Drug-facilitated sexual assault and chemical submission

 © Psychology, Society, & Education, 2017. Vol. 9(2), pp. 263-282 ISSN 2171-2085 (print) / ISSN 1989-709X (online) Doi 10.25115/psye.v9i2.701 Drug-Facilitated Sexual Assault and Chemical Submission Manuel Isorna Folgar1, Coromoto Souto Taboada1, Antonio Rial Boubeta2, Antonio Alías3 and Kieran McCartan4 1University of Vigo, Spain 2University of Santiago de Compostela, Spain 3University of Almería, Spain 4University of the West of England, United Kingdom (Received on March 2, 2017; Accepted on April 10, 2017) ABSTRACT: In recent years, the use of psychoactive substances for sexual assault has taken on a greater role. The practice of sexual crimes associated with drug use is called Drug-Facilitated Sexual Assault (DFSA), while ‘Chemical Submission’ (CS) is used to include all type of crimes related to this activity. This paper reviews the epidemiology of this type of offenses, the main characteristics of the chemical substances consumed and the profiles of victims and aggressors. There have been also addressed principal signs of clinical suspicion to detect possible victims and the keys to the toxicology screening in case the victim presents evidences of being subject to chemical submission. Key Words: Alcohol, drugs and sexuality, Chemical Submission, Drug-facilitated sexual assault, sexual offenses. Drogas facilitadoras del asalto sexual y Sumisión química RESUMEN: En los últimos años, el uso de sustancias psicoactivas relacionadas con las agresiones sexuales ha asumido un mayor protagonismo. La práctica de los delitos sexuales relacionados con el uso de drogas se denomina Drogas Facilitadoras del Asalto Sexual (DFSA por sus siglas en inglés), mientras que el término «Sumisión Química» (CS) se usa para incluir todo tipo de delitos relacionados con esta actividad. En este artículo se revisa la epidemiología de este tipo de asaltos, las características de las principales sustancias químicas consumidas, así como los perfiles de las víctimas y de los agresores. Asimismo, también se abordan los principales signos de sospecha clínica para detectar posibles víctimas así como las claves del examen toxicológico en caso de que la víctima presente síntomas de estar bajo el efecto de sustancias químicas. Palabras Clave: Alcohol, drogas y sexualidad, Sumisión Química, Drogas facilitadoras del asalto sexual, delitos sexuales. Correspondence: Manuel Isorna. Faculty of Education, University of Vigo. Email: [email protected] Drug-Facilitated Sexual Assault  ©Psy,Soc,&Educ,2017,Vol.9(2)  264 Substance use to dominate victim's will has been a recurrent practice throughout history, although it has been from the last decade of the twentieth century when an increase in the prevalence among crimes against sexual freedom and against property has appeared (Shbair, 2010). Drug taking is utilised in this type of practices with the aim of manipulating victims' will, what is known as Chemical Submission (CS). The term, first used by Poyen, Rodor, Jouve, Galland, Lots, and Jouglard (1982) refers to ‘the substance administration to a person without his/her knowledge to cause him/her a change in the alertness, state of consciousness and judgment’. Victim’s vulnerability is deliberately caused, making him/her be asleep or awake but under the control of the aggressor (Saint-Martin, Furet, O'Byrne, Bouyssy, Paintaud and Autret-Leca, 2006), to perpetrate a secondary damage as theft, signing documents and, principally, sexual assault. The frequency of the phenomenon and the lack of specific revisions make necessary an updating of the data related to the prevalence, aggressor and victim’s characteristics and profile, drugs most used and preventive measures to reduce the presence of these activities. METHOD It has been performed a bibliographical computerised research of articles published between 1990 and 2015. The information consulted was indexed into the electronic databases BVS-Psi, Cochrane Library, ERIC, ISOC and IME databases of the Spanish National Research Council (CSIC), Medline, Psicodoc, PsycInfo and Scopus to search for English and Spanish keywords of the field. Terminological exploration was focused on ‘alcohol, drugs and sexuality’, ‘chemical submission’, ‘covert drug administration’, ‘drink spiking’, ‘Drug-Facilitated Sexual Assault’, ‘DFSA’, ‘Risky Sexual Behaviour (RSB)’ and ‘recreational drugs’. The search has shown the need, highlighted in number of scientific studios and publications, of putting into practice an intervention on the field. HISTORICAL BACKGROUND In ancient times, drugs existed with a cultural and religious meaning associated with rites and ceremonies whose characteristics did not imply significant health damages. Human beings searched products to increase their sexual pleasure, resorting to various natural or synthetic substances, what have constituted an important aspect of the association between sexuality and drug use. According what González et al. (2005) and Dueñas (1999) have pointed out, drugs may influence sexual activity in different ways affecting desire, sexual arousal and orgasm. While most of them present clear consequences on users’ cognitive abilities increasing their sexual desire, as substances act as aphrodisiacs, some others reduce them. Nevertheless, the consumption of a substance that increases individual's libido does not always imply an improvement in the coitus or pleasure. Ignorance or underestimation of the health possible consequences is an element that prevails in those who use drugs for sexual satisfaction, being proved that effects of drugs on female and male sexuality are highly dangerous due to the Drug-Facilitated Sexual Assault ©Psy,Soc,&Educ,2017,Vol.9(2)  265 possibility of causing irreversible and regrettable injuries for their users (Peugh and Belenko 2001; González et al., 2005). Relationship between sex and drugs has been documented for hundreds of years (Martin, 2001). Love potions were used as sexual aid in ancient, classic and contemporary texts principally when men pursued a woman (Bellis and Hughes, 2004), while the administration of opiates, magic mushrooms or other vegetable products without victim's knowledge has been practised in initiation rites of religious sects or tribes (Cruz-Landeira, Quintela and LópezRivadulla, 2008). Actually, those potions were often plants or other substances with psychoactive properties, usually provided without the individuals’ knowledge, whose aim consisted in exciting or disorienting the person. The historical relationship in both genders between alcohol and sexual desinhibition is very well known (Bellis and Hughes, 2004; Martin, 2001), as well as the habit of encouraging someone to drink alcohol to increase probabilities of having sexual activity. At present, there are more substances potentially available than in any other time that can modify, directly or indirectly, the effects on sexual behaviour. Likewise, access to drugs is relatively easy at these times and their effects begin to be widely known especially due to the information posted on the Internet and offered by the Grow & Smart shops, which also provide seeds and guidelines for cultivating some of them. Currently, Drug-Facilitated Sexual Assault (DFSA), as a special form of CS, has a great healthsocial relevance due to its extensive relation with sexual victimisation. DFSA are substances provided to an individual without his/her consent or pressuring the person to consume more quantity than he/she had planned to leave him/her in a semiconscious state, and therefore, unable resist a sexual assault. Despite the fact that alcohol is presenting as the main DFSA (Butler and Welch, 2009), it is not the only one; cocaine, ketamine, methamphetamine, GHB, benzodiazepines and some intoxicative inhalants are also used (Slaughter, 2000). In the same way, there have been men who looked for sex or services of prostitutes reporting robberies (Lusthof, Lameijer and Zweipfenning, 2000; Trullàs, Nogué, Miró and Munné, 2003). DRUG-FACILITATED SEXUAL ASSAULT AND CHEMICAL SUBMISSION EPIDEMIOLOGY Several studies (Juhascik et al., 2007; Saint-Martin, Bouyssy, O'Byrne, 2007; Elliott, 2008) suggest that it is virtually impossible to know the real number of DFSA cases that occur, due to the difficulties of victims to remember what happened and the problems to detect substances in their body because of the short stay on it. In France, a study conducted in Paris by Cheze, Duffort, Deveaux and Pepin (2005) from June 2003 to May 2004, registered 128 CS suspected cases, being analytically confirmed 23 of them, 18%. Zolpidem and clonazepam were the substances most frequently identified, followed by bromazepam, nordazepam and midazolam. Rarely, other benzodiazepines and analogues were detected, and in about 50% of cases it was confirmed a victim's previous consumption of narcotics, drugs or illicit drugs. Drug-Facilitated Sexual Assault  ©Psy,Soc,&Educ,2017,Vol.9(2)  266 As recorded in the study conducted in Canada between 1993 and 2002 by McGregor, Ericksen, Ronald, Janssen, Van and Vliet and Schulzer (2004), from the total of 1,594 cases reported as sexual assaults, 246 (15.4%) were classified as CS cases. The 95% of victims were women and the age group between 15 and 19 was the one that presented the highest risk of becoming victims. According to the authors, women under 20 are particularly vulnerable to this form of sexual assault, what makes necessary the creation of specific prevention programs targeting to this population group. The study also revealed a gradual increase in the diagnosed cases since 1999, due to: a) The increase of information that victims can access because of the spread of the subject in the media. b) The increase of the training of the health personnel, who used to diagnose as common assault CS cases. c) The increase in the information that aggressors can obtain from Internet and the availability to access to drugs on the net. In Australia during the period 2003-2004, CS cases were the 17.5% of the total number of sexual assault cases (Hurley, Parker and Wells, 2006). Victims were women in 95% of the cases and 77% of them admitted a voluntary consumption of alcohol (71% had consumed up to four units of standard drinks). Up to 46% of the victims recognised a voluntary consumption of psychoactive drugs, as benzodiazepines or antidepressants, and up to 25% admitted a recreational drug use. These data show, according to the authors, the infrequency of CS cases derived from an involuntary exposure to a chemical substance and the risk associated with the voluntary consumption of alcohol and drugs. In the United Kingdom, Kershaw et al. (2001) evidenced that only 18% of victims of DFSA sexual assaults report the criminal action to the police, what necessarily implies the noninvestigation of the conduct in four out of five cases. This fact can have its origin in the lack of victimisation awareness of the attacked person who, in the 30% of the cases, does not consider that he/she has been victim of the commission of an illicit act. Furthermore, the number of rape incidents reported in a date in the charitable association The Roofie Foundation increased from 39 in 1990 to 935 in 2002, being reported to the police only one in eight cases (Beynon, McVeigh, McVeigh, Leavey and Bellis, 2008). Epidemiological studies from other countries indicate that up to 17% of sexual assault cases could be classified as CS cases by involuntary exposure of the victim to a psychoactive substance, although a high percentage of victims admit a voluntary previous consumption of a substance (Cruz-Landeira et al., 2008). In Norway a retrospective and descriptive study conducted by Hagemann et al. (2013) between 2003-2010 evidenced that 22% out of 264 cases of sexual assault that assisted at the Sexual Assault Center of the St. Olavs University Hospital in Trondheim were suspected of being proactive DFSA, although only five had findings of sedative drugs that were not accounted for by self-reported voluntary intake. Victim’s profile was a young Western woman with an average age of 21 years old who in 22 occasions tested negative, 22 tested positive for ethanol only, while 13 tested positive for at least one drug other than ethanol. Drug-Facilitated Sexual Assault ©Psy,Soc,&Educ,2017,Vol.9(2)  267 In Spain it has been found a very little data in the field, possibly because it has had very little research on it, although currently it is being increased. Even though, the recorded data related with the prevalence of such criminal practices in the country shows that one out of three cases of sexual assault has its origin in the chemical submission (Navarro Escayola et al., 2013). The department of Seville of the National Institute of Toxicology and Forensic Sciences conducted one of the studies in this area in the period 2010-2012. When health personnel suspected of a possible CS case, a toxicological research was made to reveal the presence of alcohol or other psychoactive substances as well as the presence of semen. As conclusion of the obtained results, it was proved that more than half of the 73 studied cases presented negative results and only three of the summaries could be classified as clear cases of CS, because of the information from the victim, the facts and the results collected. The Instituto de Medicina Legal of Alicante conducted a similar study, also retrospective and descriptive, in the period 2009-2012, where out of 179 cases of sexual assault detected, 19 of them had a high probability of being a possible DFSA case (10.6%). Almost all of the victims were female (95%), aged between 14-37 years old, and in most of the cases, the aggressor was a person (74%) who was an acquaintance (47%) of the victim. Most of the victims (68%) admitted a previous voluntary alcohol consumption, pure or in combination with other psychoactive substances where cannabis and cocaine appeared more frequently. In the 47% of the cases there have been detected psychoactive substances that the victim had not voluntarily consumed and in 21% of them was found more than one substance According to Escayola and Vega (2013), drugs detected in an average time of 18.26 hours between the sexual assault and the sampling corresponded to cocaine (26.3%), cannabinoids (15.8%), benzodiazepines (15.8%), alcohol (10.5%) and amphetamines (5.3%). García-Caballero, Cruz-Landeira and Quintela (2014) conducted another descriptive and retrospective study in Spain related to cases of sexual assault associated with the consumption of chemical substances. The results of the study, based on the cases reported to the department of Madrid of the National Institute of Toxicology and Forensic Sciences during the years 2010, 2011 and 2012 found that, from the 306 cases of sexual assault or abuse submitted, 107 of them (34.96%) presented criteria to be included as CS cases. Victim's profile was a young Spanish or Latin American woman with an average age of 25.9 years old, who admitted an alcohol consumption previously to the assault, and who suffers from a total or partial amnesia of the events. The toxicological analysis identified ethanol (61.7%), drugs (40.2%, mainly benzodiazepines) and illicit drugs (27.1%, mainly cocaine), alone or in combination. Likewise, the data described by García-Caballero does not substantially differ from which Xifró et al. (2015) made in Barcelona where, from the 114-suspected cases of chemical submission, 30.7% were positive. However, it was evidenced a change in the profile of the victim corresponding in the 65.7% of the cases with foreign women whose origin in 56.5% was Western European or North American. Nevertheless, it should be noted that while the majority of attacks are carried out in urban areas and during the weekend (EMCDDA, 2008), belonging to communities with a high population index is not directly related with a higher probability of becoming in a DFAS victim. Data from Drug-Facilitated Sexual Assault  ©Psy,Soc,&Educ,2017,Vol.9(2)  268 the department of Madrid of the National Institute of Toxicology and Forensic Sciences evidenced that only 25.2% of the CS victims lived in the Autonomous Region of Madrid (whose population is 6.5M inhabitants), while the Basque Country and Galicia (with a population of 2.2M and 2.7M citizens), registered DFAS percentages of 20.6% and 15.0% respectively (García-Caballero, 2014). In the same way, it is important to note the nonexclusivity of women as the only sex victimised by chemical submission. Consequently, even sharing the main substances used to be victimised in both genders, alcohol and benzodiazepines, the objective pursued in each one is different. As a result, while women are intoxicated to be become in victims of sexual crimes, in the case of men they are drugged to be become in victims of crimes against the property (Bertomeu-Ruiz, 2013). In a study of 1,179 registered cases conducted in USA, it was detected a high prevalence of alcohol positive cases, followed by cannabinoids, benzodiazepines, amphetamines and gammahydroxybutyrate (GHB). In a high percentage of cases, the victim had voluntarily consumed some substance and the offender, often an acquaintance of him/her, had taken advantage of this situation of weakness (ElSohly and Salamone, 1999). In the United States, California has become into the first state to require students living in campus of the local universities to obtain a clear consent before having sex. The SB-967 law known as 'Yes means Yes' and signed by the California Governor Jerry Brown, defines consent to have sex as a voluntary agreement and not as a lack of resistance. The law states it must take place an 'affirmative, conscious, and voluntary agreement' to engage in sexual activity that 'can be revoked at any time', where the affirmative consent can be indicated by a verbal or non verbal 'yes'. By law, a drunk, drugged, unconscious or asleep person may not have agreed to maintain sexual relations. It also states that consent can be transmitted by a 'yes' indicated verbally or non verbally, but the lack of resistance or protest cannot be taken as consent. The law requires universities that receive funds or assistance from the state to adopt the new law and to inform students about the difference between consensual sexual relations and sexual assault. It also notes 'silence or lack of resistance does not constitute consent', and specifies that a defendant cannot plead that he/she had assumed that the victim had given the consent when he/she was drunk, drugged, unconscious or asleep. In some countries, such as New Zealand, rape with drugs is also considered when someone supplied substances to the victim and takes advantage of his/her semiconscious state to commit sexual acts (Jansen, 2004; New Zealand Herald, 2003). However, although most of the attention has focused on the use of illegal drugs in many countries, it is certain that the most detected substance in those cases of rape with drugs is alcohol (ElSohly and Salamone, 1999). Drug-Facilitated Sexual Assault ©Psy,Soc,&Educ,2017,Vol.9(2)  269 DRUGS, SEX AND GO PARTYING: A RECIPROCAL RELATION Go partying on weekends has a direct relationship for both men and women with sex and drugs. A lot of the scenarios, clubs or areas where people go out possess an aesthetic and cultural significance aimed at encouraging dates, interrelations and sex (Gilbert and Pearson, 2003; Calafat, Juan, Becoña, Mantecón and Ramón, 2009). Undoubtedly, it is in the night-time fun context when most of the weekly consumption is produced, being common in this environment the polydrug (Observatorio Español sobre Drogas, 2013) which is linked to an increase on the number of sexual relations (Calafat et al., 2009). This use of substances is positively valued by young people as they consider them as facilitator instruments for sexual relations (Sumnall, Beynon, Conchie, Riley and Cole, 2007); in fact, in both genders opinion, alcohol in a party is fundamental to create the right atmosphere (Østergaard, 2007). In many cases, drug consumption is associated with the search of different effects in a sexual relation. Regarding this aspect, the most positive valued substance is alcohol, because of its ability to facilitate intercourse, involvement in risky experiences and the increase of the arousal; while the second one for young people is cocaine as it increases the duration of the sexual relation (Calafat, Juan, Becoña and Mantecón, 2008). There is a great variety of publications that analyse possible relation between the development of risky sexual behaviours and the consumption of a substance (Lau, Tsui and Lam, 2007; Roberts and Kennedy, 2006; Antón-Ruiz and Espada, 2009). Different studies as the conducted by So, Wong and De Leon (2005) found that 23.8% of young people had consumed alcohol before sex at some time in their life, and 6% of the total consumed the substance at the time of the study. They also found that the 4.4% of the people who consumed other drugs before the sexual activity and the 1.2% of who were using substances at that time evidencing, because of the study, significant relations between the development of risky sexual behaviours and the use of alcohol and other drugs. Likewise, Calafat et al. (2009) shown that a great number of people (76.6%) had had sexual relations under the alcohol effects at least on one occasion, and 55.2% under the influence of illicit drugs. In a more recent study of Calafat et al. (2013) with 700 young people, mainly from Germany and The United Kingdom who spend their holidays in the touristic areas of the Mediterranean coast, found that the 1.5% of the survey group reported having had sex against their will during this period. The sexual activity had been committed through physical force, duress or under the influence of alcohol or other drugs, finding no differences between men and women; that is, women were no more likely to have had sex against their will than heterosexual men. However, homosexual or bisexual men had even seven times more probabilities than men or women of any heterosexual sexuality of having sex against their will. The report suggests that it is possible that tourist drunk women can be seen as easy targets for both male tourists and local people of the area. Drug-Facilitated Sexual Assault  ©Psy,Soc,&Educ,2017,Vol.9(2)  270 In an intrasubject research Isorna, Fariña, Sierra and Vallejo-Medina (2015) show how under the influence of alcohol and other drugs almost all of the subjects present a significant change towards to a more favourable attitude to the use of DFSA and to the practise of risky sexual behaviours, being the results equally positive for both men and women. While other studies have found significant differences between the development of risky behaviours and alcohol consumption before sexual activity, there are no significant connections in the case of the use of other drugs (Messiah, Bloch and Blin, 1998). Hingson et al. (2009) and Miller et al. (2007), agree that getting drunk is associated with several negative health behaviours. Going on a car driven by a drunk driver, car accidents, fights, smoking, risky sexual relations and the use of other drugs that individuals had no a prior intention of consuming are actions that increase the individual’s level of intoxication and reduce his/her psycho-physical abilities. There are other practices related to sexuality that also indicate risky behaviours. In this aspect, the study conducted by Calafat et al. (2009), emphasises that a 7.3% of people had paid for sex, with significant differences between men (14.3%) and women (0.9%), or had been paid for practising sex, again with significant differences between genders (6.7% men, 0.4% women). However, there are no differences between males and females in having done a STD test (14.3% of the sample) or having exchanged sex for drugs (2.5%), whereas the study highlights the fact that younger people had been paid for having sexual activity more commonly than the elder ones. By contrast, other studies argue that alcohol and other drugs are not the direct cause of later risky sexual behaviours (Taylor, Fulop and Green, 1999). Generally, young people know and understand alcohol or drug effects on their sexual behaviour and, despite of this fact, they keep consuming them; however, for an increasing minority of people, the consumption of substances that alter their sexual behaviour is not a choice. Drugs are being used, secretly and in a growing way, to leave victims in a semiconscious state and unable to resist a sexual attack. The victim, commonly a young woman, declares being in a party, in a working dinner or in a friend's/acquaintance’s house when she loses the consciousness after taking a drink. When the person recovers consciousness hours later he/she is confused, does not remember what happened during this time period and has the feeling of having had sexual relations with someone. The aggressor is a man and, in a high percentage of the cases, an acquaintance of the victim. Detection of sexual assaults related with chemical submission becomes commonly difficult because of number of factors as the delay in searching for help from the victim, what facilitates the removal of the substance from the body, the low doses employed by the perpetrator and the confusion of the clinical situation with a voluntary alcohol poisoning (Cruz-Landeira et al., 2008). As amnesia is often a side effect of some of the drugs used for raping in a date, most of the victims never report criminal actions to the police (EMCDDA, 2002, 2003; Schwartz, Milteer and LeBeau, 2000) being difficult, as a result, evaluate the real impact of the DFSA (Saint-Martin et al., 2007; Elliott, 2008). Nevertheless, it is important to point that the reported Drug-Facilitated Sexual Assault ©Psy,Soc,&Educ,2017,Vol.9(2)  271 cases are often related with the illicit administration of substances such as rophynol and other benzodiazepines, GHB and ketamine, mixed with drinks in the meeting places (Schwartz et al., 2000). Studies evidenced that a significant percentage of the analysed young people had experienced risky practices during last year, being drugs significantly present. There are no significant differences between men and women in using condoms or taking measures for birth control, although there is some divergence in practising sex under the influence of alcohol and illicit drugs, where males present higher rates of practices than females (Calafat et al., 2009). DRUGS USED AS FACILITATED OF SEXUAL ASSAULT As Cruz-Landeira et al., (2008) and García-Repetto and Luisa-Soria (2011) have proved, substances regularly used to commit sexual assault present a series of characteristics that make them suitable for the intended purpose of the aggressor: - They are easy to obtain: among them, ethanol, some psychotropic drugs and the illicit substances are the most commonly used. The most common means of acquisition for the substances, and necessary for the preparation techniques, are Internet and the Smart & Grow Shops (Dumestre-Toulet and Verstraete, 1998). - They have to be able to be activated at low doses to go unnoticed. - They are short and fast-acting substances to facilitate control over the victim, to avoid his/her suspicion, and to prevent the changing circumstances can frustrate the aggressor’s goals. - They produce confused symptoms, which can induce health personnel to a confusion between victim's symptomatology and an alcoholic intoxication or an organic upset, causing a delay in the clinical diagnosis while the substance is being eliminated from the body. - The administration to the victim has to be discreet, usually orally, and added to alcoholic beverages, which are the ideal vehicle to mask the taste and colour while enhancing the effects. - Substances have to be difficult to detect by the victim, with no taste, odour or colour that can show their presence. - Usually, they produce disinhibition, which is an advantage for the offender during the sexual assault because the victim can accept situations considered as intolerable for him/her in a normal state of consciousness. Finally, as reflected by Gaulier, Fonteau, Jouanel and Lachâtre (2004), substances have to produce the desired effects by the aggressor to have the victim under his control: - Anterograde amnesia which possesses a very positive effect for the aggressor, due to it limits the information provided by the victim, the testimony, as well as it delays, hindering early biological sampling, or even sometimes impedes, the criminal accusation, especially when the amnesia is associated with a guilty or shameful feeling. This fact was evidenced in the Spanish study conducted by Xifró et al. (2015) where almost 90% of the victims showed anterograde amnesia, and two out of three, anterograde amnesia related with the sexual assault. Drug-Facilitated Sexual Assault  ©Psy,Soc,&Educ,2017,Vol.9(2)  278 Studies as the conducted by McGregor, Ericksen, Ronald, Janssen, Van Vliet, Schulzer (2004) and Elliott (2008) reflect the need to work on prevention and information with potential victims, such as women under 20, who are particularly vulnerable to this form of sexual assault. Because of this, it is fundamental to create specific prevention programs targeting this population group and also to train health personnel, due to an appropriate and early sampling is a key factor in confirming the diagnosis. It cannot be forgotten that 100% of cases of sexual violence, and at least 2/3 of the remaining ones, present considerable emotional reactions, especially fear, depression and anger that lead victims to present significant changes in their lifestyles (Shapland, 1990). 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