Violence against women: Physical and mental health effects. Part I: Research findings

Psychosocial interventions for survivors of rape and sexual assault experienced during adulthood

BACKGROUND

Exposure to rape, sexual assault and sexual abuse has lifelong impacts for mental health and well-being. Prolonged Exposure (PE), Cognitive Processing Therapy (CPT) and Eye Movement Desensitisation and Reprocessing (EMDR) are among the most common interventions offered to survivors to alleviate post-traumatic stress disorder (PTSD) and other psychological impacts. Beyond such trauma-focused cognitive and behavioural approaches, there is a range of low-intensity interventions along with new and emerging non-exposure based approaches (trauma-sensitive yoga, Reconsolidation of Traumatic Memories and Lifespan Integration). This review presents a timely assessment of international evidence on any type of psychosocial intervention offered to individuals who experienced rape, sexual assault or sexual abuse as adults.

OBJECTIVES

To assess the effects of psychosocial interventions on mental health and well-being for survivors of rape, sexual assault or sexual abuse experienced during adulthood.

SEARCH METHODS

In January 2022, we searched CENTRAL, MEDLINE, Embase, 12 other databases and three trials registers. We also checked reference lists of included studies, contacted authors and experts, and ran forward citation searches.

SELECTION CRITERIA

Any study that allocated individuals or clusters of individuals by a random or quasi-random method to a psychosocial intervention that promoted recovery and healing following exposure to rape, sexual assault or sexual abuse in those aged 18 years and above compared with no or minimal intervention, usual care, wait-list, pharmacological only or active comparison(s). We classified psychosocial interventions according to Cochrane Common Mental Disorders Group's psychological therapies list.

DATA COLLECTION AND ANALYSIS

We used the standard methodological procedures expected by Cochrane.

MAIN RESULTS

We included 36 studies (1991 to 2021) with 3992 participants randomly assigned to 60 experimental groups (3014; 76%) and 23 inactive comparator conditions (978, 24%). The experimental groups consisted of: 32 Cognitive Behavioural Therapy (CBT); 10 behavioural interventions; three integrative therapies; three humanist; five other psychologically oriented interventions; and seven other psychosocial interventions. Delivery involved 1 to 20 (median 11) sessions of traditional face-to-face (41) or other individual formats (four); groups (nine); or involved computer-only interaction (six). Most studies were conducted in the USA (n = 26); two were from South Africa; two from the Democratic Republic of the Congo; with single studies from Australia, Canada, the Netherlands, Spain, Sweden and the UK. Five studies did not disclose a funding source, and all disclosed sources were public funding. Participants were invited from a range of settings: from the community, through the media, from universities and in places where people might seek help for their mental health (e.g. war veterans), in the aftermath of sexual trauma (sexual assault centres and emergency departments) or for problems that accompany the experience of sexual violence (e.g. sexual health/primary care clinics). Participants randomised were 99% women (3965 participants) with just 27 men. Half were Black, African or African-American (1889 participants); 40% White/Caucasian (1530 participants); and 10% represented a range of other ethnic backgrounds (396 participants). The weighted mean age was 35.9 years (standard deviation (SD) 9.6). Eighty-two per cent had experienced rape or sexual assault in adulthood (3260/3992). Twenty-two studies (61%) required fulfilling a measured PTSD diagnostic threshold for inclusion; however, 94% of participants (2239/2370) were reported as having clinically relevant PTSD symptoms at entry. The comparison of psychosocial interventions with inactive controls detected that there may be a beneficial effect at post-treatment favouring psychosocial interventions in reducing PTSD (standardised mean difference (SMD) -0.83, 95% confidence interval (CI) -1.22 to -0.44; 16 studies, 1130 participants; low-certainty evidence; large effect size based on Cohen's D); and depression (SMD -0.82, 95% CI -1.17 to -0.48; 12 studies, 901 participants; low-certainty evidence; large effect size). Psychosocial interventions, however, may not increase the risk of dropout from treatment compared to controls, with a risk ratio of 0.85 (95% CI 0.51 to 1.44; 5 studies, 242 participants; low-certainty evidence). Seven of the 23 studies (with 801 participants) comparing a psychosocial intervention to an inactive control reported on adverse events, with 21 events indicated. Psychosocial interventions may not increase the risk of adverse events compared to controls, with a risk ratio of 1.92 (95% CI 0.30 to 12.41; 6 studies; 622 participants; very low-certainty evidence). We conducted an assessment of risk of bias using the RoB 2 tool on a total of 49 reported results. A high risk of bias affected 43% of PTSD results; 59% for depression symptoms; 40% for treatment dropout; and one-third for adverse events. The greatest sources of bias were problems with randomisation and missing outcome data. Heterogeneity was also high, ranging from I2 = 30% (adverse events) to I2 = 87% (PTSD).

AUTHORS' CONCLUSIONS

Our review suggests that survivors of rape, sexual violence and sexual abuse during adulthood may experience a large reduction in post-treatment PTSD symptoms and depressive symptoms after experiencing a psychosocial intervention, relative to comparison groups. Psychosocial interventions do not seem to increase dropout from treatment or adverse events/effects compared to controls. However, the number of dropouts and study attrition were generally high, potentially missing harms of exposure to interventions and/or research participation. Also, the differential effects of specific intervention types needs further investigation. We conclude that a range of behavioural and CBT-based interventions may improve the mental health of survivors of rape, sexual assault and sexual abuse in the short term. Therefore, the needs and preferences of individuals must be considered in selecting suitable approaches to therapy and support. The primary outcome in this review focused on the post-treatment period and the question about whether benefits are sustained over time persists. However, attaining such evidence from studies that lack an active comparison may be impractical and even unethical. Thus, we suggest that studies undertake head-to-head comparisons of different intervention types; in particular, of novel, emerging therapies, with one-year plus follow-up periods. Additionally, researchers should focus on the therapeutic benefits and costs for subpopulations such as male survivors and those living with complex PTSD.

Experiences of Sexual Assault and Financial Stability: Sense of Control as a Potential Mechanism

This investigation utilized the Midlife in the United States Survey (N = 3,258) to assess the relationships between sexual assault, sense of control, and financial stability. Age of first sexual assault and sexual assault revictimization were also considered in analyses of sexual assault survivors' data. Results revealed consistent associations between experiences of sexual assault and revictimization with lower financial stability and suggest that sense of control may be an indirect mechanism linking these variables. Findings have policy relevance and practical implications for practitioners. Restoring sexual assault victims' internal loci of control may promote more positive financial outcomes.

Survivor, family and professional experiences of psychosocial interventions for sexual abuse and violence: a qualitative evidence synthesis

BACKGROUND

It is well-established that experiencing sexual abuse and violence can have a range of detrimental impacts; a wide variety of interventions exist to support survivors in the aftermath. Understanding the experiences and perspectives of survivors receiving such interventions, along with those of their family members, and the professionals who deliver them is important for informing decision making as to what to offer survivors, for developing new interventions, and enhancing their acceptability.

OBJECTIVES

This review sought to: 1. identify, appraise and synthesise qualitative studies exploring the experiences of child and adult survivors of sexual abuse and violence, and their caregivers, regarding psychosocial interventions aimed at supporting survivors and preventing negative health outcomes in terms of benefits, risks/harms and barriers; 2. identify, appraise and synthesise qualitative studies exploring the experiences of professionals who deliver psychosocial interventions for sexual abuse and violence in terms of perceived benefits, risks/harms and barriers for survivors and their families/caregivers; 3. develop a conceptual understanding of how different factors influence uptake, dropout or completion, and outcomes from psychosocial interventions for sexual abuse and violence; 4. develop a conceptual understanding of how features and types of interventions responded to the needs of different user/survivor groups (e.g. age groups; types of abuse exposure; migrant populations) and contexts (healthcare/therapeutic settings; low- and middle-income countries (LMICs)); 5. explore how the findings of this review can enhance our understanding of the findings from the linked and related reviews assessing the effectiveness of interventions aimed at supporting survivors and preventing negative health outcomes.

SEARCH METHODS

In August 2021 we searched MEDLINE, Embase, PsycINFO and nine other databases. We also searched for unpublished reports and qualitative reports of quantitative studies in a linked systematic review, together with reference checking, citation searches and contacting authors and other researchers to identify relevant studies.

SELECTION CRITERIA

We included qualitative and mixed-methods studies (with an identifiable qualitative component) that were linked to a psychosocial intervention aimed at supporting survivors of sexual abuse and violence. Eligible studies focused on at least one of three participant groups: survivors of any age, gender, sexuality, ethnicity or [dis]ability who had received a psychosocial intervention; their carers, family members or partners; and professionals delivering such interventions. We placed no restrictions in respect of settings, locations, intervention delivery formats or durations.

DATA COLLECTION AND ANALYSIS

Six review authors independently assessed the titles, abstracts and full texts identified. We extracted data using a form designed for this synthesis, then used this information and an appraisal of data richness and quality in order to stratify the studies using a maximum variation approach. We assessed the methodological limitations using the Critical Skills Appraisal Programme (CASP) tool. We coded directly onto the sampled papers using NVivo and synthesised data using a thematic synthesis methodology and used the GRADE-CERQual (Confidence in the Evidence from Reviews of Qualitative research) approach to assess our confidence in each finding. We used a narrative synthesis and matrix model to integrate our qualitative evidence synthesis (QES) findings with those of intervention review findings.

MAIN RESULTS

We identified 97 eligible studies and sampled 37 of them for our analysis. Most sampled studies were from high-income countries, with four from middle-income and two from low-income countries. In 27 sampled studies, the participants were survivors, in three they were intervention facilitators. Two included all three of our stakeholder groups, and five included two of our groups. The studies explored a wide range of psychosocial interventions, with only one type of intervention explored in more than one study. The review indicates that features associated with the context in which interventions were delivered had an impact on how individuals accessed and experienced interventions. This included organisational features, such as staff turnover, that could influence survivors' engagement with interventions; the setting or location in which interventions were delivered; and the characteristics associated with who delivered the interventions. Studies that assess the effectiveness of interventions typically assess their impact on mental health; however, as well as finding benefits to mental health, our QES found that study participants felt interventions also had positive impacts on their physical health, mood, understanding of trauma, interpersonal relationships and enabled them to re-engage with a wide range of areas in their lives. Participants explained that features of interventions and their contexts that best enabled them to benefit from interventions were also often things that could be a barrier to benefiting from interventions. For example, the relationship with the therapist, when open and warm was a benefit, but if such a relationship could not be achieved, it was a barrier. Survivors' levels of readiness and preparedness to both start and end interventions could have positive (if they were ready) or negative (if they were not) impacts. Study participants identified the potential risks and harms associated with completing interventions but felt that it was important to face and process trauma. Some elements of interventions were specific to the intervention type (e.g. faith-based interventions), or related to an experience of an intervention that held particular relevance to subgroups of survivors (e.g. minority groups); these issues could impact how individuals experienced delivering or receiving interventions.

AUTHORS' CONCLUSIONS

We had high or moderate confidence in all but one of our review findings. Further research in low- and middle-income settings, with male survivors of sexual abuse and violence and those from minority groups could strengthen the evidence for low and moderate confidence findings. We found that few interventions had published quantitative and qualitative evaluations. Since this QES has highlighted important aspects that could enable interventions to be more suitable for survivors, using a range of methodologies would provide valuable information that could enhance intervention uptake, completion and effectiveness. This study has shown that although survivors often found interventions difficult, they also appreciated that they needed to work through trauma, which they said resulted in a wide range of benefits. Therefore, listening to survivors and providing appropriate interventions, at the right time for them, can make a significant difference to their health and well-being.

Investigating the associations between intimate partner violence and nutritional status of women in Zimbabwe

Background

Intimate partner violence (IPV) against women and poor nutritional status are growing health problems in low and middle-income countries (LMICs). Moreover, violence against women has been shown to be associated with poor nutrition. This study investigated the relationship between IPV and nutritional status (i.e., underweight, overweight, and obesity) among women of reproductive age (15–49 years) in Zimbabwe.

Methods

Pooled data from the 2005/2006, 2010/2011, and 2015 Zimbabwe Demographic Health Surveys (ZDHS) on 13,008 married/cohabiting women were analysed. Multinomial logistic regression models were used to examine the associations between the various forms of IPV and the nutritional status of women. We further estimated the prevalence of BMI ≥ 25.0 kg/m2 (overweight and obesity) by intimate partner violence type.

Results

The mean BMI of women was 24.3 kg/m2, more than one-fifth (24%) were overweight and about 12% were obese. Forty-three percent (43%) of women reported to have ever experienced at least one form of intimate partner violence. More than one-third (35%) of women who reported to have ever experienced at least one form of intimate partner violence had a BMI ≥ 25.0 kg/m2 (p< 0.01). Relative to normal weight, women who had ever experienced at least one form of IPV (i.e., physical, emotional, or sexual) were more likely to be obese (aOR = 2.59; 95% CI = 1.05–6.39). Women’s exposure to any form of intimate partner violence was not significantly associated with the likelihood of being underweight or overweight relative to normal weight.

Conclusions

The study findings show that women of reproductive age in Zimbabwe are at high risk of both IPV and excess weight. Moreover, we found a positive relationship between exposure to at least one form IPV and obesity. Public health interventions that target the well-being, empowerment and development of women are needed to address the complex issue of IPV and adverse health outcomes, including obesity.

Coping strategies and perceived barriers of women hospitality workplace employees to sexual harassment in Bahir Dar city, Ethiopia: a grounded theory approach

Background

Coping depicts how people detect, appraise, deal with, and learn from stressful encounters. Applying preferred coping strategies in various situations makes the issue a persistent agenda in hospitality workplaces, where women are unduly victims of sexual harassment. Thus, this study aimed to develop a context specific and data-driven coping strategy framework and barriers to coping strategy mechanisms for sexual harassment victimisation against women working in hospitality workplaces.

Methods

A qualitative, grounded theory approach was used. Data were collected from female employees, managers, cashiers, and customers. Semi-structured focus-group discussions and in-depth interview guides were employed. A constant comparative approach was used to describe the meanings and summarise the data. Data were coded, categorised, and networks were visualised using the ATLAS ti version 8.4.24 software package.

Results

In this study, six focus group discussions, ten in-depth interviews, and thirteen key informant interviews were conducted. The provided context specific coping strategic framework consists of four strictly interconnected dimensions with corresponding barriers practised by female hospitality employees. These were normalisation, engagement, help-seeking, and detachment. The normalisation dimension encompasses silence, acceptance, denial, refusal, grief, and tolerance. Confrontation, negotiation, retaliation/threatening, and discrimination of the perpetrators were included in the engagement dimension. Elements such as discussing with friends, complaining with supervisors, consulting professionals, and accusing perpetrators were in the help-seeking dimension. Lastly, job-hopping, job withdrawal, work withdrawal, and distancing were in the detachment dimension. Some barriers deterred all dimensions, some factors facilitated normalisation, and some adverse outcomes ended the engagement dimension.

Conclusion

Our study demonstrated that the coping capacities of sexual harassment among female hospitality employees have been apparent, providing space for stakeholders to intervene. Our new coping strategy framework can serve as a valuable guide for designing context-specific interventions. These interventions could help women and stakeholders prevent sexual harassment, decrease barriers, and alleviate these effects.

Psychosocial Impacts of the COVID-19 Quarantine: A Study of Gender Differences in 59 Countries

Background and Objectives: There is strong evidence in the literature that women experience psychological disorders at significantly higher rates than men. The higher rates of psychological disorders in women may partly be attributable to gender differences in response to stressors and coping styles. The objective of this study was to contribute to the growing body of literature investigating gender differences in mental health outcomes and coping styles during the coronavirus disease 2019 pandemic in a large sample of individuals from 59 countries with variable demographic and socio-cultural characteristics. Materials and Methods: Survey data were collected from the general population following a snowball sampling method, and the survey was promoted through social media platforms and mailing lists. Participants included 6882 individuals from the general population from 59 countries around the world. A combination of both standardized and adapted measures was used to create a survey, originally in English and then translated to Spanish, Italian, French, German, and Turkish. Results: Compared with men, women presented with higher levels of trauma-related distress; had a harder time decompressing; were more depressed, anxious and stressed; showed decreased frustration tolerance and reported lower quality of sleep and an increased likelihood of taking sleep medication or other natural sleep remedies. Overall, women tended to be more vulnerable during the pandemic in developing symptoms consistent with various forms of mental disorders such as depression, anxiety and post-traumatic distress. However, they also were more likely than men to use a variety of adaptive coping strategies, including concentrating on doing something about the situation and getting emotional support from others. Conclusions: A high prevalence of mood symptoms was noted among women. In addition to meeting the physical health needs of the population, emphasis needs to be given to mental health and the prevention of psychiatric disorders, particularly in women.

Intimate Partner Sexual Violence Among Canadian University Students: Incidence, Context, and Perpetrators' Perceptions

Men's sexual violence against women is pervasive and is commonly committed against young women by intimate partners. Limited research has examined occurrence rates of intimate partner sexual violence among university students separated by various tactics and sexual acts. Using surveys with convenience samples of 142 Canadian university women and 441 Canadian university men, we examined women's self-reported intimate partner sexual violence victimization and men's self-reported perpetration rates in their most recent heterosexual intimate relationship in the past year. We examined a detailed breakdown across different tactics (i.e., verbal coercion, intoxication, and threats of harm/physical force) and sexual acts (i.e., nonpenetrative sexual contact; oral, vaginal, and anal penetration). Thirty-three percent of women reported at least one victimization experience, and 16% of men reported at least one perpetration experience. The most common tactic reported was verbal coercion for both women's victimization and men's perpetration, and the most common sexual act reported was vaginal penetration for women's victimization and oral sex for men's perpetration. We also examined contextual features and perceptions of the effects of perpetrators' most memorable incidents. These most memorable incidents often occurred either in their own or their partner's home and involved alcohol consumption. Most men reported no significant effects of their sexual violence on their relationships and sometimes normalized their behavior. We briefly discuss the implications of our results for future research and interventions.

Psychopathological Factors and Perpetration of Intimate Partner Aggression: A Multivariate Model

Using a sample of 1,190 married Spanish community couples in opposite-sex relationships, this study evaluated a path analytic model exploring the associations between individual and dyadic factors and partner aggression for both males and females. Specifically, the perpetrator's report of their individual mental health symptomatology (borderline and antisocial traits, alcohol use), their report of relationship quality, and their report of perpetration were modeled to predict their partner's victimization. The resultant model exhibited good fit as measured by multiple indices for both male-to-female and female-to-male perpetration. Furthermore, results demonstrated that antisocial and borderline traits were associated with each other, that alcohol use was associated with perpetration, and that one partner's perpetration was associated with his or her partner's victimization for both males and females. However, the pattern of significant pathways between individual pathology and relationship violence differed somewhat for male-to-female and female-to-male aggression. Given the results, policy makers concerned about prevention of partner aggression may consider interventions aimed at symptoms associated with antisocial and borderline traits and substance use, and may identify differential targets for intervention based on the perpetrator's gender.

Trends in prevalence and correlates of intimate partner violence against women in Zimbabwe, 2005-2015

BACKGROUND

Intimate partner violence (IPV) is a widespread problem affecting all cultures and socioeconomic groups. This study explored the trends in prevalence and risk factors associated with IPV among Zimbabwean women of reproductive age (15-49 years) from 2005 to 2015.

METHODS

Data from the 2005/2006, 2010/2011 and 2015 Zimbabwe Demographic and Health Survey (ZDHS) on 13,409 women (survey year: 2005/2006; n = 4081), (survey year: 2010/2011; n = 4411) and (survey year: 2015; n = 4917) were analyzed. Multiple logistic regressions and hierarchical modelling techniques were applied to examine the associations between demographic characteristics, socioeconomic status, media exposure and IPV against women. We further estimated IPV prevalence by type (physical, sexual and emotional) over time.

RESULTS

The prevalence of IPV decreased from 45.2% in 2005 to 40.9% in 2010, and then increased to 43.1% in 2015. Some of the risk factors associated with IPV were younger age, low economic status, cohabitation and rural residence. Educational attainment of women was however not significantly associated with IPV.

CONCLUSIONS

The findings indicate that women of reproductive age are at high and increasing risk of physical and emotional violence. There is thus an urgent need for an integrated policy approach to address the rise of IPV related physical and emotional violence against women in Zimbabwe.

Sexual assault victimization and psychopathology: A review and meta-analysis

Sexual assault (SA) is a common and deleterious form of trauma. Over 40years of research on its impact has suggested that SA has particularly severe effects on a variety of forms of psychopathology, and has highlighted unique aspects of SA as a form of trauma that contribute to these outcomes. The goal of this meta-analytic review was to synthesize the empirical literature from 1970 to 2014 (reflecting 497 effect sizes) to understand the degree to which (a) SA confers general risk for psychological dysfunction rather than specific risk for posttraumatic stress, and (b) differences in studies and samples account for variation in observed effects. Results indicate that people who have been sexually assaulted report significantly worse psychopathology than unassaulted comparisons (average Hedges' g=0.61). SA was associated with increased risk for all forms of psychopathology assessed, and relatively stronger associations were observed for posttraumatic stress and suicidality. Effects endured across differences in sample demographics. The use of broader SA operationalizations (e.g., including incapacitated, coerced, or nonpenetrative SA) was not associated with differences in effects, although including attempted SA in operationalizations resulted in lower effects. Larger effects were observed in samples with more assaults involving stranger perpetrators, weapons, or physical injury. In the context of the broader literature, our findings provide evidence that experiencing SA is major risk factor for multiple forms of psychological dysfunction across populations and assault types.

Quality of Women's Lives in India: Some Findings from Two Decades of Psychological Research on Gender

Research on gender is being increasingly recognized as critical to accomplishing the goals of societal development. This article reviews the engagement of psychological research in India with issues of gender over the last two decades in particular and the consequent production of knowledge about quality of women's lives. Three significant areas of inquiry can be identified: the work—family interface; mental health experiences; and violence against women. The work—family linkage among urban middle-class women is vigorously pursued in mainstream psychological research reflective of a sample bias. Mental health and domestic violence, on the other hand, are areas of research emanating from the cross-disciplinary engagement between academics and advocacy groups and characterized by a critical women's studies perspective, calling attention to the power relations that are disempowering forces in women's lives.

Mexican American Women’s Definitions of Rape and Sexual Abuse

Focus group approach was used to explore concepts related to rape and sexual abuse among 17 Mexican immigrant women living in rural Arizona. The women discussed definitions of various forms of unwanted sexual experiences, their personal knowledge of someone who had been raped or sexually abused, and their perceptions of the roots of sexual abuse. Distinctions between rapto and violación, child versus adult rape (including marital rape), motivations for rape, and social factors contributing to victim silencing were identified. The meaning and perceived impact of rape reflected the gender relations of the culture. Keeping silent was a consistent theme, underscoring the difficulties of accurately assessing rape prevalence in Latinas. Research, prevention, intervention, and treatment programs need to recognize the social context and impact of rape and be designed accordingly. Participants reported many rape experiences, suggesting that underreporting is a major problem in estimating rape prevalence for Latinas.

Sexual Victimization in Relation to Perceptions of Risk: Mediation, Generalization, and Temporal Stability

There is evidence that personal experience with trauma is associated with increases in both personal and comparative risk perception. This study investigates this relation in terms of sexual victimization among women, focusing on three potential mediators: perceived control over sexual assault, perceived similarity to a typical sexual assault victim, and psychological distress. Mediational analyses were investigated using structural equation modeling. Although victimization experience was not related to comparative risk perception, it was associated with greater personal risk perception. This relation was mediated by perceived similarity to a typical sexual assault victim. Prospective analyses indicated that personal risk perception does change in response to sexual victimization but also indicated that heightened risk perception may be an accurate assessment of risk that actually precedes victimization experience. Implications for the meaning of perceived similarity and perceptions of risk for sexual assault victims are discussed.

Fear of Rape

This study examines the magnitude and prevalence of fear of crime as a function of seriousness and probability of occurrence among Greek university students aged 17 to 29. The findings show that fear of rape is the greatest fear of almost all young Greek women, greater than the fear of other serious offenses such as murder. This finding is interpreted in light of rape's reported likelihood in conjunction with its reported seriousness. Further, the precautionary measures show an avoidance pattern in Greek women toward crimes requiring them to physically defend themselves. The study's findings are similar to those reported in other countries and in line with the feminist claim regarding the universality of the fear of rape in the daily life of young women. Discussion includes explanations of high fear in terms of physical and social vulnerability and as a possible reflection of hidden violence against Greek women.

High Rape Chronicity and Low Rates of Help-Seeking Among Wife Rape Survivors in a Nonclinical Sample

Research on sexual assault experiences and outcomes has not consistently reported analyses by victim/offender relationship and has not provided much detail on sexual assaults by husbands and ex-husbands. National Crime Victimization Survey data were analyzed to examine sexual assault chronicity and help-seeking behaviors among survivors of marital, acquaintance, and stranger sexual assault. Marital sexual assault survivors were significantly more likely than acquaintance and stranger survivors to experience multiple assaults, with many marital survivors experiencing more than 10 assaults in a 6-month period. The marital group was also less likely to seek medical, police, or agency help. Implications for research and practice are discussed.

The Global Health Burden Of Rape

Women's rights to be free from male violence are now recognized by the United Nations as fundamental human rights. Two parallel transformations in the understanding of rape have been central to the international effort to achieve this declaration. The first is increased recognition of the extent to which rape typically involves intimates. The second is the shift from regarding rape as a criminal justice matter towards an appreciation of its implications for women's health. The focus of this paper is the health burden of rape, which is addressed from the global perspective and includes discussion of its prevalence and psychological, sociocultural, somatic, and reproductive health consequences. Quantitative efforts to capture the relative economic impact of rape compared to other threats to women's health are also discussed. The paper concludes with an agenda for future research on rape that could enrich activists' efforts on behalf of women's health and development.

Self-injurious behaviors in posttraumatic stress disorder: an examination of potential moderators

BACKGROUND

Despite increasing evidence for a relation between posttraumatic stress disorder (PTSD) and self-injurious behaviors (SIB), limited research has examined the factors that may moderate the associations between PTSD and both nonsuicidal SIB (deliberate self-harm; DSH) and suicidal SIB (suicide attempts). Nonetheless, research suggests that characteristics of the traumatic event, co-occurring borderline personality disorder (BPD), and emotion dysregulation may influence the relations between PTSD and SIB.

METHODS

Thus, the aim of this study was to examine the moderating role of these factors in the association between PTSD and SIB (including history and frequency of DSH and suicide attempts, and DSH versatility) among a sample of substance use disorder inpatients with (n=116) and without (n=130) a history of PTSD.

RESULTS

Results from stepwise regression analyses indicate that sexual assault-related PTSD predicted suicide attempt frequency and DSH versatility among those with PTSD. Furthermore, results from hierarchical linear and logistic regression analyses suggest that co-occurring BPD moderates the relationship between PTSD and both DSH history and versatility and emotion dysregulation moderates the relationship between PTSD and DSH frequency. Specifically, the relations between PTSD and DSH outcomes were stronger among participants with co-occurring BPD and higher levels of emotion dysregulation.

LIMITATIONS

This study is limited by its reliance on cross-sectional, self-report data.

CONCLUSIONS

Despite limitations, findings suggest distinct risk factors for suicide attempts and DSH, and highlight the importance of examining characteristics of the trauma and associated BPD and emotion dysregulation in assessing risk for SIB in PTSD.

Psychiatric evaluation of women who were assisted at a university referral center in Campinas, Brazil, following an experience of sexual violence

OBJECTIVE

To present the sociodemographic characteristics and psychiatric symptoms of women who have been raped.

METHODS

Between 2006 and 2010, a retrospective study was conducted of 468 women who underwent psychiatric evaluation at a university referral center in Brazil after an experience of sexual violence.

RESULTS

The women had a mean age of 24.1 years; were predominantly white, unmarried, childless, and employed; had 9-11 years of education; and had a religion. Rape was the first sexual intercourse for 124 (26.8%) of 462 for whom data were available; 53 (13.6%) of 389 had a personal history of sexual violence and 29 (8.0%) of 361 had a family history. No psychiatric symptoms were reported in 146 (32.9%) of 444 women, mild/short-term symptoms were reported in 107 (24.1%), and a psychiatric diagnosis was made for 191 (43.0%). Psychiatric comorbidity was seen in 59 (12.6%) women, and 174 (38.0%) received pharmacologic treatment. All follow-up consultations were attended by 215 (45.9%) of 468 women; 166 (35.5%) attended some, and 87 (18.6%) attended only one during the 6-month follow-up period.

CONCLUSION

The frequency and severity of psychiatric symptoms and mental disorders among women who have been raped highlights the importance of mental health monitoring.

Moving forward by looking back: reflecting on a decade of CDC's work in sexual violence prevention, 2000-2010

In 2011, the Division of Violence Prevention (DVP) within CDC's Injury Center engaged an external panel of experts to review and evaluate its research and programmatic portfolio for sexual violence (SV) prevention from 2000 to 2010. This article summarizes findings from the review by highlighting DVP's key activities and accomplishments during this period and identifying remaining gaps in the field and future directions for SV prevention. DVP's SV prevention work in the 2000s included (1) raising the profile of SV as a public health problem, (2) shifting the field toward a focus on the primary prevention of SV perpetration, and (3) applying the public health model to SV research and programmatic activities. The panel recommended that DVP continue to draw attention to the importance of sexual violence prevention as a public health issue, build on prior investments in the Rape Prevention and Education Program, support high-quality surveillance and research activities, and enhance communication to improve the link between research and practice. Current DVP projects and priorities provide a foundation to actively address these recommendations. In addition, DVP continues to provide leadership and guidance to the research and practice fields, with the goal of achieving significant reductions in SV perpetration and allowing individuals to live to their full potential.

Looking ahead toward community-level strategies to prevent sexual violence

The Division of Violence Prevention within CDC's National Center for Injury Prevention and Control recently undertook a systematic review of primary prevention strategies for sexual violence (SV) perpetration. This review identified the lack of community-level strategies to prevent SV as a critical gap in the literature. Community-level strategies function by modifying the characteristics of settings (e.g., schools, workplaces, neighborhoods) that increase the risk for violence victimization and perpetration. Identification of evidence-based strategies at the community level would allow implementation of ecologic approaches to SV prevention with a greater potential for reducing the prevalence of SV perpetration. The field will face several challenges in identifying and evaluating the effectiveness of promising community-level strategies to prevent SV. These challenges include limited knowledge of community-level and societal-level risk factors for SV, a lack of theoretical or empirical guidance in the SV literature for identification of promising community-level approaches, and challenges in evaluating SV outcomes at the community level. Recognition of these challenges should guide future research and foster dialogue within the SV prevention field. The development and evaluation of community-level approaches to SV prevention represent a vital and logical next step toward the implementation of effective, multilevel prevention efforts and a population-level reduction in the prevalence of SV.

[Physical violence during pregnancy in Morocco]

INTRODUCTION

Physical abuse are a serious social problem and an issue of perinatal health.

MATERIAL AND METHODS

This article presents the results of a survey conducted at the CHU Ibn Rochd of Casablanca (Morocco), over a period of one year, in order to determine their frequency, risk factors, maternal diseases and obstetric complications.

RESULTS

The results of our survey found that women who reported physical abuse have a frequency of 12.3% (107 cases). The average age of these women is 22.3 years; 65.6% of parturients are illiterate, 45% are from a disadvantaged socioeconomic status, 47% originated from a rural county; 37% are unmarried; half of the abused are multiparous with an average of 3.2 living children; 23% of the pregnancies are unplanned. Lastly, 37.3% of pregnant partners are unemployed and 67% have toxic habits. Obstetric complications are fairly frequent and mental effects are not negligible with 3 attempted suicides and attempted homicide.

CONCLUSION

Early identification of abuse suffered by pregnant women and taking measures to prevent them could reduce the occurrence of these adverse effects.

Acceptance of sexual aggression myths in a representative sample of German residents

A representative sample of German residents (N = 5397) was surveyed with the aim of studying their acceptance of contemporary rape myths (RMA), using items from the Acceptance of Modern Myths About Sexual Aggression Scale [AMMSA; Gerger et al., 2007] in relation to demographic variables (e.g., gender, age), intolerant belief systems (e.g., sexism, islamophobia), the ideologies of rightwing authoritarianism (RWA), and social dominance orientation (SDO), as well as gender identification. Age showed a U-shaped relationship with RMA, whereas gender was unrelated to RMA. For men (women), greater identification with their gender was associated with higher (lower) RMA. Substantial correlations of RMA with intolerant belief systems support the idea of a schema of intolerance. Although RWA and SDO were both related to RMA, only RWA explained unique variance beyond the effects of intolerant belief systems. Results are discussed in comparison to prior studies using mainly student samples.

Violence as a Public Health Risk

Violence is a public health problem that affects people of all ages. In 2007, violence was one of the top 10 leading causes of death in the United States for people from birth to age 64 years. Violence takes many forms, such as child maltreatment, intimate partner violence, sexual violence, self-directed violence, and youth violence. Violence may be best understood and prevented through a public health approach. A focus is placed on preventing violence before it occurs (primary prevention), employing a scientific approach to understand the problem and what action can be taken to prevent it, taking a population perspective that places an emphasis on broad-based changes in communities and society that benefit the largest number of people, and working across sectors (eg, health, justice, education) and integrating knowledge from multiple disciplines (eg, epidemiology, psychology, sociology, medicine). In this article, the authors review the incidence and burden of different forms of violence and the factors that place people at risk for, or protect people from, experiencing violence either as a victim or as a perpetrator. The authors also review strategies based on the best available evidence that may be implemented to prevent violence from occurring, highlighting violence prevention tools for health practitioners. By understanding the burden of violence, the factors that place people at risk for and protect people from experiencing violence, and strategies that can prevent and interrupt violence, health practitioners can play a more active role in enhancing the health and safety of their patients.

Prevalence and consequences of adult sexual assault of men: review of empirical findings and state of the literature

Male victims of adult sexual assault (ASA) are understudied as compared with female victims. Further, commonly-held myths about sexual assault suggest that men cannot be victims or that, if men are victims, they are relatively physically and emotionally unharmed by sexual assault. The goal of this paper was to systematically review the empirical literature on ASA among men to evaluate the veracity of these myths. This paper also sought to examine the methodological quality of the body of research in this area, identify limitations and gaps in the current literature, and suggest directions for future research. Eighty-seven relevant studies were identified through a systematic review of the literature. The reported prevalence of men's sexual aggression varied widely depending on the methods used and the population studied; some populations (e.g., veterans, prison inmates, and gay and bisexual men) reported higher rates of ASA than men in the general population. Few studies have systematically examined the consequences of male ASA; however, those that have suggest that ASA can have notable adverse physical and psychological consequences for some men.

Eliminating the battering of women by men: Some considerations for behavior analysis

Based on review of representative literature, history and current research indicate that battering by male partners is a major health problem for women. Use of physical aggression and verbal coercion can be described by three-term contingencies involving escape, avoidance, punishment, and positive reinforcement. These contingencies occur within societal practices, rules, and models that involve oppression of women and insubstantial consequences for men who batter. The difficulties in directly observing a couple's interactions and their aggression have been a methodological barrier to the involvement of behavior analysts in treatment of and research on domestic violence. Recommendations are made for behavior analysts to contribute to reducing battering through development and analysis of program components and application of contingency management and behavioral training technology.

Motivational interviewing with perpetrators of intimate partner abuse

Recent controlled trials have shown promising benefits of motivational interviewing (MI) as a pretreatment intervention for perpetrators of intimate partner violence (IPV). A 2-session intake, containing motivational interviewing and structured assessment feedback, was developed for this predominantly court-mandated clientele. The goals were to reduce initial hostility toward treatment, facilitate verbalization of motivation to change, resolve ambivalence, and increase receptivity to structured group therapy for IPV. An extended case report illustrates the value of MI spirit and techniques, including empathic reflection, evocative questions, affirmation, and rolling with resistance, in achieving these intervention goals.

An ecological model of the impact of sexual assault on women's mental health

This review examines the psychological impact of adult sexual assault through an ecological theoretical perspective to understand how factors at multiple levels of the social ecology contribute to post-assault sequelae. Using Bronfenbrenner's (1979, 1986, 1995) ecological theory of human development, we examine how individual-level factors (e.g., sociodemographics, biological/genetic factors), assault characteristics (e.g., victim-offender relationship, injury, alcohol use), microsystem factors (e.g., informal support from family and friends), meso/ exosystem factors (e.g., contact with the legal, medical, and mental health systems, and rape crisis centers), macrosystem factors (e.g., societal rape myth acceptance), and chronosystem factors (e.g., sexual revictimization and history of other victimizations) affect adult sexual assault survivors' mental health outcomes (e.g., post-traumatic stress disorder, depression, suicidality, and substance use). Self-blame is conceptualized as meta-construct that stems from all levels of this ecological model. Implications for curbing and/or preventing the negative mental health effects of sexual assault are discussed.

[Impact of moment of disclosure of a sexual assault on certain affective and relational aspects of adult victims]

This study examines if the timing of disclosure (early or late) of a sexual assault and if the romantic partner's participation in the study have an impact on relational and affective aspects of the victims at Time 1 (initial interview) and Time 2 (4 months later). The sexual assault occurred to victims (N = 27) between 1 month to 7 years prior to the first assessment interview. Twenty-six percent of victims were diagnosed with posttraumatic stress disorder (PTSD). Descriptive analyses indicate a difference between timing of disclosure and romantic partner's participation in the assessment process of the study. All victims indicate that they have received more emotional support at the second assessment in the study, whether they have disclosed the aggression early or lately. Victims have disclosed the assault early reported more depressive symptoms.

Gender-based violence: concepts, methods, and findings

The United Nations has identified gender-based violence against women as a global health and development issue, and a host of policies, public education, and action programs aimed at reducing gender-based violence have been undertaken around the world. This article highlights new conceptualizations, methodological issues, and selected research findings that can inform such activities. In addition to describing recent research findings that document relationships between gender, power, sexuality, and intimate violence cross-nationally, it identifies cultural factors, including linkages between sex and violence through media images that may increase women's risk for violence, and profiles a host of negative physical, mental, and behavioral health outcomes associated with victimization including unwanted pregnancy and abortion. More research is needed to identify the causes, dynamics, and outcomes of gender-based violence, including media effects, and to articulate how different forms of such violence vary in outcomes depending on cultural context.

Validation of the Sexual Assault Symptom Scale II (SASS II) using a panel research design

To examine the utility of a self-report scale of sexual assault trauma, 223 female victims were interviewed with the 43-item Sexual Assault Symptom Scale II (SASS II) at 1, 3, 7, 11, and 15 months postassault. Factor analyses using principal-components extraction with an oblimin rotation yielded 7 common factors with 31 items. The internal consistency was high for 4 factors and moderate for 2 factors. The multitrait-multimethod matrix, correlating the factor subscale scores of self-reported trauma and clinical assessment ratings, demonstrated both convergent and discriminant validity, indicating that the SASS II has construct validity. Correlations between the SASS II subscales and the intrusion subscale of the Impact of Events Scale also indicated the convergent and discriminant validity of the SASS II. Significant positive correlations between current and prior trauma levels further evidence the validity of the SASS.

Information processing of sexual abuse in elders

Sexual abuse is considered to be a pandemic contemporary public health issue, with significant physical and psychosocial consequences for its victims. However, the incidence of elder sexual assault is difficult to estimate with any degree of confidence. A convenience sample of 284 case records were reviewed for Post-Traumatic Stress Disorder (PTSD) symptoms. The purpose of this paper is to present the limited data noted on record review on four PTSD symptoms of startle, physiological upset, anger, and numbness. A treatment model for information processing of intrapsychic trauma is presented to describe domain disruption within a nursing diagnosis of rape trauma syndrome and provide guidance for sensitive assessment and intervention.

Spousal Abuse Against Women and Its Consequences on Reproductive Health: A Study in the Urban Slums in Bangladesh

OBJECTIVES

Spousal violence is common and results in costly problems both for society and for the reproductive health of women. Despite the recognition that violence may be associated with serious consequences for women's reproductive health, our understanding of the relationship between the two remains limited. In this study, we assessed the association between spousal violence and women's reproductive health.

METHODS

Data from an interviewer-administered questionnaire assessing socioeconomic, demographic, behavioral profiles, and spousal violence-related information was collected from 496 women. Subjects were chosen from eight randomly selected urban slums from four metropolitan cities.

RESULTS

Spousal violence was significantly higher amongst the group of less educated women who had been in several marriages; indicating that the social and behavioral traits of women act as catalysts for spousal violence. Abusive husbands also had been married several times and were more likely to be addicted to alcohol or drugs. This demonstrates that the behavioral traits of husbands were also responsible for spousal violence. Spousal violence injuries adversely affect the health and well-being of women. More than three-quarters of physically violated women suffered injuries as a result of this violence. About 50% of these injuries were minor and about 10% serious. Sexual violence adversely affected women's health; more than 80% of sexually violated women complained of pelvic pain, more than 50% reported reproductive tract infections, and more than 50% reported symptoms of irritable bowel syndrome. Abused women suffered from gynecological problems at the time of pregnancy significantly more than non-abused women (p<0.05) and abused women suffered from reproductive tract infections significantly more than non-abused women (p<0.01). Abusive husbands suffered from sexually transmitted diseases (STD) significantly more than non-abusive husbands (p<0.05). Abused women used contraception significantly less than non-abused women (p<0.01). Logistic regression analysis suggested that spousal violence was the most important contributing factor for reproductive health problems in women.

CONCLUSIONS

The findings of this study may enhance our understanding of the impact of spousal violence against women and their reproductive health and therefore highlight the importance of spousal violence prevention measures. Increasing the awareness and understanding of the relationship between violence against women and reproductive health could be achieved if lawyers, researchers, clinicians, practitioners, and government workers from multiple disciplines and agencies worked together.

The relationship between posttraumatic stress disorder and self-reported health problems

OBJECTIVE

There is increasing awareness that posttraumatic stress disorder (PTSD) influences physical health. The current study used the National Comorbidity Survey (NCS) data to determine if the physical health risk imparted by PTSD was an artifact of a broad range of empirically identified confounding variables.

METHODS

Participants (n = 5877) were administered a modified version of the DSM-III-R PTSD module from the Diagnostic Interview Schedule (DIS). The prevalence of 14 classes of physical disorders was assessed along with six groups of variables predictive of negative health outcomes (demographics, perception of health, stress, health-related behaviors, insurance coverage, trauma/psychiatric history, and neuroticism).

RESULTS

The PTSD group had a higher frequency of most disorders and scored higher on variables predictive of negative health outcomes. To determine if the health risk imparted by PTSD was an artifact of these confounding variables, a mixed direct-sequential binary logistic regression was computed. After controlling for sex, health perceptions, stress, health-related behaviors, insurance coverage, total trauma exposure, total number of psychiatric diagnoses, and neuroticism, persons with PTSD were more likely to report the presence of a disorder.

CONCLUSIONS

Previous scholars have noted that PTSD could affect health outcomes. This study found that after controlling for a wide range of variables predictive of poor health, PTSD was predictive of poor health.

Domestic violence against women in Egypt--wife beating and health outcomes

Research has consistently demonstrated that a woman is more likely to be abused by an intimate partner than by any other person. Many negative health consequences to the victims have been associated with domestic violence against women. Data from the 1995 Egyptian Demographic and Health Survey, a nationally representative household survey, were analyzed for 6566 currently married women age 15-49 who responded to both the main questionnaire and a special module on women's status. Multivariate logistic regressions were used to examine the association of ever-beating, beating in past year or frequency of beatings in past year with contraceptive use, pregnancy management, and report of health problems. Thirty-four percent of women in the sample were ever beaten by their current husband while 16% were beaten in the past year. Ever-beaten women were more likely to report health problems necessitating medical attention as were women beaten in the past year compared to never-beaten women. Regarding reproductive health, higher frequency of beating was associated with non-use of a female contraceptive method, while ante-natal care (ANC) by a health professional for the most recent baby born in the past year was less likely among ever-beaten women (OR = 0.17, p < 0.05). Unexpectedly, among professional ANC patients, those ever-abused were more likely to make four or more visits (OR = 36.54, p < 0.05). In Egypt as elsewhere around the world, wife beating is related to various negative health outcomes. Women's programmes must take domestic violence into account if they want to better address the needs of a non-negligible proportion of their target population.

Differences in psychological health and family dysfunction by sexual victimization type in a clinical sample of African American adolescent women

We examined levels of sexual victimization among a sample of 249 14- to 19-year-old African American adolescent women. Victimization was common: 32.1% reported having been raped, 33.7% had experienced sexual coercion, and 10.8% reported an attempted rape. Only 23.4% had never been victimized. We investigated whether levels of psychological health and family dysfunction varied as a function of the type of sexual victimization. Girls who had been raped had lower levels of self-esteem and mastery and higher levels of depression compared to girls who reported no sexual victimization. Significantly higher levels of family cohesion and significantly lower levels of family support were reported by girls who had been raped versus girls who reported no sexual victimization. These findings are a starting point for future studies by providing evidence that levels of mental health and family dysfunction vary by the type of sexual victimization experienced.

What would MacGyver do? The meaning(s) of resistance and survival

Drawing on interviews conducted with victims of New Zealand serial rapist, Malcolm Rewa, this article highlights the limitations of the terms resistance and survival as they are typically applied to women's responses to rape attacks. Although acknowledging that formulations that stress women's abilities to resist and their capacities to survive have been critically important in challenging popular notions of women as passive victims, the women's accounts presented here suggest a need to question whether such formulations are adequate to reflect the complexity and diversity of women's responses to sexual assaults. A preliminary attempt is also made to explore the implications associated with embracing expanded understandings of what resistance and survival might mean.

The role of insecure attachment and gender role stress in predicting controlling behaviors in men who batter

The authors hypothesized that masculine gender role stress would mediate the relationship between insecure attachment and controlling behaviors in a sample of men who batter. To examine this hypothesis,143 men who were court mandated to attend a batterers' intervention program in a northeastern state completed measures including the Controlling Behavior Index, the Gender Role Stress Scale, the Relationship Questionnaire, and the Marlowe-Crowne Social Desirability Scale. After controlling statistically for social desirability, results indicated that both fearful attachment and gender role stress significantly predicted controlling behaviors, with gender role stress partially mediating the relationship between fearful attachment and controlling behaviors. The discussion focuses on the importance of understanding partner abuse through a gendered context.