Protocol for the first large-scale emergency care-based longitudinal cohort study of recovery after sexual assault: the Women's Health Study

Research with women sexual assault survivors presenting for emergency care is safe: Results from a multi-site, prospective observational cohort study

A barrier to research with sexual assault survivors is the concern that research participation might be a negative experience for participants. We report the experiences with research of adult women sexual assault survivors participating in a large-scale, multi-site, prospective observational study that enrolled participants at the time of presentation for emergency care. Participants (n = 706, M = 28 years of age; 57% white, 15% Black) self-reported their experience with research 1 week, 6 weeks, 6 months, and 1 year post-assault. The vast majority rated the research experience as positive (95-97%), reported no drawbacks (84-89%), and felt that participating was worth it (93-95%). Positive experiences with research remained stable across the year, were generally consistent across demographic and clinical groups, and were reflected in qualitative comments. Given the tremendous morbidity experienced by sexual assault survivors and lack of progress in developing improved treatments for this population, ethically-conducted research with sexual assault survivors receiving emergency care should be encouraged.

Development of a brief bedside tool to screen women sexual assault survivors for risk of persistent posttraumatic stress six months after sexual assault

This study aims to develop and validate a brief bedside tool to screen women survivors presenting for emergency care following sexual assault for risk of persistent elevated posttraumatic stress symptoms (PTSS) six months after assault. Participants were 547 cisgender women sexual assault survivors who presented to one of 13 sexual assault nurse examiner (SANE) programs for medical care within 72 h of a sexual assault and completed surveys one week and six months after the assault. Data on 222 potential predictors from the SANE visit and the week one survey spanning seven broadly-defined risk factor domains were candidates for inclusion in the screening tool. Elevated PTSS six months after assault were defined as PCL-5 > 38. LASSO logistic regression was applied to 20 randomly selected bootstrapped samples to evaluate variable importance. Logistic regression models comprised of the top 10, 20, and 30 candidate predictors were tested in 10 cross-validation samples drawn from 80% of the sample. The resulting instrument was validated in the remaining 20% of the sample. AUC of the finalized eight-item prediction tool was 0.77 and the Brier Score was 0.19. A raw score of 41 on the screener corresponds to a 70% risk of elevated PTSS at 6 months. Similar performance was observed for elevated PTSS at one year. This brief, eight-item risk stratification tool consists of easy-to-collect information and, if validated, may be useful for clinical trial enrichment and/or patient screening.

"The facilitator is not a bystander": exploring the perspectives of interdisciplinary experts on trauma research

Objective

This study investigates the concepts, knowledge, and guiding principles that inform the practice of professionals researching trauma or working directly with individuals who have lived and living experiences of trauma. These aspects are explored with the aim of identifying current practices and potential gaps which may contribute to more trauma-informed biomarker-based research approaches.

Method

The perspectives of experts were explored through semi-structured interviews with seven participants; these individuals represented trauma research, clinical practice, and trauma-informed physical activity domains.

Results

A thematic analysis of the collected data revealed three focal areas highlighted by participants from all disciplines: "If I want to know trauma in the body of a person I need to know the person's language" which related to experiences of discussing trauma with clients; "What all people need is a safe place" relayed the importance of safety for participants working with the trauma expert; and "the facilitator is not a bystander" framing trauma-related work as a collaborative process between participants and their care providers.

Conclusion

Evidence of formal implementation of trauma-informed practices within research settings is lacking. This gap is identified within background literature, while the importance of implementing these practices is emphasized by the participants of this study. This presents an opportunity to apply the insights of the interviewed experts toward advancing trauma research methodologies. Adapting biomarker-based research methodologies to fit a trauma- and violence-informed model may have benefits for the quality of participant experiences, research data, and knowledge of effective interventions.

CpG Methylation Levels in HPA Axis Genes Predict Chronic Pain Outcomes Following Trauma Exposure

Chronic post-traumatic musculoskeletal pain (CPTP) is a common outcome of traumatic stress exposure. Biological factors that influence the development of CPTP are poorly understood, though current evidence indicates that the hypothalamic-pituitary-adrenal (HPA) axis plays a critical role in its development. Little is known about molecular mechanisms underlying this association, including epigenetic mechanisms. Here, we assessed whether peritraumatic DNA methylation levels at 248 5'-C-phosphate-G-3' (CpG) sites in HPA axis genes (FKBP5, NR3C1, CRH, CRHR1, CRHR2, CRHBP, POMC) predict CPTP and whether identified CPTP-associated methylation levels influence expression of those genes. Using participant samples and data collected from trauma survivors enrolled into longitudinal cohort studies (n = 290), we used linear mixed modeling to assess the relationship between peritraumatic blood-based CpG methylation levels and CPTP. A total of 66 (27%) of the 248 CpG sites assessed in these models statistically significantly predicted CPTP, with the three most significantly associated CpG sites originating from the POMC gene region (ie, cg22900229 [β = .124, P < .001], cg16302441 [β = .443, P < .001], cg01926269 [β = .130, P < .001]). Among the genes analyzed, both POMC (z = 2.36, P = .018) and CRHBP (z = 4.89, P < .001) were enriched in CpG sites significantly associated with CPTP. Further, POMC expression was inversely correlated with methylation levels in a CPTP-dependent manner (6-months NRS<4: r = -.59, P < .001; 6-months NRS ≥ 4: r = -.18, P = .2312). Our results suggest that methylation of HPA axis genes including POMC and CRHBP predict risk for and may contribute to vulnerability to CPTP. PERSPECTIVE: Peritraumatic blood levels of CpG methylation sites in HPA axis genes, particularly CpG sites in the POMC gene, predict CPTP development. This data substantially advances our understanding of epigenetic predictors and potential mediators of CPTP, a highly common, morbid, and hard-to-treat form of chronic pain.

Trends in US Emergency Department Use After Sexual Assault, 2006-2019

Importance

Adult sexual assault (SA) survivors experience numerous emergent health problems, yet few seek emergency medical care. Quantifying the number and types of survivors presenting to US emergency departments (EDs) after SA can inform health care delivery strategies to reduce survivor morbidity and mortality.

Objective

To quantify ED use and factors that influenced seeking ED care for adult SA from 2006 through 2019.

Design, Setting, and Participants

This cross-sectional study used SA data from the Nationwide Emergency Department Sample from 2006 through 2019, which includes more than 35.8 million observations of US ED visits from 989 hospitals, a 20% stratified sample of hospital-based EDs. The study also used the Federal Bureau of Investigation's Uniform Crime Reporting Program, which includes annual crime data from more than 18 000 law enforcement agencies representing more than 300 million US inhabitants. The study sample included any adult aged 18 to 65 years with an ED visit in the Nationwide Emergency Department Sample coded as SA. The data were analyzed between January 2020 and June 2022.

Main Outcomes and Measures

Annual SA-related ED visits, subsequent hospital admissions, and associated patient-related factors (age, sex, race and ethnicity, income quartile, and insurance) were analyzed using descriptive statistics.

Results

Data were from 120 to 143 million weighted ED visits reported annually from 2006 through 2019. Sexual assault-related ED visits increased more than 1533.0% from 3607 in 2006 to 55 296 in 2019. Concurrently, admission rates for these visits declined from 12.6% to 4.3%. Female, younger, and lower-income individuals were more likely to present to the ED after SA. Older and Medicaid-insured patients were more likely to be admitted. Overall, the rate of ED visits for SA outpaced law enforcement reporting.

Conclusions and Relevance

This cross-sectional study found that US adult SA ED visits increased from 2006 through 2019 and highlighted the populations who access emergency care most frequently and who more likely need inpatient care. These data can inform policies and the programming needed to support this vulnerable population.

Pain is common after sexual assault and posttraumatic arousal/reactivity symptoms mediate the development of new or worsening persistent pain

ABSTRACT

Clinically significant new or worsening pain (CSNWP) is a common, yet often overlooked, sequelae of sexual assault. Little is known regarding factors influencing the development of CSNWP in sexual assault survivors. The current study used data from a recently completed prospective study to evaluate whether posttraumatic alterations in arousal and reactivity in the early aftermath of sexual assault influence the transition from acute to clinically significant new or worsening persistent pain. Women ≥ 18 years of age (n = 706) presenting for emergency care after sexual assault to 13 emergency care sites were enrolled in the study. Women completed assessments at the time of presentation as well as at 1 week (n = 706, 100%) and 6 weeks (n = 630, 91%). Nearly 70% of women reported CSNWP at the time of emergency care (n = 475, 69%), which persisted to 6 weeks in approximately 2 in 5 survivors (n = 248, 41%). A structural equation model adjusted for age, race, past trauma exposure, and preassault pain levels suggested that posttraumatic alterations in arousal/reactivity symptoms 1 week after assault partially mediated the transition from acute to persistent CSNWP. A significant portion (41%) of women sexual assault survivors develop CSNWP 6 weeks postassault. Posttraumatic arousal/reactivity symptoms in the early aftermath of assault contribute to CSNWP development; such symptoms are potential targets for secondary preventive interventions to reduce chronic postassault pain.

Peritraumatic 17β-estradiol levels influence chronic posttraumatic pain outcomes

ABSTRACT

Biologic factors that predict risk for and mediate the development of common outcomes of trauma exposure such as chronic posttraumatic pain (CPTP) are poorly understood. In the current study, we examined whether peritraumatic circulating 17β-estradiol (E2) levels influence CPTP trajectories. 17β-estradiol levels were measured in plasma samples (n = 254) collected in the immediate aftermath of trauma exposure from 3 multiethnic longitudinal cohorts of men and women trauma survivors. Chronic posttraumatic pain severity was evaluated 6 weeks, 6 months, and 1 year after traumatic stress exposure. Repeated measures mixed models were used to test the relationship between peritraumatic E2 levels and prospective CPTP. Secondary analyses in a nested cohort assessed the influence of participant body mass index on the E2-CPTP relationship. In women, a statistically significant inverse relationship between peritraumatic E2 and CPTP was observed (β = -0.280, P = 0.043) such that higher E2 levels predicted lower CPTP severity over time. Secondary analyses identified an E2 * body mass index interaction in men from the motor vehicle collision cohort such that obese men with higher E2 levels were at greater risk of developing CPTP. In nonobese men from the motor vehicle collision cohort and in men from the major thermal burn injury cohort, no statistically significant relationship was identified. In conclusion, peritraumatic circulating E2 levels predict CPTP vulnerability in women trauma survivors. In addition, these data suggest that peritraumatic administration of E2 might improve CPTP outcomes for women; further research is needed to test this possibility.

"I still feel so lost": experiences of women receiving SANE care during the year after sexual assault

OBJECTIVE

Emergency caregivers provide initial care to women sexual assault (SA) survivors. An improved understanding of the issues facing this population can aide emergency care practitioners in providing high quality care. The goal of this study was to share the experiences of women SA survivors with the emergency care practitioners that care for them.

METHODS

English-speaking adult women (n = 706) who received SA Nurse Examiner (SANE) evaluation within 72 hours of SA at 1 of 13 geographically distributed sites were enrolled in a prospective, longitudinal multi-site observational study. We qualitatively analyzed responses to the open-ended question: "What do you think is most important for researchers to understand about your experience since the assault?" asked 1 week, 6 weeks, 6 months, and 1 year after enrollment.

RESULTS

Themes from responses (n = 1434) from 590 women (84% of study sample) fell into 12 broad categories: daily life, justice, medical, and social services, mental health, physical health, prior trauma, recovery, romantic relationships, safety, self, shame, and social interactions. Responses demonstrated that the assault permeates many aspects of assault survivors' daily lives.

CONCLUSIONS

Qualitative analyses of open-ended responses from a large cohort of women SA survivors receiving SANE care highlight the challenges for survivors and can increase understanding among the emergency care practitioners who care for them. The authors propose a brief acronym to help emergency care practitioners recall important messages for SA survivors.

Perceived Care Quality Among Women Receiving Sexual Assault Nurse Examiner Care: Results From a 1-Week Postexamination Survey in a Large Multisite Prospective Study

INTRODUCTION

This study examined the perspectives of female patients who had been sexually assaulted regarding the quality of care provided by sexual assault nurse examiners, including whether the patients' perspectives varied by their demographic characteristics and health status before the assault.

METHODS

A total of 695 female patients who received care from sexual assault nurse examiners at 13 United States emergency care centers and community-based programs completed standardized surveys 1 week after receiving sexual assault nurse examiners' care for sexual assault.

RESULTS

Most patients strongly agreed that the sexual assault nurse examiners provided high-quality care, including taking patients' needs/concerns seriously, not acting as though the assault was the patient's fault, showing care/compassion, explaining the sexual assault examination, and providing follow-up information. The perceptions did not vary by the patients' demographic characteristics or preassault health status.

DISCUSSION

Female patients who had been sexually assaulted and who were evaluated at 13 widely geographically distributed sexual assault nurse examiners' programs consistently reported that the sexual assault nurse examiners provided high-quality, compassionate care.

Health care utilization by women sexual assault survivors after emergency care: Results of a multisite prospective study

BACKGROUND

Approximately, 100,000 US women receive emergency care after sexual assault each year, but no large-scale study has examined the incidence of posttraumatic sequelae, receipt of health care, and frequency of assault disclosure to providers. The current study evaluated health outcomes and service utilization among women in the 6 weeks after sexual assault.

METHODS

Women ≥18 years of age presenting for emergency care after sexual assault to twelve sites were approached. Among those willing to be contacted for the study (n = 1080), 706 were enrolled. Health outcomes, health care utilization, and assault disclosure were assessed via 6 week survey.

RESULTS

Three quarters (76%) of women had posttraumatic stress, depression, or anxiety, and 65% had pain. Less than two in five reported seeing health care provider; receipt of care was not related to substantive differences in symptoms and was less likely among Hispanic women and women with a high school education or less. Nearly one in four who saw a primary care provider did not disclose their assault, often due to shame, embarrassment, or fear of being judged.

CONCLUSION

Most women receiving emergency care after sexual assault experience substantial posttraumatic sequelae, but health care in the 6 weeks after assault is uncommon, unrelated to substantive differences in need, and limited in socially disadvantaged groups. Lack of disclosure to primary care providers was common among women who did receive care.

Anxiety Sensitivity Prospectively Predicts Increased Acute Posttraumatic Stress and Related Symptoms After Sexual Assault

Anxiety sensitivity is a potential risk factor for posttraumatic stress symptoms (PTSS) and has been hypothesized to contribute to PTSS development. However, few prospective studies have evaluated whether anxiety sensitivity predicts PTSS. In a subsample of 48 women sexual assault survivors enrolled as part of a larger prospective observational study, elevated anxiety sensitivity measured via a brief assessment 1 week after experiencing a sexual assault was concurrently associated with PTSS at 1 week and prospectively predicted PTSS 6 weeks after the event, with small-to-medium effect sizes, η2 p = .10, even after covarying for trauma history. Heightened anxiety sensitivity at 1-week postevent also interacted with time to predict anxiety and depression both before and after sexual assault, with medium-to-large effect sizes, ηp 2 = .21- .24. This is consistent with research linking anxiety sensitivity to PTSS, but this was the first prospective study of which we are aware to demonstrate that anxiety sensitivity in the acute posttrauma period predicts PTSS among women who have recently experienced sexual assault. Future research should use the full Anxiety Sensitivity Index to replicate findings in a larger sample and explore whether targeting anxiety sensitivity could mitigate the development of PTSS in this vulnerable population.

Secondary prevention for posttraumatic stress and related symptoms among women whohave experienced a recent sexual assault: A systematic review and meta-analysis

BACKGROUND

Women who have experienced a recent sexual assault (SA) are at high risk for posttraumatic stress disorder (PTSD) and related conditions, with approximately half of women experiencing SA meeting criteria for PTSD. There are no guidelines for the prevention of PTSD and other common mental health disorders after SA. Thus, the purpose of this systematic review and meta-analysis is to synthesize research on secondary preventions for PTSD after SA, determine efficacy whether any intervention seems promising, and ascertain when, how, and to whom interventions should be delivered.

METHODS

After searching electronic databases for secondary preventions for PTSD and related conditions among women who have experienced a recent SA, 17 studies were reviewed, their quality was rated on the clinical trial assessment measure, and 10 studies were meta-analyzed (7 were excluded, as they were not randomized controlled trials or due to the absence of heterogeneity).

RESULTS

Results suggested a small-to-moderate effect of prevention on reducing PTSD and related symptoms. There was no moderating effect of medication versus psychosocial interventions, timing, treatment modality, or targeted versus universal prevention. Half of the studies were of high quality.

CONCLUSION

Cognitive-behavioral secondary preventions for PTSD appear to be safe and effective among women who have experienced a recent SA. Future research should identify best practices and mechanisms of treatment, and once identified, it should move toward implementation science.