapists (and other violent criminals) into "organised" and "disorganised" subtypes. Organised being those who plan carefully, leave few traces of their crime, do not do random acts of "ultra-violence". Disorganised being those who display "chaotic" features (such as ultra-violence, lack of planning, messiness, etc.) The FBI model has very little evidence to back it and unsurprisingly is widely derided as simplistic, artificial, unreaistic and, well, incorrect.

More Modern Typologies of Rape, Stalking and Sexual Murder

The only reason for the multiplicity of categories in the diagram below is because of the overlap present in the typologies of rapists, sexual murderers and stalkers in the studies below. These studies took data from crime scenes, criminals and victims and came up with distinct behavioural and motivational clusters. (Click for larger version) However, when you compare the studies it would be more accurate to speak of roughly 6 subtypes as follows:

• 1a: Violent, aggressive types who are motivated by pure revenge against the victim. Thus, entirely violent, paranoid motivations, associated with paranoia as well as Cluster B* (antisocial, narcissistic, borderline, histrionic) personality traits.
• 1b: Violent, angry and power-obsessed types who are motivated because of (perceived) rejection by the victim. Thus, sex/intercourse is also a factor. Associated with Cluster B traits.
• 2a: Socially inept, intimacy seeking, incompetent types who do not know any other sure-fire method of procuring intimacy/intercourse and/or who rape because they feel socially inadequate and insecure. They are purely motivated by the desire for sex/intimacy and only use as much force is necessary to get what they want. Murder is an accidental sequel to this. Usually socially inept/of low IQ.
• 2b: Delusional, intimacy seeking types who believe that their victim is in love with them back. Associated with psychosis and schizophrenia.
• 3: Sadistic, fetishistic, predatory types who plan meticulously and whose motivation is complex violent sexual fetish- an extreme form of the combination of sex and violence. Very dangerous, unrepentant, skilled. Associated with psychopathy and extreme paraphilias.
• 4: "Other". This more nebulous group includes oppportunistic, inept, short term, unplanned acts of random violence, often associated with the commission of other crimes including robbery.

*Cluster B personality disorders include: antisocial (violence, disregard for others' rights, egocentrism, low empathy, includes the subgroup of psychopaths), narcissistic (egocentricity, inflated self-esteem, callous disregard for others), histrionic (attention-seeking, shallow but dramatic moods, egocentrism, overdramatic), borderline (unpredictable behaviour, low self-esteem, inner emptiness, clingy behaviour, mood swings, rapid change from idolisation to demonisation). This group of disorders has high overlap and there is a (possibly cultural) propensity for men to be diagnosed (or misdiagnosed) with APD or narcissism vs women and BPD or histrionicity. So you see, it is not as simple as "organised" vs "disorganised", "sane" vs "insane", or "rape as power". Rape has many many motivations including power, sex, revenge, delusion, opportunity. Similarly it is not just psychopaths who rape. Fully half of all rapes are committed by people who have other psychological problems, or even no identifiable psychological problem at all. The results of the rape are also varied. Someone who is motivated by an inept desire for intercourse may end up killing the victim. Someone motivated by psychopathic predatory thoughts may only stalk their victim and never proceed to rape or sexual murder.

MTC:R3 - Towards a More Complex Model of Rape

I did lie. There was some significance to the multiplicity of categories. (Click for larger version) The Massachusetts Treatment Center Rapist typology, Version 3 (Knight & Prentky, 1990) This taxonomy (think species) of rapists is more nuanced and based on a larger set of data. Rather than relying on 4-6 unrelated categorisation, it incorporates underlying psychopathology, motive and the level of violent and/or sexual motivation that is behind these rapes. There is, then, an interesting distinction that comes about which I shall illustrate below: (Click for larger version) I have recoloured the diagram so that the level of red represents sexualisation and the level of yellow represents violence. In non-psychopathic sexual offenders, violence and sexualisation are inversely correlated- they range from red to yellow with only a very muted orange in-between. However, in psychopathic sexual offenders, violence and sexualisation are positively correlated- they are only various shades of orange. Note that this is true only for psychopathic RAPISTS, not for ALL psychopaths. Thus, perhaps in that minority of psychopaths who rape, violence and sex are much of the same emotion. This is in fact reinforced by the finding that while the VRAG (violent risk appraisal guide) which includes the PCL:R (the most common scale for measuring psychopathy) is a reasonable predictor for psychopathic rape and recidivism, an adjusted scale known as the SORAG (sex offending risk appraisal guide) which includes physical measurement of sexual arousal to sexual deviance in fact correlates with this criminal behaviour much better. And here we reach perhaps the crux of what I used to not understand about this crime. How such a thing could be done.

How could someone do this?

Some people do not know how to have sex, so they force it out of someone to get their way; they do not know much better. Some people are particularly angry and want to hurt and humiliate someone in particular and they know the effect that rape has; it is not about sex, it is about power and violence. Some people are just so horny and angry at the same time, or so turned on by domination and humilation that they plot and plan and find a victim to lash out at and fulfil their fantasies. And. Some people do it because there's someone right there and they just can, very easily- maybe just ignore that they're saying no or that they passed out or that they're drunk or drugged or happened to be there, pretend that it was the heat of the moment and they were really asking for it and how could someone stop themselves in that situation. I mean, you understand don't you? It's not like [person] would've ever been in that position if they didn't really want it, and you know how [person] is such a tease and they put me in this position where I just couldn't help myself. What are you gonna do in that situation? Just stop? I guess my point is that many people are apologists for the opportunity rapist and the date rapist. In fact, there are many who argue that it is not rape or that in that situation maybe they would do the same thing, or that the victim is to blame for the assault. Look at the underlying thought process and see its real meaning though:

"I raped because I could"

It is an abnormal thought process. It is in fact a psychopathic thought process. It is not the product of the usual human mind. The "I could not stop myself" and the "she was asking for it" are merely excuses and justifications for the true reason- "because I could".

Discussion

I believe that it is facile and simplistic to conclude that distinguishing particular patterns of rape means that some rapes (as defined above) are not rapes or that rape is a lesser crime according to motivation or psychopathology. The effect on the victim of the rape is dependent on many factors including the psychology of the victim- we do not claim that it is not a rape if the victim recovers better from the psychological trauma, so why should we claim that it is not a rape if the motivation for the rape was X, Y or Z? Sentencing is yet another issue and an altogether unrelated one. Sentencing takes into account societal impact, likelihood of recidivism and other factors- it is not and should not be interpreted purely as a measure of morality. It is a means by which society maintains social control, order, attempts to reduce the likelihood of crime and segregates the potential recidivist from potential future victims. Some rapists, stalkers, sexual murderers are far more amenable to rehabilitation than others. Some rehabilitation exercises do reduce recidivism and some do not. These factors are very important to find because of the following statistics:

• 50% of rapists re-offend in some way
• 50% do not
• Nearly all stalkers who harrass their victims have an associated psychiatric diagnosis- which may vary from frank schizophrenia/psychosis to an embedded personality disorder.
• Non-psychopathic offenders respond well to rehabilitation and therapy- some reoffend anyway but in significantly lower numbers
• Psychopathy as a personality trait has shown very little promise for treatment and psychotherapies used for non-psychopathic offenders in fact increase or have no effect on recidivism rate- but early research suggests psychopathic offenders may show lower recidivism rates as a result of punishment/behaviour based regimens

Thus, as a heterogenous group of people it is important that society does more research and action into finding appropriate stategies for managing these complex crimes. There is some suggestion that the gradually increasing sentence and taboo against rape has in fact led to a far lower rate of conviction for offenders than previously- someone is far more likely to plead guilty to a 2 year sentence than a 10 year one. Perhaps we should champion a graded system for rape and sexual assault- the first offence being 2 years and psychiatric evaluation, treatment and rehabilitation. The 2nd offence, 5 years with treatment and close community monitoring, the 3rd 10 years with treatment and very intensive community monitoring. First time offenders would be more likely to admit to their crime and all would undergo measures to attempt to rehabilitate them. However the punishment would increase with each subsequent offence- and remember it is much easier to reconvict someone than to convict someone on a first time offence. Accordingly there should be close surveillance of this vulnerable group to lessen the risk of re-offending. With stalking, the psychiatric diagnosis is paramount; some stalkers are experiencing a frank psychotic episode and requite psychiatric hospitalisation and treatment. Others may be motivated by a personality disorder such as borderline personality or psychopathy. Depending on what this is, treatment and punishment should proceed accordingly.

Conclusion

Rape and stalking are common crimes affecting a large percentage of the population. They are also under-reported crimes. Thus it is highly likely if not definitely true that we all know someone who has been raped, stalked or both. Even if the number of perpetrators is low - this would imply a high re-offending rate, consistent with the data. Not only are these crimes common, but their incidence far outweighs the likelihood of a false report. False reports no doubt happen and it is very unfortunate and vindictive if they do so; however such events are very rare indeed and far more common is true rape, stalking and sexual assault. Rapists and stalkers both commit their crimes for a variety of reasons, sexual, violent or both. These reasons include desire for intimacy, revenge/retaliation, sexual fetishism and pure opportunity. Both rapists and stalkers have a high rate of recidivism and co-existing psychiatric diagnosis, whether it be psychotic, mood-related or personality disorder including psychopathy. They are a complex group of criminals with varying motivations and modes of activity but this makes their crimes no less wrong. Similarly, victims range from young women of reproductive age to babies to old women to old men to young men and anywhere in between. This variability indeed highlights the fact that no victim of rape or stalking is deservent of the crime but is in fact a "convenient object" for the commission of the crime. If it were not them, it would be someone else, so to speak. It is important that we recognise that these crimes do happen to people we know and are far more common than we realise. It is also very important not to blame the victim and to realise that most of the perpetrators are mentally ill individuals who require psychiatric treatment, rehabilitation and/or even segregation from the greater community.

House of God by Samuel Shem is full of many sorry truths of hospital medicine, of General Medicine in particular. One of those is the art of the "buff" and "turf". No-one wants extra work. It is an eternal rule of human nature (unless you are a workaholic such as myself and find work somehow interesting, exciting or, heaven forbid - fun). And it is true that being in hospital for too long is bad for patients. The "buff" is the polishing up of the patient so that they are as healthy as you can get them from your point of view. The "turf" is the act of sending them to another medical team, to rehab or home or to a nursing home. And you want to do this in such a way that they don't "bounce" - otherwise known as a failed discharge. On the whole this can be an effective system. Certainly it is the kind of system that everyone seems to like - administrators, consultants, registrars, residents and the patients themselves. Less work, less costs, less time in hospital- you can see the advantages right there. Sadly though this leads to the very predictable problem wherein no-one wants patients unless somehow the rules state they can't be discharged or turfed. Usually the "buff" is very incomplete at this stage. Because we are all just focussed on the turf. So we have some 75 year old patient with an uncomplicated heart attack being admitted under general medicine rather than cardiology because she has a urinary tract infection as well. Or no-one has bothered to check liver function tests and someone with ascending cholangitis ends up on general surgery instead of gastroenterology. Or neurosurgery takes a patient who "definitely has an acute disc prolapse" because overnight no-one wants to argue with the emergency registrar who wants to get patients out of a full emergency department and they turn out to have septic arthritis. It is well documented that admitting patients under the appropriate speciality unit leads to significantly improved outcomes - in particular coronary care units and acute stroke units are cited as examples. It leads to shorter hospital stay, lower complication rates and marked improvements in morbidity and mortality. This is relevant to both speciality and general units, I feel. Often general medicine is better for complex or geriatric patients because rehabilitation and multiple referrals are streamlined, while speciality units can be very focussed- and can miss multisystem disorders. Perhaps what will happen in the futures is that we will have speciality multisystem units- those dealing with "metabolic syndrome and smoking diseases", those dealing with disorders of immunity and infections and such-like. Either way, appropriate unit protocols can be a way of reducing fighting over rejecting patients. It certainly simplifies the process of admission. Another thing that must be done is reducing bed pressures and simplifying routine task management for junior doctors. It is high (and unnecessary) workloads and often very unfair bed concerns that mean the "buff" is not complete. And so they bounce.