LAUSR

Coming from a region where rates of gender-based violence are high and public discourse on adolescent sexual assault limited, the study Medium-term health and social outcomes in adolescents following sexual assault: a prospective mixed-methods cohort study by Clark and colleagues holds deep personal relevance for us. This quantitative and qualitative cohort study of adolescents who have experienced sexual assault offers valuable, nuanced and sensitive insights into their mental health, physical health and social outcomes 13 to 15 months post-trauma. Our comments intend to add to and reflect upon points raised in the study and are trifocal—the location of rape (and sexual assault) in mental health discourse, the bidirectional relationship and reflexive nature of deprivation and trauma in early life, and the diversity of social systems an adolescent engages with (and their functioning within these systems after sexual assault, by extension). In adolescents, as in this study, the neurobiological basis of the trauma response to sexual assault involves amygdalar activation and encoding, with impaired prefrontal lobe functioning; and associated involvement of the hypothalamic–pituitary–adrenergic axis, with adrenergic response in the acute phase and upregulation of serum cortisol levels in the chronic phase [1]. Of theories on trauma informed psychotherapy, Herman described three stages of recovery with central tasks of establishment of safety, remembrance and mourning; and reconnection with ordinary life, in each [2]. Sexual assault occurs as the adolescent’s brain undergoes synaptic pruning and completion of frontal myelination [3]. Synchronously, the young person also undergoes socialization and consolidation of personality with establishment of autonomy and identity (identity versus role confusion as in Eriksonian psychosocial development) [3]. That sexual assault in the adolescent would incur deep and lasting consequences on their physical and mental health, and impact upon social functioning, particularly against a background of socio-economic deprivation and previous adverse early childhood experiences is clear and unambiguous. The authors demonstrate interventions for sexual assault (as well offered by the Havens) can mitigate the impact in adolescents. However, as they indicate, the risk for physical and mental illnesses, and impaired social outcomes in the form of revictimization, homelessness, and impaired educational and occupational functioning remains high. As in other studies, external stigma and internalized shame, as well as the subjective meaning of sexual assault, often mediate the relationship between assault and prospective health/functioning [4, 5]. There is also the nature of trauma to be considered. Trauma and recovery are solitary experiences for adolescents, leaving them to handle deeply personal consequences of a crime that is (dis)social in nature. Interventions for trauma, despite being survivor-led, well-designed and evidence-based shift focus from the inter-personal nature of the assault to its intra-psychic recovery. Qualitative studies describe the sense of unfairness persons who have experienced sexual assault experience, of the responsibility of the crime being the perpetrator’s while the responsibility of the healing is that of the survivor [6]. The 29% participation rate This commentary refers to the article available at https:// doi. org/ 10. 1007/ s0012702102127-4.