Contextualizing rape: Reviewing sequelae and proposing a culturally inclusive ecological model of sexual assault recovery

Sexual Victimization Outcomes and Adjustment Among Bisexual Women: A Review of the Quantitative Literature

Bisexual women experience worse mental health outcomes than lesbian and heterosexual women, which may be explained by greater rates of sexual violence among bisexual women. The current comprehensive literature review aimed to synthesize research on mental health and substance use outcomes related to lifetime sexual violence among bisexual women. A comprehensive literature search was conducted within the PsycINFO and Medline databases (final search conducted in August, 2021). Inclusion criteria required articles to examine a mental health or substance use correlate/outcome of lifetime sexual victimization experiences among bisexual women. Fifteen studies met inclusion criteria and were reviewed. Results indicate that there are significant gaps in this literature, including limited research on psychological distress outcomes. Most notably, there is a limited focus on the experiences of bisexual women specifically and the role of bisexual minority stress. Findings indicate that lifetime sexual victimization experiences are linked with increased posttraumatic stress, depression, and alcohol (and other substance) use and consequences. It appears that bisexual women are vulnerable to cumulative victimization, which may further exacerbate outcomes. Clinicians working with bisexual women should provide bisexual-affirmative care, help bisexual women access positive social supports, and build more effective coping strategies for managing post-trauma distress. Future research on outcomes of violence among bisexual women would benefit from contextualizing adjustment following sexual assault within a bisexual minority stress-informed approach for a more comprehensive understanding of this process.

An ecological approach to understanding the impact of sexual violence: a systematic meta-review

Aim

A systematic meta-review was conducted to examine (1) the broad range of negative and positive individual and interpersonal changes following adult sexual violence, as well as (2) the risk/protective factors at multiple levels of the social ecology (e.g., individual, assault, and micro/meso/exo/macro/chronosystem factors)-influencing the impact of sexual violence.

Methods

Searches of Web of Science, Pubmed, and ProQuest resulted in inclusion of 46 systematic reviews or meta-analyses. Review findings were extracted for summary and a deductive thematic analysis was conducted.

Results

Experiencing sexual violence is associated with many negative individual and sexual difficulties as well as revictimization risk. Only a limited number of reviews reported on interpersonal and positive changes. Factors at multiple levels of the social ecology play a role in the intensity of these changes. Reviews including macrolevel factors were non-existent, however.

Conclusion

Reviews on sexual violence are fragmented in nature. Although the use of an ecological approach is often lacking, adopting such a perspective in research is necessary for a fuller understanding of the multiple influences on survivor outcomes. Future research should evaluate the occurrence of social and positive changes following sexual violence, as well as the role of macrolevel factors in influencing post-assault outcomes.

The Role of Social Reactions to Disclosures in the Relationship Between Sexual Assault Acknowledgment and Psychological Symptoms

Following a sexual assault, women experience a host of negative psychological consequences. While some survivors label their sexual assault experience as such (i.e., are acknowledged survivors), other survivors do not. The effect of acknowledgment of sexual assault on postassault outcomes has yielded mixed findings. It was hypothesized that social reactions may account for the relationship between acknowledgment status and psychological symptoms. Results indicated that acknowledged survivors reported more severe posttraumatic stress disorder symptoms, which were partially accounted for by turning against social reactions. Future studies should explore the mechanisms responsible for these relationships and analyze the individual social reactions.

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.

Social Movement and Mental Health of South Korean Women Sexual Violence Survivors, 2012-2019

Objectives. To examine whether the #MeToo movement influenced depressive symptoms among women in South Korea with a history of experiencing sexual violence. Methods. We used data from a nationally representative sample (n = 4429) of women 19 to 50 years of age who participated in the Korean Longitudinal Survey of Women and Families between 2012 and 2019. A difference-in-differences model was used to estimate within-person changes in depressive symptoms attributable to the #MeToo movement across women with and without a history of experiencing sexual violence. Depressive symptoms were measured with the Center for Epidemiologic Studies Depression Scale (CESD). Results. After adjustment for potential confounders, the #MeToo movement led to a 1.64 decrease in CESD scores among women with a history of experiencing sexual violence relative to women without such a history. Conclusions. Our findings suggest that the #MeToo movement in Korea led to reduced depressive symptoms among women with a history of experiencing sexual violence. Public Health Implications. Despite the progress of the #MeToo movement, there are still judicial and institutional problems that can revictimize sexual violence survivors. Further policy changes will likely improve the mental health of survivors. (Am J Public Health. 2022;112(9):1337-1345. https://doi.org/10.2105/AJPH.2022.306945).

Trauma History as a Significant Predictor of Posttraumatic Growth Beyond Mental Health Symptoms in Women-Identifying Survivors of Undergraduate Non-Consensual Sexual Experiences

There is little data on what influences posttraumatic growth for women who experienced non-consensual sexual contact (NCSC) as an undergraduate college student. The purpose of this study is to garner a better understanding of posttraumatic growth among women-identifying survivors of undergraduate NCSC by addressing the following aims: 1) evaluate the mediating role of NCSC-related shame on the relationship between perceived peer rape myth acceptance and posttraumatic growth (n = 174); and 2) evaluate the shared and independent variance contributions of mental health symptoms and trauma history clusters on posttraumatic growth (n = 151).NCSC-related shame did not mediate the relationship between perceived peer rape myth acceptance and posttraumatic growth. Mental health symptoms and trauma history significantly contributed to 35.27% of posttraumatic growth variance, with the trauma history cluster significantly influencing posttraumatic growth scores beyond mental health symptoms. Based on these findings, it is important that clinicians assess for a history of trauma and the impact of that trauma in addition to mental health symptoms when trying to understand posttraumatic growth after campus sexual violence.

Trauma-Informed Sex Positive Approaches to Sexual Pleasure

This paper develops a trauma-informed sex-positive framework as a public health, clinical, and research approach to sexual experience over the life course. The framework centers trauma-informed sex positivity as the linkage for sexual pleasure (along with sexual wellbeing and sexual health) to the social, cultural, and legal concepts of sexual justice. By providing a conceptual distinction of sexual pleasure from sexual wellbeing and sexual health, the framework improves clarity about how these constructs are related as well as provides possibilities for detailed operationalization in public health surveillance and in the new research.

The impact of sociocultural contexts on mental health following sexual violence: A conceptual model

OBJECTIVE

Sexual violence has substantial mental health effects on survivors around the globe. Although there has been increasing attention to the ways that sociocultural environments can affect survivors' recovery, there has been no review to our knowledge of the specific factors within sociocultural environments that offer risk or protection, or the mechanisms by which these factors affect recovery.

METHOD

To address this gap, we present a conceptual model supported by a theoretical and empirical review that prioritizes research conducted with ethnic minority and global samples.

RESULTS

We identify three components of global sociocultural settings-norms, structures, and environmental stressors-that may affect mental health following sexual violence. We propose that these components may affect survivors' mental health by (1) influencing how survivors themselves, survivors' social contexts, and the systems with which survivors come into contact think about and respond to sexual violence, and (2) creating additional sources of stress, burden, or protection for survivors.

CONCLUSIONS

We argue that future research, practice, and policy could have a greater effect on survivors by attending to sociocultural factors in recovery.

Trauma, social media, and #WhyIDidntReport: An analysis of twitter posts about reluctance to report sexual assault

Recent social trends regarding sexual violence and gender have included elements of "hashtag activism," which involves using social media tools for cultural awareness and change. For example, the Twitter hashtag: #WhyIDidntReport was created for survivors of sexual victimization to share their barriers to reporting. In this project, 600 tweets attached to this hashtag were analyzed using a combination of grounded theory and content analysis methods. Results were organized into a conceptual map, with a central category (power), connected to three other ecological categories (culture, community systems, and relationships) and one category of survivor experiences. Each category has subcategories which illustrate certain contextual and internal barriers to reporting assault. The model shows how these barriers intersect and interact, and often further traumatize those who have been assaulted. The model offers implications for professionals working with those who have survived sexual trauma, as well as those studying the dynamics of abuse.

Characterizing Sexual Violence in Intimate Relationships: An Examination of Blame Attributions and Rape Acknowledgment

Rape by an intimate partner frequently involves a precedence of sexual consent between victim and perpetrator, often does not include the use of physical force, and may not fit societal definitions of rape. Given these unique characteristics, women who are assaulted by an intimate partner may be less likely to acknowledge the experience as a rape. In turn, they might make fewer blame attributions toward themselves and their perpetrators than victims of rape by a nonpartner. Consistent with these expectations, results from 208 community women reporting rape in adulthood revealed the presence of indirect effects of perpetrator type (nonpartner vs. intimate partner) on both behavioral self-blame and perpetrator blame through rape acknowledgment, even when controlling for both victim substance use at the time of the assault and coercion severity. Compared with women who experienced a rape by a nonpartner, women who experienced rape in the context of a marital or dating relationship were less likely to blame themselves or the perpetrator for the assault, in part because they were less likely to label their experience as a rape. Overall, these findings highlight the unique nature of intimate partner rape and provide further information about the relatively underresearched area of sexual violence in intimate relationships.

Associations Between Sexual Assault Severity and Psychological and Physical Health Outcomes: Similarities and Differences Among African American and Caucasian Survivors

There are well-established associations between sexual assault victimization and deleterious psychological and physical health outcomes. The present study contributes to the emerging health disparities literature by examining similarities and differences in relationships between the severity of the sexual assault and health in a community sample of African American and Caucasian survivors. Although the overall pattern of relationships was expected to be comparable for all survivors, some associations were hypothesized to be stronger for African American survivors as compared with Caucasian survivors based on theories of chronic stress. Single, African American, and Caucasian women were recruited for a study of dating experiences through random digit dialing in one large metropolitan area. Participants who experienced a sexual assault since age 14 were included in this study (121 African American and 100 Caucasian women). Multigroup path analyses indicated that for both African American and Caucasian survivors, sexual assault severity was significantly positively associated with posttraumatic stress disorder (PTSD) symptoms, and depressive symptoms were significantly positively associated with physical health symptoms. Among African American survivors, sexual assault severity affected physical health symptoms indirectly through its impact on depressive symptoms, and assault severity indirectly affected drinking problems through its impact on PTSD symptoms; these relationships were not found for Caucasian survivors. These findings highlight the need for additional research that focuses on health disparities in sexual assault survivors' recovery process, so that treatment programs address culturally relevant issues.

Demedicalizing the Aftermath of Sexual Assault: Toward a Radical Humanistic Approach

An entrenched assumption in the mental health field is that if left “untreated” the aftermath of sexual assault will inevitably lead to some diagnosable form of emotional distress. This assumption has focused the search for pathology on individual survivors rather than systems and led to societal pressure for medical or psychotherapeutic treatment following unwanted sexual experiences in the United States and globally. Humanistic psychology is grounded in an existential phenomenological approach that privileges agency and a sociopolitical context of lived experience. As such, it has great overlap with the social justice mission of liberation psychology and is well equipped to respond to sexual assault survivors and the oppressive and patriarchal systems that perpetuate gender-based violence. This article explores the rising use of neoliberal medicalized frameworks to respond to sexual assault in therapy, analyzing both positive and negative aspects of medicalization. Implications for responses to the global prevalence of sexual violence are discussed. Suggestions for alternative epistemic and therapeutic approaches that can be used by humanistic psychologists and that aim to enhance an appreciation for the context of survivor’s experiences are provided.

Unwanted Sexual Experiences in University Settings: Survivors' Perspectives on Effective Prevention and Intervention Strategies

Unwanted sexual incidents on university campuses pose significant public health and safety risks for students. This study explored survivors' perspectives on secondary prevention of campus sexual assault and effective strategies for intervention programs for unwanted sexual incidents in university settings. Twenty-seven student survivors of unwanted sexual experiences participated in semi-structured in-depth interviews. Data were analyzed using thematic analysis and a constructionist perspective. The findings were contextualized using the ecological model. Barriers to reporting included concerns about one's story not being believed, personal minimization of the incident, belief that no action will be taken after reporting, confidentiality concerns, and other perceived costs of reporting. Survivors provided valuable insight on potentially effective prevention and intervention strategies to address the problem of unwanted sexual incidents on university campuses. These findings may be useful for prevention and intervention policies and programs in university settings and for providers who assist survivors of unwanted sexual experiences.

An Ecological Model of Well-being After Sexual Assault: The Voices of Victims and Survivors

In this article, the authors describe factors that enhance or detract from well-being after adult sexual assault from the perspective of sexual assault victims and survivors. The authors present a holistic view of the complex ways in which women respond to and cope with the impact of adult sexual assault while trying to create a sense of well-being. The forces that facilitate or detract from well-being are organized into an ecological model. The data originate from a grounded theory study in 2015, with 22 adult female adult sexual assault victims/survivors.

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.

Up for Grabs? Sexual Objectification as a Mediator Between Women's Alcohol Use and Sexual Victimization

Sexual objectification, the tendency to reduce women to their bodies, body parts, or sexual functions for use by others, has been theorized to set the stage for more severe acts of violence but has been largely absent from the existing sexual victimization literature. The purpose of this study was to explore the role of sexual objectification in mediating the well-established link between women's alcohol use and sexual victimization. A large sample of undergraduate women ( N = 673) reported their alcohol use (frequency and quantity), experiences of sexual objectification (body evaluation and unwanted explicit sexual advances), and sexual victimization. Results indicated positive bivariate correlations among all study variables. Path analyses showed that mild forms of sexual objectification (body evaluation) mediated the link between the frequency of alcohol use and more extreme forms of sexual objectification (unwanted advances). Furthermore, the combined effect of sexual objectification (body evaluation and unwanted advances) mediated the link between alcohol use (frequency and quantity) and sexual victimization. The current findings are among the first to evaluate sexual objectification as a mechanism in the link between alcohol use and sexual victimization. Results suggest that efforts to prevent alcohol-related sexual violence may benefit from addressing sexual objectification.

Depression and PTSD in Survivors of Male Violence: Research and Training Initiatives to Facilitate Recovery

Male violence is an enduring feature of women's lives from childhood through old age. The review covers child sexual abuse, rape, and partner violence with emphasis on the prevalence of violence, its mental health consequences, the course of recovery, and mediators and moderators of traumatic impact. The primary focus is depression and posttraumatic stress disorder, the two major diagnostic entities through which postassault emotions and behaviors have been conceptualized and measured. The effects of psychiatric conceptualizations of victimization and patterns of individual recovery are critically reviewed. The PTSD paradigm as the sole foundation for most victimization research is also debated. Following the review, mental health services for victimized women are examined. The article concludes with public policy recommendations to improve the availability and accessibility of mental health services with emphasis on reaching those survivors who are less likely to consult the formal system.

General and Culturally Specific Factors Influencing Black and White Rape Survivors' Self-Esteem

Grounded in a culturally inclusive ecological model of sexual assault recovery framework, the influence of personal (e.g., prior victimization), rape context (e.g., degree of injury during last assault), and postrape response factors (e.g., general and cultural attributions, rape related coping) on self-esteem of Black and White college women, who were survivors of attempted and completed rape, were examined. As predicted, Black and White women identified similar general variables (e.g., general attributions) as important in the recovery process. Black women, however, identified a cultural factor (i.e., cultural attributions) as more important in influencing their reactions to the last rape compared to their White counterparts. Using path analysis, findings from this cross-sectional study indicated that severity of the last assault and prior victimization were related to lower self-esteem indirectly through avoidance coping strategies, and victim blame attributions for the latter. Results also suggested that the link between cultural attributions and self-esteem was explained through victim blame attributions, primarily for Black participants. The model accounted for 26% of variance in self-esteem.

What Is Nonconsensual Sex? Young Women Identify Sources of Coerced Sex

Extending the American Psychological Association (APA) report on the Sexualization of Girls, this study investigated how young women identified sources of coerced sex. Findings from three focus groups with 25 Black and White adolescent women uncovered a perceived overarching force that "pushed" them to have sex before they felt ready. Participants identified four domains of coerced sex: (a) Sociocultural Context, (b) Internalized Sexual Scripts, (c) Partner Manipulation of Sexual Scripts, and (d) Developmental Status. Coerced sex was a complex system consisting of cultural, peer, and internal messages that create pressures to engage in sexual activities. Future implications for research and practice are presented.

Social Identities in Contexts

The five articles comprising the Major Contribution in this issue are synthesized and serve as the foundation of an ecological model for contextualizing multicultural counseling psychology processes. Specifically, the proposed contextual model outlines the recursive influence of individual and systemic factors on multiple subsystems (i.e., macrosystem, mesosystem, exosystem, and microsystem) influencing human behavior. Implications for multicultural training practices that are grounded in the contextual model as well as recent multicultural counseling literature are provided.

Long-term Trends in Depression among Women Separated from Abusive Partners

This study tested a cumulative adversity hypothesis, where differences in postseparation stressors among battered women were expected to lead to a widening gap in levels of women's depression over time. Ninety-four women separated from their abusive partners were interviewed six times over a 2-year period. Consistent with the hypothesis, inequalities grew over time. Women who were exposed to the greatest amount of violence and secondary stressors shortly after shelter exit experienced relatively higher levels of depression that either did not improve or significantly increased with time. Social support was the only resource to have the hypothesized decreasing effect on depression.

Structural Models of the Relations of Assault Severity, Social Support, Avoidance Coping, Self-Blame, and PTSD Among Sexual Assault Survivors

A number of studies have identified which survivors of sexual assault are more likely to develop symptoms of posttraumatic stress disorder (PTSD). Most correlates that have been identified have been at the individual level. Insufficient attention has been given to whether survivors' social interactions impact their individual responses to assault and subsequent levels of psychological symptomatology. In this study, a large, diverse sample of community-residing women ( N = 636) was surveyed. Structural equation modeling was used to examine the relationships between assault severity, global support, negative social reactions, avoidance coping, self-blame, traumatic life experiences, and PTSD symptoms. The results suggest that negative social reactions and avoidance coping are the strongest correlates of PTSD symptoms and that the association typically observed between victim self-blame and PTSD symptoms may be partially due to the effect of negative social reactions from others. These reactions may contribute to both self-blame and PTSD. Implications for future research and clinical practice are discussed.

Emotional Reactions of Rape Victim Advocates: A Multiple Case Study of Anger and Fear

This research explores the emotional reactions of a rarely studied group of women who work closely with survivors of sexual violence: rape victim advocates. Women who assist rape victims in obtaining medical, criminal justice, and mental health services were interviewed about their experiences, and qualitative analysis was used to delineate the situational context of the advocates' emotional reactions. Results indicate that respondents experienced anger and fear in response to both individual (e.g., a perpetrator's menacing glare) and environmental (e.g., community denial of a problem) cues. Additionally, some experienced rape victim advocates perceived their emotional reactions to be an important part of their work with rape victims. These findings suggest that intense emotional reactions, previously conceptualized within a vicarious trauma framework, may at times serve as resources for women working with rape survivors.

Prevalence and factors associated with depressive symptoms among young women and men in the Eastern Cape Province, South Africa

PURPOSE

There is little research on prevalence of depressive symptoms and associated factors among youth in sub-Saharan Africa. This paper explores factors associated with depressive symptomatology in South Africa.

METHODS

A cross-sectional analysis of interviews with 1 415 women and 1 368 men aged 15-26 was undertaken. The Centre for Epidemiological Studies on Depression Scale (CESD Scale) was used to establish depressive symptomatology.

RESULTS

The prevalence of depressive symptoms was 20.5% in women and 13.5% in men. For women, depressive symptoms were associated with increased childhood adversity (aOR 1.34 95% CI 1.116, 1.55); drug use (aOR 1.98 CI 1.17, 3.35); experience of intimate partner violence (aOR 2.21 CI 1.16, 3.00); sexual violence before the age of 18 years (aOR 1.45 CI 1.02, 2.02) and lower perceptions of community cohesion (aOR 1.23 CI 1.07, 1.40). For men, depressive symptoms were associated with a mother's death (aOR 2.24 CI 1.25, 4.00); childhood adversity (aOR 1.61 CI 1.38, 1.88); alcohol abuse (aOR 1.63 CI 1.13, 2.35), sexual coercion by a woman (aOR 2.36 CI 1.47, 3.80) and relationship conflict (aOR 1.07 CI 1.01, 1.12).

CONCLUSIONS

Depressive symptoms were more highly prevalent in women than in men. Depressed mood was associated with childhood adversity, sexual violence and substance misuse in both women and men. This study further suggests gender differences in that for women, depressive symptoms were associated with intimate partner violence and lower perceptions of community cohesion, while for men the associations were with a mother's death and relationship conflict.

Examining Cultural, Social, and Self-Related Aspects of Stigma in Relation to Sexual Assault and Trauma Symptoms

The current study investigated a model explaining sexual assault victims’ severity of trauma symptoms that incorporated multiple stigma constructs. Integrating the sexual assault literature with the stigma literature, this study sought to better understand trauma-related outcomes of sexual assault by examining three levels of stigma—cultural, social, and self. Results showed self-stigma was significantly and positively related to trauma symptom severity. Thus, results revealed that the internalized aspect of stigma served as a mechanism in the relation between sexual assault severity and increased levels of trauma symptom severity, highlighting the importance of assessing self-stigma in women reporting sexual assault experiences.

Healing pathways: longitudinal effects of religious coping and social support on PTSD symptoms in African American sexual assault survivors

African American women are at a slightly increased risk for sexual assault (A. Abbey, A. Jacques-Tiaura, & M. Parkhill, 2010). However, because of stigma, experiences of racism, and historical oppression, African American women are less likely to seek help from formal agencies compared to White women (Lewis et al., 2005; S. E. Ullman & H. H. Filipas, 2001) and/or women of other ethnic backgrounds (C. Ahrens, S. Abeling, S. Ahmad, & J. Himman, 2010). Therefore, the provision of culturally appropriate services, such as the inclusion of religion and spiritual coping, may be necessary when working with African American women survivors of sexual assault. Controlling for age and education, the current study explores the impact of religious coping and social support over 1 year for 252 African American adult female sexual assault survivors recruited from the Chicago metropolitan area. Results from hierarchical linear regression analyses reveal that high endorsement of religious coping and social support at Time 1 does not predict a reduction in posttraumatic stress disorder (PTSD) symptoms at Time 2. However, high social support at Time 2 does predict lower PTSD at Time 2. Also, it is significant to note that survivors with high PTSD at Time 1 and Time 2 endorse greater use of social support and religious coping. Clinical and research implications are explored.

Correlates of Perceived Helpfulness of Mental Health Professionals Following Disclosure of Sexual Assault

A diverse sample of more than 365 adult sexual assault survivors, recruited from college and community sources, was surveyed about sexual assault experiences, post-assault factors, and perceived helpfulness of and satisfaction with mental health professionals. Regression analyses were conducted to identify factors associated with perceived helpfulness of and satisfaction with mental health professionals. Older age, higher posttraumatic stress disorder (PTSD), greater control over recovery, and more emotional support reactions were associated with positive perceptions of mental health professionals. Stranger offenders, greater resistance during assault, high victim post-assault upset, and blaming social reactions from others were associated with negative perceptions of mental health professionals.

A review of the health effects of sexual assault on African American women and adolescents

OBJECTIVE

To review the research findings for mental and physical health outcomes and health behaviors of African American women and adolescents after sexual assault.

DATA SOURCES

Searches of the Cumulative Index to Nursing and Allied Health Literature, Cochrane Library, PsycINFO, and PubMed from January 2001 through May 2012 using the terms Blacks, African Americans, sexual abuse, sexual offenses, and rape.

STUDY SELECTION

Criteria for inclusion included (a) results of primary research conducted in the United States and published in English, (b) African American females age 13 and older, (c) sexual assault or sexual abuse reported as distinct from other types of abuse, and (d) health status as an outcome variable. Twenty-one publications met inclusion criteria.

DATA EXTRACTION

Articles were reviewed for the mental and physical health and health behavior outcomes associated with sexual assault of African American women and adolescents.

DATA SYNTHESIS

Sexual assault was associated with increased risk of poor mental and physical health outcomes in the general population of women and adolescents. There was an increased risk of unhealthy behaviors (e.g., drinking, drug use, risky sexual behaviors) for all women and adolescents, with the highest risk reported for African American women and adolescents. Help seeking from family and friends demonstrated conflicting results. Cumulative effects of repeated assaults appear to worsen health outcomes.

CONCLUSION

Sexual assault has significant effects on the physical and mental health and health behaviors of women and adolescents in the general population. Less evidence is available for differences among African American women and adolescents. More research is needed to understand the influence of race on women's and adolescents' responses to assault.

Revictimization and recovery from sexual assault: implications for health professionals

Twenty-seven adult females' responses from an online qualitative questionnaire were analyzed to explore their views on being recovered from an experience of sexual assault, and identify aspects of their postassault health service encounters that facilitated or impeded their recovery process. Being recovered involved accepting the experience, being freed from negative states, regaining control and trust, and receiving help from and being believed by others. Participants predominantly reported negative experiences with health services. Factors perceived as impeding the recovery process include health professionals' inexperience in dealing with survivors of sexual assault, adhering to rape myths and stereotypes, and disrespectful or inconsiderate treatment of survivors. We argue that these postassault negative experiences revictimized survivors. Addressing these factors may reduce revictimization, facilitate recovery, and decrease assaulted women's long-term use of health services.

Prospective effects of method of coercion in sexual victimization across the first college year

Women who enter college with a sexual victimization (SV) history may be at particular risk for deleterious outcomes including maladaptive alcohol involve posttraumatic stress, and re-victimization. Further, pre-college SV may be an impediment for the achievement of academic mile and may negatively impact the transition into college. Recent work shows that the method of coercion used in SV may be an important predictor of post-victimization outcomes. As such, the identification of pathways between type of SV and outcomes can aid in early identification and intervention for those at highest risk. In a sample of newly-matriculated female college students, this study examined unique outcomes associated with two specific types of SV, (1) threats/use of physical force (Force SV) or (2) incapacitation (Incap SV). Participants completed assessments of SV, alcohol involvement, posttraumatic stress, and academic outcomes at 6 time-points over their first year of college. Results showed differential outcomes based on pre-matriculation exposure to Force SV or Incap SV. Women with Incap SV were higher on problem drinking indices whereas women with Force SV were at greater risk for re-victimization and marginally more PTSD symptoms. Having a history of either type of SV predicted attrition, but there were no differences when comparing Force SV to Incap SV. Overall, results from this study support the utility of delineating SV experiences by method of coercion, and point to the potential of highlighting different outcomes in tailored intervention programs.

Gender differences in cognitive and affective responses to sexual coercion

This study examined gender differences in responses to sexual coercive experiences in mixed-sex (male-female) relationships. Participants were 112 women and 28 men who had experienced sexual coercion and completed measures of cognitive (attributions to self, attributions to the coercer, internal attributions) and affective (guilt, shame) self-blame, trauma symptoms, and upset at the time of the incident) with respect to their most serious or upsetting sexually coercive experience. The women were more upset than were the men at the time of the incident. Contrary to predictions, the men and women did not differ in the extent to which they attributed blame to themselves or the strength of their internal attributions, guilt, or shame. Both the men and women attributed more blame to the coercer than to themselves; however, the women attributed more blame to the coercer than did the men. The women reported more trauma symptoms than the men did which was related to the finding that more women than men had experienced sexual coercion involving physical force. These results are discussed in terms of the similarities and differences between men's and women's cognitive and affective responses to sexual coercion.

Effects of participation in a sexual assault risk reduction program on psychological distress following revictimization

The current study followed women who participated in a sexual assault risk reduction program and a wait-list control group for 4 months. Those women in both groups who reported being revictimized (N = 147) were assessed to determine the effect of program participation on psychological distress. Intervention group participants reported a significant reduction in both psychological distress and posttraumatic stress disorder (PTSD) symptoms at follow-up relative to wait-list control participants, even after controlling for frequency of revictimization. Significantly fewer intervention participants met criteria for PTSD from Time 1 to Time 2. Hierarchical multiple regression analyses indicated frequency and severity of victimization and behavioral and characterological self-blame, and use of avoidance coping explained a significant amount of the variance in distress following revictimization. Implications for future research and risk reduction programs are discussed.

Sex without desire: characteristics of occasions of sexual compliance in young adults' committed relationships

Sexual compliance (i.e., willingly engaging in sexual activity that one does not desire) is a common behavior among young people. Little is known about the characteristics of occasions of sexual compliance in the context of a committed relationship. This study used both a diary method and in-depth interviews to assess occasions of sexual compliance, as well as types of sexual activity, condom use, pleasure, and feelings of pressure and control. Participants included 63 young adults (18-24 years old) in committed, heterosexual relationships. Seventeen percent of all sexual activity was rated as sexually compliant. Occasions of sexual compliance were rated as less enjoyable and more unexpected. In-depth interviews revealed four key themes including endorsement of an implicit contract between partners, partner awareness of low desire, past experience of pressure, and justification for reporting low desire. Future research should evaluate the long-term impact of sexual compliance on a relationship.

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.

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.

A Gendered Approach to Adolescent Dating Violence: Conceptual and Methodological Issues

This article argues that adolescent dating violence should be considered within a social ecological model that embeds the individual within the context of adolescent friendships and romantic relationships, as well as family and other social institutions that shape a young person's sense of self. Two additions to the model are recommended. First, gender is considered in the model at the individual, interactional and structural levels. Second, identity is treated as a metaconstruct, affecting and being affected by all levels of the social ecology. Examples from research are presented and recommendations for future research are offered.

Male-on-Male Rape of an Adult Man: A Case Review and Implications for Interventions

Male-on-male rape is a critical and timely topic for mental health nurses as they continue to improve their value to society. Only recently have scholars begun to address adult male sexual assault and rape survivorship. A reality for some of the men mental health nurses encounter in practice, male sexual assault and rape causes despair and suffering for which mental health nurses can help facilitate health and healing. As illustrated in a case review of male-on-male rape and selected literature, quality humanistic interpersonal relationships are deemed important for the survivor's health. J Am Psychiatr Nurses Assoc, 2009; 14(6), 454-461.

Violence-related behaviors among Dominican adolescents: examining the influence of alcohol and marijuana use

This study identified the predictors of youth violence and violent victimization among a sample of Dominican adolescents (N=155) attending high school in a northeastern urban community. As part of a broader community-based needs assessment, students participated in an evaluation of a substance abuse prevention program funded by the Substance Abuse and Mental Health Services Administration. Correlations, principal components, multiple imputation, and stepwise regression analyses were systematically employed to develop a parsimonious model for predicting violence-related behaviors among Dominican youth. Findings suggest that early onset of alcohol and marijuana use was associated with an increased likelihood of engaging in violence-related behaviors or being the victim of a violent act. In addition, students who reported a lowered sense of safety were more likely to be involved in acts of violence. However, adolescents who reported depressive symptoms were less inclined to become involved in violence-related behaviors. Implications for culturally-tailored violence and substance abuse prevention programming efforts are discussed.

Psychosocial correlates of PTSD symptom severity in sexual assault survivors

This study's goal was to assess the effects of preassault, assault, and postassault psychosocial factors on current posttraumatic stress disorder (PTSD) symptoms of sexual assault survivors. An ethnically diverse sample of over 600 female sexual assault survivors was recruited from college, community, and mental health agency sources (response rate = 90%). Regression analyses tested the hypothesis that postassault psychosocial variables, including survivors' responses to rape and social reactions from support providers, would be stronger correlates of PTSD symptom severity than preassault or assault characteristics. As expected, few demographic or assault characteristics predicted symptoms, whereas trauma histories, perceived life threat during the assault, postassault characterological self-blame, avoidance coping, and negative social reactions from others were all related to greater PTSD symptom severity. The only protective factor was survivors' perception that they had greater control over their recovery process in the present, which predicted fewer symptoms. Recommendations for intervention and treatment with sexual assault survivors are discussed.

Positive and negative adjustment and social support of sexual assault survivors

The roles of positive (i.e., growth) and negative (i.e., posttraumatic stress symptoms and general symptomatology) adjustment following adult sexual assault experience(s) were examined using a standardized definition of abuse. These reactions were explored in association with positive and negative support from formal and informal providers. Finally, using standardized measures, the collective impact of positive and negative support, formal and informal support were investigated in predicting positive and negative psychological adjustment. Both forms of informal support were found to be associated with positive outcomes. Only negative informal support was associated with posttraumatic stress symptoms. First responders should consider whether support resources are appropriate to victims' needs.

Conceptualizing the harm done by rape: applications of trauma theory to experiences of sexual assault

Based on a review of theory and evidence, this article highlights the limitations of trauma response models and applications of posttraumatic stress to characterize the experiences of women who are raped. There are two primary problems with trauma response theories. First, traditional notions of trauma are likely too narrow to accurately capture the complexities of women's experiences of sexual violence in a gendered society. Second, the symptoms emphasized by clinical applications of the trauma model may legitimate one sociocultural manifestation of distress while excluding others. Alternative conceptualizations are presented to stimulate more ecologically grounded and culturally inclusive study of sexual violence. Using the rape of women as an example, this article illustrates the limitations of Western views of trauma and encourages researchers and practitioners to expand notions of survivors' responses to painful events.

Perceived control and distress following sexual assault: a longitudinal test of a new model

Longitudinal data were collected from female sexual assault survivors (N = 171) at 4 points postassault. Consistent with the predictions of the temporal model (P. Frazier, M. Berman, & J. Steward, 2002), past, present, and future control were differentially related to posttrauma distress. Both personal past (behavioral self-blame) and vicarious past (rapist blame) control were associated with higher distress levels. In addition, the belief that future assaults are less likely was more strongly associated with lower distress levels than was future control. Present control (i.e., control over the recovery process) was most adaptive. Hierarchical linear modeling analyses revealed that changes in perceived control were associated with changes in distress after linear change in distress over time was accounted for.

A multiple case study of rape victim advocates' self-care routines: the influence of organizational context

This study assumes that rape victim advocates who provide community outreach services to victimized women must adjust to a heightened awareness of sexual violence to do their jobs. Using qualitative methodology, this multiple case study explored rape victim advocates' strategies for incorporating repeated exposure to sexual assault into their daily lives as well as ways that organizations can support such endeavors. Findings suggest that advocates' self-care routines draw upon various personal resources (i.e., cognitive, physical, social, spiritual, verbal), and serve 2 roles for coping with rape-related pain: (a) cathartic releasing of traumatic material, and (b) improving capacity to integrate the traumatic material into one's life. Additionally, over 20 organizational characteristics that workers perceive to be supportive (e.g., weekly meetings, flexible hours) were identified. Nonparametric and categorical statistical analyses were used to analyze the relationship between organizational support and self-care routines, finding that advocates working in organizations with higher levels of support utilize more strategies that are integrative in nature. Implications of these findings are discussed.

Predictors of PTSD symptom severity and social reactions in sexual assault victims

Demographics, assault variables, and postassault responses were analyzed as correlates of PTSD symptom severity in a sample of 323 sexual assault victims. Regression analyses indicated that less education, greater perceived life threat, and receipt of more negative social reactions upon disclosing assault were each related to greater PTSD symptom severity. Ethnic minority victims reported more negative social reactions from others. Victims of more severe sexual victimization reported fewer positive, but more negative reactions from others. Greater extent of disclosure of the assault was related to more positive and fewer negative social reactions. Telling more persons about the assault was related to more negative and positive reactions. Implications of these results for developing contextual theoretical models of rape-related PTSD are discussed.