Elsevier

Clinical Psychology Review

Volume 56, August 2017, Pages 65-81
Clinical Psychology Review

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

https://doi.org/10.1016/j.cpr.2017.06.002Get rights and content

Highlights

  • Associations between sexual assault and psychopathology are meta-analyzed.

  • Sexual assault was associated with increased risk for and severity of all disorders.

  • Effects were largest and most robust for PTSD and suicidality.

  • Samples reporting more severe assaults evidenced more psychopathology.

  • Sexual assault history should be considered when treating common mental disorders.

Abstract

Sexual assault (SA) is a common and deleterious form of trauma. Over 40 years 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.

Introduction

Sexual assault (SA) is a common form of trauma: 17–25% of women and 1–3% of men will be sexually assaulted in their lifetime (Black et al., 2011, Fisher et al., 2000, Koss et al., 1987, Tjaden and Thoennes, 2000, Tjaden and Thoennes, 2006). The high prevalence of SA is particularly concerning in light of its significant psychological consequences for survivors (e.g., Campbell, Dworkin, & Cabral, 2009). Indeed, SA appears to have a more substantial impact on mental health than other forms of trauma (Kelley et al., 2009, Kessler et al., 1995). As a result, SA is an issue of major public health concern.

The past forty years have represented a period of significant growth and evolution in both public and research attention to SA. Beginning as early as the 1970s, increasing attention to SA as a feminist issue as well as growing interest in the impact of traumatic life experiences manifested in several seminal academic works on the psychological impact of SA. Sutherland and Scherl (1970) interviewed 13 women who had been sexually assaulted, and described a condition involving an early period of anxiety and fear, followed by a depressive phase. Burgess and Holmstrom (1974) interviewed 146 women admitted to a hospital with a presenting complaint of SA. “Rape trauma syndrome,” as they called the condition they observed, was described as involving a spectrum of acute symptoms including somatic reactions like muscle tension and stomach pain, as well as emotional reactions like fear and self-blame. Over time, survivors were said to enter a “reorganization” phase that included nightmares, phobic reactions to trauma reminders, and increases in motor activity. These articles set the groundwork for an explosion of research on the impact of SA (Koss, 2005).

By 1980, the set of symptoms described by these early studies was recognized to be highly similar to descriptions of other trauma-related syndromes (e.g., “combat fatigue”), and a new condition reflecting these syndromes, called posttraumatic stress disorder (PTSD), was introduced to the Diagnostic and Statistical Manual of Mental Disorders (DSM; APA, 1980). Although the framing of SA's impact through the lens of a single form of psychopathology was critiqued by feminist scholars (see Wasco, 2003), a benefit of this new construct was a substantial increase in research attention to both trauma generally and SA specifically. This increased attention was reflected in several early longitudinal studies assessing the impact of SA. For example, Kilpatrick, Resick, and Veronen (1981) followed 20 recent SA survivors and 20 controls over a year, and identified elevations in fear and anxiety within the SA group across this period. Atkeson, Calhoun, Resick, and Ellis (1982) assessed 115 recent SA survivors and 87 controls for a year, and found that group differences in depression had resolved by four months post-assault. Epidemiological research also began to assess the impact of SA during this time. In the earliest epidemiological assessment of trauma-related psychopathology to assess SA, the Detroit Area Survey of Trauma (N = 1007) found that the prevalence of PTSD in survivors of non-SA traumas ranged from 12% to 24%, but the prevalence of PTSD in survivors of SA was 80% (Breslau, Davis, Andreski, & Peterson, 1991). Similarly, the National Comorbidity Survey (N = 5877) found that rape was the most common cause of PTSD in women, and nearly half of men and women exposed to SA met criteria for lifetime PTSD (Kessler et al., 1999).

As the field evolved, epidemiological studies began to examine the relationship between traumas like SA and conditions beyond PTSD alone. For example, results from the National Epidemiological Survey on Alcohol and Related Conditions—a large, representative US sample (N = 31,875)—indicated that experiencing adult SA was associated with significantly increased risk for new onset of several forms of psychopathology, including substance use disorder, bipolar disorder, and PTSD (Xu et al., 2013). In addition, the National Women's Study Replication—a nationally-representative sample of women (N = 3001)—found that forcible rape was associated with risk for a major depressive episode (Zinzow et al., 2010), and both forcible and drug/alcohol facilitated rape were associated with risk for PTSD.

Over the following decades, research accumulated to demonstrate that SA is associated with many forms of psychological dysfunction. A qualitative review of the prevalence of various mental disorders in survivors of adult SA found that 17%–65% of people with a history of SA develop PTSD, 13%–51% meet diagnostic criteria for depression, 12–40% experience symptoms of anxiety, 13–49% develop alcohol use disorders, 28–61% develop drug use disorders, 23–44% experience suicidal ideation, and 2–19% attempt suicide (Campbell et al., 2009). Although other psychological conditions have received less frequent attention in relation to SA, there is some evidence that SA is associated with conditions such as obsessive-compulsive disorder (Arata, 1999, Boudreaux et al., 1998, Burnam et al., 1988, Frazier and Schauben, 1994, Kilpatrick et al., 1981, Walker et al., 1995, Winfield et al., 1990) and bipolar disorder (Arata, 1999, Burnam et al., 1988, Xu et al., 2013).

It is evident from this work that, although SA is a life-altering experience for many survivors, not all who are assaulted develop psychological problems. Thus, many studies have attempted to understand who is most at risk for developing post-trauma psychopathology. Much of this work has focused on characteristics of individuals (e.g., demographics, prior assault history) or assaults (e.g., assailant type, peritraumatic dissociation) as correlates of post-assault distress, as reflected in early reviews in this area (e.g., Goodman, Koss, & Russo, 1993). In a past meta-analysis of 50 studies assessing the association between interpersonal violence and psychopathology, however, the only demographic characteristics related to distress were the percent of women in the sample and age at the time of victimization (Weaver & Clum, 1995). Characteristics of traumas experienced, such as the amount of force used and survivors' subjective appraisals of the trauma (e.g., self-blame), were also associated with recovery in this analysis.

In contrast to this search for correlates of recovery at the level of individuals or assaults, researchers have increasingly applied an ecological lens to identifying correlates of SA recovery (see Carter-Snell and Jakubec, 2013, Campbell et al., 2009, and Neville & Heppner, 1999 for ecologically-based reviews). This perspective emphasizes that SA recovery occurs in a multilevel social context, in which the unique aspects of SA as a form of trauma interface with aspects of the environment to affect recovery. From this work, it is clear that SA remains a highly stigmatized experience (Kennedy & Prock, 2016) that is associated with societal “rape myths,” such as the idea that survivors are to blame for assault (Edwards, Turchik, Dardis, Reynolds, & Gidycz, 2011). There is evidence that survivors internalize this stigma, leading to self-blame, shame, and unwillingness to seek help (Kennedy & Prock, 2016). In addition, survivors who choose to disclose their assault to friends, relatives, or professionals often experience negative social reactions, such as victim blame, that have been associated with increased risk for PTSD in longitudinal research (Ullman & Peter-Hagene, 2014). Reflecting both the increased public attention to the importance of improving community responses SA and the unique nature of SA as a form of trauma, a variety of dedicated services are now available to survivors of SA that may affect their recovery processes (e.g., Sexual Assault Nurse Examiners, rape crisis centers, SA medical and legal advocates) (Campbell et al., 1999). However, the impact of these specialized services on survivors' mental health has been largely unexplored.

Four decades of research on the psychological impact of SA offer a rich body of work that can be examined to identify patterns in findings across studies. Although the bulk of the research on this topic has identified associations between SA and various forms of psychopathology, exceptions exist, and studies differ with regard to the strength of the association that they identify. Clarifying the conditions under which associations between SA and psychopathology are observed has the potential to inform theoretical understandings of the development of mental disorders after trauma, which in turn, could inform the development of efficacious interventions and prevention strategies. Next, we outline unresolved questions in research on SA's psychological impact—those that have received limited research attention or yielded mixed findings across studies—that can be explored by examining this body of literature as a whole.

In understanding the mechanisms by which traumas like SA produce psychopathology, it is important to understand whether SA is a specific risk factor for certain conditions or a more general risk factor for psychological dysfunction. The psychological literature on trauma has primarily focused on posttraumatic stress disorder, and other conditions often observed in traumatized populations (e.g., depression, anxiety, substance use disorders) have received relatively less attention (aside from their co-occurrence with PTSD). This focus on PTSD is based in a theoretical understanding of PTSD as a unique phenotype arising from trauma that is conceptually different from other disorders that often are seen in trauma survivors (e.g., depression, anxiety disorders) in that its etiology necessarily involves an external trauma event (APA, 2013). These other disorders are thought to be associated with or exacerbated by a trauma, but are not dependent on an experience of trauma in most cases (Friedman, Resick, Bryant, & Brewin, 2011). Indeed, in the DSM-5, PTSD was moved out of the anxiety disorders into a new diagnostic category, called “trauma- and stressor-related disorders” (APA, 2013). The extent to which this focus on PTSD as a primary, distinct, and unique outcome of traumas like SA is justified remains unclear, given the wide variation in prevalence estimates of disorders other than PTSD in trauma survivors described previously. Clarifying whether traumas like SA are specifically associated with PTSD or broadly associated with multiple forms of psychopathology could expand the understanding of the nature of the impact of SA, which may have implications for theory development as well as the assessment and treatment of psychopathology following assault.

In understanding inconsistencies in observed relationships between SA and psychopathology across studies, it also is important to account for unique aspects of SA as a form of trauma and corresponding variation in research on this topic. SA is a particularly common, deleterious, and stigmatized trauma that is the focus of much public discourse regarding issues such as the degree to which various forms of SA are expected to produce psychological harm. Because of these characteristics, SA has received significant focused research attention—with unique methodological characteristics—independent from other traumas, and numerous debates have arisen regarding best-practice approaches to researching SA. We next review how these differences in study methods and samples might account for differences in study results.

There is significant variation in the field regarding methods of assessing SA. Some studies use the Sexual Experiences Survey (Koss et al., 2007), which includes a variety of types of SA (e.g., coerced, incapacitated, and forced; attempted and completed; fondling and penetrative SA) and, given its specificity, is considered to be a gold standard self-report measure for assessing SA victimization. However, researchers using the Sexual Experiences Survey vary in terms of the items they use to operationalize SA for analytic purposes. Other researchers create their own measures that include varying operational definitions across these dimensions. Still, other studies use single-item measures of SA that refer broadly to “sexual assault” or “rape” and leave the operational definition of these terms to study participants. This raises two major issues. First, it is not known whether the breadth of operational definitions of SA (e.g., including coerced SA in operational definitions) used in research is associated with the observed strength of the SA-psychopathology relationship. Indeed, an ongoing debate over the appropriate operational definition of SA (Cook et al., 2011, Koss, 2011) has centered on concerns that broad definitions of SA may obscure its connection with psychopathology. If survivors of assaults that fall under broader operationalizations truly are less affected by their experiences, then broadening operational definitions should result in smaller observed differences from unassaulted samples. Second, these differences in assessment also represent differences in quality. Best-practice approaches to assessing SA include the use of multi-item validated instruments that explicitly define both behaviors considered assaultive (e.g., vaginal penetration), as well as the tactics through which these behaviors are achieved (e.g., force, coercion). If high-quality assessments capture a wider range of experiences of SA (e.g., less severe forms of SA), and low-quality assessments might fail to capture actual survivors of SA (i.e., false negatives), higher assessment quality would likely reduce observed group differences in psychopathology. Clarifying the impact of assessment quality on observed relationships between SA and psychopathology could help to guide methodological decisions in this research area.

Similar quality issues are present in assessments of psychopathology. The quality of assessment measures range from single-item self-report instruments that are not directly connected to DSM symptom criteria, to standardized, validated diagnostic interviews. Although a past meta-analysis on the relationship between interpersonal violence and distress did not find evidence that indicators of validity were associated with the magnitude of observed effects (Weaver & Clum, 1995), it is not clear whether this relationship has changed in the past 20 years of methodological development in this area. If higher-quality assessments capture more “true” psychopathology, and differences in psychopathology exist between SA and no-SA groups, low-quality assessment methods would be expected to reduce these observed differences. Because using the highest-quality assessment measures is resource-intensive, understanding the extent to which they minimize bias could help to inform methodological decisions.

It is unclear in comparison to whom sexually assaulted people evidence greater psychopathology. Some studies use comparison groups that are selected for their lack of trauma experience, others use comparison groups that have not experienced SA, and others use comparison groups that have experienced another form of trauma (e.g., motor vehicle accidents). Experiencing any trauma is an environmental stressor that is likely to increase risk for psychopathology; therefore, sexually assaulted people should evidence higher levels of psychopathology relative to people who have never experienced trauma. In addition, there is some evidence to suggest that SA is a particularly harmful form of trauma (Kessler et al., 1995, Kelley et al., 2009). An earlier meta-analysis on psychological distress related to interpersonal violence found no difference between SA and other interpersonal trauma types in terms of their level of distress (Weaver & Clum, 1995), but did not compare SA to non-interpersonal traumas. Such comparisons would be needed to clarify the unique impact of SA relative to other traumas.

Unlike the broader trauma literature, which generally assesses lifetime exposure to a number of forms of trauma (including SA), the SA literature has been largely siloed into research on childhood SA and adolescent/adult SA (i.e., at or after age 12–15, depending on study definitions). The degree to which these bodies of literature are comparable is unclear, and correspondingly, existing systematic quantitative and qualitative reviews of the impact of SA have limited their scope to childhood SA (Chen et al., 2010, Smolak and Murnen, 2002) or adult SA (Campbell et al., 2009). Indeed, evidence from meta-analyses that younger age at trauma exposure is associated with increased risk for PTSD (Brewin et al., 2000, Ozer et al., 2003) suggests that studies of lifetime SA might not be directly comparable to studies of adolescent/adult SA. However, the lifetime SA literature offers an rich potential source of information, and thus, the comparability of lifetime SA studies to adolescent/adult SA studies is an important empirical question to inform further reviews and theory development.

Interpersonal violence does not inevitably lead to psychopathology (Weaver & Clum, 1995), and it remains unclear how its effects differ across people. Thus, it is important to explore how the relationship between SA and psychopathology differs as a function of sample characteristics (e.g., types of assaults experienced, average time since assault, sample demographics).

Assaults vary in terms of characteristics that could affect psychopathology, such as the presence of physical injury, weapon use by the perpetrator, or the relationship of the victim to the offender. In a past qualitative review of the relationship of these SA assault characteristics to psychopathology, only physical injury was associated with psychopathology (Campbell et al., 2009). This may be because injury increases perceived life threat, which a past meta-analysis has found to predict PTSD across types of trauma (Ozer et al., 2003). Similarly, a meta-analysis of psychopathology related to child sexual abuse did not find differences based on victim-offender relationship (Paolucci & Genuis, 2001), although child sexual abuse tends to involve different perpetrator types (e.g., family members) than adult SA (Tjaden & Thoennes, 2006). Further examination of how assault characteristics predict psychopathology in relation to SA specifically is needed to clarify the unique aspects of SA experiences that contribute to psychopathology.

Time since assault may alter observed relationships with psychopathology. In a meta-analysis of the association between distress and interpersonal violence, time since stressor was negatively associated with effect sizes (Weaver & Clum, 1995), and a review of the impact of intimate partner violence on psychopathology found that rates of depression decline over time (Golding, 1999). Because SA is thought to have a stronger relationship with psychopathology than other interpersonal forms of trauma (Kessler et al., 1995), it is possible that its effect is more persistent over time. However, this has not been tested.

SA may have a different impact on survivors depending on their demographic characteristics, such as age, gender, and race/ethnicity. A qualitative review of associations between SA specifically and multiple forms of trauma identified mixed findings regarding the importance of current age in post-SA psychopathology: most studies identified no relationship between age and distress, and several identified either positive or negative associations between age and specific forms of psychopathology (Campbell et al., 2009). In terms of gender, results also are mixed. One meta-analysis found that the percentage of women in the sample was positively associated with the magnitude of the relationship between interpersonal victimization and psychological distress (Weaver & Clum, 1995), but this analysis included few samples of men and combined types of interpersonal victimization, which potentially resulted in an underestimation of the impact of SA on men. In contrast, one meta-analysis suggested that the association between interpersonal violence and PTSD is not stronger for women than men (Tolin & Foa, 2006), and a second also did not identify gender differences in the association between child sexual abuse and psychopathology (Paolucci & Genuis, 2001). Results for racial/ethnic differences appear more clear: most studies have not identified an association between race/ethnicity and SA-related psychopathology (Campbell et al., 2009), but no meta-analysis has tested this relationship. Generally, because SA is—unlike many other forms of trauma—disproportionately experienced by women and young people, and there is some evidence to suggest that racial differences exist in SA victimization (Acierno, Resnick, & Kilpatrick, 1997), it is important to clarify whether demographic differences exist in the impact of SA specifically. Understanding who is most affected by SA has the potential to inform targeted efforts to prevent psychopathology.

Finally, increasing attention has been paid to the specific impact of SA on populations such as college students and veterans/military personnel. It is unclear whether different relationships between SA and psychopathology are observed depending on which population is sampled. There is evidence that a lack of a college education is associated with higher likelihood of suicide attempts among SA survivors (Ullman & Brecklin, 2002), and less-educated SA survivors evidence more self blame compared to college-educated survivors (Long, Ullman, Starzynski, Long, & Mason, 2007). However, when considering population-level differences in psychopathology, it is likely that SA survivors who are able to maintain college enrollment or some other professional role despite trauma exposure are likely to reflect a somewhat higher-functioning subset of survivors relative to the general population (i.e., those most affected by SA may be more likely to withdraw from employment or college enrollment and thus not be reflected in group comparisons). Addressing how study population affects study results is important to inform methodological decisions and the interpretation of results.

Section snippets

The current study

In sum, given the relevance to theory and practice of understanding the SA-psychopathology relationship, as well as the multiple unresolved questions that exist in this literature, a systematic summary of this relationship is needed. Specifically, summarizing the literature could clarify (a) the breadth versus specificity of the impact of SA on psychopathology and (b) how this relationship might differ as a function of differences in studies' methods and samples. Qualitative reviews on this

Literature search and study retrieval

We followed several steps to identify relevant studies for inclusion.

Results

We begin our presentation of the meta-analysis results by discussing the identification and management of outliers and our examination of publication bias. Then, we characterize the sample and present summary effects. Finally, we describe tests of moderation.

Discussion

As research on SA's psychological impact has evolved, it has become increasingly clear that SA can have major implications for psychopathology in survivors. In the current meta-analysis, which included 497 estimates of the relationship between SA and psychopathology representing approximately 238,623 individual participants, people who experienced SA evidenced significantly more psychopathology across diagnostic categories than people who have not experienced SA. Further, the effect of SA on

Strengths and limitations

This meta-analysis had a number of strengths. First, our exhaustive study retrieval strategy led to the identification of a large number of effects, many of which were unpublished, which minimizes publication bias while also increasing confidence in effects. Second, because we used both continuous and categorical measures of psychopathology to calculate effect sizes, our findings reflect both syndromal and subsyndromal psychopathology, and thus provide a more accurate representation of the

Conclusion

There is strong evidence that SA victimization is associated with increased risk for multiple forms of psychopathology across most populations, assault types, and methodological differences in studies. This indicates that conditions beyond PTSD alone should be considered in relation to histories of trauma exposure in research and practice, and that increased dissemination of evidence-based practices for trauma-related conditions to SA survivors is critically needed.

The following are the

Funding

Manuscript preparation was supported in part by a grant from NIAAA [grant number T32AA007455, PI: Larimer]. NIAAA had no role in the study design, collection, analysis or interpretation of the data, writing the manuscript, or the decision to submit the paper for publication.

Contributors

ERD designed the study and conducted statistical analyses in consultation with NEA, SVM, and JB. ERD and SVM developed the protocol, reviewed study eligibility, and coordinated data extraction. ERD, SM, and JB were primarily responsible for extracting data. ERD drafted the manuscript with contributions from SVM, JB, and NEA. All authors contributed to and have approved the final manuscript.

Conflict of interest

All authors report that they have no conflicts of interest.

Acknowledgments

The authors would like to thank Konrad Bresin, Yara Mekawi, and Xiaolu Zhu, who provided methodological consultation, Debra Kaysen and Yara Mekawi, who provided feedback on a draft manuscript, the researchers who provided unpublished data, and the undergraduate research assistants who assisted with this study: Amanda Abraham, Alexis Thorstenson, Allison Schartman, Ashton Fields, Christina Mantas, Kulsumjehan Siddiqui, Laura Seimetz, Mary Kennedy, Namrata Nanavaty, and Thane Fowler assisted with

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