Rape Trauma Experts in The Courtroom

Psychology, Public Policy, and Law Copyright 1998 by the American Psychological Association, Inc.
1998, Vol. 4, No. 1/2, 414-432 1076-8971/98/S3.00
RAPE TRAUMA EXPERTS IN THE COURTROOM
Laura E. Boeschen, Bruce D. Sales, and Mary P. Koss

University of Arizona
This article analyzes the scientific legitimacy of using expert testimony relating to
psychological sequelae of rape victimization in the courtroom and attempts to
determine boundaries within which such testimony should remain to respect the
limitations of current knowledge. Descriptions of the rape-related diagnoses
currently used in expert testimony are followed by a discussion of the problematic
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
issues associated with using rape trauma syndrome in the courtroom and a review of
This document is copyrighted by the American Psychological Association or one of its allied publishers.
the validity and reliability issues associated with diagnosing posttraumatic stress
disorder in forensic settings. The authors consider the scientific appropriateness of
admitting different levels of rape expert testimony on the basis of the limitations of
the scientific knowledge discussed.
It is impossible to consider sexual offending without focusing on both the

perpetrator and the victim. For example, in criminal prosecutions against alleged
rapists, the veracity of the victim's allegations is often on trial at the same time as
the defendant's culpability. In civil litigation, where the victim is the plaintiff
against the alleged offender, the defendant may focus a substantial part of the
defense on the plaintiffs veracity and credibility. In focusing on the alleged victim,
clinical testimony is increasingly being used to confirm the allegation of rape or to
help establish the extent of damages appropriate in a civil tort action.
This focus on the victim is not surprising because U.S. society has a long
history of holding persistent and harmful myths about rape and those who are
victimized by it. Historically, the societal stereotype of the "good" woman was a
chaste and virtuous woman who would do everything in her power to resist being
raped (including die) and would never hesitate to immediately report the incident
(Torrey, 1995). This stereotype has also led to the myth that only certain women
could be raped: Only chaste women are raped, whereas women with a "history"
must have asked for it or done something to encourage it. And, until fairly recently,
a married woman could never have been raped by her husband (Torrey, 1995).
These stereotypes and myths have led to a society that typically shifts its
critical focus from the rapist to the victim. Women who claim rape are viewed with
some degree of skepticism. Challenges to rape victims' credibility have been
common in the courtroom and community, even though very little empirical
evidence suggests that victims frequently make false accusations. One study that
did report a high false rape allegation rate was based on a procedure that required
each woman to submit to a polygraph test (Kanin, 1994). The literature suggests
that polygraph tests are not only inconclusive, especially for rape victims who
often experience high levels of fear and anxiety following an assault, but are also
Laura E. Bueschen and Bruce D. Sales, Department of Psychology, University of Arizona; Mary
P. Koss, Arizona Prevention Center, Arizona Health Sciences Center, University of Arizona.
We thank Toni Massaro for her helpful comments on a draft of this article.
Correspondence concerning this article should be addressed to Mary P. Koss, Arizona
Prevention Center, University of Arizona, 2223 East Speedway Boulevard, Tucson, Arizona 85719.
Electronic mail may be sent to mpk@u.arizona.edu.
414
RAPE TRAUMA EXPERTS 415
mentally distressing and unwarranted (Sloan, 1995). Thus, it is not surprising that
41% of the women in this study recanted their rape allegations upon confrontation
with such a test, even though it is unclear whether these women falsely recanted
true allegations in an effort to escape a distressing and distrusting situation. Other
studies that did not use such methodology have found that only 2-4% of victims
falsely allege that rape has occurred, which is the same estimate of false allegations
for other crimes (Katz & Mazur, 1979). Courts have also acknowledged that
victims rarely file false reports and that there are powerful disincentives to
reporting a rape (Fischer, 1989). Indeed, studies show that only 16% of rape
victims report to the police (Kilpatrick, Seymour, & Edmonds, 1992), establishing
rape as one of the most underreported crimes in the United States (Koss et al.,
1994).
Why is it then that rape is so hard to prosecute and people find it so hard to
believe a rape survivor? To start, our courts have a history of placing the rape
survivor more on trial than the alleged perpetrator. Common law not only required
that women had independent evidence corroborating their story, but the victim also
had to prove that she had done everything within her power to resist. (Torrey,
1995). Until very recently, the victim's background and behavior were also under
intense scrutiny, as the victim's sexual history was permissible testimony (Torrey,
1995). Rape shield laws were passed in the 1970s and 1980s in an attempt to
protect survivors from some of these practices. These laws limited cross-
examination of victims' sexual histories, redefined rape in a way that made it
gender neutral and focused it on the actions of perpetrator (e.g., rape is the act of
sexual penetration by use or threat of force), redefined consent (e.g., so that it does
not include the defendant only having thought that the victim consented), and
eased or eliminated proof of resistance by the victim (Fischer, 1989). Although
they were important steps, these laws have unfortunately made little difference in
the rates of arrests, prosecutions, and conviction of rapists (Torrey, 1995). The
statistics show that much more needs to be done (e.g., Goldberg-Ambrose, 1992;
Homey & Spohn, 1991). As one commentator remarked, laws are easier to change
than prejudices (Gaines, 1997).
As an additional means of combating prevalent rape myths in an effort to more
successfully prosecute rape cases, many prosecutors now look to expert testimony
on rape trauma syndrome (RTS) and posttraumatic stress disorder (PTSD).
Although experts can provide important information when testifying, unsubstanti-
ated, nonscientific testimony on PTSD and especially RTS can harm not only
victims and alleged offenders, but also the field of psychology as a whole. If the
field of psychology is to be acknowledged as scientific, then psychologists must
operate within the limitations of the empirical research.
Several law and psychology review papers have addressed the use of expert
testimony in rape cases (e.g., Fischer, 1989; Frazier & Borgida, 1992; Gaines,
1997; Stefan, 1994; Torrey, 1995). Although some of the older reviews included
discussions of relevant psychological literature, they focused more on RTS than on
PTSD as it is currently conceptualized and studied. Frazier & Borgida (1992), for
example, provided a thorough review of not only the admissibility of RTS
evidence, but also the psychological research that they considered relevant to the
"scientific reliability, helpfulness, and prejudicial impact of RTS evidence."
Fischer's (1989) review provided a thoughtful summary of how the evidentiary
416 BOESCHEN, SALES, AND KOSS
principles of expert testimony have been applied to RTS testimony and cataloged
court decisions on the basis of the types of expert testimony presented at trial.
However, she, too, primarily analyzed the appropriateness of expert testimony in
regard to RTS and did not address the more recent uses of PTSD evidence. The
more recent articles (e.g., Gaines, 1997; Stefan, 1994; Torrey, 1995) have been law
reviews that focused on case law, at most only mentioning the relevant
psychological research that pertains to the validity and reliability of the PTSD
diagnosis. Therefore, these articles stop short of addressing the scientific validity
of using this diagnosis within the context of expert testimony on rape.
Thus, the purpose of this article is to analyze the scientific legitimacy of using
rape expert testimony and to determine boundaries within which such testimony
should remain to respect the limitations of current knowledge. Because the

scientific literature is different for juvenile and adult victims, we do not combine
both in this article. We focus only on the latter. In addition, rather than focusing the
analysis primarily on questions of law and RTS-related evidence, as Fischer (1989)
did, this review emphasizes the most recent evidence of the reliability and validity
of the PTSD diagnosis as it pertains to rape trauma testimony. The next section of
the article provides a brief description of the rape-related diagnoses currently used
in expert testimony (RTS, PTSD, and acute stress disorder [ASD]) and highlights
the problematic issues associated with the use of RTS in the courtroom in an effort
to demonstrate that it is an outdated, confusing construct inappropriate for forensic
settings. The next section reviews the literature on the PTSD diagnosis, assessing
the validity and reliability issues of PTSD that are most relevant to forensic
settings. The final portion presents a categorical system (similar to Fischer, 1989)
of levels of expert testimony commonly presented in rape cases and considers the
scientific appropriateness of presenting each type of testimony, given current
knowledge on PTSD.
RTS, PTSD, and ASD

RTS
RTS has come to refer to three different types of empirical literature: the
original RTS developed in the 1970s, the more recent and empirically strong
studies of reactions to rape, and the diagnosis of PTSD by the Diagnostic
Statistical Manual of Mental Disorders (4th ed.; DSM-IV', American Psychiatric
Association, 1994) of which RTS is often considered a subset (Frazier & Borgida,
1992). These multiple connotations become confusing and problematic in the
courtroom because judges, attorneys, and even some experts often presume that
"RTS" is a reference only to the original construct and literature developed by
Burgess and Holmstrom (1974), when an expert may be commenting on "RTS" in
the context of the more recent and empirically sound studies of common reactions
to rape, including studies of PTSD. A brief description of each of these sets of
literature will be provided below to help clarify their differences in development,
purpose, and utility.
The original RTS was introduced by pioneering researchers Ann Burgess and
Lynda Holmstrom in the early 1970s as a two-phase description of the commonly
shared experiences of the rape survivors seen in the emergency room. Their model
consists of an "acute" stage of extreme fear and other emotional, physical, and
psychological symptoms experienced immediately after a rape, and a second,
"reorganizational" phase of the more moderate and varied symptoms that appear
in the course of recovery (Burgess & Holmstrom, 1974). This syndrome, which
was defined to aid in the therapeutic process, was soon after used in the courts by
expert witnesses to educate jurors about common reactions to rape (Massaro,
1985). The original RTS, however, has proven to be problematic in the courtroom
for several reasons. First, the term RTS is not found in the DSM-IV (1994), nor in
any previous editions. RTS is therefore an inappropriate term for the courtroom, as
mental health workers should be restricting their testimonial comments to those
constructs and terms with widely accepted meaning among mental health
professionals. Furthermore, the original RTS was based on limited empirical work,
and the more recent studies have not found support for Burgess's and Holmstrom's
conceptualization of general stages of recovery (Frazier & Borgida, 1992).

Although the original syndrome does not provide rape experts a solid
foundation on which to base their testimony, the work of Burgess and Holmstrom
acted as a historical catalyst that motivated other trauma researchers to conduct
controlled empirical studies on the psychological reactions to rape using control
groups, larger sample sizes, long-term assessments, and objective assessment
measures (Frazier & Borgida, 1985). These empirical studies confirmed many of
Burgess's and Holmstrom's observations, including findings that rape survivors
experience more depression, anxiety, fear, and social and sexual problems than do
other women (see Ellis, 1983; Resick, 1993; Steketee & Foa, 1987 for reviews of
these early studies).
PTSD
PTSD, rather than RTS, is now more commonly measured in the aftermath of
rape because PTSD is the primary trauma-related diagnosis included in the
DSM-IV. To qualify for a PTSD diagnosis, a person must satisfy six criteria.
Criterion A requires that the person "experienced, witnessed, or was confronted
with an event or events that involved actual or threatened death or serious injury, or
a threat to the physical integrity of self or others," and had a response that
"involved intense fear, helplessness, or horror" (DSM-IV, 1994, p. 427). To meet
the B, C, and D symptom criteria, a person must qualify for at least one Criterion B
reexperiencing symptom of the event (e.g., have recurrent and intrusive distressing
recollections or dreams), three Criterion C avoidance symptoms (e.g., avoid
stimuli associated with the trauma), and two Criterion D increased arousal
symptoms (e.g., experience difficulty in falling asleep or concentrating). Criterion
E requires that symptoms occur at a clinically significant level, and Criterion F
requires that the person experience the symptoms for at least a month.
Although PTSD was originally constructed to address the psychological
trauma of veterans returning from the Vietnam War (Peebles, 1989), it was soon
recognized that the diagnosis had broad applications to trauma, making PTSD a
common diagnosis for rape survivors. In fact, there are now more rape survivors
classified as suffering from PTSD than any other trauma group (Morris, 1992). This
movement to incorporate all traumas under the diagnosis of PTSD has potential
benefits for rape survivors in the forensic setting. Although it has yet to be tested
empirically, it is widely believed that rape survivors gain more credibility in the
courtroom when they qualify for a PTSD diagnosis.
Because PTSD was originally constructed with war veterans in mind,
however, the use of the PTSD diagnosis with rape survivors can be problematic.
PTSD only accounts for some (not all) of the postrape symptoms identified by
researchers and has been criticized for failing to acknowledge the complexity of
women's responses to trauma (Koss et al., 1994). Although many of the symptoms
associated with rape trauma overlap with the diagnostic criteria of PTSD, RTS
cannot be considered synonymous with it.
The PTSD criteria listed above cover the intense fear that many rape survivors
experience, as well as the desire to avoid situations that are reminders of the rape
experience. However, the PTSD criteria do not account for the depression, anger,
sexual dysfunction, guilt, humiliation, and disruption in core belief systems about
the self and others that are also common symptoms among rape survivors (e.g.
Atkeson, Calhoun, Resick, & Ellis, 1982; Becker, Skinner, Abel, & Treacy, 1982;
Janoff-Bulman & Frieze, 1983; Kilpatrick et al., 1985; McCann & Pearlman,
1990). The National Women's Study indicated that there are a number of rape
survivors who meet the criteria for depression, for example, but who do not meet
the criteria for PTSD (Acierno, Kilpatrick, Resnick, Saunders, & Best, 1996).
Some researchers have suggested creating a subset of PTSD for rape trauma
survivors that would include the postrape symptoms mentioned above that are not
addressed in the original criteria. For example, Herman (1992) has suggested a
"complex PTSD" categorization for people who suffer from chronic interpersonal
violence (such as incest or domestic violence survivors) that would include such
criteria symptoms as affective dysregulation, dissociation, and self-destructive
behaviors. Although this complex PTSD category is not appropriate for the
one-time trauma survivor, it is an example of a way in which to expand the
DSM-IV (1994) diagnosis to describe the full experience of one subset of trauma
survivors.
The lack of overlap in the symptom criteria of PTSD and the more extensive
symptoms common to the postrape experience can be problematic for prosecuting
rape cases. Because of the variability in reactions to rape, the PTSD diagnosis may
not be broad enough to account for rape survivors who suffer mainly from
depression or sexual dysfunction. This issue may not be problematic in the clinical
setting if providers consider all reported symptoms (as they should), rather than
just PTSD-related ones. The courtroom, however, often inappropriately places
more emphasis on the diagnoses as a sign that a trauma did occur (Stefan, 1994;
see below, Admissibility of Proffered Expert Testimony). Although it has not yet
been documented, one might suppose that it is more helpful in court if the survivor
suffers from PTSD than not, given that it is the diagnosis most associated with
trauma. Unless an expert clarifies that rape survivors often suffer from symptoms
other than PTSD, jurors and judges may have a more difficult time associating the
described distress with alleged trauma and ultimately regard the rape survivor as
less credible. Thus, the current PTSD diagnosis could cause problems in the
courtroom for women who do not meet the diagnostic criteria (see Stefan, 1994
for similar critique of RTS). More inclusive criteria for PTSD would make for a
more etiologically appropriate and consolidated diagnosis for women suffering
from rape. Finally, at least one study has acknowledged "partial PTSD" trauma
survivors who still suffer from several symptoms, but who do not meet the full
criteria necessary for a PTSD diagnosis (Weiss et al., 1992). A subcategory that
acknowledges these subthreshold survivors may also be an important gain in a

prosecution process that places such emphasis on diagnosis.
ASD
A final diagnosis that could be used by expert witnesses to describe reactions
to rape trauma is ASD. According to the DSM-IV (1994), a rape survivor can be
diagnosed with PTSD only after 1 full month of symptomotology. ASD is
therefore used to describe the condition of a rape survivor who suffers from
PTSD-like intrusions and avoidance symptoms before the 1-month time frame is
up. We are unaware of any cases where ASD has been used in rape litigation, and
therefore it will not be discussed further in this article (see Briere, 1997, for a full
review of the reliability and validity of this diagnosis).
Assessment of the PTSD Diagnosis for Forensic Purposes

Validity of the PTSD Diagnosis
Linking PTSD to rape. Although PTSD is the strongest rape-related
diagnosis on which to base educational expert testimony, there are several
limitations to this diagnosis that prevent courts from being able to use it as a litmus
test for rape (Briere, 1997). To start, it is difficult to link a presentation of PTSD
symptomotology to a rape. The PTSD criteria require only that a victim has
suffered from a horrifying traumatic event. It is therefore possible that a trauma
other than rape produced some or all of the symptoms in question (Briere, 1997).
Certain steps can be taken to obtain information that might help tease apart the
cause and effect, however. Such steps include conducting a thorough assessment of
the temporal sequence of events and symptoms (e.g., did PTSD symptoms occur
only after the alleged event in the absence of other intervening traumas?), and
obtaining a detailed description of the nature of the victim's intrusive symptoms
(e.g., flashbacks and intrusive images of the specific rape experience). Collecting
outside information from family, friends, medical doctors, psychologists, and
medical and psychological files and records can be even more important, given
that survivors are often poor historians if they are currently suffering from the
distorting effects of dysphoria (Briere, 1997) or are trying to recall a traumatic
event that occurred in the distant past (Koss, Figueredo, Bell, Tharan, & Tromp,
1996). Although it has not been empirically tested yet, it is likely that victims who
have backup collaboration from medical records or other sources, for example,
will be more believable that those lacking documentation of the onset of their
symptoms.
Unfortunately, there are many cases in which even external corroboration
cannot clarify the situation. For example, it is not uncommon for a victim to have
survived multiple traumas, in which case it is difficult to attribute symptoms to
only one of the events. In other cases, other negative life events have since
intervened, making the symptom picture more complex (Briere, 1997). The
symptoms may not always be severe enough to meet the PTSD criteria, they may
"only" meet the diagnostic criteria for other diagnoses such as depression, or both.
In summary, although there are clues that can suggest that a rape occurred, it is
difficult to say with certainty that a specific traumatic event, such as that rape, has
caused a PTSD reaction.
Comorbidity. The issue of comorbidity also makes it more difficult for

experts to reach strong conclusions solely on the basis of the presence of PTSD
symptoms. PTSD symptoms overlap with the criteria for several other clinical
disorders including depression, panic disorder, phobias, obsessive compulsive
disorder, and alcohol and drug abuse (for review, see Davidson & Fairbank, 1993;
Fairbank, Schlenger, Saigh, & Davidson, 1995). For example, epidemiological
studies have found that 62-88% of people with PTSD meet criteria for at least one
other psychiatric disorder (Fairbank et al., 1995). These comorbidity rates are not
surprising, however, given that several symptom criteria of PTSD overlap with
symptom criteria of anxiety disorders and depression (Davidson & Foa, 1991).
Avoidance of habitual associations and activities, for example, is characteristic of
both depression and PTSD. Hyperarousal is seen in many forms of anxiety

disorders. Researchers have suggested that posttraumatic depression may be a

partial form of PTSD, rather than a manifestation of depression (Davidson &
Fairbank, 1993). On the other hand, comorbidity may simply be an artifact of the
DSM-IV (1994) approach to defining these disorders. Nevertheless, comorbidity
raises questions about PTSD as a distinct diagnostic entity (Weathers, Keane,
King, & King, 1997).
Malingering. Malingering is another issue that needs to be addressed in
using the PTSD diagnosis in forensic situations. Because survivors may have a
stronger case if they receive a PTSD diagnosis and generally have much to gain
from winning their case (either money in civil cases or redemption in criminal
cases), it is important to be able to show that people faking symptoms can be
caught. Most PTSD scales unfortunately have high face validity, which means that
people are more likely to be able to determine the construct being assessed and
distort responses to fit their purposes (Weathers et al., 1997). Several studies have
looked at whether "fakers" can be caught. Some studies have found that PTSD
symptoms can in fact be faked. Lyons, Caddell, Pittman, Rawls, and Perrin (1994),
for example, found that three non-PTSD control groups who were instructed to
respond as though they had the disorder indeed obtained the same scores as the
veterans who actually had PTSD on the Mississippi Scale for Combat-Related
PTSD (Keane, Caddell, & Taylor, 1988), a reliable diagnostic instrument of PTSD.
Fortunately, the validity scales of the second edition of the Minnesota
Multiphasic Personality Inventory (MMPI-2) look to be promising tools for
catching fakers because symptom exaggerators often have elevated, invalid
profiles (Butcher, Dahlstrom, Graham, Tellegen, & Kaemmer, 1989). Even though
several studies have shown that victims of abuse and Vietnam veterans also often
have elevated scores on the validity scales, the Frequency scale in particular (e.g.,
Elliot, 1993; Jordan, Nunley, & Cook, 1992; Smith & Frueh, 1996), other studies
have shown that fakers tend to obtain even more invalid scores on certain MMPI-2
validity scales. For example, Wetter, Baer, Berry, Robinson, and Sumpter (1993)
found that nonclinical people instructed to fake PTSD who were first given
information on PTSD symptoms and a promise of monetary reward for success
scored significantly higher on the Frequency and back F scales, Dissimulation
Index, and Depression validity scales than the legitimate Vietnam veterans
who suffered from PTSD. After optimal cutting scores were calculated,
researchers could obtain a 78-80% hit rate (i.e., they could correctly determine
that the participant was a legitimate PTSD patient) on the basis of how the
respondents scored on the Frequency, Dissimulation Index, or Depression validity

scales. These conclusions, however, are based on studies with small sample sizes
of veterans and relatively large standard deviations (Briere, 1997). Pending further
research, psychologists cannot suggest absolute cutoffs for fakers, guarantee that
all diagnoses of PTSD are legitimate, nor assert that every malingerer presenting
with PTSD symptomotology will be caught. But, if used in conjunction with
interviews such as the Structured Interview of Reported Symptoms (Rogers,
Bagby, & Dickens, 1992), the MMPI-2 validity scales can be helpful in detecting
probable cases of intentional lying or exaggeration.
Updated assessment instruments. Finally, the validity of the diagnosis
requires that experts use updated PTSD assessment instruments. Older instruments
have the potential to confuse intrusive PTSD symptoms with hallucinations,

obsession, and faking responses, to name a few (Briere, 1997). In addition, several
scales have not yet been updated to include the DSM-IV (1994) criteria changes
(Weathers et al., 1997). The above means that the expert must choose carefully
when selecting assessment instruments. This choice is not always easy to make,
given how often the criteria for a diagnosis of PTSD change. Formal diagnostic
criteria for PTSD were first introduced in the Diagnostic and Statistical Manual of
Mental Disorders (3rd ed.; DSM-III; American Psychiatric Association) in 1980.
However, the criteria have changed with each subsequent volume of the DSM,
specifically the Diagnostic and Statistical Manual of Mental Disorders (3rd ed.,
revised; DSM-III-R; American Psychiatric Association, 1987), and then again in
the DSM-IV (Weathers et al., 1997). The PTSD construct continues to evolve as
more information about the disorder becomes available through research on
memory and physiological arousal, for example, as well as on different trauma
groups such as rape survivors and traumatized children. Although it is important
for the diagnostic criteria to reflect the findings of the research, it is difficult for
researchers to develop reliable and valid tools for evolving criteria.
PTSD Assessment Tools

There are generally two different sets of measures taken to assess PTSD: One
set of instruments assesses the trauma (Criterion A), and the second assesses the
symptoms (Criteria B-F). Researchers who assess the prevalence of rape need to
be careful to use Criterion A assessment tools that describe the events behaviorally
rather than more generally (i.e., screening items must describe the specific type of
conduct involved instead of using the general term "rape") because many people
will not necessarily know that they have been raped or will refuse to identify with
the label rape (Koss, 1993). Forensic rape cases, however, rarely have to address
the reliability and validity issues of the Criterion A tests, given that rape has been
generally accepted as a trauma that meets the Criterion A definition and that a
woman does not come to trial in forensic cases unless she thinks she has been
raped. Nevertheless, the Criterion A measures should still be given carefully to
assess whether a survivor has experienced additional traumatic experiences. As
was previously discussed, it is especially important to assess the time frame in
which the additional traumatic experiences occurred. It is also important to assess
the existence of the DSM-IV (1994) "intense fear, horror, helplessness" criterion
about which some of the older measures do not ask (see Norris & Riad, 1997, for a
discussion of Criterion A measures of civilian trauma).
The second set of instruments assesses whether the trauma survivor meets the
symptom criteria of PTSD (Criteria B-F). There are several types of these
instruments, including structured diagnostic interviews, trauma-specific self-
report measures, and the more general objective tests such as the MMPI-2. More
recently, psychophysiological measures have also been studied as a potential
measure of PTSD. All of these measures have individual strengths and weaknesses
in terms of validity and reliability, but they can prove fairly effective when used
together in a comprehensive assessment.
Structured diagnostic interviews. The structured diagnostic interviews are
useful in testing for PTSD primarily because they tend to be more thorough and
specific, providing a list of diagnostic criteria and questions to address each
criterion. Materials have even been developed for both the Structured Clinical
Interview DiagnosisIIIR, PTSD Module (Spitzer, Williams, Gibbon, & First,

1990) and the Clinician-Administered PTSD Scale (CAPS-1; Blake et al., 1995)
to help clarify the decision-making process in determining the presence or absence
of a criterion symptom (Weiss, 1997). It is important to recognize, however, that
the use of a structured diagnostic interview does not eliminate the chance of
diagnostic error, for several reasons. First, these measures often do not link specific
symptoms to one specific event but rather just assess the presence of the
appropriate symptoms (Briere, 1997). As previously noted, this precise link is
important in the forensic arena, where the goal is to link a person's symptoms to
only one specific rape event. Second, these structured interviews are limited in that
many of them have not yet been updated to reflect the changes in the DSM-IV
(1994) PTSD criteria (Weathers et al., 1997). Clinicians thus need to be cautious
when selecting these instruments. Finally, some of the most promising interviews
(such as the CAPS-1) were developed and validated on veterans, making their
appropriateness for civilian trauma questionable until they are empirically proven
to generalize to other populations (Weathers et al., 1997). Measures that have been
validated on sexual assault victims, such as the PTSD Symptom ScaleInterview
(PSS-I; Foa, Riggs, Dancu, & Rothbaum, 1993), should be used when assessing
rape survivors.
Trauma-specific self-report measures. Trauma-specific self-report measures
are useful in that they ask the specifically relevant questions that pertain to a
particular trauma. Yet these assessments also have several limitations to their
ability to reliably diagnose, and it is best to rely on convergent information from
multiple types of instruments to obtain a reliable diagnosis (Schlenger, Fairbank,
Jordan, & Caddell, 1997). First, few of these self-reports have been studied
rigorously over time primarily because researchers keep presenting slightly
different versions of essentially the same trauma measure instead of spending time
cross-validating and improving the current scales (Morris & Riad, 1997). Second,
these scales use a 17-item approach that only provides 1 item per criterion of
PTSD. A single item is a less reliable estimate of a construct. If even one item is
avoided or misunderstood, the diagnosis could be greatly affected (Briere, 1997).
Objective tests. Several objective tests now have special items or scoring
approaches on both for diagnosing PTSD, such as the MMPI-2 PK (PTSD-Keane,
Keane, Malloy, & Fairbank, 1984) and PS (PTSD-Schlenger, Kulka, Fairbank,
Hough, Jordan, Marmar, & Weiss, 1989). These more general personality tests
have been criticized, however, when used to diagnose PTSD populations because
they include a large variety of non-PTSD-like symptom items and do not

thoroughly assess the DSM-IV symptom criteria (Weathers et al., 1997). They also
generally fail to assess the 1-month time requirement for symptom experience as
well as the requirement that the reaction to the trauma be upsetting (Briere, 1997).
The MMPI-2 is also limited in its use on civilian populations because it was
developed and validated on war veterans.
Validity and reliability. Ample empirical studies have looked carefully at the
convergent validity of these different measures of PTSD (Weathers et al., 1997).
Convergent validity assures that the different tests are measuring the same
construct. Fortunately, the findings suggest that a person who scores high on one
measure of PTSD is also very likely to have a high score on another measure of
PTSD. Very few studies, however, have looked at the divergent validity of PTSD,
which assesses whether the PTSD instruments are measuring a construct separate
and distinct from other DSM-IV diagnoses. The few existing studies do not show
promising results. This fact is not surprising, however, given the previously
mentioned comorbidity issues associated with PTSD. For example, Weathers
(1992) conducted a study that looked at the convergent as well as divergent
validity of PTSD by comparing the CAPS-1 with measurements of three different
DSM diagnoses. Like other studies, CAPS-1 was found to correlate strongly with
the other measures of PTSD. Although he found that the CAPS-1 correlated
weakly with the measures of antisocial personality disorder (suggesting good
divergent validity), the CAPS-1 correlated moderately with measures of depres-
sion and anxiety, again suggesting that there are similarities between the diagnoses
of depression, anxiety, and PTSD, making for poor divergent validity.
In terms of reliability, many of the instruments that measure PTSD and that
have been validated on civilian populations are psychometrically sound with good
internal consistency (alpha usually = .S5-.95) and test-retest reliability (r usu-
ally = .80-.96). Such reliable measures include the PSS, the Revised Civilian
Mississippi Scale (Morris & Perilla, 1996), and the National Women's Study PTSD
Module (Kilpatrick, Resnick, Saunders, & Best, 1989; for a comprehensive review
of all PTSD instrument reliabilities, see Wilson & Keane, 1997). Therefore, it
appears that several measurements of PTSD can provide reliable assessments.
However, this is only the case if the assessor carefully matches the specific client
with measures that have been proven reliable with a similar population. Almost all
of the psychometrically sound scales have already been validated on war veterans,
but as discussed, only some of the scales have demonstrated reliability with rape
survivors (See Norris & Riad, 1997, for a comprehensive review of measures of
civilian PTSD).
Most studies that have assessed the sensitivity of the above mentioned
instruments for sexual assault survivors have found that these scales can generally
correctly identify 80-90% of people who have PTSD, or the "true positives"
(Norris & Riad, 1997). For rape experts, this means that very few rape survivors
who qualify for the current PTSD diagnosis will go undetected by these tools.
Studies of specificity have also generally found rates of 80-90% (Norris & Riad,
1997), which suggest that these scales diagnose non-PTSD people incorrectly
(false positives) only 10-20% of the time. Although similar to many other tests of
other DSM-IV diagnoses, this finding admits that there is a small percentage of
people who are diagnosed with PTSD who actually should not be. None of these
scales can promise a hit rate of 100%. However, no scale for any DSM-IV
diagnosis can promise a 100% hit rate. These are the limitations in working with
psychological tools. Some tools are good, but none is perfect.
Psychophysiology. In the hopes of further improving the hit rate for diag-
noses such as PTSD, several psychologists have turned to the study of psychophysi-
ology. It is the goal of these scientists to eventually discover the presence or
absence of a physiological response to trauma-related cues that can be used as a
marker for the existence of PTSD (Orr & Kaloupek, 1997). Unfortunately, the
work has only just begun, and although some initial studies have reached tentative
findings on war veterans, these findings do not reveal a strong, reliable test of
PTSD. Furthermore, few studies have studied rape survivor populations, and little
has been written about the practical application of these measures to an actual
diagnosis of PTSD (See Orr & Kaloupek, 1997, for a full review). Although it may
be a promising area of study, psychophysiology currently offers no better litmus
test for PTSD than do the pen and pencil tests previously described.
Other promising non-self-report methods for assessing PTSD are in similar
stages of discovery. Laboratory studies suggest that an index of intrusive cognitive
activity can be measured through nonintrospective methods such as the Stroop
Test, which may help assess PTSD in rape survivors. Researchers have found thai
rape survivors who have PTSD generally exhibit more cognitive interference when
presented with trauma cues than nontraumatized controls and rape survivors who
do not have PTSD (Cassiday, McNally, & Zeitlin, 1992; Foa, Feske, Murdock,
Kozak, & McCarthy, 1991). Like psychophysiology, however, this line of research
on cognitive interference does not yet provide a solid basis for documenting
PTSD.
Admissibility of Proffered Expert Testimony

The preceding discussion of the validity and reliability of these diagnoses has
clarified the limitations of our knowledge and laid the foundation to evaluate the
scientific appropriateness of admitting rape trauma expert testimony. We explici-
tyly avoid using a legal lens for this evaluation. For a discussion of the law's
approaches to admitting expert clinical and scientific testimony see Shuman and
Sales (in press). This section will describe past admissibility decisions in rape
cases, using categorical levels similar to those first described by Fischer (1989)
and integrating a discussion of the scientific propriety of allowing such testimony
into court, given the empirical findings described above.
Level 1: Testimony on Specific Behaviors of Rape Survivors That Are

Described as "Unusual" by the Defense
Testimony at this level is used by the victim's counsel in both criminal and
civil trials to rebut the perpetrator's argument that a victim exhibited an unusual
behavior following a rape. The sole purpose of this type of testimony is to combat
untrue, damaging myths that jeopardize the victim's credibility. It does not provide
any circumstantial evidence on the issue of consent (whether or not the victim
agreed to have sex). Attorneys for alleged offenders have introduced testimony
about several unusual behaviors, including a victim's delay in reporting, a failure
to recall details, the omission of certain aspects of the rape, an inability to
immediately tell the police the name of the attacker, an inability to identify the
attacker 2 weeks later, a lack of emotion following assault, the denial of being
raped to friends, memory loss of events preceding the rape, asking an assailant not
to tell anyone about the rape, and having a rapist establish a brief relationship with
the victim before the assault (Fischer, 1989).
This level of testimony has usually been found to be helpful by courts. It can
also be considered scientifically valid now that researchers have the stronger
empirical studies on rape responses to support the argument that most of these
seemingly unusual behaviors (i.e., behaviors that appear to be inconsistent with a
claim of rape) are actually not that unusual for rape survivors. However, not all of
the unusual responses described above have actually been proven in the literature
to be a common response to rape (Frazier & Borgida, 1992). For example, one
expert claimed that it is very common for a victim to ask an assailant not to tell
anyone about the assault (Lessard v. State, 1986), even though this is not a
behavior that has been documented in the rape literature (see Frazier & Borgida,
1992, for review of empirical evidence pertaining to these unusual behaviors). It is
obviously unethical for a rape trauma expert to testify on unusual behaviors that
have not been documented as common responses to rape (see Ethics Code
Provision 1.06: Basis for Scientific and Professional Judgments, American
Psychological Association, 1992). In addition, the expert must not only know but
must admit to the limits of empirical knowledge; the role of the expert witness is
not to advocate for a side but rather to educate the jurors and judges. Psychologists
have an ethical obligation to do so. Section 7.04b of the Ethics Code reads,
"Whenever necessary to avoid misleading, psychologists acknowledge the limits
of their data or conclusions" (American Psychological Association, 1992, p. 1610).
Some courts have ruled that the experts presented by the victim's attorney can
only rebut the specific unusual behaviors brought up by the attorney for the alleged
offender (e.g., Commonwealth v. Mamay, 1990; State v. Hall, 1987) and are not
allowed to present general information about common responses to rape. This
limitation appears too severe in that it permits the expert to dispel only one or two
misconceptions about rape. It does not permit the expert to address the other myths
that may prejudice the jury against the victim. Empirical evidence suggests that the
average juror does not have an adequate knowledge of rape (Frazier & Borgida,
1988). Laypersons have been found to score significantly lower (at almost chance
level) than experts on a questionnaire about sexual assault (Frazier & Borgida,
1988), suggesting that it would be helpful to triers of fact to receive more
information on reactions to rape. Furthermore, this level of testimony should not
be considered prejudicial against the alleged offender because it only provides
general information to the jurors in an effort to combat the negative stereotypes
often believed about rape victims. Future research will need to assess jurors'
reactions to limited versus general testimony on reactions to rape.
Level 2: Testimony on the Common Reactions to Rape and the General

Diagnostic Criteria ofRTS orPTSD
This level of testimony involves a discussion of common postrape behaviors
and experiences, including a description of the symptom criteria for RTS or PTSD.
At this level of testimony, the expert does not examine the alleged victim and is not
allowed to discuss the specific victim's behaviors or symptoms. The testimony is
kept at a general, descriptive level. In State v. Moran (1986), for example, the court
ruled that lay witnesses could testify about the victim's behavior, but that the
expert could only talk about the reactions of rape survivors in general.
Although still commonly found in the forensic setting, RTS is a phrase no
longer used in the clinical setting and thus should no longer be used by a mental
health expert. Several courts have come to a similar conclusion, but for a different
reason: prejudicial language. In State v. Home (1986), for example, the court
allowed the expert to provide a general description of common rape responses but
not a description of RTS because it deemed the language in the term rape trauma
syndrome to be too prejudicial. The court's fear was that if a jury hears that a
woman is described as suffering from RTS, the jury will conclude that she must
have been raped.

On the other hand, the empirical research supports the relevance of admitting
general educational testimony on PTSD in the courtroom. For example, 90% of
rape survivors experience PTSD symptoms immediately after the rape (Rothbaum,
Foa, Murdock, Riggs, & Walsh, 1992), and 15% of rape survivors are diagnosed
with lifetime PTSD, making rape survivors the largest group of trauma victims
who suffer from PTSD (Morris, 1992). Thus, it is appropriate to discuss PTSD in
rape cases.
An expert should not solely provide a description of a PTSD diagnosis,
however, but should also include an explanation of the empirically validated,
common postrape symptoms that are not covered by the diagnosis (e.g. sexual
dysfunction, depression, etc.). The expert should also acknowledge that the
majority of rape survivors do not fit a full diagnosis for PTSD and therefore the
lack of a diagnosis does not prove that the rape did not occur. The most important
limitation to which an expert can admit is that the field of mental health does not
have a litmus test for PTSD and that a PTSD diagnosis does not prove conclusively
that a rape has occurred.
Level 3: Expert Gives an Opinion About the Consistency of a Victim's

Behavior or Symptoms With RTS or PTSD
The expert testifying at this level of testimony is allowed to discuss whether
the victim's symptoms are consistent with RTS or the symptom criteria of the
PTSD diagnosis (e.g., People v. Douglas, 1989). The expert does not examine or
diagnose the victim, claim that she suffers from RTS or PTSD, nor imply that she is
being truthful in her description of her own symptoms. Some commentators feel
that this level of testimony is important to a fair trial because they are afraid that
jurors may not be able to see the consistencies between rape survivors' symptoms
and the expert's description of postrape responses without the expert's testimony
identifying them (e.g., Fischer, 1989).
This type of testimony is much more controversial than that of Level 1 or 2
because it permits the expert to go beyond the general, educational information
and apply it to a specific case. Some courts have felt that such testimony is
prejudicial to the defendant because it indirectly boosts the victim's credibility to
have an expert discuss her symptoms (e.g., People v. Gray, 1986), even though the
expert does not interview the victim nor comment on the truthfulness of her
self-reported symptoms.
Fortunately, researchers have begun to address this question of credibility.
Brekke (1985) had mock juries listen to reenactments of rape cases containing
either no expert testimony, general information on RTS, or testimony specific to
the particular case (similar to this level of testimony). The study found that
although the mock jurors did rate the victim's credibility higher when the expert
explicitly explained the lines of consistency between the victim's alleged
symptoms and RTS symptoms, the defendant's credibility was not affected across
conditions. A similarly designed study by Brekke and Borgida (1988) found that
juries were most likely to convict when they had been exposed to the specific
expert testimony but only when the testimony had been presented early in the trial.
The authors concluded that the expert testimony appeared to function as a filter for
subsequent facts when it came early in the trial, but that the jurors' preconceived
notions and biases led the deliberations when the testimony came at the end of the
trial (Brekke & Borgida, 1988). Analyses of the jury deliberations again showed
that the specific expert testimony did not afreet the favorability of the defendant's
credibility, suggesting that the testimony is not prejudicial to the defendant.
Instead, it appears that the expert testimony serves to counteract the pervasive rape
myths that bias the average juror against alleged victims (Borgida & Brekke,
1985). Although these studies should be replicated using a description of PTSD to
ensure their generalization to the contemporary situation, they suggest that this
additional level of admissibility helps to make the trial less tainted by bias against
the victim.
In sum, it appears that the consistency level of testimony in regards to PTSD
(not RTS) is a valid use of expert testimony, given that the expert does not appear
to unfairly comment on the victim's credibility. Furthermore, the expert does not
make a diagnosis of PTSD and thus avoids any concern over the specificity or
sensitivity limitations of the PTSD diagnosis. Several empirical questions need to
be addressed, however, before the full implications of admitting this level of
testimony are understood. For instance, researchers need to empirically investigate
the question implied above: Can juries see the consistencies between the victim's
symptoms and the expert's description of postrape responses on their own? They
also need to determine whether jurors' ratings of victims are actually unfairly low
without this level of testimony.
Level 4: Testimony Stating That the Victim Suffers From RTS or PTSD
At this level of admissibility, the expert describes the victim's symptoms and
states that she meets the criteria for a clinical diagnosis of PTSD. The expert stops
short, however, of stating that the victim was raped. Courts that have permitted this
level of testimony (e.g., State v. McQuillen, 1984) argue that the testimony is not
unfairly prejudicial because the defense is allowed to cross-examine the state's
expert or bring in their own expert. In addition, in stating that a woman suffers
from PTSD, an expert is not declaring that the woman was raped but only
suggesting that she has survived one of many different types of life-threatening
traumas.
The issues surrounding RTS testimony discussed at previous levels are again
relevant here: There is no clinical RTS diagnosis or solid empirical research on
which to base ethical RTS expert testimony. The decision to testify about a PTSD
diagnosis, however, is ethically less clear. Some could argue that the reliability and
validity of the diagnosis are not strong enough to use in a courtroom because no
test or clinical interview can produce a 100% positive diagnosis of PTSD.

However, no DSM diagnosis can meet a 100% standard of proof. The question then
becomes, should mental health workers be prohibited from testifying about all
clinical diagnoses? Given the extent of current knowledge about the diagnosis of
PTSD, including the limitations of assessment tools and the diagnosis in general,
mental health professionals have a significant amount of information that they can
ethically convey to the judge and jury. It then becomes the job of the opposing
counsel, but more importantly and realistically, the ethical standards of the expert,
to ensure that any discussion of a diagnosis is accompanied by a discussion of the
demonstrated limitations as laid out earlier. Psychologists have a moral responsibil-
ity, one that often goes beyond requirements of the law, to stay within the limits of
their knowledge (Lavin & Sales, 1998).

Finally, some may want to argue against the admissibility of this level of
testimony on the belief that it will be prejudicial against the defendant because it
will unfairly boost the victim's credibility. However, we do not yet have the
empirical work that would suggest what impact this level of testimony can have on
a trial and its participants.
Level 5: Expert Opinion That Goes Beyond a Diagnosis

At this level of testimony, the expert states that the victim is telling the truth,
states that the victim was raped, or both. Almost all states refuse to admit this level
of testimony because it clearly invades the jury's province and bears directly on the
victim's credibility (Fischer, 1989). The courts, as well as the literature, do not
support the use of RTS testimony at this level. However, in Maryland's State v.
Allewalt (1986), the expert was permitted to say that the victim's PTSD diagnosis
was caused by rape. The court ruled that this was admissible because the opinion
was based on a medical diagnosis. The current state of the PTSD literature,
however, would suggest that the court and the expert acted inappropriately in this
case: The court permitted testimony that went beyond scientific knowledge, and
the expert failed to acknowledge the limitations of the diagnosis and the difficulty
in linking specific traumas to specific symptoms and instead answered a question
that should have been addressed only by a judge or jury.
Conclusion
Although RTS has historical importance, it makes for confusing and poten-
tially unscientific expert testimony and should no longer be used in the courtroom.
PTSD although far from being a perfect diagnosis for rape survivors, looks to be a
more reliable and valid diagnosis for expert testimony, especially when accompa-
nied by a description of the additional postrape symptoms absent from the PTSD
diagnostic criteria.
Empirical studies of PTSD make clear that, as with other psychiatric disorders,
no instrument is 100% accurate. There is no litmus test for PTSD, and researchers
may never discover one for the act of rape. Furthermore, PTSD was initially
created as a political gesture to the veterans of the Vietnam War, not as a general
diagnosis of trauma survivors to which it is now routinely applied. Thus, the PTSD
criteria do not comprehensively cover all empirically validated common reactions
to rape, and high rates of comorbidity raise questions about the diagnosis as a
whole. These facts do not deem expert testimony useless, but they do limit the
ways in which the testimony can be helpful as opposed to harmful. If used

cautiously and appropriately, expert testimony on PTSD can help to educate the
judge or jury about common reactions to rape.
It appears that there is now enough empirical knowledge to allow experts to go
so far as to discuss the PTSD diagnosis of a particular victim, but only if they first
acknowledge the limitations of the validity of the diagnosis and the reliability of
the current measurement tools. Future research is necessary, however, to discover
if jurors listen to these limitations and also to verify that this type of testimony does
not unfairly prejudice the jury against the defendant. There are currently several
levels of testimony allowed by different courts. It is imperative that experts
determine at what level they can testify ethically and that they do not allow
themselves to be pressured into answering questions that exceed these boundaries.

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Psychology, Public Policy, and Law Copyright 1998 by the American Psychological Association, Inc.

1998, Vol. 4, No. 1/2, 414-432 1076-8971/98/S3.00

RAPE TRAUMA EXPERTS IN THE COURTROOM

Laura E. Boeschen, Bruce D. Sales, and Mary P. Koss

It is impossible to consider sexual offending without focusing on both the

should remain to respect the limitations of current knowledge. Because the

RTS, PTSD, and ASD

conceptualization of general stages of recovery (Frazier & Borgida, 1992).

acknowledges these subthreshold survivors may also be an important gain in a

review of the reliability and validity of this diagnosis).

Assessment of the PTSD Diagnosis for Forensic Purposes

Comorbidity. The issue of comorbidity also makes it more difficult for

both depression and PTSD. Hyperarousal is seen in many forms of anxiety

disorders. Researchers have suggested that posttraumatic depression may be a

respondents scored on the Frequency, Dissimulation Index, or Depression validity

have the potential to confuse intrusive PTSD symptoms with hallucinations,

PTSD Assessment Tools

Interview DiagnosisIIIR, PTSD Module (Spitzer, Williams, Gibbon, & First,

they include a large variety of non-PTSD-like symptom items and do not

Admissibility of Proffered Expert Testimony

Level 1: Testimony on Specific Behaviors of Rape Survivors That Are

Level 2: Testimony on the Common Reactions to Rape and the General

have been raped.

Level 3: Expert Gives an Opinion About the Consistency of a Victim's

test or clinical interview can produce a 100% positive diagnosis of PTSD.

their knowledge (Lavin & Sales, 1998).

Level 5: Expert Opinion That Goes Beyond a Diagnosis

ways in which the testimony can be helpful as opposed to harmful. If used

themselves to be pressured into answering questions that exceed these boundaries.

Commonwealth v. Mamay, 553 N.E.2d 945 (1990).

epidemiologic profile of post-traumatic stress disorder: Prevalence, comorbidity, and

risk factors. In M. J. Friedman, D. S. Charney, & A. Y. Deutch (Eds.), Neurobiological

Mental health correlates of criminal victimization: A random community survey.

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