sexual assault personal essay

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I Was Sexually Abused as a Boy—Here’s What I Know About Abused and Abusive Men

I used to think I was special. I used to think I came from great American families, where the relatives up and down my family tree did wonderful and interesting things. My parents loved me. We were middle-class and well-educated. That is the truth. I was sexually abused as a child. I come from families with long histories of substance use disorder. I am now a 32-year-old man who has spent 28 years waiting to escape the maximum security lockup of the traumatized self because of what was done to me by two people whom I trusted, whom my parents trusted, and who betrayed us. That is also the truth.

My oldest living relative is my grandmother, who came from the Midwest and is a Quaker, a peaceful sect of Christians who honor simplicity, reflection, and silence. Grammy, please know I am only doing what you taught me: I have reflected silently, and now I am standing up to share my truth. What I do here, telling this story for the first time, I am doing in homage to the ideals for which members of my family have given their lives—law, education, psychology, therapy, writing, history—and I’m proud of my family’s accomplishments.

But make no mistake: Love should never be correlated with accomplishments. A child shouldn’t feel that he or she needs to accomplish things to be worthy of love. All the wonderful and interesting conversations and accomplishments in the world will never fill the void left by abuse or neglect, nor will it offer absolution for your trespasses.

It’s often said that everything happens for a reason . That’s a lie. Everything happens for two reasons, but we usually blame one thing, turning a blind eye to the other. Both sides of my family spoke openly about the alcoholism to which they had a predisposition—sometimes in raised voices, gin blossoms blooming—but never did anyone talk about abuse, whether physical, sexual, or emotional. This is classic misdirection. Alcoholism and abuse are symbiotic, in cause and effect.

Abuse is often intergenerational and institutional, thriving in hierarchical power structures, such as primate groups—or human families. Payback is almost always paid forward, down the chain of command from the alpha to the beta, all the way to the most vulnerable. That’s how it goes: Be hurt, hurt, hurt . But evolution can be slow. There always will be a pull to protect our own, whether in our schools, at our workplaces, or in our family.

We know the stakes of speaking out are high and the upside is opaque at best. To name abuse feels like a betrayal of the highest order—not only does it shatter the illusions to which we all cling in polite society, but it reopens us up to another assault. But this is wrong. We must bear in mind two things: Nothing is as bad as the original trauma, which we survived, and the trauma we endured now has a real meaning the second time around. It must.

As my favorite writer James Baldwin surmised in 1962: “Pain is trivial except insofar as you can use it to connect with other people’s pain; and insofar as you can do that with your pain, you can be released from it, and then hopefully it works the other way around too; insofar as I can tell you what it is to suffer, perhaps I can help you to suffer less.” That is a beautiful formula—first for healing, second for salvation, and third for action.

Abuse is always a covert operation, and it is always hypnotic. You can be tricked into thinking that you are crazy, that you are the problem, that your memories are false. You can become mesmerized by what is wrong seeming right, even though you know it is not. The abuser emanates power, becoming a kind of vengeful god, holding sway over even your self-conception.

To the abuser, power is the ability to humiliate. But abusing others will never satisfy the abuser until he confronts the humiliation he himself suffered: that is why abuse is serial and compulsive. Payback is paid forward. The only other response to abuse—when not open rebellion—is to invest that abuse back into the self, in the form of self-hatred, self-medication, and self-harm, and I know from experience that even these inward-facing responses hurt those you love, your girlfriends and friends.

This is all very new to me. When a young mind and body are traumatized, they go into a kind of shock. The events that have occurred are too far outside the window of experience, and so the mind takes over, bent on protection and survival. Memories can be formed, repressed, and stored away, like the Ark of the Covenant at the end of the Indiana Jones movie. I recovered mine only recently, and they came back first in my body—twitches and bruises, aches and pains—the meat of myself trying to make sense of the actions that the mind never processed fully, like a movie where the sound and motion are out of sync.

These days, I’ve been rebuilding, trying to synchronize, because when working properly the mind and body are the same: We are one organism with five senses. Sometimes, I think I have answers. I don’t. I used to think abuse happened to other people, not me. I used to think other people hurt people, not me. I was sure of it. I am capable of great feats of self-delusion. In all of this, I am not alone.

Men know, but often forget, that when they say no, people hear it. Women say no, or a resigned yes due to circumstances, or remain silent to survive (often out of fear of a reprisal), and we proceed with the grace and goodwill of a two-ton wrecking ball. Throughout human history, men have consciously and unconsciously acted out their malice and anger, their own feelings of inferiority, upon women—often, it must be said, aided and abetted by alcohol. Payback is paid forward.

But woke, sober, and righteous men can be the most self-deluded of all. “We are not like the brutes,” we say. “We hate the brutes!” To us, the brutes are the guys who got the girls in junior high because their voices deepened before ours, the guys who secreted hormones while we still had no pubic hair. The brutes also humiliated us .

So, once we get elected to office, or produce an Oscar-winning movie, or rise to editor in chief, or fill Madison Square Garden with thousands of people to hear our jokes, we feel that we have won, that we are entitled to a little fun. We are better than the brutes. We deserve something too. We act through willful ignorance, an indefensible suspension of morals and a byproduct of a culture, of families, and of institutions that fail to set the proper boundaries, instill the proper values, or mete out proper reprimands when they’re early enough to take, or late enough to matter.

Preaching is not my job. As a literary agent, I try to find people who can change the way we think about the world, often applying the lessons of the past to make sense of the present for a better future. So I feel on firmer ground when I paraphrase from David France’s How to Survive a Plague , a book another agent I know helped to shepherd into being.

In the 1980s, an illness called AIDS descended predominantly upon a group of people in this country who had done no harm to anyone; they loved, that is all. Millions died, while others slept, postured, or turned away. The courageous acts of the men and women who refused to be silenced by the stigma and pain associated with AIDS and with being gay ended up forcing the U.S. government, the medical community, and the culture to respect their needs. They fought for and won their rights. They saved lives.

The revolution began by breaking the silence. Silence equals death. My silence is over. I choose life.

Elias Altman is a literary agent in New York City.

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Sexual Abuse

Sexual assault survivor pens powerful letter to her attacker, one woman opens up about trauma recovery..

Posted March 2, 2021 | Reviewed by Ekua Hagan

• What Is Sexual Abuse?
• Find counselling to heal from sexual abuse

In 2011, Ashley Hunt’s world was shattered by a sexual assault. Ten years later—facing daily emotional challenges and a sense that she was robbed of so much happiness —she decided to write a letter to her attacker. Rather than sending the letter, she feels the best way to help reduce sexual assaults is to share her story and talk about her struggles with forgiveness , anger , anxiety , power, and pain.

Here is the letter written by Ashley:

This year is the 10-year anniversary of surviving your sexual assault. It has been a windy up-and-down decade of trauma recovery. Two years ago, I thought I had made a lot of progress in my recovery but then something significant happened when I traveled to Alaska. It was the first trip I have been on that I wasn’t thinking or getting inspired for my work. Being in nature and out in the middle of nowhere with no service and no noise put me in such a state of peace. This experience shined a light on the only thing that was not peaceful within me, and that was you.

I thought a lot that week about you. I bet you had no idea how much of a ripple effect your one decision would have had on me. How could you, when you knew nothing about me? A sexual assault is enough for anyone to break but because you did not know me you had no idea that a year and a half prior to that night my mom died. The combination of traumas in such a short time frame nearly took my life. I question if you ever think about what you did, if you have remorse, and if it haunts you the way it haunts me.

I have spent much of the last 10 years going through phases of feelings about you and that night. I have wanted to kill you. I have hated you. I have felt the deepest level of sadness and despair because of you; and at times I have felt indifference.

You robbed me of everything I had known of myself for 19 years. You stole my innocence, trust, hope, safety, and openness . Did you know that trauma survivors' brain neurons rewire; creating “trauma loops” which is why triggers are so extreme because something as simple as a movie scene can make you feel like you are reliving it? Do you know that it gets ingrained into your DNA and lives in your body forever? Did you know that suicide rates skyrocket after a sexual assault? Did you know that I thought about it after months of feeling like I was physically suffocating in my own shell of a body? I said to my counselor that first year, that I died the night you attacked me. Your decision took my choice to have a certain type of life. One that involved a level of innocence and naivety to the wrong and evil of the world. But when I left your house, I had to come to terms that the life that I had before was gone and I had to choose the life that I could have next. I walked out of your house a different person and one that I didn’t recognize for years. But I know her now and I’m going to make sure you do too.

In the last 10 years, I have had to rebuild and reclaim myself. I had to learn how to love myself again and regain control over my body and my life. But what has surprised me is all the things I have come to learn and all the things I have done since you.

Since that event, I started my own company that helps people heal from chronic pain , and we have an advocacy portion that helps survivors of sexual violence heal and raise awareness. I have hosted fundraisers, co-authored books, and have spoken in front of hundreds of people sharing my story of surviving your attack. I even shared my story in the quad of our university, right where I met you. Many people have asked me how I am brave enough to talk openly about my attack. My answer is simple. I thought I was going to die that night, and then many times again that first year. When I chose to live and fight, that experience made me fearless in a way. It made me tough, and for a while, even hardened. This trauma sparked a fire in me.

That fire lasted eight years. It allowed me to fight through the first few years of my career and share my story. It allowed me not to break with every story I was told from another survivor. It kept me angry and hungry for change. I befriended and harnessed my rage for years. Channeling it into purpose and for good. But being in Alaska I came to realize a few things about this feeling.

I thought for a long time that I needed it because I thought it was the thing that allowed me to become the woman I am today. I thought it was what made me strong and resilient . But being in such peace and beauty made me realize that my rage and hatred for you just gives you power and takes the power away from me. It keeps you alive and a part of my current story. It was then that I realized my rage was never my source of power; it was my ability to continue to love.

I have pondered what forgiveness and strength mean to me for a long time. I used to think that by not forgiving you it gave me power over you. But I was wrong. My anger and rage had a purpose when it did but at the end of the day, it is and was, still just rage and anger. Those two things silently eat at you and take up space where you could have peace and joy.

I have recently gotten to a place in my life for the first time that I no longer feel that I am just surviving. This shift in feelings did not come from anger, rather, it came from love. I met someone that embraced all of me. My scars, my passions, my anger, and my joy. I started to thrive when I learned how to open my heart up and to let someone in. But to love with all I have means that I have to make more room. I have to push my anger, resentment, and hatred out of the way to go all in. And you are the last thing I need to push out.

We are a part of each other’s story and always will be. Whether we like it or not your one action has created a ripple effect in both of our lives. I have heard it has caused you a lot of fear and hiding. I am sorry for you and that you have had to live that way. I did know a thing or two about fear because of you the first few years after you attacked me; but then I learned how to make you afraid and I liked it. I liked that I had your name and could use it at any time. I liked that you are documented in the system so if you ever do something like that again you will go straight to jail, no questions this time.

I have watched so many movies about love and “how it conquers all” and honestly I felt like it was kind of corny and cliche. I didn’t fully understand what it meant. But what I realize now is that if I choose to stay angry and I use my work to scare you then I am equally a part of the problem. In my lifetime, I want to make a dent in reducing sexual assaults and the only way we are going to be able to do that is through love. You didn’t do what you did because you were pain-free. I believe you did what you did because you were wounded and self-destructive. I don’t know who made you feel powerless but I am sorry someone did that to you. I feel bad for what you must have gone through in your life to make you do what you did. People don’t just choose to be violent and hurt others, they learn how to.

I know you have seen the news and the #metoo movement. There are a lot of men like you that have made similar decisions. We can’t go back and we can’t change the past, but we can damn well change the future. We will continuously fight this battle and lose if we lead with anger. I have used my experience to help others and will continue to do so. I hope that you have actually changed and continue to work on yourself. I hope you learn about love and heal whatever was broken in you. I hope you change another man’s heart and prevent others from doing what you did.

I may not be ready to say “I forgive you,” but I do know that 10 years later, I forgive myself and have relieved myself from any blame I have carried. I am so grateful I chose to survive those first few years. I had no idea how much beauty could come from such pain. I may have lost much that night, but I have gained far more since then.

I am writing this letter to say goodbye to you, my rage, and pain. I am choosing to lead this next chapter of my life with love because my husband deserves that, my future kids deserve that, and most of all I deserve it.

I hope you choose to do the same.

Helping to reduce sexual assaults

Ashley Hunt is the Founder and CEO of Pancea . Justine Luong, COO of Pancea and Ashley scaled their Corrective Exercise Specialist experience through this software-based platform. Pancea is an affordable and scalable integrative health platform that uses a biopsychosocial approach in creating personalized chronic pain relief and trauma recovery programs. The company participates in annual giveback events raising money in the past for BAWAR and now for RAINN . Ashley continues to do speaking engagements with organizations and universities to raise awareness of sexual violence and educates victims in holistic techniques and tips to aid in their trauma recovery.

Help for victims of sexual assault

• National Sexual Assault Hotline. Free. 24/7. Confidential: 800.656.HOPE
• RAINN (Rape, Abuse & Incest National Network) is the nation's largest anti-sexual violence organization

If you or someone you love is contemplating suicide, seek help immediately. For help 24/7 contact the National Suicide Prevention Lifeline , 1-800-273-TALK, or the Crisis Text Line by texting TALK to 741741. To find a therapist near you, see the Psychology Today Therapy Directory.

Kevin Bennett, Ph.D., is a teaching professor of social-personality psychology at Penn State University Beaver Campus and host of Kevin Bennett Is Snarling, a podcast about danger, deception, and desire.

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Is There a Smarter Way to Think About Sexual Assault on Campus?

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If I were asked by a survey to describe my experience with sexual assault in college, I would pinpoint two incidents, both of which occurred at or after parties in my freshman year. In the first case, the guy went after me with sniper accuracy, magnanimously giving me a drink he’d poured upstairs. In the second case, I’m sure the guy had no idea that he was doing something wrong. I had joined a sorority, and all my social circles were as sloppy, intense, and tribal as the Greek system—the groups that made these incidents possible are the same ones that made my life at the time so good. In college, everything is Janus-faced: what you interpret as refuge can lead to danger, and vice versa. One of the most highly valorized social activities, blacking out and hooking up, holds the potential for trauma within it like a seed.

I got to thinking about this—and picturing my college self as a sort of avatar in an extended risk simulation—after talking with Jennifer Hirsch and Claude Ann Mellins, at Columbia University’s Mailman School of Public Health, in Washington Heights, on a biting, windy day last December. Hirsch, an anthropologist, and Mellins, a clinical psychologist, are Columbia professors. Both women are in their fifties, have shoulder-length brown hair, and grew up in Jewish families in Manhattan. They share a sharp, maternal pragmatism—between them, they have five sons, ranging in age from fifteen to twenty-three. For the past three years, they have been leading a $2.2-million research project on the sexual behavior of Columbia undergraduates. The project is called SHIFT , which stands for the Sexual Health Initiative to Foster Transformation.

The problem of campus sexual assault can seem unfathomable and intractable. We generally think of it as a matter of individual misbehavior, which, various studies have shown, most prevention programs do little to change. But Hirsch and Mellins think about sexual assault socio-ecologically: as a matter of how people act within a particular environment. They are doggedly optimistic that there is, if not a single fix, a series of new solutions.

Watch “The Backstory”: Jia Tolentino discusses reporting on campus sexual assault.

A four-year residential college is what sociologists call a total institution: it controls the conditions under which students eat, sleep, work, and party. “You can just imagine all these contextual dimensions in college that could be tinkered with to create a less stressful, less hard-drinking, more respectful environment,” Hirsch said. The assumption is that some college students are committing sexual assault when they don’t intend to, and that many are more vulnerable to sexual harm than they ought to be. Either idea can be controversial, and focussing on contributing factors, such as drinking, rather than just on the bad acts of perpetrators, can seem beside the point. But Hirsch and Mellins insist that their approach to prevention does not ignore personal responsibility; rather, it aims to nudge students toward responsible behavior on a collective scale. The first time we met, on Columbia’s main campus, Hirsch put it to me more plainly: “We have to stop working one penis at a time!”

SHIFT was born out of a crisis. In the past several years, as students all over the country became more vocal about the problem of rape in college, the press seized on a series of dramatic incidents, including one at Columbia. A rare combination of academic talent and initiative was then unleashed by the university, which may have felt the need to demonstrate its commitment to the cause, and this produced, after two years of sunup-to-sundown effort, the most rigorous, nuanced, and wide-ranging examination of the problem that has ever been carried out on a college campus. “It’s better for universities if sexual assault is positioned as a matter of sexual health, rather than as a scary threat,” the journalist Vanessa Grigoriadis, who published a book last year, “Blurred Lines,” about sexual assault on campus, told me. She added, “We’re in a new phase of the movement.”

You can trace that movement back at least four decades, to 1977, when a senior at Yale named Ann Olivarius—along with another student, three graduates, and a male professor—sued the school, citing quid-pro-quo sexual harassment by professors, a hostile environment, and a lack of reporting procedures. The plaintiffs, advised by a recent Yale Law graduate named Catharine MacKinnon, argued that this was a violation of Title IX—the federal statute, passed five years before, that prohibits gender discrimination in educational institutions. The women lost the case, but the district court ruled that it was “perfectly reasonable to maintain that academic advancement conditioned upon submission to sexual demands constitutes sex discrimination in education.” Two years later, MacKinnon published her landmark book, “Sexual Harassment of Working Women,” which argued that “economic power is to sexual harassment as physical force is to rape.”

The proper scope of Title IX was argued in court over and over in the years that followed; rulings narrowed its application, then expanded it again. Meanwhile, anti-rape activism progressed on campuses across the country. Take Back the Night marches, which had begun in the seventies, became a feature of college life in the eighties; Columbia’s first Take Back the Night march was held, in front of the Barnard gates, in 1988. The Columbia University Senate passed the first school-wide sexual-assault policy in 1995—it required that complaints be handled through an alternative form of the school’s standard disciplinary procedure. Student activists weren’t satisfied: they wanted the deans who handled sexual-assault cases to receive additional training, and they wanted to know how many incidents were being reported. They staged a prolonged campaign that culminated, in 1999, in a twenty-three-hour vigil, during which hundreds of students marched through campus shouting, “Red tape can’t cover up rape!”

Seven years ago, the Office of Civil Rights, under President Obama, issued a “Dear Colleague” letter, reasserting that sexual violence on campus was a violation of Title IX, and pushing universities to handle sexual-assault cases in a timely, transparent, accuser-friendly manner. A year later, the Department of Justice expanded its definition of rape to include male victims and multiple types of violations. (The previous definition—“the carnal knowledge of a female, forcibly and against her will”—had been in place since 1927.) Today, the D.O.J. defines sexual assault as unwanted sexual contact, which means that groping counts, as does attempted assault. The crime hinges on intention, and there are often no witnesses, which makes it uniquely difficult to adjudicate in any legal system, let alone one made up of college administrators. Campus judiciary systems don’t have a criminal court’s investigative powers or evidentiary procedures, but they do have many of a criminal court’s responsibilities. To complicate matters further, everyone involved in the process—accuser, accused, administrator—essentially works under the same roof. Betsy DeVos, Trump’s Secretary of Education, has called the current approach a “failed system,” and said that she would seek to replace it.

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It might seem simpler to let the criminal-justice system handle things, but universities have a responsibility to insure that women have equal access to education. And, in addition, many students prefer to address these matters outside that system—they don’t necessarily want to send their assaulters to prison, and they may not be able to prove their cases beyond a reasonable doubt. Columbia now has twenty-three staffers with Title IX responsibilities, including case managers, investigators, and administrators, and provides free legal services to accusers and accused. The school’s gender-based misconduct policy is thirty-one pages long.

Freshman year at Columbia, as at any college, can be overwhelming: awkward encounters at parties in the “social dorm,” where the long wooden doors can be taken down to serve as beer-pong tables; a rush to find a home base in extracurriculars and clubs. Juliana Kaplan, a Barnard junior, told me, “On the one hand, you have kids at Columbia who come from kings of Wall Street—you have a secret society based completely on wealth. On the other, you have a demographic of first-generation, low-income students of color. People come in through very different contexts.” When I asked her about the tenor of student conversation on sexual assault, she told me, “I try to remember that some people have been super aware of these issues for their whole life, due to any number of factors, and then there are some people, such as men, who have to actively learn about it while they’re here.”

Five years ago, a Columbia sophomore named Emma Sulkowicz filed a complaint with the university, accusing another student of rape. (Sulkowicz, who has been working as an artist since graduation, identifies as non-binary, and uses the gender-neutral pronouns “they” and “them.”) A consensual encounter on the first day of the school year had turned violent, Sulkowicz alleged: in the midst of sex, the student anally penetrated and choked them while they struggled and told him to stop. (He has consistently maintained that the entire encounter was consensual.) Sulkowicz decided to report the incident after another student said that she’d had a similar experience with the same man. Columbia held a series of hearings and found the man “not responsible,” and Sulkowicz was subsequently denied an appeal. The following April, twenty-three students and alumni, each with a story of assault, filed a hundred-page federal complaint against the university. Student activists formed a group called No Red Tape, evoking the protests of the nineties. When the fall semester began, Sulkowicz, an art major, started carrying a fifty-pound, twin XL mattress around campus. It was a performance project: they would stop carrying it, they said, when the student who had raped them was expelled. (Sulkowicz carried it until graduation; the man they accused later sued Columbia, arguing that the university’s support of the project, for which Sulkowicz had received academic credit, constituted gender discrimination, negligence, and intentional infliction of emotional distress. The university settled with him out of court.) Soon after Sulkowicz began carrying the mattress, dozens of other Columbia students brought mattresses to the steps of Low Library and told their own stories of sexual assault.

It was around this time that Jennifer Hirsch attended a meeting of Columbia’s Women’s, Gender, and Sexuality Studies Council, where faculty members gathered in a conference room and picked over a catered breakfast. She sat next to Suzanne Goldberg, who at the time was a special adviser to Columbia’s president, Lee Bollinger, on the subject of sexual-assault prevention and response. The debates concerning rape on campus and what to do about it have been waged primarily between students and administrators, with professors off to the side. Hirsch had become frustrated by the focus, in those debates, on adjudication and punishment, rather than on the ways in which the environment of college makes students vulnerable. As the meeting ended, and people began collecting their things, Hirsch turned to Goldberg and spontaneously proposed conducting an ethnography: she would interview students, learn the everyday context of their sex lives, document the stories that the university couldn’t see. Goldberg said that sounded terrific, and told Hirsch to write up a few pages pitching the project.

A couple of weeks later, Hirsch popped into Mellins’s office, two floors down from hers in the Mailman building. The two professors have been friends since 2005, when Hirsch, who teaches in the sociomedical-sciences department, began doing work at the H.I.V. center at Columbia, which Mellins co-directs. Hirsch handed Mellins the paper she’d drafted, and began peppering her with questions. Mellins was the lead author of a 2011 study into the mental health, drug use, and sexual behavior of adolescents who had been infected with H.I.V. in the womb or as infants. She knew something about discussing uncomfortable matters with young people, and quantifying those conversations for research purposes. She answered Hirsch’s questions, and started asking her own.

Hirsch looked at her closely. “Do you want to do this with me?” she asked.

They spent the next few weeks brainstorming—on the phone, over e-mail, in each other’s offices, on whiteboards. They thought about the relevant expertise of their colleagues. Who really knew about interpersonal violence? Who really knew about epidemiology? Statistics? Trauma in young adults? As the fall turned crisp, they tracked down the faculty members whose help they wanted, and asked them if they would join SHIFT . In November, 2014, they submitted their proposal, and Goldberg quickly secured the university’s approval.

Goldberg, who is in her mid-fifties and speaks with a flat, equanimous affect, became Columbia’s first executive vice-president for university life in 2015. She has a long career of progressive advocacy—she was a co-counsel for the defendants in Lawrence v. Texas, which nullified Texas’s sodomy law. She leads Columbia Law School’s Center for Gender and Sexuality Law, and she was integral to the development of SHIFT . (“We had many breakfasts,” Hirsch explained.) But she has become a maligned figure among student activists. Amelia Roskin-Frazee, a senior involved with No Red Tape, spoke to me dismissively about the Sexual Respect Initiative, a consent-education requirement, instituted by Goldberg in 2014, that included an arts option: students could write a poem, submit a drawing, or perform a dance. When I asked Goldberg about this criticism, she said, “The initiative meets students where they are.”

Roskin-Frazee is a queer activist who, at fourteen, founded a nonprofit that provides schools and shelters with L.G.B.T.Q.-themed books. She is currently suing Columbia. She says that, two months after arriving on campus, she was violently raped in her dorm room by a stranger, and that, a few months later, she was raped again, by an assailant she suspects to be the same person. (She told me more than once that she knew this was not a typical campus assault; last year, she wrote a piece for HuffPost criticizing the notion that “true stranger rapes” are any more serious than those committed by people who know their victims.) She asked to move out of her dorm room, and alleges that Columbia violated Title IX by requiring her to do so within twenty-four hours, and telling her it would cost five hundred dollars. Columbia has moved to dismiss Roskin-Frazee’s lawsuit, arguing that she obstructed her own investigation by waiting months to file an official report. In October of last year, with a group of protesters, Roskin-Frazee barged into one of Goldberg’s law classes to publicly accuse her of endangering student survivors.

The creation of SHIFT was announced to the university at the end of February, 2015, in an e-mail from President Bollinger. Hirsch and Mellins began soliciting applications for a paid undergraduate advisory board, ultimately selecting a dozen or so students, including members of the Greek system, student-government leaders, a ballerina in Columbia’s General Studies program, anti-sexual-assault activists, a sex educator, a Barnard student, and an R.A. For the next two years, when school was in session, the group met over bagels at 8 A . M . every Monday. The board created a typology of Columbia students—the hyper-involved, the completely disinterested, the kids who find their thing and stick to it—and corrected the researchers in their sometimes fumbling attempts to classify student identities. (Each time they pointed out such a mistake, one student-board member told me, the researchers’ eyes would pop in surprise, and then they’d come back the next week saying, “We had seventeen meetings since the last time we saw you, and we’re going to do what you say.”) The students planned promotional events, setting up SHIFT tables outside the dining hall and the gym. They brought the researchers, who answered questions for students, and made sure they always had snacks. “Snacks, we learned, were a really big thing,” Hirsch said.

Meanwhile, Hirsch and the Columbia sociologist Shamus Khan prepared a team of ethnographers—current and recent grad students, who were close to their subjects in age—to talk with undergraduates about intimate subjects. These interviews would be the first big component of SHIFT ’s information-gathering. The ethnographers began, that fall, with “participant observation”—i.e., hanging around football games and drinking club soda at student bars. Shortly afterward, a story appeared in the student newspaper the Daily Spectator , in which an unnamed sophomore said that Khan had been spotted taking notes at 1020, a popular bar near campus. (The plans for the ethnographic research had been announced in the Daily Spectator months before.) The story was picked up by the Post , which reported that “Columbia University researchers are spying on the school’s students at bars and campus parties as part of a new study about sexual health and violence—and the students say it’s creeping them out.”

In fact, by all accounts, the process went pretty smoothly. Some students, after talking to the researchers for a while, invited them to parties, or to kick it in dorm rooms. Many university employees are required to report sexual assault to the Title IX coördinator, but the researchers received a waiver so that they could promise students confidentiality while engaged in SHIFT research. Alexander Wamboldt, an affable, bearded Princeton Ph.D. who worked as a SHIFT ethnographer, told me that it was important, in these encounters, to “model good, consensual research behavior”—he announced his name and his purpose, along with a disclaimer about confidentiality, before entering a conversation. He and the other researchers conducted one-on-one interviews with a hundred and fifty-one students about their sex lives and their experiences at Columbia. (Students were paid for the time they spent in these interviews.) Hirsch and Khan sorted through the data and adjusted their approach when they weren’t getting all the information they needed. Wamboldt was hired to focus on so-called high-status men, such as those involved in athletics and fraternities, a group of students who hadn’t, up to that point, spoken much with the ethnographers, perhaps wary of the possibility that they’d be portrayed badly in whatever the researchers wrote up.

The interviews were bracing. Talking about sex brings a lot to the surface—students discussed loss, family, trauma, hardship, fear. Some of the men Wamboldt spoke to cracked offhand jokes about having been raped. The members of the ethnography team soon decided that they needed to do a mental-health check-in at their weekly meetings: they would go around the room, and everyone would relate how he or she was coping with the work.

In one advisory-board meeting, Mellins and Hirsch shared preliminary observations, and Mellins brought up affirmative consent—the practice of actively, mutually soliciting enthusiasm throughout a sexual encounter, which is now the legal standard for universities in New York and California. Most college students learn about it in orientation seminars or from online modules that they are required to complete. Mellins told the administrators that affirmative consent rarely factored into the experiences that students were describing.

“One of our institutional advisers pretty much fell off her chair,” Mellins told me. “She said, ‘How can it not be a thing? We’re working so hard to teach them.’ And our point was: there’s a really broad disjuncture between what students learn and what they actually practice.” The researchers found that the practice is much simpler to understand than its detractors, who tend to picture a stack of paperwork accompanying every make-out session, seem to think—and also less common than its proponents would like to believe. ( SHIFT plans to publish a paper on affirmative consent later this year.)

Hirsch and Mellins launched the second phase of the study, an enormous daily-diary project, in October. Four hundred and twelve students were asked to fill out a short online questionnaire every day for sixty days. (The student board convinced the researchers that the only way to maintain subject participation through midterms was to pay: diarists got a dollar an entry.) The idea was that researchers would be able to quickly scan each twenty-four-hour period for mood, sleep, sexual activity, substance use, and unusual experiences. The pool of data could then be parsed for patterns and fine-grained interactions. Researchers might find, for example, that unwanted sexual contact is more likely to occur in the midst of other crises, or after a person has experienced unwanted sexual attention in another setting.

In January, 2016, the SHIFT team recruited students for Part 3: a sweeping, onetime survey. The student board roped in peers with the promise of gift cards, and by talking to them about how important the project was, how it could show that Columbia took sexual assault more seriously than other universities, and how, if they participated, they’d get snacks. (Students who took the survey in SHIFT ’s temporary office got fruit, candy, pizza, and chips.)

The survey contains hundreds of questions, many of them startlingly intimate. It seems likely that no previous survey has so accurately reflected how sexual assault actually occurs in college—as an event embedded within the fabric of everyday life, which both perpetrator and victim understand based on their background, their habits, their state of mind. The survey asks students about sleep, exercise, eating habits, mental health, where they get alcohol, what sort of dorm room they live in, where they party and how. It asks about money, family, friends, their sexual experiences before college, their sense of agency and of self-worth. It asks about gender identity and attraction, about the moments just before an incident—who was around, what was happening—and what followed, immediately and in the long term. It asks about consent: if students expect their partners to ask, if they think it’s a matter of body language, if they think that asking once at the beginning of a hookup is fine. It asks about attitudes regarding sex and gender, sussing out common cultural biases: To what degree do they think that women lie to get ahead? Do they think that men should reveal vulnerability? Do they believe that it can’t be rape if both people are drunk? Are they not at all sure, a little sure, somewhat sure, pretty sure, or very sure that they could say no to having sex with someone if they want to date that person? What if they want the person to fall in love with them, or if the person won’t use a condom? What if they’ve had sex with the person before?

Twenty-five hundred Columbia and Barnard undergraduates were invited to participate in SHIFT ’s survey, and sixty-seven per cent of them did so. I took the survey myself one day at the end of December—answering in the present, as a twenty-nine-year-old, and thinking about how I would have answered at eighteen. In the course of a half hour, I felt nauseated, and then oddly comforted, by how well the questions were outlining my life. A detailed constellation emerged of all the things that had protected me in college: a chemically stable disposition, satisfying relationships, a sense of control over my experience at school, a lack of confusion about what I wanted sex to be. My vulnerabilities—a certain recklessness, a freshman-year social life that depended on spaces and substances provided by men—were just as clear. I could see the desires and the habits, sexual and otherwise, that traced the path between then and now. I started to wonder if the research that SHIFT is producing might start closing the gap between two seemingly contradictory realities. Sexual assault on campus is frequently portrayed as lurid and dark and complex. But the experiences that live in our heads are often obvious and ordinary, sometimes heartbreakingly so. SHIFT is, in a sense, a reporting project of unprecedented scale, a map that genuinely reflects the size of the territory. It could be one of the first endeavors to show the magnitude and the texture of the problem at the same time.

S HIFT ’s research concluded in the fall of 2017. Since then, the team has been analyzing the data and preparing to publish a slew of papers about the results in peer-reviewed journals. (In December, Hirsch and Khan sold a book about SHIFT , tentatively titled “The Sexual Project,” to Norton, to be published in 2019.) The first paper, which appeared in the open-access online journal PLOS ONE in November, laid out what the team learned about the frequency of sexual assault at Columbia. Sexual-assault research is notoriously contested and spotty—many regularly cited statistics come from studies with big design flaws, such as small sample sizes, or loose definitions of “college student.” The record-setting response rate for the SHIFT survey makes its data unusually comprehensive and reliable. In certain important respects, its numbers are in keeping with previous findings: a little more than one in five respondents said they had experienced sexual assault since starting college—twenty-eight per cent of women, twelve per cent of men, and nearly forty per cent of gender-nonconforming students. (The survey did not use the term “sexual assault”; it asked about “unwanted sexual contact.”) But there were also surprises. It’s long been established that women and L.G.B.T.Q. students are especially vulnerable to assault; SHIFT found that students who are struggling to pay for basic necessities are, too. Men in fraternities are, in fact, more likely than other male students to be perpetrators; SHIFT found that they were more likely than other men to be victims as well. A culture that doesn’t teach men to ask for consent often doesn’t teach them that they can withhold it, either.

Hirsch and Mellins avoid the term “rape culture” when discussing their work. I’ve never liked that phrase, not because it doesn’t name something real but because it emphasizes the way that the world is already prepared to hurt me, rather than emphasizing my personal, and not entirely predictable, relationship to the world. (As Jennifer Doyle, an English professor at the University of California, Riverside, puts it in her book “Campus Sex, Campus Security,” the term distances sexual violence from “the force of the ordinary.”) Hirsch and Mellins often talk about “sexual citizenship,” which they define as a “person’s understanding of his or her right, and other people’s equivalent right, to sexual self-determination.” In the conference room at the Mailman building, Hirsch told me, “Part of what I see our work doing is disrupting these scripts that women give consent and men secure it—that men are sexual agents and women are gatekeepers, which is affirmed by consent education that frames men exclusively as potential perpetrators.”

“Of course, you don’t want to minimize the fact that women are still holding the burden on this, in terms of absolute numbers,” Mellins said. She hesitated. “But you want to work in a way where there isn’t a single story.” A trans student who is assaulted at a party is experiencing something different from a freshman girl whose hookup is ignoring her protests in a dorm room. Both of them are experiencing something different from a boy who has never imagined that he would ever give or receive a no. Mellins pointed to an article about a Brown University student who’d been assaulted in a bathroom by another man, and then, later that day, attended a standard prevention workshop, where he felt entirely alone. “If you don’t give someone permission to be at risk, then they can’t seek help,” Mellins said.

The researchers discussed their findings with the student board—they’re all still in a group chat together—and also with administrators. Certain fixes, they’ve realized, are impossible to implement. All college students would benefit from drinking alcohol in a gentler manner: often with food, rarely in basements. But colleges can’t encourage that among underage students without breaking federal law. When I was talking with Hirsch and Mellins, I thought about my own experience with the Greek system. The National Panhellenic Conference, which adheres to rather antiquated gender norms, forbids sororities from holding parties where alcohol is served, which means that, at many schools, the most accessible parties for freshmen take place on fraternity terms, and on fraternity turf.

Every school’s environment is different—where students drink, how they get home from parties, the geographies and the conditions of their vulnerability—and the nudges and interventions have to vary accordingly. But Hirsch and Mellins hope that their research can serve as the beginning of a network of innovative cross-campus studies. In the meantime, they’re talking to administrators about the interrelationship of mental health, substance abuse, and sexual assault, and about how different types of incidents and different types of students require different types of prevention and response. Many of these conversations have echoed long-standing conclusions in public-health research, and also what some students are already asking for: more crisis support, more consideration for specific populations, more access to spaces on campus that feel like their own. “I’m grateful the SHIFT team chose to do this,” Roskin-Frazee told me. “I hope they are persuasive to administrators who are not easily persuaded.”

One night in January, I called Emma Sulkowicz to talk about Hirsch and Mellins’s project. Sulkowicz was disarming and philosophical, despite having spent five hours in the dentist’s chair earlier that day. Sulkowicz had not heard about SHIFT before, and was politely resistant to the idea: “My view in this whole thing is that, the more that Columbia can retreat behind ‘Here’s a program, here’s a study, here’s a process,’ the less that any human that finds themselves in this machine will ever be incentivized to act based on their moral compass.”

What if, I asked, the idea behind the study was tinkering with the machine, figuring out how to reorient that moral compass?

“That makes me think of asking someone to wash the dishes, and they tell you, ‘I’ll try,’ ” Sulkowicz said. “I think that’s the difference between spending two million dollars to try to understand the conditions that create a community that’s conducive to sexual assault versus just doing the right thing—expelling people who sexually assault other students.”

Sulkowicz wants to change behavior, too, but thinks that punishment is more efficacious than tweaks to campus life. When Columbia settled the lawsuit filed by the man Sulkowicz accused of rape, it put out a statement, noting that his “remaining time at Columbia became very difficult for him and not what Columbia would want any of its students to experience.” But Sulkowicz believes that what he went through had a salutary effect. “He’s been scared shitless,” they said. (The man’s lawyer called this statement “preposterous,” and said that he had done nothing wrong.)

Sulkowicz also said something that I kept hearing from Columbia students: “It’s about finding a way to make your institution, and the people who run it, more human.” Earlier that week, I’d spoken to a former SHIFT student-board member named Morgan Hughes, a laid-back twenty-three-year-old hip-hop musician. She called me from a coffee shop in Cleveland, where she’d moved after graduation. She had been a disengaged student, by her own account, mainly focussed on her music. Her friends at school, most of whom were people of color, had found it difficult to secure space and permission from Columbia to hold their own events, she told me. “Everything is so regulated, so limited, everything’s super uptight,” she said. “Columbia always says they’re listening, taking students into account, and then they turn around and make a decision that doesn’t acknowledge any of that conversation. But SHIFT did listen. They changed their agenda based on what we talked about. It didn’t feel like we were just wasting our breath.”

Would SHIFT make things different at Columbia? “Every four years, there’s a new student body, and I think Columbia is used to just waiting it out,” she said. “But this time there are professors involved. Shamus Khan is going to be there, Jennifer Hirsch is going to be there. It’s up to Columbia if they want to shoot themselves in the foot and ignore it, but people are actually paying attention to this.” She paused, and coffee-shop noises tinkled in the background. “I mean, Columbia, you should want to solve the problem, so you don’t keep having to solve the problem , you know what I mean?”

The question now is whether Columbia values SHIFT as a flagship research project or as a practical guide to institutional change. I asked Goldberg, over the phone, whether she thought Columbia would change after SHIFT . She had spoken carefully throughout our conversation, seeming to calibrate every word against the various, sometimes competing interests that she’s expected to balance. “I think,” she said, “that SHIFT ’s research is profoundly important to the work we are doing here.” It will be difficult, under Title IX, for people who live or work on campus to entirely separate sex from bureaucracy. When I asked Mellins what she hopes to ultimately accomplish with SHIFT , she said, “I’m a clinician. I’ve come to feel that, if the work we do makes the lives of even a small amount of students better, that’s what we want. We want to eradicate sexual assault, but, short of that, I think we just want to make a difference.”

The SHIFT approach, for all its rigor and scope, is in some ways remarkably modest: the idea is that small structural adjustments to student life could change how students interact with one another—help them find their moral compass more easily, feel more at home on campus, have some obstacles cleared out of their path. These humble expectations can seem deflating. But SHIFT makes a powerful argument that sexual-violence prevention must embrace the ordinary and the particular. Its programming suggestions may matter less than its potential to transform how people think about the problem. At one point in my conversation with Hirsch, she brought up an optimistic analogy. Forty years ago, alcohol played a role in more than sixty per cent of traffic deaths. Since then, a comprehensive, multilevel campaign against drunk driving has cut that number in half. This required institutional change, in the form of new laws, and social change, as school and community programs taught people to designate a driver and to intervene when a wobbly friend grabbed his car keys. It also involved changes to the physical environment: cities established police checkpoints, and offenders were required to install Breathalyzer locks on their cars. Citizens lobbied for better street lights, more speed bumps.

A version of this thinking applies to life in college: there are checkpoints and speed bumps that could decrease the likelihood of harm. Picture the freshman who’s depressed but doesn’t realize it, or can’t get an appointment at the counselling office, or doesn’t trust the counsellors. It’s easier to just drink twenty beers each weekend. On one of those weekends, he goes to a party and meets a girl who hasn’t slept in two days and is subsisting on cereal; she didn’t want to come to this party, but her roommates gave her an iced-tea bottle full of Fireball and dragged her out. The boy and the girl start talking. Their friends cheer when they make out. At 2 A.M. , when the party begins to clear, one of them says they should get a bite, but no place on campus is open. They go to her bedroom, but there’s nowhere comfortable to sit except the bed. What happens next is a blur of mismatched fears and assumptions. The girl panics, freezes, thinks the guy will hurt her if she yells at him, starts making horrible calculations of futility: anyone who hears this story will think it’s her fault for inviting him in. The guy, having half-deliberately drunk himself beyond conscious decision-making, ignores her stiffness and whatever she’s mumbling; he thinks he’s doing exactly what college students are supposed to do. There are at least a dozen small changes beyond their control that might have led to a different outcome. There will always be people, mostly men, who experience a power differential as license to do what they want. But SHIFT proposes that it is possible to protect potential victims and potential perpetrators simultaneously, and that we are, at this moment, less eager to hurt one another than we seem to be. ♦

AGNI is publishing this essay as part of The Ferrante Project.

“What would happen,” the poet Muriel Rukeyser asks in her oft-quoted poem “Käthe Kollwitz,” “if one woman told the truth about / her life? / The world would split open.” Over the past few years, I’ve begun to question the truth of that statement, especially as it relates to telling the truth about sexual violence. What is the purpose and function of writing about rape? More to the point, what to me is the purpose and function of writing when writing about my rape?

These questions grew more painful to consider after I published my first book, which examined the long-term effects of violence and survival, and more painful still when I learned this book had ended up on the reading lists of various feminist tastemakers on Twitter, one of whom noted that she was using the book as a writing prompt for her students’ exploration of violence. Thus my personal experience was to become a jumping-off point for others’ creativity, my descriptions of my assault disseminated and refracted through the exercises of strangers so they could understand the effects of such violence themselves. My assault would thus become both symbol and trope, something that could be parsed and imitated until all the rage and humanness drained out of it.  I had always known, of course, that this one of the possible outcomes of publishing such a book, especially one that ended up in the maw of social media. But actually reading this student’s response to my essay, in which my assault was reimagined and repeated back to me in her language, made me feel both sickened and small.

Speak truth to power, writers and non-writers alike declaim, and now I’ve seen this phrase trickle through the feeds of people on Facebook and Twitter. The aim is to tell the truth of our lives as we see it, as directly and with as little remorse as possible. Such an outpouring of personal testimony has indeed cracked open the world, in part by reminding participants in social media that the things most American institutions want to forget about our nation—its violence against people of color, its killing of LGBTQ people, its seemingly implacable hatred of women and their bodies—stubbornly persist. There is indeed a power and value to truth-telling. But truth-telling relies on narrative, and narrative telling—even supposedly artless, immediate telling—is in fact crafted. It wants a particular response, and nothing crafts language so effectively as a Web format that requires you to express yourself in 280 characters or less, and sells these truth-telling nuggets in a stream of visual media, making it impossible for the audience to focus on any but the most extreme, compelling, and direct language.

Social media and truth-telling both encourage the reader, primarily, to emote. And having emoted, having felt all the things and thought all the thoughts the writer has asked us to think and feel within that limited format, we can walk away from the engagement satisfied with the blunt, brute fact of our feelings. Social media offers a veneer of authenticity that claims the authority of survivorship and thus makes autobiography and resilience satisfactory political goals.

A memoir about sexual assault guarantees a certain amount of attention, because it is sensational and because writing about violence encourages a kind of voyeurism. But while this may be one possible response, it is not this writer’s desire to make the reader participate in the imagined reconstruction of violence. And reconstructing another person’s trauma is not what we teach other budding writers about the purpose of testimonies of violence, in particular the testimonies of violence that women might produce. If anything, we argue, women’s testimonies should inspire not empathy (or not only empathy) but political outrage, in large part because women’s autobiographical writing has been so effectively suppressed over centuries. Women’s writing about violence serves as a public novelty, one which, if it does not always receive the social stamp of high art, at least promises an authentic expression of rage, of grief, of endurance and survival, and—most powerfully—of hope.

But I’m not actually that interested in resilience. I want jail time for offenders. I want politicians tossed out of office, priests defrocked, federal judges fired and replaced. I want a country that doesn’t treat violence against women as sexual entertainment.

Over the past year, I’ve begun to hate the book I published. The more I read from and talk about it, the more politically and aesthetically suspicious my own writing appears to me. Who had I written it for? Who did I really imagine as its audience? The project started, in part, as a reaction to the 2009 Lilly Ledbetter Fair Pay Act, which got me thinking about the ways in which sex discrimination has shaped my working life, which got me thinking about the sexual assault I experienced as a twenty-year-old woman at a coat factory where I worked one summer as a down stuffer along with several itinerant workers, one of whom attacked me. The book was finally published around the time that our current president, then a presidential candidate, admitted to grabbing women “by the pussy,” which made the #MeToo hashtag started by Tarana Burke in 2006 erupt into a firestorm. Into this storm my book was tossed, and while I was happy at first to add my voice to the movement, over time I began to feel that the book sounded less like me than an automated reply. Using the same language that has characterized the experience of so many other women certainly brings me into community with them, but that shared language also makes the stories of survivors feel depressingly interchangeable and flat.

Perhaps this flattening is created in part by our social expectations about female psychology and women’s writing, in particular our assumption that women’s writing is primarily or only autobiographical, not imaginative, and that it stems from an institutionally disadvantaged position that we equate with pain. This, too, enrages me. It feels as though, because I am female, I was born into this language and psychology; as a woman and a writer, I am a grievance waiting to be heard and endured. At times it feels that the best I can do is pay close attention to that grievance, to give it a slightly different shape and coloration. By writing about my assault, I confirm the most inarguably authentic position of the not-male, and also the not-white: the pained, the wounded, the helpless, the small .

To speak about one’s assault in a way that feels actually authentic is to thread the needle through an incredibly slender eye, made ever more narrow: by the pressure of therapeutic services, which argue that such narratives are not only good, but necessary for psychic healing; political and social institutions, where truth-telling makes for good rallying cries and possible legislation; and by social media, which argues for ever more devastating expressions of the self to be streamed and consumed and disseminated.

Effective writing about violence shares many of the aesthetic traits of political language, which is to say its directness resists excessive or subtle interpretation. It compresses time and context in order to focus on the moment at hand. Writing about violence authenticates itself through the performance of immediacy and vivid feeling. This is what suggests truth—and it is surprisingly, distressingly easy to duplicate.

The social media performances of grief, selfhood, and outrage I daily read feel suspiciously like masquerades. In my feeds, writers try to outshine and outthink the politicians and abusers inspiring our outrage, using language whose nuance rarely rises above theirs. In this way, we are shackled to victimizing doubles. As much as I despise the self-help books, the prayer circles, the thin whine of grief on Twitter and its overuse of the word trauma , the only identity that seems unable to be challenged or shamed is that of the victim. Thus I and others willingly write into and about how we have been diminished or shamed, to stop ourselves from being attacked by those claiming to be more morally progressive online, because the only way to keep yourself safe within that group, it seems, is to become the witting accomplice to your own self-objectification.

Refracting and repeating narratives of violence also risk downplaying or even ignoring matters of race and class in favor of the sensational act itself, even as race and class make violence a more or less likely experience for a person to have. It is not lost on me, for example, that I come from a middle-class family and was attacked by someone skirting the poverty line, that what brought us together was a coat factory that relied on both our labor to exist: me, the mixed-race college student earning money for her next year’s tuition; my attacker, a white man who moved from job to job, city to city, aimless and resentful of the opportunities I would have in a world he imagined pandered to minorities. It is not lost on my either that the stories we repeat most often online are those told by and about middle and upper middle class white women. Our retweeting and sharing of these stories replicates the culture’s co-opting of Tarana Burke’s #MeToo hashtag into the world of (largely) white and (largely) middle-class feminism.

The young student, consciously or unconsciously, performed this co-option when she imitated my writing. She understood that some part of writing about and against violence, especially the violence that women experience, is imitative and coercive. One does not have to be a victim of violence to render that violence believably or powerfully. The actual experience of an assault may be private, it may reveal the world to be artless and cruel, but the sharing of it depends entirely on creative skills, detailed images, and ideas of identities that can be appropriated.

 Even as I write this, it strikes me that perhaps I’m wrong to think we’ve become numb to, or jaded about, female narratives of pain. I think back to that look on Arizona senator Jeff Flake’s face in the elevator as he fled the Kavanaugh hearings, the moment when a protester pried apart the elevator doors to demand he hear about the assault she’d survived. I see again the pain twist across his face. Perhaps the reason the #MeToo movement hasn’t achieved more substantial victories for women is not that its language has started to feel formulaic, but that it really is too painful for people to witness. It’s too painful because it asks those who have not suffered to imagine the limits of their physical invulnerability—to realize, if only empathetically, that their sense of self-protection is a fantasy. We turn away from the language of violence not because it has become anodyne, but because we see how easily each of us can be made a victim.

“Perhaps writers like us really can change the world,” one young woman wrote to me recently in a private Twitter message. “Your book inspired me to tell my own story. You can check out my feed.” I thumbed down the screen to read it, the words of this stranger who, like me, was humiliated and hurt, raw and furious, her own terrible story wedged now between video grabs from a Trump rally and a trailer for John Wick 3 . I stopped reading and her story flickered past. I wrote privately to thank her, added a few glib notes of praise, and told her I hoped she’d continue writing. Then I deleted her message.

The Ferrante Project: The freedom of anonymity brings together sixteen women writers of color (alongside sixteen visual artists in a linked project with the Warhol Museum) who anonymously contributed new works in response to, or critique of, the cult of personality, posturing, and preemptive celebrity of writers at the expense—sometimes—of the quality and provocation of the work itself. This is a collaboration between Aster(ix) and CAAPP: Center of African American Poetry and Poetics.

Contributors include Angie Cruz, Sarah Gambito, Dawn Lundy Martin, Khadijah Queen, Ru Freeman, Ayana Mathis, Vi khi nao, Cristina García  Cathy Linh Che, Aimee Nezhukumatathil, Deborah Paredez, Emily Raboteau, Paisley Rekdal, Natalie Díaz, Lyrae Van Clief-Stefanon, and Jamey Hatley.

This page collects the works of anonymous writers published by  AGNI.

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Sexuality & Narratives of Consent & Control

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Amanda Charles Follow

Sexual Assault and its Impacts in Young Adult Literature

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As sexual abuse has become a more prominent topic in the media it has become necessary to find helpful ways in which young adults can discuss sexual assault without feeling threatened. Young adult novels have become a vehicle through which teenagers can begin to understand sexual assault and the trauma that follows it. These novels are able to extend their reach to both victims and their peers. The following essay highlights my research on the effects of discussing sexual abuse in young adult literature. As a victim of sexual assault, I found solace in the young adult novel Speak which narrates the aftermath of rape in a 14 year old girl’s life. Having connected with and begun my personal healing process through a young adult novel, I began my search to find evidence that there were other teenagers like myself, young adults who found comfort in books that discussed sexual abuse. My journey uncovered the great resource that these novels can be in the classroom and out of it. When discussed correctly in a classroom or read appropriately outside of school, rape novels become a source of strength to victims and a dispeller of rape myths among victims’ peers. I found that exceedingly dark and explicit novels discussing sexual abuse are generally targeted at an older audience and therefore do not pose the threat to innocence that most adults are afraid of. YA novels discussing sexual abuse have proved to be a place of sanctuary, compassion, and discussion among young adults. They offer a safe place within which young adults can connect and heal. Their presence is not only beneficial but crucial.

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Chris Crowe

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A different path for confronting sexual assault

What is restorative justice? A practitioner explains how it works.

by sujatha baliga

“When I was crying, that was no,” Sofia yelled. “When I pushed your hands away, that was no! And when I said, ‘I’m not that kind of girl,’ that was NO! I want to know what you were thinking. What were you thinking?”

I was sitting with Sofia, 15 years old, as she directly addressed Michael, her 18-year-old schoolmate who had sexually assaulted her. This face-to-face dialogue was the conclusion of a month-long process during which I’d been helping these young people practice restorative justice.

Michael’s eyes darted between mine and Sofia’s. “I don’t want to say anything that makes it your fault,” he said. “I don’t want to say what I was thinking ’cause it was stupid.”

He looked at me again. I nodded to encourage him to share what he’d shared with me earlier. He took a deep breath, pulled out the sheet of paper he’d written his notes on, and began.

A solution for justice outside of the legal system

As a survivor of child sexual abuse, sexual assault, and rape, I’ve often wondered what justice would look like for the sexual violence I’ve endured. I, like professor Christine Blasey Ford and the vast majority of survivors, never reported any of the men who violated me. Even as a child, and later, as a young woman, I knew what I needed could not be delivered by a school expulsion hearing or a court proceeding.

I wanted what Ana María Archila Gualy, the survivor who confronted Sen. Jeff Flake when he stated he planned to vote to confirm Brett Kavanaugh to the Supreme Court, described: “The way that justice works is that you recognize harm, you take responsibility for it, and then you begin to repair it.”

But for this to happen, everyone impacted by sexual violence needs to feel they can speak openly. Expulsion hearings, tribunals, or courts of law are not designed to do this; rather, these forums disincentivize truth-telling because those who harmed us know they’ll be punished if they admit what really happened. The risks are also high for survivors, who face social stigma for coming forward about their experiences and are often forced to undergo painful questioning.

We are seeing this play out on the national stage today. After Ford testified about the violent sexual assault she remembers enduring as a teenager, she continues to receive death threats against her family and has been forced to leave her home for safety reasons. She also underwent a painful cross-examination-style questioning in front of Congress and the entire country. The president of the United States mocked her testimony at a rally, and his audience cheered and laughed. All of this is surely why her opening remarks before the Judiciary Committee included the words, “I am here today not because I want to be.”

Those words made me remember why, 12 years ago, I left the practice of law and its winner-takes-all approach for the field of restorative justice. Restorative justice brings those who have harmed, their victims, and affected families and communities into processes that repair the harm and rebuild relationships. This can take several forms, such as peacemaking circles and conferencing models . Restorative justice can help resolve nearly any kind of wrongdoing or conflict, including serious harms such as robbery, burglary, assault — even sexual and intimate partner violence, and even murder .

The process invites truth-telling on all sides by replacing punitive approaches to wrongdoing in favor of collective healing and solutions. Rather than asking, “What law was broken, who broke it, and how should they be punished?” restorative justice asks, “Who was harmed? What do they need? Whose obligation is it to meet those needs?” At its best, restorative justice produces consensus-based plans through face-to-face dialogue that meets the needs of everyone impacted, beginning with the crime survivor.

Sexual violence could be addressed through restorative justice in many formats. Some schools have restorative justice alternatives to suspension and expulsion, with restorative justice coordinators on school sites. A handful of district attorneys divert cases to nonprofits who are trained in facilitating restorative justice processes (that’s how Michael and Sofia’s case came to me). Sometimes rape or sexual assault survivors who hear of my work call me directly and ask me to facilitate a dialogue with the person who harmed them.

What is restorative justice? Here’s how it works.

As a restorative justice facilitator, my work begins with asking what survivors want from meeting with the person who harmed them. While their answers vary, in sexual violence cases there is a common thread — they want to hear the person who assaulted them say, “You’re telling the truth. I did that to you. It’s my fault, not yours.” They often want this admission to happen in the presence of both of their families and friends. Most survivors are also looking for some indication that the person who harmed them truly understands what they’ve done and that they won’t do it again. Some request to never have to see that person again.

The length of the process and the number of meetings required to get us there varies from case to case. Sometimes a circle or conference happens within days or weeks of the harm, while others can take months for everyone to feel prepared. Because sexual violence occurs and continues through shame and secrecy, restorative interventions are most effective when family and/or close friends of both parties are included. Given that personal and often humiliating details are often shared, survivors have final say over who can attend.

A quick note: In restorative justice, we avoid defining people by their behaviors and experiences with labels like “victim,” “offender,” and “perpetrator” because those terms deny that all people are capable of growth and change. Instead, we use the word “survivor” because it honors that a person is in the process of transcending something painful or unjust. We also use phrases like “the responsible person” or “the person who assaulted the survivor” to show that people are more than the worst thing they have ever done.

At the end of the process, which typically ends with one or more face-to-face sessions with the entire circle, a plan to meet the survivor’s self-identified needs is made by consensus of everyone present. The responsible person is supported by family and community to do right by those they’ve harmed. For example, if joining a sports team is a part of the responsible person’s plan to help them stay out of trouble after school, people in his circle agree to take him to practice, or pay for the enrollment fees.

Ideally, root causes of the harm are also addressed, such as the impact of growing up in a home where people witnessed domestic violence. Many men I’ve met in restorative justice circles in prisons speak about the sexual abuse they endured as children and how that unresolved trauma gave rise to their offending. In those discussions, we are clear about the distinction between explanation and excuse. Some restorative justice practitioners encourage addressing structural inequities that gave rise to the offending behavior as well.

Restorative justice in practice

What does restorative justice look like in practice? Let’s return to Sofia and Michael, a case I facilitated a few years ago (all names and some details have been changed to protect anonymity). Not only was Sofia suffering from the aftermath of the assault itself, but Michael’s friends had posted on social media that Sofia had lied about the assault. Michael was a well-liked kid, and there were no witnesses to the sexual assault, so people were quick to believe his initial denials.

With the help of her friends, Sofia told a teacher, which led to Michael being arrested. The district attorney diverted the case to a nonprofit I’d trained in restorative circles and conferencing, who asked for my guidance. The first step was to reach out to Michael to assess his willingness to work with us. Our first meeting with Michael focused on building trust, answering questions, and, without pressuring him, determining his willingness to participate. He quickly agreed, saying he wanted to “make this right.”

This was possible, in part, because we’d assured Michael that by agreement with the district attorney and the school district, nothing Michael or Sofia said could be used against them in school discipline or juvenile justice processes. Once Michael agreed to participate, we contacted Sofia and her family to determine her interest. While people were surprised to learn such a program existed, everyone, including parents on both sides, felt like the process would be a good thing for Michael and Sofia.

In advance of the big meeting, my co-facilitator and I met separately several times with Sofia, Michael, and the supporters they planned to bring to the dialogue. First, I helped them both choose who should be part of the meeting. At first, there was resistance — Michael initially didn’t want anyone there to support him, but over time he opened up to the idea of his mother and sister being present. Sofia decided that she was too embarrassed to have any men from her or Michael’s family present, and both families accepted this. The meeting ended up including Sofia, Michael, both of their mothers, and Michael’s younger sister.

In my prep meetings with Sofia and her mother, we discussed what she wanted to say to Michael about the impact of the assault. We worked with Michael to understand the implications of what he did and where that behavior came from. We shared information about when and where the meeting will be held, who will enter the room first, who will sit where, who will speak first, and who will be present. These details are primarily driven by the safety needs of the survivor but can occasionally be impacted by the desires of the person who caused the harm. The key is to set things up so that both parties know what to expect and feel safe to share freely and openly.

Sometimes, it’s hard for people to imagine speaking directly to the person who harmed them. While preparing for the meeting, Sofia expressed her desire to stay silent and have her mother speak for her. But the moment Michael entered the room, Sofia’s demeanor instantly changed from timid to emboldened, and a powerful dialogue ensued about the impact of the assault on Sofia’s life and on her family. Sofia told the group she had lost weight, was sleeping in her mother’s bed, woke up with nightmares, and had stopped going to school because of the rumors that she was lying for attention. As they worked through the details of the assault and its aftermath, Michael finally answered Sofia’s question about what he was thinking at the time of the assault.

“I know you’re a good girl, and I thought all good girls have to fight a little the first time,” he said.

Michael’s sister gasped, and the room went silent for a little while. Even as the words came out of his own mouth, we could all see Michael realize how wrong this was. He bent over and put his face in hands, and when he looked up, Sofia’s mother squinted at him in disbelief, shaking her head. After what felt like an eternity, Michael’s mother finally broke the silence, saying to her own daughter, “See? I brought you so you’d know even nice boys like your brother can think things like this, do things like this.”

Upon hearing Michael’s mother take Sofia’s “side,” both Sofia and her mother broke down in tears, and Michael’s mother stood up and hugged them. Then she sat back down, placed her hand gently on her son’s arm, and shared stories of sexual violence endured in the past by members of her own family.

As the women and girls spoke of the impact of daily street harassment and other sexual harm they’ve seen or experienced, Michael alternated between silence and occasional thoughtful questions. He also spoke honestly about what he’s learned from media representations of consent and how his friends talk about girls they have been intimate with. He confessed his own struggle to understand the line between expressing interest and being creepy. He talked about how his ex-girlfriend broke up with him, in part because, according to her, he didn’t “chase her enough.”

At that point, Michael confessed that he thought that what he did was okay because he felt that Sofia had expressed interest in him. Sofia looked him directly in the eyes and told him that this had no bearing on his choice to assault her when she said no. When she said this, Michael paused. Everyone could see that her point was sinking in.

Sofia’s transformation was breathtaking — she found her voice that day. And by the end of our time together, it felt like Michael had gained an understanding of consent. As we moved into creating a plan to repair the harm, Michael offered to clear up Sofia’s reputation by posting on social media a public apology to her, which included the words “she didn’t lie.” Michael also agreed with Sofia’s request for him to spend a month of school at home to give Sofia space. Afterward, everyone except for Michael and Sofia hugged.

In the weeks that followed, Sofia’s mother reported that her daughter had even more self-confidence than she’d had before the assault; not only had she moved back into her room and stopped wearing the baggy clothes she’d started wearing after the assault, she also spoke up more about her feelings and opinions, including with the men in the family. And after graduation, Michael sent me a copy of a research paper he’d chosen to write on sexual violence.

Restorative justice in the real world

Restorative justice processes aren’t always this satisfying. In other cases, when legal or other punitive consequences have hung over the heads of the young people (i.e., school expulsion, Title IX hearings, immigration consequences, etc.), admissions were couched in exculpatory language and the assault was minimized. The stakes remain too high for the truth to come out, and restorative justice’s core work — recognizing harm, taking responsibility for it, and beginning to repair it — cannot happen under these circumstances.

While this is extremely frustrating for survivors, some choose to engage in a dialogue nonetheless. Even without an admission of guilt from the person who harmed them, a survivor may still find some benefit from being able to say, face to face, “I don’t care if you deny it; I know you did this to me.” This is something that those who give victim impact statements might also experience in a court of law, even though victim impact statements rarely alter the outcome of a case, especially when survivors are asking for sentences that go above or below what the law prescribes. Hopefully, Ford experienced some portion of catharsis by telling her story in a public arena, even though the outcome of this hearing did not validate her bravery.

Restorative justice practices have been primarily applied to youth who’ve caused harm. In Baltimore, Nashville, Oakland, and several other cities across this nation, people under the age of 18 can be diverted before charges are filed to a nonprofit that is trained to facilitate restorative circles and conferences. School districts in many major cities have adopted some form of it as an alternative to more punitive approaches. Our growing understanding of the changing brains of youth, coupled with our rejection of the “superpredator” myth that there are (primarily African-American) youths predisposed to a life of senseless violence, has made us more open to approaches that give kids “a second chance.” But restorative justice offers equal benefits when applied to adults, and when parties are willing, it should be as readily available to them as well.

While restorative justice is nothing new — the theory and practice can be traced to many indigenous communities the world over — it has yet to genuinely circumvent or replace punitive systems in any meaningful way, despite its greater efficacy on several fronts. In a recent study of the first 100 felony cases diverted to restorative justice in Alameda County, California — including some sexual violence cases — 91 percent of survivor-participants reported they would participate in another conference, and an equal number (91 percent) stated they would recommend the process to a friend. Moreover, youth who participated in the program were 44 percent less likely to commit future crimes than those whose crimes were addressed through the county’s juvenile justice system. The cost savings, as compared to adjudicating youth delinquents, are enormous.

Some jurisdictions have thought to make restorative justice an add-on to court proceedings. But for restorative justice to be effective, it must remain outside the purview of the courts or other punitive measures. Restorative justice’s beauty and effectiveness flow from people feeling free to tell the truth, and being welcomed to do so.

Another key effective aspect of restorative justice is the way power is rebalanced through dialogue. Crime survivors define their own needs rather than remaining at the mercy of a court’s legitimation. Survivors often state that simply being asked questions like, “How do you define the harm? What do you need now? What will make this right?” is the most important part of the process because it allows them to reconnect with their power after experiencing trauma that made them feel powerless.

As I’ve watched this Supreme Court battle unfold, I’ve wished I had met Ford and Kavanaugh decades ago when they were teenagers. Restorative justice might have been able to help Kavanaugh and his friends process the impact of the behavior they’ve been accused of. And it could have provided an opportunity for Ford, Deborah Ramirez, and others to find their voices in more supportive environments. We would all be better off for it.

sujatha baliga directs the Restorative Justice Project at Impact Justice. She is currently working on a book about her life and work.

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On Writing as a Survivor

• March 23, 2022

Every survivor has a story. Telling that story can help them celebrate their voice, their creativity, bring awareness to the issues, or even advocate for prevention. Although not for everyone, writing has long been celebrated for its healing capabilities . While online spaces of writing, poetry corners , books , and blogs can play a positive influence in the lives of those healing from trauma, they can also constitute spaces of abuse and harassment. When writers put their experiences, thoughts, feelings, or narratives online, they can become targets for criticism , victim blaming or trolling.

If survivors face harassment for their work or writings online, it creates a whole second wave of trauma. Online harassment can create emotional, mental, and psychological harm that is just as impactful as trauma that occurs offline. Research shows that cyberbullying causes acute mental health issues in victims which are no less severe simply because they take place online. In fact, one study shows that more than one-third of cyber victims (35%) had “clinically significant” post-traumatic stress disorder (PTSD) symptoms.

When we consider the impacts of trauma on a person, we want to be aware of the layering aspect of it. That is, trauma is not one single thing that one acquires and then gets rid of; people may encounter new traumatic experiences as they heal from previous ones. Perhaps they are not yet healed from those previous traumas, and new crises unfold. When someone who is already working through trauma faces harassment or bullying, it compounds negative emotions in a way that can be immensely harmful. This is very much the case when those who write about their experiences encounter online abuse as a result of telling their story.

Many survivors are aware of these risks and, as a result, limit themselves and the actions they want to take to reclaim their power. Telling their story can also be difficult for survivors when speaking through someone else or being interviewed by someone else — that is, when other writers or journalists “cover” their story or focus on their life or experiences for a piece. Survivors should always have control of their own voices and stories. It’s extremely important that journalists and members of the media understand how to be trauma-informed and understand the sacrifices survivors make when telling their story. For example, although interviewers themselves may be well informed in how to talk about sexual violence, the piece they ultimately publish may garner negative comments online which may be harmful. Telling victims to “just ignore it” does little to mitigate the impact.

Yet, research shows that journalists are no strangers to harassment themselves. Data has indicated that journalists who identify as women face disproportionate rates of harassment and further expectations to accept it as an aspect of their profession. According to a study done by The Center for Media Engagement, women in journalism often “felt strong pressure to engage online as part of their job and often felt they had no choice but to face the harassment.” The nature of the harassment did not always revolve around the content of their writing, but it focused on their gender, aspects of their appearance, or their sexuality. Those who actively chose to refrain from social media felt it hurt their career and visibility as a result.

This all showcases the ways in which patriarchy pervades the virtual world. As such, it is vital for survivors to have access to resources and support, and for the media to be trauma-informed in its coverage and collaborations with survivors. The following materials may prove useful for survivors, journalists, or other  members of the media writing about sexual assault.

For Survivors Writing

My Story, My Terms

The goal of this workbook from Women’s Justice NOW is to guide individuals through the healing power of storytelling and help those who are considering sharing their stories make an informed decision about doing so.

 Speaking Out From Within: Speaking Publicly About Sexual Assault 

This pamphlet from PCAR was written for survivors who are thinking they want to do public speaking around their experience.

Survivors Write: Writing practice for personal and community transformation

This free e-book from Jen Cross of Writing Ourselves Whole describes resources for those interested in writing in groups with others (or alone), including a sample eight-week syllabus, additional writing prompts, writing guidelines, and a bibliography.

How Writing Letters to My Body Helps Me Heal From Sexual Assault In this piece published in them ., Lexie Bean explains how writing can be a tool to rebuild, to question, and to validate survivors’ own experiences.

Writing About Surviving and Being an Expert on Sexual Assault

In this piece, Katie Guest Pryal gives guidance on writing about tough topics, like sexual assault, when you identify as a survivor.

For Writers Facing Harassment

Online trolling: You are not alone! 

The page from the International Federation of Journalists (IFJ ) is a hub for relevant publications on the topic of gendered abuse against journalists.

Journalists and Online Harassment 

The piece by Slaughter & Newman from the Dart Center covers what online harassment against journalists is, how prevalent it is, and how journalists can effectively respond.

Practical and legal tools to protect the safety of journalists

The Thomson Reuters Foundation has partnered with UNESCO , IWMF and INSI to develop a range of practical and legal tools for journalists, media managers, and newsrooms to strengthen responses to online and offline harassment and to protect free and independent media.

For the Media

Reporting on Sexual Violence This resource page of the National Sexual Violence Resource Center (NSVRC )  provides guidance and tips for journalists reporting on sexual violence.

Guide for Journalists

Know Your IX has assembled this guide for reporters and editors who are covering gender-based violence, particularly on college campuses.

If You're Writing About Assault

Amelia Roskin-Frazee covers six tips for writing about sexual assault.

Reporting Sexual Assault: A Guide for Journalists 

The purpose of the guide by the Michigan Coalition Against Domestic and Sexual Violence   is to provide insight into new trends and assist journalists in developing strategies to accurately frame the public discussion on sexual assault, as well as encourage an accurate and compassionate approach to reporting on this issue and facilitate relationship building between journalists and local sexual assault experts.

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The Female Revolution Is Here & Boy Does It Hurt

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We should call this loose, messy movement what it is: a revolution.

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

Emily r. dworkin.

1 University of Washington, Seattle

Suvarna V. Menon

2 University of Illinois, Urbana-Champaign

Jonathan Bystrynski

Nicole e. allen, associated data.

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 1970–2014 (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 stronger associations were observed for posttraumatic stress and suicidality. Effects endured across differences in sample demographics. Broader SA operationalizations (e.g., including incapacitated, coerced, or nonpenetrative SA) were 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.

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, Cullen, & Turner, 2000 ; Koss, Gidycz, & Wisniewski, 1987 ; Tjaden & Thoennes, 2000 , 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 significant impact on mental health than other forms of trauma ( Kelley, Weathers, McDevitt-Murphy, Eakin, & Flood, 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 Holstrom (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, 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 and colleagues (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 and colleagues (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, Kilpatrick, Resnick, Best, & Saunders, 1998 ; Burnam et al., 1988 ; Frazier & Schauben, 1994 ; Kilpatrick, Resick, & Veronen, 1981 ; Walker, Gefland, Gefland, Koss, & Katon, 1995 ; Winfield, George, Swartz, & Blazer, 1990 ) and bipolar disorder ( Arata, 1999 ; Burnam et al., 1988 ; Xu, Olfson, Villegas, Okuda, Wang, Liu, & Blanco, 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, 1993). 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 & Jakubec, 2013 , Campbell et al., 2009 , and Neville & Hepner, 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, Turchick, 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, and professionals often experience negative social reactions, such as victim blame, that have been found to increase 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.

Unresolved Questions in Research on Sexual Assault’s Psychological Impact

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.

Is sexual assault a risk factor for PTSD or psychological dysfunction broadly?

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, although 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.

How do differences in study methods and samples alter observed relationships?

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.

Operationalization of constructs and assessment quality

There is significant variation in the field regarding the assessment of 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, Gidycz, Koss, & Murphy, 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.

Comparison group

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 high 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.

Lifetime vs. adult/adolescent SA

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 & 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, Andrews, & Valentine, 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.

Differences in samples

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, Best, Lipsey, & Weiss, 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 underestimated 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, 1998), 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, 2002b ), and less-educated SA survivors evidence more self blame compared to college-educated survivors ( Long, Ullman, Starzynski, Long, and 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.

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 topic tend to be unsystematic, and as such, do not offer a rigorous, thorough picture of the state of the science in this area. Although meta-analyses on related topics exist, they have several major limitations that this work aims to address. First, the most thematically similar quantitative analysis ( Weaver & Clum, 1995 ) assessed dysfunction broadly (e.g., including problems in living) rather than psychopathology specifically. To inform theory and practice regarding the development of mental disorders after trauma, a targeted analysis is needed. Second, several assessed only a single form of psychopathology (e.g., Brewin et al., 2000 ; Ozer et al., 2003 ; Smolak & Murnen, 2002 ), and those that assessed multiple domains of psychopathology did not conduct statistical comparisons across domains (e.g., Chen et al., 2010 ; Golding, 1999 ; Paolucci & Genuis, 2001 ). Attention to multiple specific manifestations of psychopathology raises the possibility of cross-condition comparisons, which could clarify the relative strength of their association with a highly common form of trauma, and thus advance the field’s understanding of how various forms of psychopathology relate to trauma. In particular, forms of psychopathology that have been often been discussed as correlates of SA—like depression 1 , anxiety, trauma and stressor-related conditions, substance abuse/dependence, suicidality, and disordered eating —as well as certain conditions common in traumatized populations (e.g., bipolar conditions, obsessive-compulsive conditions)—warrant focused attention. Finally, although the amount of research on the association between SA and psychopathology has been increasing, the most recent similar meta-analysis—assessing associations between trauma exposure broadly and PTSD—was conducted in 2003 ( Ozer et al., 2003 ). By quantitatively reviewing the literature from 1970 to 2014, we hoped to update earlier qualitative reviews and reflect the state of the science on this topic.

The first goal of the current meta-analysis is to quantitatively synthesize the degree of association between SA and various mental disorders to clarify whether traumas like SA are specifically associated with PTSD or broadly associated with multiple forms of psychopathology. We hypothesized that SA would have a significant positive relationship with each form of psychopathology (Hypothesis 1). Given the lack of research regarding the differential impact of SA on various forms of psychopathology, we chose to approach this analysis in an exploratory manner rather than making non-empirically supported hypotheses about the relative magnitude of each average effect size.

A secondary goal of this work is to understand how differences in studies and samples might alter observed relationships between SA and psychopathology. We hypothesized that broadening operational definitions of SA would be associated with smaller effect sizes (Hypotheses 2a–c), lower-quality SA assessment methods would be associated with higher observed effect sizes (Hypothesis 3), lower-quality psychopathology assessment methods would be associated with smaller observed effect sizes (Hypothesis 4), and studies using a no/low-trauma comparison group would result in significantly larger effect sizes than studies using no-SA comparison groups but no difference in effect sizes would be observed for studies using an other-trauma comparison group (Hypotheses 5a–b), and samples assessing lifetime SA would evidence larger effect sizes than those assessing adult SA only (Hypothesis 6), Finally, related to sample characteristic differences, we hypothesized that higher percentages of each assault characteristic (i.e., stranger perpetrators, weapon use, physical injury) would be positively related to observed effect sizes (Hypothesis 7a–c), time elapsed since assault would be negatively related to observed effect sizes (Hypothesis 8), no differences in effect sizes would be observed as a function of age, gender, or race (Hypotheses 9a–c), and samples reflecting college students would evidence smaller effect sizes than other samples (Hypothesis 10).

Literature Search and Study Retrieval

We followed several steps to identify relevant studies for inclusion.

Searching databases

We searched PsychINFO, ProQuest Digital Dissertations & Theses, and Academic Search Premier for the following combinations of search terms anywhere in the article, using Boolean operators: (rape* OR “sexual assault” OR “sexual victimization”) AND (“mental health” OR depression* OR anxiety* OR bipolar* OR mania* OR anxiety* OR phobia* OR distress* OR PTSD OR “post-traumatic” OR “substance dependence” OR “substance abuse” OR suicide* OR “eating disorder” OR “disordered eating”). We limited searches to results published between 1970 and 2014 in English, resulting in 125,780 search results that received title review. Given the large number of results obtained and the targeted efforts to obtain relevant studies described next, these search terms and databases were deemed sufficiently comprehensive. All articles ( m = 2813) judged to be potentially eligible based on their titles received full-text review. Finally, we examined a database of articles collected by the first author for a previous review of the mental health effects of SA ( Campbell, Dworkin, & Cabral, 2009 ).

Examining citations

We examined the citations of every eligible article, every article that would have been eligible had it not omitted relevant data, and every article that would have been eligible had it included a comparison group. We also examined reference sections of literature reviews and meta-analyses on similar topics ( Brewin et al., 2000 ; Campbell et al., 2009 ; Carter-Snell & Jakubec, 2013 ; Goodman, Koss, & Russo, 1993 ; Jewkes, 2000 ; Jordan, Campbell, & Follingstad, 2010 ; Koss, Heise, & Russo, 1994 ; Neville & Heppner, 1999 ; Ozer et al., 2003 ; Resick, 1987 ; Resick, 1993 ; Sarkar & Sarkar, 2005 ; Steketee & Foa, 1987 ; Tolin & Foa, 2006 ; Weaver & Clum, 1995 ).

Identifying unpublished data

The file drawer effect is a perennial problem in the academic literature ( Rosenthal, 1979 ), which makes it particularly important to attempt to minimize publication bias in meta-analyses ( Lipsey & Wilson, 2001 ). To accomplish this, we took several steps. First, we searched for eligible dissertations and theses. Second, we posted a notice on the APA Division 56 (Traumatic Stress) listserv requesting unpublished data. Third, we developed an initial list of eligible studies and contacted all authors with three or more eligible studies from this list to request unpublished data. Fourth, for studies conducted between 2004–2014, when we believed that it was possible that researchers had collected eligible data that was not presented, or when eligible data was not presented in a format from which we could obtain effect size estimates, we asked study authors for data. In all, we sent 124 requests for additional data, 48 (38.71%) of which yielded usable data, with a total of 108 effects coded from these requests. Fifth, when we made these requests for data, we also requested unpublished data. Ultimately, 35% of the effect sizes that we coded (175/497) used unpublished data obtained through these methods.

Reviewing journals

We reviewed 2010–2014 issues of journals from which we had obtained three or more articles from our tentative list of eligible studies (i.e., Journal of Consulting and Clinical Psychology , Journal of Interpersonal Violence , Violence and Victims , Violence Against Women , Psychology of Women Quarterly , Journal of Traumatic Stress , and Addictive Behaviors ).

Determining eligibility

Our inclusion criteria were as follows (see Figure 1 for the percent of articles excluded based on each criterion).

Study Selection

• The study must have been quantitative in nature with a sample size of N > 10.
• We must have been able to create a sexually assaulted group comprised of survivors of either adolescent/adult or lifetime SA. We defined SA as unwanted sexual contact, which must have been operationalized through terms like “rape,” “sexual violence,” or “sexual assault” and/or behavioral descriptions including (but not necessarily limited to) forced penetration. Because there have been several meta-analyses conducted on associations between child sexual abuse and psychopathology (e.g., Chen et al., 2010 ; Smolak & Murnen, 2002 ), in an effort to present a nonduplicative analysis, the SA group must not have been exclusively comprised of children or child sexual abuse survivors. However, because many studies assessed SA across the lifespan (i.e., combined child and adolescent/adult), we coded lifetime effects when no separate data for adolescent/adult SA was available to ensure that the population of studies was not overly restricted, consistent with a similar meta-analysis ( Brewin et al., 2000 ). Thus, adolescent/adult-only and mixed adolescent/adult and child samples were eligible.
• Data for a comparison/no-SA group comprised of people who did not experience SA during the focal time period (e.g., adulthood, past 4 weeks) must have been available, either in the article or by request from authors. A comparison group was needed to compute an effect size representing risk for psychopathology associated with experiencing SA; comparisons between people who experienced SA were outside of the scope of the analysis. The construct of SA must not have been operationalized in such a manner that people who had experienced SA were likely to be included in the no-SA group. For example, studies that compared people who had experienced military SA to those who had not were likely to have included survivors of non-military SA in the no-SA group, and were excluded.
• The study must have reported data on a construct within at least one of the following domains in both the SA and no-SA group: bipolar conditions (e.g., diagnosis of bipolar I, manic symptoms), depression (e.g., depressed mood, diagnoses of major depressive disorder), anxiety (e.g., fear, anxiety sensitivity, worry, generalized anxiety disorder), obsessive-compulsive conditions (e.g., diagnosis of obsessive-compulsive disorder, presence of obsessions and compulsions), trauma and stressor-related conditions (e.g., diagnosis of acute stress disorder, posttraumatic stress symptoms), substance abuse/dependence (e.g., alcohol use disorder, presence of drug dependence symptoms), suicidality (e.g., attempts, ideation), and disordered eating (e.g., diagnosis of anorexia nervosa, presence of bulimic symptoms). We included only those effects that provided coverage of the domain itself (e.g., depressed mood) or a specific diagnosis within the domain (e.g., major depressive disorder) through an interview or self-report measure, and excluded effects that represented single symptoms of a disorder within the broader domain (e.g., purging, insomnia). We excluded effects that were based on chart diagnoses or self-reports of past diagnoses made by a clinician, as these captured help-seeking behavior for mental health rather than the existence of the condition itself. We excluded studies that, by design, assessed SA risk prospectively after onset of a mental disorder. We included only baseline data for repeated-measures studies ( m = 23, 12% of studies), consistent with similar meta-analyses ( Ozer et al., 2003 ), to avoid underestimating the effect size by averaging across assessment periods.
• The study population or SA group must not have, by design, only consisted of people who were seeking psychological treatment or people who had an existing mental illness. The study must also not have intentionally oversampled such individuals (i.e., in cases where recruitment was targeted to clinical settings, when the study recruited set numbers of participants with and without particular disorders). We excluded these studies to avoid clinical selection bias ( du Fort, Newman, & Bland, 1993 ), consistent with meta-analyses on related topics ( Brewin et al., 2000 ; Tolin & Foa, 2006 ). In addition, because we were interested in the degree to which experiencing SA affords risk for psychopathology and these samples were usually entirely comprised of people with psychopathology, we would have been unable to calculate estimates of group differences in such samples.
• The study must have presented adequate data in English to calculate the selected effect size (i.e., Hedges’ g ) or we must have been able to obtain these data from the authors.
• The study must not have been fully duplicative of another eligible study.

Identifying effects from shared samples

We examined articles that shared an author to determine whether effects were based on the same sample. When authors noted that they used a particular dataset or had published results from the same study elsewhere, we recorded this information to ensure that we retained only one effect for each form of psychopathology per sample and assigned a shared identification number across effects representing different forms of psychopathology from a single sample.

Study Moderators

Domain of psychopathology.

We coded each effect size as reflecting one of the eight domains defined in our eligibility criteria that were within the scope of the current study.

Operationalization of SA

We coded three dichotomous moderators to reflect how the study operationalized SA. First, we indicated whether the operational definition of SA in each study included both attempted and completed SA or only completed SA. Second, we coded whether each study explicitly included the following tactics through which SA was achieved: coercion (e.g., due to pressure, arguments, or misuse of authority), incapacitation (i.e., victim was unconscious or incapacitated by drugs and/or alcohol), and/or force (i.e., achieved through force or threats of harm). We then created a four-level composite variable to represent a 2×2 interaction of the presence of incapacitation and/or coercion. All studies that specified at least one tactic included force, and studies that did not specify at least one tactic were coded as missing. Third, we coded whether participants could have been included in the SA group on the basis of experiencing nonpenetrative SA (e.g., kissing, touching, fondling), or whether experiencing penetrative SA was necessary to be included in the SA group. Studies that did not specify at least one assaultive sex act that comprised SA were coded as missing. For studies that specifically recruited survivors of SA, we coded these variables based on study recruitment materials and/or inclusion criteria. For all other studies, we obtained this information from SA assessment measures. We recorded missing values for studies that did not provide enough information to determine the operational definition through which the SA group was formed. For example, in studies that used a multi-item measure of SA such as the Sexual Experiences Survey, when authors specified which items were used to determine membership in the SA group, we recorded values for these moderators based on the wording of the specified items; however, when authors did not specify which items were used to determine membership and codes would differ based on items included, we coded these values as missing.

Assessment quality

Psychopathology assessment quality was operationalized as the proportion of the following criteria met: the measure (a) was administered via interview, (b) was previously published, (c) included multiple items, and (d) was explicitly stated to be based on and/or validated against DSM criteria (suicide measures were coded as not applicable for this criterion). Drawing from methodological recommendations ( Cook et al., 2011 ), SA assessment quality was operationalized as the proportion of the following criteria met: the measure (a) was previously published, (b) included multiple items, (c) described at least one sex act behaviorally, and (d) specified at least one tactic (e.g., force or coercion), through which the sex act occurred. For both variables, a proportion of the total criteria for which information was available was calculated if at least three criteria were available.

Comparison group type

We created a categorical variable to represent comparison group type— comparison groups that were selected for their lack of trauma experience (i.e., no/low-trauma groups), comparison groups that had not experienced SA (i.e., no-assault groups), and comparison groups that had experienced another form of trauma (i.e., other-trauma groups)—for each effect.

Lifetime vs. adolescent/adult SA

A dichotomous variable indicated whether the SA group was comprised of participants who experienced lifetime SA or SA in adolescence/adulthood. A study was considered to assess adolescent/adult SA if the minimum age at which SA could have occurred was 12 years old or greater. All other studies, including cross-sectional studies that did not specify an age at which SA could have occurred, were considered to represent lifetime SA.

Features of assaults experienced by participants

We coded three continuous study-level moderators to capture characteristics of the actual assaults experienced by participants. Specifically, we coded the percent of assaults that involved a stranger perpetrator, the percent that involved weapon use, and the percent that involved physical injury to the survivor.

Time since SA

A continuous variable represented the mean number of years elapsed since the focal SA on which participants reported, or if this was not available, the most recent SA.

Sample demographics

We coded the percent of women in the sample, the mean age in the sample, and, for US samples 2 , the majority (>60%) racial group represented by the sample.

Sample type

A categorical variable indicated the majority (>60%) type of participants that comprised the overall sample (i.e., including both the SA and no-SA group). Categories were college students, general population (i.e., unselected for any particular characteristic), people seeking medical treatment, military personnel or veterans, and people seeking support for crime-related needs. An “other” category included sample types represented in two or fewer samples (e.g., people with a cognitive disability). Mixed samples represented 2–3 of the aforementioned categories; typically, these samples represented either combined college and community recruitment efforts or samples of a help-seeking SA group compared to a college or community no-SA group.

Coding Procedures

The coding team consisted of the first, second, and third authors (i.e., the primary coders) and 10 trained research assistants (i.e., the secondary coders). Every effect was coded by at least two coders (i.e., a primary and secondary coder), but review by three coders was common, and the first author reviewed every effect. In addition, every coding discrepancy was tracked and received review by the primary coder and/or at least one other team member; discrepancies were resolved in group meetings. Additional information about this coding process is available in Appendix A .

To assess coding accuracy, several moderators that were judged to be the most difficult to code were reserved for coding by the primary coders. The primary coders recorded their codes independently and inter-rater reliability was calculated. The variable “operational definition includes both forced and coerced SA or forced SA only” had substantial agreement ( κ = 0.77 for first vs. second author and κ = 0.77 for first vs. third author), “operational definition includes both forced and incapacitated SA or forced SA only” had substantial to near-perfect agreement ( κ = 0.70 for first vs. second author and κ = 0.94 for first vs. third author), “operational definition includes both penetrative and nonpenetrative SA or penetrative SA only” had near-perfect agreement ( κ = 0.80 for the first vs. second author and κ = 0.80 for the first vs. third author), and “operational definition includes both attempted and completed SA or only completed SA” had substantial agreement ( κ = 0.61 for first vs. second author and κ = 0.76 for first vs. third author). All discrepancies were resolved by discussion.

Hedges’ g and its variance were calculated using Comprehensive Meta Analysis ( Borenstein, Hedges, Higgins, & Rothstein, 2005 ). We selected g as a conservative alternative to d that represents group differences on both dichotomous and continuous variables and corrects for sample size. In this study, g represents the magnitude of the difference in psychopathology between people who had been sexually assaulted and people who had not been sexually assaulted.

Because multiple effects were commonly presented in a single study (i.e., when researchers operationalized the same form of psychopathology in multiple ways or studied multiple forms of psychopathology), we used a multilevel structural equation modeling procedure using the metaSEM package ( Cheung, 2012 ) in R 3.3.1 ( R Development Core Team, 2008 ) to account for nonindependence of effect sizes. We created 3-level models, in which level 1 represented the individual effect sizes, level 2 represented differences in effect sizes within a study, and level 3 represented differences between studies. Additional information about the analytic approach is available in Appendix B .

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.

We ran influential case diagnostics using the metafor package in R ( Viechtbauer, 2010 ). In an effort to be conservative in calculating summary effect sizes, we identified and excluded outliers specific to each domain of psychopathology as well as the overall sample. Effects with studentized deleted residuals ≥ 2 were considered to be outliers ( Viechtbauer & Cheung, 2010 ). Following Gnambs (2013) , these outliers were truncated to the upper bound of the 95% confidence interval of the true effect for the applicable domain of psychopathology, which was calculated by computing unconditional models using a dataset from which the outliers had been removed. Thirteen effects were identified as outliers, which is in the expected range for a meta-analysis of this size ( Viechtbauer & Cheung, 2010 ). Comparing these outliers to nonoutliers on study characteristics (e.g., country of data collection) using bivariate analyses revealed no significant differences. All further results describe the sample including truncated outliers.

Publication Bias

Publication bias is a pervasive problem in the empirical literature ( Rosenthal, 1979 ). Despite our extensive efforts to include unpublished work and the significant number of unpublished effects in our sample (175/500 effects), it is likely that there was still more that we were unable to identify.

We used three strategies to assess publication bias. We first compared published ( M = 0.64, SD = .41, k = 322) to unpublished ( M = 0.50, SD = .31, k = 175) effect sizes, and concluded that published effect sizes were significantly larger, t (443.74) = 4.30, p < .0001. We then calculated Rosenthal’s fail-safe N ( Rosenthal, 1979 ), and determined that 2,153,789 effects evidencing no relationship between SA and psychopathology ( g = 0) would be needed to reduce the significance level of the summary effect size to .05. This suggests that substantial publication bias would need to be present to nullify the observed effect. We next constructed a funnel plot ( Figure 2 ) of the relationship between published effect sizes and their corresponding inverse standard errors (an index of study precision) to visually and statistically assess the presence of publication bias. Funnel plots display the spread of effect sizes around the “true” effect size as a function of study precision; lower-precision studies produce wider variation in observed effect sizes (i.e., the mouth of the funnel), and higher-precision studies cluster closely around the true effect size (i.e., the neck of the funnel). Funnel plot asymmetry indicates that effects that are larger or smaller than the true effect are systematically underpublished. We used the trim and fill method to identify the number of effects missing from each side of the funnel plot, impute these missing values, and re-estimate the overall effect including these values ( Duval & Tweedie, 2000a , 2000b ). Because methods for assessing publication bias in multilevel meta-analysis have not yet been developed and so this test treats effect sizes as independent observations, we randomly selected one effect size from every study in our sample to include in this test to avoid unduly weighting studies that contributed more effects. Eighteen effects were missing from the right side of the funnel and no effects were missing from the left side. Including the 18 imputed missing values, the summary effect was 0.63 ( SE = 0.03), as compared to a summary effect of 0.56 ( SE = 0.03) without these effects using a fixed-effects meta-analysis using the randomly selected published data. Using Egger’s regression test for funnel plot asymmetry in a model with standard error as a predictor ( Egger, Davey Smith, Schneider, & Minder, 1997 ), we found that this asymmetry was not statistically significant, z = 1.69, p = 0.09. Thus, there is no evidence for publication bias based on the funnel plot.

See Table 1 for a summary of included studies, Appendix C for the full dataset ( Dworkin, Menon, Bystrynski, & Allen, 2017 ), and Appendix D for corresponding references. The full dataset included k = 497 estimates of effect from 204 sources and m = 195 studies (i.e., independent samples). Results from some samples were published in multiple sources and some sources contained multiple samples. Aggregating sample sizes across studies (using the minimum N used to calculate effect sizes in a given study), this meta-analysis represents N = 238,623 individuals (study range: 27 to 32,075). Among the m = 153 studies where the comparison group was not selectively sampled and the prevalence of SA was an estimate of the prevalence in the population studied, the average SA prevalence was 24.12% ( SD = 17.56%, range: 1.59% to 92.57%). Most studies were conducted in the US (77%) and were published journal articles (76%) or dissertations/theses (20%)

Study Characteristics

Is Sexual Assault Associated with Psychopathology?

The average effect size across types of psychopathology was g = 0.61 ( SE = 0.02), suggesting a moderate association between SA and psychopathology. In this unconditional model, the heterogeneity within studies (due to differences in domains/measures of psychopathology) was τ 2 2 = 0.04 ( SE = 0), and the heterogeneity between studies (controlling for differences in domains/measures of psychopathology), or was τ 2 3 = 0.06 ( SE = 0.01). Both were significant at p < .001, indicating that significant heterogeneity existed which could be potentially accounted for by moderators.

Moderator Analyses: What Accounts for Differences in Observed Effects?

A summary of moderation analysis results can be found in Table 2 .

Moderation Results

R 2 (L2) is the proportion of explained variance within studies

R 2 (L3) is the proportion of explained variance between studies

Note. All values of g differed significantly from 0 at p < .01

k = number of effect sizes used in specific analysis

m = number of studies used in specific analysis

What types of psychopathology are associated with sexual assault?

In our sample, depression was the most common domain studied, k = 129, m = 102, followed by trauma and stressor-related conditions, k = 121, m = 103. The most infrequently-studied domain was bipolar conditions, k = 6, m = 4. Average effects were largest for suicidality, g = 0.74, SE = 0.05, k = 38, m = 26, and smallest for substance abuse/dependence, g = 0.37, SE = 0.04, k = 59, m = 33. All domain-level average effect sizes were significantly different from zero ( p < .001). All effect sizes were in the moderate range ( Cohen, 1988 ), except for disordered eating and substance abuse/dependence, which were in the small range.

To compare the magnitude of these effect sizes, we selected trauma and stressor-related conditions as the referent group. Compared to effects representing trauma and stressor-related conditions, g = 0.71, SE = 0.03, effect sizes were significantly smaller for depression, Δ g = −0.11, SE = 0.03, p < .001, anxiety, Δ g = −0.19, SE = 0.03, p < .001, disordered eating, Δ g = −0.33, SE = 0.07, p < .001, and substance abuse/dependence, Δ g = −0.35, SE = 0.04, p < .001. In contrast, the following effects were not significantly different than trauma and stressor-related conditions: obsessive-compulsive conditions, Δ g = 0.00, SE = 0.12, p = .98, suicidality, Δ g = −0.03, SE = 0.05, p = .54, and bipolar conditions, Δ g = −0.06, SE = 0.11, p = .60. Importantly, though, the effects for obsessive-compulsive conditions and bipolar conditions were based on a small number of studies and effects and had large confidence intervals. These results suggest that SA is associated with all domains of psychopathology studied, and is more strongly related to suicidality and trauma and stressor-related conditions (and, tentatively, obsessive-compulsive and bipolar conditions) than depression, anxiety, disordered eating, and substance abuse/dependence.

Methodological differences

We next tested hypotheses related to study methods.

Operational definition of sexual assault

In this sample of studies, most operationalized SA narrowly—28% included attempted SA, 44% included fondling/nonpenetrative SA, 34% included coerced SA, and 37% included incapacitated SA. We hypothesized that broadening operational definitions of SA would result in smaller effect sizes. Hypothesis 2a was supported: operational definitions that included attempted SA evidenced significantly smaller effect sizes, Δ g = −0.10, SE = 0.05, p = .02, as compared to those that included completed SA only. Against Hypothesis 2b, including fondling and other nonpenetrative SA in definitions was not associated with decreased effect sizes as compared to penetrative assault only, Δ g = −0.07, SE = 0.05, p = .14. Hypothesis 2b was not supported for operational definitions that included coercion, Δ g = −0.04, SE = 0.07, p = .63, incapacitation, Δ g = −0.04, SE = 0.07, p = .59, or both coercion and incapacitation, Δ g = −0.09, SE = 0.06, p = .12, as compared to those that included forced SA only. This suggests that, with the exception of the inclusion of attempted SA, more evidence would be needed to conclude that changing operationalizations of SA is associated with changes in observed differences between assaulted and nonassaulted samples on psychopathology.

SA assessment quality varied across effects. Most included multiple items (68% of effects), described at least one sex act behaviorally (70% of effects), and specified at least one tactic through which the sex act occurred (68% of effects), but fewer were previously published (46% of effects). Mean percent quality was 0.68 ( SD = 0.35). Hypothesis 3, that lower-quality assessments would be associated with higher effects, was supported, β = −0.07, SE = .03, p < .01, indicating that studies using lower-quality assessments of SA evidenced larger differences between the SA and no-SA groups.

Studies also varied in the quality of their assessments of psychopathology. For most effects, the measure was previously published (88% of effects) and included multiple items (91% of effects), but fewer were administered via interview (47% of effects) or were explicitly stated to be based on and/or validated against DSM criteria (53% of effects). Hypothesis 4, predicting that higher-quality assessments would be associated with higher observed effects, was supported: average quality score was 0.71 ( SD = 0.26), and this value was significantly associated with the magnitude of effect sizes, β = 0.04, SE = .02, p = .04. This indicates that indicating that studies using higher-quality assessments of psychopathology evidenced larger differences between the SA and no-SA groups.

Most studies (81%) used comparison groups that had not experienced SA (i.e., no-assault groups), fewer (17 % ) used comparison groups that had experienced another form of trauma (i.e., other-trauma groups), and very few (1%) used comparison groups that were selected for their lack of trauma experience (i.e., no/low-trauma groups). Other-trauma groups were most often comprised of people who had experienced physical assault (8%) or any non-SA trauma (11%). Consistent with Hypothesis 5a, compared to studies using a no-SA comparison group, other trauma groups did not differ, Δ g = −0.01, SE = 0.05, p = .82 and consistent with Hypothesis 5b, no trauma groups had significantly higher effect sizes, Δ g = 0.64, SE = 0.20, p < .01. This indicates that SA survivors evidence significantly greater psychopathology when compared to people who have not experienced trauma, relative to comparisons to people who have experienced a different trauma or who have not experienced SA.

Adult/adolescent or lifetime assault. 3

Most samples limited the SA group to those who experienced SA in adolescence and/or adulthood, k = 260, m = 93. Against Hypothesis 6, here was no observed difference in effects as a function of limiting SA to adolescence/adulthood, Δ g = −0.02, SE = .04, p = .61, suggesting that there is not enough evidence to indicate that the strength of the association between SA and past-year psychopathology differs when examining lifetime versus adolescent/adult assault.

Sample differences

Our final set of hypotheses addressed differences in samples.

Features of actual assaults experienced by sample

On average, 24% of assaults involved a stranger perpetrator ( SD = 23%, range: 0–90%, k = 90, m = 33), 26% involved physical injury ( SD = 13%, range: 11–49%, k = 30, m = 8), and 21% involved the use of a weapon ( SD = 23%, range: 2–66%, k = 27, m = 11). We hypothesized that higher percentages of each characteristic in the SA group would be positively related to observed effect sizes (i.e., the SA group would be more different from the no-SA group when more members of the SA group experienced assaults with these characteristics). Hypothesis 7a was supported: the percent of survivors who were injured was positively related to the magnitude of difference between groups, β = 0.18, SE = .04, p < .001. Hypothesis 7b was also supported: the percent of assaults that involved a weapon was positively related to the magnitude of difference between groups, β = 0.21, SE = .09, p = .02. Hypothesis 7c was not supported: the percent of stranger perpetrators was unrelated to group differences, β = 0.10, SE = .06, p = .07. Together, this provides evidence that some indices of assault severity are associated with greater severity or frequency of psychopathology.

Time since assault

We limited the sample to those effects that represented past-year psychopathology and reported time since assault ( k = 94, m = 47). The mean time elapsed since SA in this subsample was 4.55 years ( SD = 9.51, median = 0.63, range: 0.004 to 49.70). Hypothesis 8 was not supported: effects did not differ as a function of years since assault, β = −0.02, SE = .06, p = .70, suggesting that there is not enough evidence to indicate that the strength of the association between SA and past-year psychopathology differs by time since assault. To account for within-study variation in time since assault, we limited the sample to studies assessing past-year SA, and found no differences in effect sizes, β = −0.01, SE = .05, p = .78 ( k = 50, m = 23).

Demographic differences

We next tested demographic moderators.

The average of participants’ mean age across studies was 29.84 ( SD = 11.13, range: 18.03 to 81.90). We limited the sample to past-year psychopathology because older participants would have a larger range of time in which lifetime psychopathology could have occurred. Hypothesis 9a was supported: effects did not differ as a function of sample mean age, β = 0.00, SE = .02, p = .99. We then limited the sample to studies assessing both past-year SA and past-year psychopathology in order to assess the impact of age at assault on psychopathology. Effect sizes did not differ as a function of sample mean age, β = −1.11, SE = .06, p = .86 ( k = 37, m = 19). Finally, to account for within-study variation in participant age, we limited the sample to studies in which most participants had an age within 5 years of the mean (i.e., those studies with SD < 5), and again found no difference in past-year psychopathology, β = 0.01, SE = .03, p = .76 ( k = 140, m = 72). These results suggest that there is not enough evidence to suggest that the strength of the association between SA and psychopathology differs by age.

In the studies included in this analysis, an average of 81.66% of study participants were women ( SD = 28.62%). In support of Hypothesis 9b, that effect sizes would not differ as a function of the women in the sample, we found that the percentage of women in the sample was not associated with effect size magnitude, β = −0.03, SE = .02, p = .17. However, because women are significantly more likely to be sexually assaulted, in mixed-gender samples, women may be better-represented in the SA group than men, which could bias the results. Thus, we restricted the dataset to single-gender effect sizes (women-only samples: k = 330, m = 122; men-only samples: k = 14, m = 8). Again, effect sizes did not differ as a function of sample gender, β = −0.02, SE = .06, p = .30. These results suggest that there is not enough evidence to suggest that the association between SA and psychopathology differs by gender.

Most US samples were majority-White/Caucasian (69%). In support of Hypothesis 9c, compared to primarily-White samples, the following groups were not significantly different: majority Black/African American samples, Δ g = −0.08, SE = 0.09, p = .40, majority Latino/a samples, Δ g = −0.04, SE = 0.15, p = .80, majority Native American samples, Δ g = 0.47, SE = 0.31, p = .13, and no-majority samples, Δ g = 0.02, SE = 0.05, p = .76. Thus, there was not enough evidence to conclude that racial differences exist in the effect of SA on psychopathology.

Type of sample

Most samples examined college students, k = 169, m = 68, or unselected general population samples, k = 141, m = 52. In partial support of Hypothesis 10, compared to college samples, only general population samples, Δ g = 0.12, SE = .05, p = .01, and mixed samples, Δ g = 0.20, SE = .08, p = .02, had significantly higher effect sizes. No other differences were observed.

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 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 psychopathology appears to be stronger than previously estimated. The only prior meta-analysis to examine the association between adult SA and distress (broadly defined to include both psychopathology and distress across domains of life functioning) across 38 studies estimated an average effect size of r = .21 ( Weaver & Clum, 1995 ), which is roughly equivalent to g = .43. The overall effect size of g = 0.61 observed in the current analysis indicates that an experience of SA is associated with more than half a standard deviation increase in psychopathology, and provides evidence that many survivors of SA experience increased frequency or severity of psychopathology.

What Forms of Psychopathology are Associated with Sexual Assault?

An unresolved question in this body of literature is whether SA has a narrow psychological impact (i.e., on PTSD) or a broad impact on a range of mental disorders. PTSD has been reconceptualized in DSM-5 as a condition distinct from the anxiety disorders given that trauma exposure is seen as a necessary condition for its onset ( APA, 2013 ). Although other disorders (e.g., depression) may follow trauma, they may also emerge in the absence of trauma. In this analysis, although trauma and stressor-related conditions evidenced one of the strongest associations with a history of SA, SA was significantly positively related to all forms of psychopathology studied, suggesting that SA is broadly associated with psychopathology. The relatively high effect size for trauma and stressor-related disorders is unsurprising, because trauma exposure is a necessary precondition to receive a diagnosis of PTSD, and effect sizes compared groups that had experienced one such trauma (i.e., SA) to groups that had not necessarily been exposed to trauma. Thus, SA groups would be expected to, by definition, evidence more PTSD than no-SA groups. As a result, although SA was associated with greater risk for PTSD than depression, anxiety, disordered eating, and substance abuse/dependence, it is important to be cautious about interpreting the relative magnitude of these effects as evidence to support the idea that PTSD is necessarily a distinct psychological phenomenon. It also is possible that the higher prevalence of non-PTSD disorders in SA populations reflects the high comorbidity of these disorders with PTSD or overlapping symptoms between PTSD and conditions like depression and anxiety ( Kessler et al., 1995 ). Patterns of comorbidity with PTSD in SA populations should be investigated in future research to understand whether these conditions arise directly from SA or are secondary to PTSD.

Survivors of SA appear to be at substantially increased risk for suicidal ideation and attempts; indeed, relative to other conditions, SA was associated with the highest increases in risk for suicidality. This is consistent with past epidemiological studies that have controlled for other risk factors ( Ullman & Brecklin, 2002 ; Stein et al., 2010 ). Of the disorders assessed in this analysis, suicidality is explicitly included as part of the diagnostic criteria in DSM-5 for depression only, which evidenced a significantly smaller effect size relative to suicidality ( APA, 2013 ). Thus, although explicitly shared symptoms with other disorders are likely an insufficient explanation for the strong association between SA and suicidality, all types of psychopathology included in this analysis have been associated with elevated risk for suicidality ( Harris & Barraclough, 1997 ; Panagioti et al., 2012 ; Preti et al., 2011 ), including in SA-specific samples ( Ullman & Brecklin, 2002 ). It is possible, then, that survivors of SA are at high risk for suicidality because its risk is elevated across forms of psychopathology associated with SA, and may be even more highly elevated when disorders co-occur ( Panagioti et al., 2012 ). However, evidence from cross-national epidemiological studies indicates that SA is more strongly associated with suicidality than other forms of trauma, and this effect appears to be independent of co-occurring disorders ( Stein et al., 2010 ). It is also possible that this is due to the high degree of stigma and shame associated with SA victimization ( Rudd, 2006 ). This evidence highlights the importance of screening for lethality risk and safety planning among SA survivors, and suggests that future research clarifying the mechanism of the relationship between SA and suicidality would be useful.

SA also appears to be associated with substantially increased risk for bipolar conditions and obsessive-compulsive conditions. Although these conditions are typically thought to be highly genetically-based ( Etain et al., 2008 ; Hettema, Neale, & Kendler, 2001 ), emerging empirical evidence suggests that trauma may play a bigger role in their development than previously thought ( Cromer, Schmidt, & Murphy, 2007 ; Etain et al., 2008 ). These results must be interpreted with caution, given the relatively small number of studies on which they were based coupled with their large confidence intervals, but it is still important to consider associations between SA and both conditions. One potential explanation is that experiencing SA could trigger symptom expression in these disorders (e.g., mania, checking rituals) to a greater degree than other conditions ( Cromer et al., 2007 ). Comorbid PTSD may also explain this relationship. For example, there is some evidence that PTSD can be misdiagnosed as bipolar disorder ( Hernandez et al., 2013 ), and intrusive thoughts related to trauma could instead be miscategorized as a symptom of obsessive-compulsive disorder. In addition, having PTSD related to SA could interfere with obsessive-compulsive disorder treatment ( Gershuny et al., 2002 ).

Although the association between substance use disorders and PTSD after SA (e.g., Kilpatrick et al., 1997 ) has been well-documented, survivors of SA appear to be at relatively lower risk of substance use disorders than other conditions. Prospective studies have found no effect for SA on problem substance use when controlling for pre-assault drinking ( Testa & Livingston, 2000 ; Testa, Livingston, & Hoffman, 2007 ). It is possible that substance use, rather than abuse/dependence per se, is associated with assault, given that much of the literature in this area has identified associations for substance use. Because substance use after SA has been conceptualized as a strategy to reduce negative affect ( Kilpatrick et al., 1997 ), it would seem to be more likely to be present either in the subset of survivors with other disorders (e.g., PTSD; Chilcoat & Breslau, 1998 ; Stewart & Conrad, 2003 ) or in the early aftermath of assault only, when distress is more typical (e.g., Rothbaum, Foa, Riggs, Murdock, & Walsh, 1992 ). Survivors in the latter group might not have significantly higher substance use than nonsurvivors who use substances to cope with other life stresses, and any negative affect driving substance use would be likely to dissipate relatively quickly. This possibility should be tested empirically.

Although it is difficult to discern whether SA necessarily has an etiological role in psychopathology, the greater prevalence and severity of a range of mental disorders in survivors of SA suggests that trauma exposure should be considered when treating mental disorders. Trauma exposure generally, and SA exposure specifically, should be assessed to inform case conceptualization. If SA plays an etiological role in the development of non-PTSD conditions, trauma-informed interventions may be more effective than disorder-specific treatments for survivors of SA with these conditions. Additionally, if SA is considered to be a broad risk factor for distress rather than a specific etiological risk factor for certain disorders, transdiagnostic approaches, such as the Unified Protocol ( Ellard, Fairholme, Boisseau, Farchione, & Barlow, 2010 ), could have added success in treating distress arising from SA. This possibility, as well as the possible etiological role of SA in a range of mental disorders beyond PTSD, should be investigated in future research.

How do Differences in Study Methods and Samples Alter Observed Effects?

To guide future research on SA and psychopathology, it is important to understand how methodological choices—such as the measures used and population sampled—might affect study results. Next, we review these methodological choices in light of the current results.

Critics have raised questions about the appropriate breadth of operational definitions of SA (e.g., Gilbert, 1993 ). These critics argue that the only people who should be considered victims in a research context are those who experienced forms of SA that match narrow societal stereotypes regarding the types of sexual acts involved and tactic used to compel them (e.g., forcible rape) ( Cook et al., 2011 ; Koss, 2011 ). In light of these controversies, it is important to understand whether broadening operational definitions has an effect on differences in psychopathology between assaulted and unassaulted groups. In the current analysis, we found that including coerced, and incapacitated SA in operational definitions did not significantly alter observed group differences in psychopathology. Although including attempted SA reduced group differences, it is important to note that studies that included both attempted and completed assaults still evidenced moderate-sided effects. This indicates that broadening operational definitions to include attempted SA may reduce effect sizes somewhat, but they are not lowered to the point of inconsequentiality. An important limitation of these findings is that they only reflect the operational definition of SA, and not the actual inclusion of assaults that fall under these broader operational definitions in the SA group. For example, it is possible that a study considered people who experienced either attempted or completed SA to fall in the SA group, but all members of the SA group experienced completed SA. It is likely, though, that broadening these operational definitions added a substantial number of participants to the SA group who would otherwise have been in the comparison group. Indeed, past studies have found that including attempted rape increased the size of the SA group by 65–79% ( Fisher et al., 2000 ; Koss et al., 1987 ), including coerced SA increased the size of the SA group by 77–164% ( Koss et al., 1987 ), and including nonpenetrative SA increased the size by 94–232% ( Koss et al., 1987 ). Further, a meta-analysis failed to find differences in psychopathology between penetrative and nonpenetrative child sexual abuse ( Paolucci & Genuis, 2001 ), providing support for the current findings. Thus, in spite of these limitations, our results provide evidence that narrowing operational definitions in terms of the acts and tactics included does not significantly obscure group differences.

The quality of measures used to assess SA and psychopathology may also affect study results. Lower-quality SA assessment methods—which we defined as those using measures that contained a single item only, were unpublished, did not behaviorally define SA, and/or did not specify a tactic through which SA could have occurred—tended to overestimate group differences. It is possible that societal disagreement about what “counts” as SA necessitates more assessment specificity. SA survivors who have not experienced assaults that are consistent with societal SA schemas (e.g., acquaintance rape) might be less likely to endorse questions like, “have you ever been raped?,” and their inclusion in the no-SA group would thus lessen observed group differences. It is notable that the population of studies included in this analysis varied widely in the quality of SA assessments. The same was not true for the psychopathology assessment quality: lower-quality assessment methods appeared to underestimate group differences. While a past meta-analysis on the relationship between interpersonal violence and distress did not find evidence that indicators of validity were associated with effects, this prior analysis was not limited to diagnostic constructs ( Weaver & Clum, 1995 ). Although rigorous assessment methods tend to be more time-intensive for participants, these results suggest that researchers may introduce bias to their estimates of the impact of psychopathology on SA by using lower-quality assessments.

The selection of the group against which sexually assaulted people are compared may also alter study results. As expected, effect sizes were significantly higher for studies using no-trauma comparison groups than for studies using no-assault or other-trauma comparison groups. It is likely that no-assault comparison groups are comprised mostly of people who experienced some other form of trauma, even though they were not selected for this quality, so it is not surprising that intentionally selecting a comparison group comprised of no/low trauma resulted in large differences from a SA group. These results also suggest that SA has a stronger association with psychopathology than other forms of trauma, consistent with past work ( Kelley et al., 2009 ; Kessler et al., 1995 ). SA’s uniquely strong impact on psychopathology could occur for several reasons. First, SA commonly co-occurs with other forms of trauma like intimate partner violence and child sexual abuse ( Campbell, Greeson, Bybee, & Raja, 2008 ). The increased risk of psychopathology observed in SA might be associated with cumulative trauma exposure rather than SA specifically ( Green et al., 2000 ). Indeed, although having a past trauma generally increased the risk for PTSD in a different meta-analysis, this effect was strongest when the current trauma was interpersonal violence ( Ozer et al., 2003 ). Second, it is possible that survivors of SA receive less social support following trauma than survivors of other traumas, given the stigma associated with rape, and social support has been identified as a correlate of PTSD ( Brewin et al., 2000 ; Ozer et al., 2003 ). Third, it is possible that pre-trauma psychological problems might be more common in SA than in other traumas, which would increase risk for post-trauma psychopathology ( Ozer et al., 2003 ). Fourth, experiencing an interpersonal trauma of such a personal nature could be uniquely violating ( Green et al., 2000 ). These possibilities should be explored in future meta-analyses.

Given the large number of studies from the general trauma literature that do not specify at what age SA must have occurred, as well as the division of the SA literature into adult/adolescent SA research and child SA research, it is important to understand whether lifetime SA studies can be integrated into reviews and theoretical development regarding adolescent/adult SA. Although prior meta-analyses found that age at trauma exposure was associated with PTSD ( Brewin et al., 2000 ; Ozer et al., 2003 ), we did not find that including lifetime SA studies—which likely included survivors of child SA in their SA groups—reduced effects. In light of the high rates of adolescent/adult victimization after childhood SA ( Classen, Palesh, & Aggarwal, 2005 ), it is possible that few survivors of child SA who had not also experienced adolescent/adult SA were included in the SA group in lifetime studies. Nevertheless, these findings do not suggest that studies of lifetime SA and adolescent/adult SA are so distinct as to be incomparable.

Understanding how assault features might be associated with psychopathology can clarify the development of psychopathology and inform targeted interventions to mitigate the harm of assault. It appears that assault characteristics like stranger perpetrators, weapon use, and resulting physical injury, are associated with higher risk for psychopathology. It is possible that these assault characteristics make the assault itself more distressing or increase perceived life threat, which then increases risk for the development of later psychopathology ( Ozer, Best, Lipsey, & Weiss, 2003 ). These results help to contextualize the findings of a past review on gender differences in PTSD by trauma type: adult SA was one of the only traumas that did not appear to have a higher frequency or severity of PTSD in women as compared to men, and the authors hypothesized that this might be explained by the greater likelihood of physical injury and other markers of severity or life threat not addressed in this meta-analysis (e.g., multiple perpetrators) ( Tolin & Foa, 2006 ). Early intervention efforts could be targeted to survivors of these types of assaults in order to reduce their impact.

The effect of SA on psychopathology appears to be relatively durable over time. In one of the earliest prospective longitudinal studies of the impact of SA on PTSD, results suggest that symptoms decrease rapidly over the first month post-SA for survivors who do not ultimately develop PTSD, but are relatively durable over time for survivors with PTSD ( Rothbaum et al., 1992 ). In contrast, past reviews suggest that the impact of interpersonal violence broadly on distress appears to decrease over time ( Weaver & Clum, 1995 ), as does the impact of intimate partner violence on depression ( Golding, 1999 ). It is possible that SA has a more durable effect on psychopathology than other types of interpersonal violence. This emphasizes the critical importance of increasing access to the multiple highly-effective short-term treatments for PTSD (e.g., Cognitive Processing Therapy, Prolonged Exposure Therapy) and other conditions (e.g., cognitive behavioral therapy for depression, exposure and response prevention for OCD) among SA survivors. Because these treatments are designed to resolve symptoms within months, their use can reduce the long-term impact of SA while making efficient use of provider time and minimizing survivors’ financial costs and time investment. Rape crisis center counselors can be trained to offer these treatments, or can maintain community referral lists to connect survivors with these services.

Understanding which demographic groups are most affected by SA can help to target outreach and prevention efforts. However, it does not appear that any particular demographic group evidences relatively higher post-assault psychopathology. Although race/ethnicity and age had little support from past meta-analyses in relation to observed effects, there had been some prior support for the role of gender. A meta-analysis identified gender differences in the impact of interpersonal violence on distress ( Weaver & Clum, 1995 ), but this previous analysis’s study population lacked representation from men and contained no men-only samples, which could have underestimated the impact of SA on men. Men, people who identify as transgender, and sexual minorities are significantly understudied populations with regard to the impact of SA, and more research is needed to understand their post-assault experiences.

Across populations like college students, people seeking healthcare, military/veterans, prison inmates, and people seeking support for crime-related needs, the impact of SA appears to be similarly substantial. People in most of these populations may be more likely to have characteristics that could represent better psychological functioning (e.g., employment, student status, help-seeking behavior), but regardless, people exposed to SA still evidence higher levels psychopathology relative to those unexposed to SA. In the general population, though, there are likely to be SA survivors who have withdrawn from the workforce voluntarily or involuntarily, dropped out of educational opportunities, or ceased help-seeking due to the severity of the impact of SA. As a result, research on general population samples appears to evidence the greatest differences in psychopathology between assaulted and unassaulted groups.

Causal Associations Between Sexual Assault and Psychopathology

It is clear that SA and psychopathology have a robust association, but a causal relationship between SA and psychopathology cannot be inferred from this body of work. Indeed, there are multiple mechanisms through which the observed relationship could occur.

The first set of mechanisms explaining the relationship between SA and psychopathology involve increases in vulnerability to psychopathology as a result of SA. Generally, in these mechanisms, SA and its aftermath would be expected to produce the distorted cognitions (e.g., overestimation of dangerousness of situations), alterations to mood (e.g., sadness, fear), and changes to behavior (e.g., increased substance use, behavioral avoidance, social withdrawal, compulsions) seen across all disorders studied. First, distress could arise directly from the assault or its aftermath. SA is experienced as a trauma by some survivors, and this experience of violation or life threat could cause psychopathology; indeed, in the current analysis, studies with larger proportions of survivors of assaults that likely involved more life threat (e.g., weapon use) evidenced larger effect sizes. In addition, negative experiences at multiple levels of the social ecology (e.g., negative experiences with community responders, lack of social support) could intensify distress ( Campbell et al., 2009 ). Survivors’ pre-existing coping strategies could also affect the degree to which this distress becomes problematic or long-lasting ( Ullman et al., 2007 ). Second, SA could worsen existing disorders. In support of this idea, a meta-analysis of risk factors for PTSD found that past difficulties with psychological adjustment were particularly strongly related to post-trauma psychopathology for survivors of SA relative to other traumas ( Ozer et al., 2003 ) and a literature review on associations between SA and psychopathology identified pre-assault mental health difficulties as a predictor of post-assault psychopathology ( Campbell et al., 2009 ). Because people who have experienced SA are particularly likely to have also experienced past traumas, like CSA, distress from these multiple traumatic experiences may be cumulative ( Arata, 1999 ). Third, SA could trigger the expression of a genetic liability. Indeed, the broader field of developmental psychopathology has moved away from diathesis-stress models towards gene-by-environment interplay models, in which environments have an interactive, rather than an additive effect on psychopathology ( Kendler et al., 1997 ; Kendler et al., 2003 ).

Another possibility, consistent with stress generation theory ( Conway, Hammen, & Brennan, 2012 ), is that psychopathology could increase risk for SA, perhaps through impairment to attentional, concentration, and motivational systems that result in reduced capacity to identify and avoid threats ( Orcutt, Erikson, & Wolfe, 2002 ; Pineles, Shipherd, Welch, & Yovel, 2007 ). Indeed, there is some evidence from the SA revictimization literature, albeit mixed, that the psychosocial consequences of childhood SA increase risk for adolescent/adult SA via increased contact with potential perpetrators (e.g., as a result of using alcohol) and/or an increased likelihood that perpetrators will target the individual (e.g., due to impaired risk recognition) ( Classen et al., 2005 ; Messman-Moore & Long, 2003 ). There is a relative dearth of prospective studies that assess the causal direction of the relationship between psychopathology and SA, but meta-analyzing these studies could clarify this issue.

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 range of effects on survivors than a study including only categorical data. Because trauma survivors may drop below a diagnostic threshold as they recover but continue to evidence chronic distress, capturing only syndromal psychopathology is likely to underestimate group differences ( Ozer et al., 2003 ). Third, our sophisticated analytic strategy involving attention to publication bias and dependency in effects increases our confidence in the study findings. Although investigating between versus within study variance was not a central research question, our approach meant that we did not violate assumptions of independence of observations because we drew multiple effect sizes from many studies.

There also are several limitations to this work. First, because the focus of this study was primarily on study-level differences in effect sizes, we did not assess a number of characteristics of survivors that could explain observed heterogeneity, including pre-trauma factors (e.g., past history of victimization), peri-traumatic factors (e.g., peri-traumatic dissociation, perceptions of life threat), and post-traumatic factors (e.g., self-blame, social support). It is also unclear whether the study-level moderators (e.g., percent of women in the sample, percent of assaults involving weapons) tested would evidence similar effects in relation to psychopathology when directly comparing survivors with these characteristics. These questions would be better answered in a meta-analysis focused on differences between survivors on these characteristics, instead of between survivors and nonsurvivors, as in the current work. Such a meta-analysis should include studies without comparison groups, which the current study did not (302 studies were excluded for this reason). Second, we are not able to make causal inferences because we coded cross-sectional data only; although few prospective longitudinal studies exist that could parse out these effects (e.g., Calhoun, Atkeson, & Resick, 1982 ; Kilpatrick et al., 1981 ; Zweig, Crockett, Sayer, & Vicary, 1999 ), future meta-analyses should address this question. Third, as in any meta-analysis, the findings are only as strong as the studies that contribute to it. A limitation of this body of work identified through this review is the use of single-item, unpublished assessments of SA without behaviorally-based descriptions, which fail to capture a large minority of SA survivors ( Cook et al., 2011 ) and appear to overestimate effects. Future meta-analyses could limit their samples to only rigorously-conducted studies to determine whether findings persist. Fourth, we are not able to rule out biased reporting as an explanation for effects. People are more likely to remember events that match their mood at the time of recall ( Bower, 1981 ), suggesting that people who are in distress due to psychopathology might be more likely to endorse SA, or people experiencing negative affect might be more likely to endorse both SA and psychopathology. Finally, we did not assess every outcome of SA. Several forms of psychopathology (e.g., personality disorders), externalizing behaviors (e.g., substance use), and problems in living (e.g., health problems), as well as co-occurring problems within and across these domains, were not within the scope of this analysis and should be investigated in future reviews.

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.

• 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

Supplementary Material

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 study retrieval and coding, and Courtney Marin, Cynthia Blocker, Daniel Szoke, Kimber Schmitt, and Lauren Knight assisted with study retrieval.

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.

Appendix A: Coding Procedure

The primary coders developed a detailed codebook and trained the secondary coders by collaboratively coding articles each week with them for a semester (18–24 articles, depending on training semester) and meeting weekly to discuss each code. After the successful completion of this training process, secondary coders independently coded articles that were then checked by a primary coder, or checked the work of the primary coders. Secondary coders independently coded k = 213 effects (43% of the effects), all of which were checked by the first author, and 46% of which were double-checked by the second author. The first author independently coded k = 263 (53%) of the effects. Of these, 58% were checked by the second author, 9% were checked by the third author, and 33% were checked by a member of the secondary coding team. The remainder of the effects were coded by the second author and checked by either the first author or both the first author and a secondary coder.

Overall SA and no-SA group sample sizes presented by authors did not always reflect the sample sizes used in specific bivariate analyses (i.e., authors sometimes did not report missing data). We coded outcome-specific sample sizes and took steps to ensure that we recorded sample sizes that reflected missing data. For dichotomous outcomes, when authors presented the number of people positive for an outcome in each group along with a percentage that that number reflected, we computed the outcome-specific sample size by dividing the number presented by the percentage (e.g., if there were 10 people with depression in the SA group and the authors stated that this was 10% of the SA group, we divided 10/.01 = 100). We also examined degrees of freedom presented for bivariate analyses to check the accuracy of sample sizes. If this information led us to believe that sample sizes were smaller than what the authors presented, and we were able to compute effect sizes by other information provided that was not dependent on sample size (e.g., t-tests), we coded these values instead of means and standard deviations. If we were not able to compute effect sizes without sample sizes, we reduced the sample size proportionally in each group to match the overall reduction in sample size (e.g., if there were 20 missing cases in a study in which 25% of the sample had been sexually assaulted, we removed 5 from the SA group and 15 from the no-SA group). These strategies allowed us to determine an accurate effect size that was unbiased by inflated sample sizes. Nevertheless, it is possible that sample sizes do not reflect missing data in cases in which the authors did not provide adequate information to allow us to make this determination.

To code effect sizes for dichotomous outcomes, we constructed a 2×2 contingency table based on data presented regarding the frequency of experiencing and not experiencing the outcome in each group. We added .5 to all cells when one or more was zero ( Lipsey & Wilson, 2001 ). To code effect sizes for continuous outcomes, we recorded means and standard deviations for both groups and the sample size specific to that outcome. If these univariate statistics were not available, we coded bivariate t , F , or point-biserial r statistics. When a study reported both a continuous and a categorical effect for the same data (e.g., mean score on a scale and the percent scoring above a specified cutoff), we coded the continuous effect.

• Lipsey MW, Wilson DB. Practical meta-analysis. Thousand Oaks, CA: Sage Publications, Inc; 2001. [ Google Scholar ]

Appendix B: Analyses

Increasingly, researchers conducting meta-analyses have attended to the issue of dependence in effect sizes. When multiple effects are presented in a single study–in the current study, this occurred when researchers operationalized the same form of psychopathology in multiple ways or studied multiple forms of psychopathology–it is desirable to code each effect. However, these effects are not independent from each other, because they are nested within the same sample and the same research methodology. There are multiple approaches to manage this problem. One approach is to treat these effects as independent. Some researchers attempt to partially account for nonindependence by weighting effect sizes by some study-level characteristic (e.g., inverse variance of effect sizes). Both approaches, though, artificially inflate study power by treating each study as contributing multiple degrees of freedom, and thus increase type I error. Another approach is to code only a single effect per study. One could achieve this by significantly limiting the scope of eligible effects, which would limit the scope of the meta-analysis, or randomly selecting a single effect size to code. Another approach is to average effects within studies (e.g., Weaver & Clum, 1995 ). However, many effect-level moderators (e.g., type of psychopathology) would then be masked, which would preclude a full examination of heterogeneity in effects through the testing of moderators.

In research beyond meta-analyses, the issue of nonindependent observations in research is typically addressed through multilevel modeling, which partials variance into within-group and between-group components. Increasingly, researchers have used variations on this approach to address this problem when it arises in meta-analyses. We selected one such variation, multilevel structural equation modeling, which we conducted using the metaSEM package ( Cheung, 2012 ) in R 3.3.1 ( R Development Core Team, 2008 ). We created a three-level model, in which level 1 represents the individual effect sizes, level 2 represents differences in effect sizes within a study, and level 3 represents differences between studies. R code used for this study is available on request from the authors.

Although a three-level meta-analysis was warranted given the data structure, we nevertheless tested the null hypothesis that heterogeneity in effect sizes exists at level 3 (τ 2 (3) = 0), which would indicate that this variance should be accounted for statistically ( Cheung, 2014 ). The likelihood ratio test was 77.53 ( df = 1), p < .0001, suggesting that the 3-level model is statistically superior to the 2-level model. We then tested whether significantly more heterogeneity exists at level 3 (controlling for differences in domains/measures of psychopathology) than level 2 (due to differences in domains/measures of psychopathology) (H 0 : τ 2 (3) = τ 2 (2) ) by conducting a likelihood ratio test in which level 2 and level 3 random effects heterogeneity variances were both constrained to 0.1. The likelihood ratio test was 3.30 ( df = 1), p = .07, suggesting that there is insufficient evidence to reject the null hypothesis that level 2 heterogeneity is equivalent to level 3 heterogeneity. These findings indicate that a 3-level meta-analysis is warranted and suggest the presence of significant heterogeneity at both level 2 and level 3 that could be accounted for by moderators.

We first tested an unconditional 3-level model (i.e., without independent variables) to examine the overall effect size and assess the amount of heterogeneity across levels. We then tested models with independent variables to examine moderation hypotheses. For each categorical moderator, all categories were entered simultaneously into the model and the intercept was constrained to zero to estimate the average effect size for each. We then compared the relative magnitude of effects by dummy coding variables and selecting one as the referent group, which was left out of the model. Continuous moderators were directly entered into the model.

Appendix D: Studies Included in Analysis

• Cheung MWL. metaSEM: An R package for meta-analysis using structural equation modeling. Frontiers in Psychology. 2012; 5 :1–7. doi: 10.3389/fpsyg.2014.01521. [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Cheung MWL. Modeling dependent effect sizes with three-level meta-analyses: A structural equation modeling approach. Psychological Methods. 2014; 19 (2):211–229. [ PubMed ] [ Google Scholar ]
• R Development Core Team. R: A language and environment for statistical computing. R Foundation for Statistical Computing; Vienna, Austria: 2008. URL http://www.R-project.org . [ Google Scholar ]
• Weaver TL, Clum GA. Psychological distress associated with interpersonal violence: A meta-analysis. Clinical Psychology Review. 1995; 15 (2):115–140. [ Google Scholar ]

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Contributors

Conflict of Interest

All authors report that they have no conflicts of interest.

1 These conditions are referred to in nondiagnostic terms to indicate that this review includes a range of forms of psychopathology in each of these domains, from subthreshhold symptoms assessed with self-report measures to diagnoses assessed with diagnostic interviews.

2 No non-US country was represented with sufficient frequency to test within-country racial differences. Cross-country tests of racial differences would have limited utility under the assumption that race is a context-dependent social construct.

3 We also tested this moderator in two-way interactions with each other moderator. No significant interactions were identified, which provides further evidence that including studies that do not limit sexual victimization to adolescence/adulthood does not appear to impact observed effects.

• Abrams MP. Human tonic immobility: An exploration of three trauma contexts. 2008 (Unpublished master’s thesis) [ Google Scholar ]
• Acierno R, Lawyer SR, Rheingold AA, Kilpatrick DG, Resnick HS, Saunders BE. Current psychopathology in previously assaulted older adults. Journal of Interpersonal Violence. 2007; 22 (2):250–258. doi: 10.1177/0886260506295369. [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Amir M, Sol O. Psychological impact and prevalence of traumatic events in a student sample in Israel: The effect of multiple traumatic events and physical injury. Journal of Traumatic Stress. 1999; 12 (1):139–154. doi: 10.1023/A:1024754618063. [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Aosved AC, Long PJ, Voller EK. Sexual revictimization and adjustment in college men. Psychology of Men & Masculinity. 2011; 12 (3):285–296. doi: 10.1037/a0020828. [ CrossRef ] [ Google Scholar ]
• Arata CM. Repeated sexual victimization and mental disorders in women. Journal of Child Sexual Abuse. 1999; 7 (3):1–17. doi: 10.1300/J070v07n03. [ CrossRef ] [ Google Scholar ]
• Arata CM, Burkhart BR. Post-traumatic stress disorder among college student victims of acquaintance assault. Journal of Psychology and Human Sexuality. 1996; 8 (1–2):79–92. [ Google Scholar ]
• Badour CL. An empirical investigation of emotional reactivity and elevated mental contamination: A comparison of sexual and physical assault. 2011 (Unpublished master’s thesis) [ Google Scholar ]
• Bailey CA, Gibbons SG. Physical victimization and bulimic‐like symptoms: Is there a relationship? Deviant Behavior. 1989; 10 (4):335–352. doi: 10.1080/01639625.1989.9967821. [ CrossRef ] [ Google Scholar ]
• Balsam KF, Lehavot K, Beadnell B. Sexual revictimization and mental health: A comparison of lesbians, gay men, and heterosexual women. Journal of Interpersonal Violence. 2011; 26 (9):1798–1814. doi: 10.1177/0886260510372946. [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Becker JV, Skinner LJ, Abel GG, Axelrod R, Treacy EC, Ma ECT. Depressive symptoms associated with sexual assault. Journal of Sex and Marital Therapy. 1984; 10 :185–192. [ PubMed ] [ Google Scholar ]
• Belik SL, Stein MB, Asmundson GJG, Sareen J. Relation between traumatic events and suicide attempts in Canadian military personnel. Canadian Journal of Psychiatry. 2009; 54 (2):93–104. [ PubMed ] [ Google Scholar ]
• Ben-Ezra M, Palgi Y, Sternberg D, Berkley D, Eldar H, Glidai Y, Shrira A. Losing my religion: A preliminary study of changes in belief pattern after sexual assault. Traumatology. 2010; 16 (2):7–13. http://dx.doi.org/10.1177/1534765609358465 . [ Google Scholar ]
• Betts KS, Williams GM, Najman JM, Alati R. Exploring the female specific risk to partial and full PTSD following physical assault. Journal of Traumatic Stress. 2013; 26 :86–93. doi: 10.1002/jts. [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Binder-Brynes KL. The prevalence of fear and depression in sexually abused women: An analysis of archival data. 1991 (Unpublished doctoral dissertation) [ Google Scholar ]
• Blanchard EB, Jones-Alexander J, Buckley TC, Forneris CA. Psychometric properties of the PTSD Checklist (PCL) Behaviour Research and Therapy. 1996; 34 (8):669–673. [ PubMed ] [ Google Scholar ]
• Blix I, Brennen T. Mental time travel after trauma: The specificity and temporal distribution of autobiographical memories and future-directed thoughts. Memory. 2011; 19 (8):956–967. doi: 10.1080/09658211.2011.618500. [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Blix I, Brennen T. Retrieval-induced forgetting after trauma: A study with victims of sexual assault. Cognition and Emotion. 2012; 26 (2):321–331. doi: 10.1080/02699931.2011.570312. [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Bolton EE, Litz BT, Britt TW, Adler A. Reports of prior exposure to potentially traumatic events and PTSD in troops poised for deployment. Journal of Traumatic Stress. 2001; 14 (1):249–256. [ Google Scholar ]
• Borja SE, Callahan JL, Rambo PL. Understanding negative outcomes following traumatic exposure: The roles of neuroticism and social support. Psychological Trauma: Theory, Research, Practice, and Policy. 2009; 1 (2):118–129. doi: 10.1037/a0016011. [ CrossRef ] [ Google Scholar ]
• Boudreaux E, Kilpatrick DG, Resnick HS, Best CL, Saunders BE. Criminal victimization, posttraumatic stress disorder, and comorbid psychopathology among a community sample of women. Journal of Traumatic Stress. 1998; 11 (4):665–678. [ PubMed ] [ Google Scholar ]
• Brener ND, McMahon PM, Warren CW, Douglas KA. Forced sexual intercourse and associated health-risk behaviors among female college students in the United States. Journal of Consulting and Clinical Psychology. 1999; 67 (2):252–259. doi: 10.1037/0022-006X.67.2.252. [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Breslau N, Davis GC, Andreski P, Peterson E. Traumatic events and posttraumatic stress disorder in an urban population of young adults lifetime prevalence of exposure to traumatic events. Archives of General Psychiatry. 1991; 48 :216–222. [ PubMed ] [ Google Scholar ]
• Brooks CW. Forgiveness and empathy in victims of sexual aggression and their relationship with mental and physical health. 2007 (Unpublished doctoral dissertation) [ Google Scholar ]
• Brown EJ. Self-discourse, social anxiety, and symptomatology in rape victim-survivors: The effects of cognitive and emotional processing. 1996 (Unpublished doctoral dissertation) [ Google Scholar ]
• Brown NL, Wilson SR, Kao Y, Luna V, Kuo ES, Rodriguez C, Lavori PW. Correlates of sexual abuse and subsequent risk taking. Hispanic Journal of Behavioral Sciences. 2003; 25 (3):331–351. http://dx.doi.org/10.1177/0739986303257147 . [ Google Scholar ]
• Brownlie EB, Jabbar A, Beitchman J, Vida R, Atkinson L. Language impairment and sexual assault of girls and women: Findings from a community sample. Journal of Abnormal Child Psychology. 2007; 35 (4):618–626. doi: 10.1007/s10802-007-9117-4. [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Bryan CJ, McNaugton-Cassill M, Osman A, Hernandez AM. The associations of physical and sexual assault with suicide risk in nonclinical military and undergraduate samples. Suicide & Life-Threatening Behavior. 2013; 43 (2):223–234. doi: 10.1111/sltb.12011. [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Burnam MA, Stein JA, Golding JM, Siegel JM, Sorenson SB, Forsythe AB, Telles CA. Sexual assault and mental disorders in a community population. Journal of Consulting and Clinical Psychology. 1988; 56 (6):843–850. [ PubMed ] [ Google Scholar ]
• Calhoun KS, Atkeson BM, Resick PA. A longitudinal examination of fear reactions in victims of rape. Journal of Counseling Psychology. 1982; 29 (6):655–661. doi: 10.1037//0022-0167.29.6.655. [ CrossRef ] [ Google Scholar ]
• Capitaine M, Rodgers RF, Chabrol H. Unwanted sexual experiences, depressive symptoms and disordered eating among college students. Eating Behaviors. 2011; 12 :86–9. doi: 10.1016/j.eatbeh.2010.11.003. [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Chang B, Skinner KM, Zhou C, Kazis LE. The relationship between sexual assault, religiosity and mental health among male veterans. The International Journal of Psychiatry in Medicine. 2003; 33 (3):223–239. [ PubMed ] [ Google Scholar ]
• Chang EC, Hirsch JK. Social problem solving under assault: Understanding the impact of sexual assault on the relation between social problem solving and suicidal risk in female college students. Cognitive Therapy and Research. 2014:1–11. doi: 10.1007/s10608-014-9664-2. [ CrossRef ] [ Google Scholar ]
• Cheasty M, Clare AW, Collins C. Child sexual abuse: A predictor of persistent depression in adult rape and sexual assault victims. Journal of Mental Health. 2002; 11 (1):79–84. doi: 10.1080/096382301200041489. [ CrossRef ] [ Google Scholar ]
• Clark CB, Perkins A, McCullumsmith CB, Islam MA, Hanover EE, Cropsey KL. Characteristics of victims of sexual abuse by gender and race in a community corrections population. Journal of Interpersonal Violence. 2012; 27 (9):1844–1861. doi: 10.1177/0886260511430390. [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Clements CM, Ogle RL. Does acknowledgment as an assault victim impact postassault psychological symptoms and coping? Journal of Interpersonal Violence. 2009; 24 (10):1595–1614. doi: 10.1177/0886260509331486. [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Cohen MH, Fabri M, Cai X, Shi Q, Hoover DR, Binagwaho A, Anastos K. Prevalence and predictors of posttraumatic stress disorder and depression in HIV-infected and at-risk Rwandan women. Journal of Women’s Health. 2009; 18 (11):1783–1791. http://dx.doi.org/10.1089/jwh.2009.1367 . [ PMC free article ] [ PubMed ] [ Google Scholar ]
• Collins B, Fischer S, Stojek M, Becker K. The relationship of thought suppression and recent rape to disordered eating in emerging adulthood. Journal of Adolescence. 2014; 37 :113–121. doi: 10.1016/j.adolescence.2013.11.002. [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Conley TD, Garza MR. Gender and sequelae of child versus adult onset of sexual victimization: Body mass, binge eating, and promiscuity. Journal of Applied Social Psychology. 2011; 41 (11):2551–2572. doi: 10.1111/j.1559-1816.2011.00828.x. [ CrossRef ] [ Google Scholar ]
• Cotton DJ. The male victim of sexual assault: Patterns of occurrence, trauma reactions and adaptive reactions. 1980 (Unpublished doctoral dissertation) [ Google Scholar ]
• Coxell A, King M, Mezey G, Gordon D. Lifetime prevalence, characteristics, and associated problems of non-consensual sex in men: Cross sectional survey. BMJ: British Medical Journal. 1999; 318 :846–850. [ PMC free article ] [ PubMed ] [ Google Scholar ]
• Cramer RJ, McNiel DE, Holley SR, Shumway M, Boccellari A. Mental health in violent crime victims: Does sexual orientation matter? Law and Human Behavior. 2012; 36 (2):87–95. doi: 10.1037/h0093954. [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Creamer M, Burgess P, McFarlane AC. Post-traumatic stress disorder: Findings from the Australian National Survey of Mental Health and Well-being. Psychological Medicine. 2001; 31 (7):1237–1247. [ PubMed ] [ Google Scholar ]
• Cuevas CA, Sabina C, Picard EH. Interpersonal victimization patterns and psychopathology among Latino women: Results from the SALAS study. Psychological Trauma: Theory, Research, Practice, and Policy. 2010; 2 (4):296–306. doi: 10.1037/a0020099. [ CrossRef ] [ Google Scholar ]
• Danielson CK, Amstadter AB, Dangelmaier RE, Resnick HS, Saunders BE, Kilpatrick DG. Trauma-related risk factors for substance abuse among male versus female young adults. Addictive Behaviors. 2009; 34 :395–399. doi: 10.1016/j.addbeh.2008.11.009. [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Dansky BS, Brewerton TD, Kilpatrick DG, O’Neil PM. The National Women’s Study: Relationship of victimization and posttraumatic stress disorder to bulimia nervosa. The International Journal of Eating Disorders. 1997; 21 (3):213–228. [ PubMed ] [ Google Scholar ]
• Davidson JR, Hughes DC, George LK, Blazer DG. The association of sexual assault and attempted suicide within the community. Archives of General Psychiatry. 1996; 53 :550–555. [ PubMed ] [ Google Scholar ]
• Deliramich AN, Gray MJ. Changes in women’s sexual behavior following sexual assault. Behavior Modification. 2008; 32 (5):611–621. http://dx.doi.org/10.1177/0145445508314642 . [ PubMed ] [ Google Scholar ]
• DiVasto P. Measuring the aftermath of rape. Journal of Psychosocial Nursing and Mental Health Services. 1985; 23 (2):33–35. [ PubMed ] [ Google Scholar ]
• Dorsett EM. Primary and secondary trauma in a non-clinical population. 1995 (Unpublished doctoral dissertation) [ Google Scholar ]
• Dubosc A, Capitaine M, Franko DL, Bui E, Brunet A, Chabrol H, Rodgers RF. Early adult sexual assault and disordered eating: The mediating role of posttraumatic stress symptoms. Journal of Traumatic Stress. 2012; 25 (1):50–56. doi: 10.1002/jts.21664. [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Duke LA, Allen DN, Rozee PD, Bommaritto M. The sensitivity and specificity of flashbacks and nightmares to trauma. Journal of Anxiety Disorders. 2008; 22 :319–327. doi: 10.1016/j.janxdis.2007.03.002. [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Dworkin ER, Allen NE. [Campus violence study] Unpublished raw data 2014 [ Google Scholar ]
• Dworkin ER, Pittenger SL, Allen NE. Disclosing sexual assault within social networks: A mixed-method investigation. American Journal of Community Psychology. 2016; 57 :216–228. [ PubMed ] [ Google Scholar ]
• Dyck KG. The relationship between attributional dimensions and symptomatology in women reporting sexual assault. 1995 (Unpublished doctoral dissertation) [ Google Scholar ]
• Eap S. Predictors of risky sexual behavior in emerging adulthood: An examination of sexual trauma and depression trajectories. 2008 (Unpublished doctoral dissertation) [ Google Scholar ]
• Edwards VJ. The risk of sexual assault and mental health problems in adult daughters of battered women. 1998 (Unpublished doctoral dissertation) [ Google Scholar ]
• Eggers LW. Attitudes toward rape and recovery from sexual assault. 1985 (Unpublished doctoral dissertation) [ Google Scholar ]
• Ehring T, Quack D. Emotion regulation difficulties in trauma survivors: The role of trauma type and PTSD symptom severity. Behavior Therapy. 2010; 41 :587–598. doi: 10.1016/j.beth.2010.04.004. [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Elklit A, Hyland P, Shevlin M. Evidence of symptom profiles consistent with posttraumatic stress disorder and complex posttraumatic stress disorder in different trauma samples. European Journal of Psychotraumatology. 2014; 5 :1–10. doi: 10.3402/ejpt.v5.24221. [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Elliott DM, Mok DS, Briere J. Adult sexual assault: Prevalence, symptomatology, and sex differences in the general population. Journal of Traumatic Stress. 2004; 17 (3):203–211. doi: 10.1023/B:JOTS.0000029263.11104.23. [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Ellis EM, Atkeson BM, Calhoun KS. An assessment of long-term reaction to rape. Journal of Abnormal Psychology. 1981; 90 (3):263–266. [ PubMed ] [ Google Scholar ]
• Elwood LS. The role of cognitive vulnerabilities in the maintenance of posttraumatic stress symptoms: A prospective examination of a diathesis-stress model. 2008 (Unpublished doctoral dissertation) [ Google Scholar ]
• Evans-Campbell T, Lindhorst T, Huang B, Walters KL. Interpersonal violence in the lives of urban American Indian and Alaska Native women: Implications for health, mental health, and help-seeking. American Journal of Public Health. 2006; 96 (8):1416–1422. [ PMC free article ] [ PubMed ] [ Google Scholar ]
• Fanslow J, Robinson E. Violence against women in New Zealand: Prevalence and health consequences. The New Zealand Medical Journal. 2004; 117 (1206):1–12. [ PubMed ] [ Google Scholar ]
• Faravelli C, Giugni A, Salvatori S, Ricca V. Psychopathology after rape. The American Journal of Psychiatry. 2004; 161 (8):1483–1485. doi: 10.1176/appi.ajp.161.8.1483. [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Filipas HH, Ullman SE. Child sexual abuse, coping responses, self-blame, posttraumatic stress disorder, and adult sexual revictimization. Journal of Interpersonal Violence. 2006; 21 (5):652–672. [ PubMed ] [ Google Scholar ]
• Forman-Hoffman VL, Mengeling M, Booth BM, Torner J, Sadler AG. Eating disorders, post-traumatic stress, and sexual trauma in women veterans. Military Medicine. 2012; 177 (10):1161–1168. [ PubMed ] [ Google Scholar ]
• Frank E, Anderson BP. Psychiatric disorders in rape victims: Past history and current symptomatology. Comprehensive Psychiatry. 1987; 28 (1):77–82. [ PubMed ] [ Google Scholar ]
• Frazier PA, Schauben LJ. Stressful life events and psychological adjustment among female college students. Measurement and Evaluation in Counseling and Development. 1994; 27 (1):280–292. [ Google Scholar ]
• Frazier PA, Anders S, Perera S, Tomich P, Tennen H, Park C, Tashiro T. Traumatic events among undergraduate students: Prevalence and associated symptoms. Journal of Counseling Psychology. 2009; 56 (3):450–460. doi: 10.1037/a0016412. [ CrossRef ] [ Google Scholar ]
• Frazier PA, Steward J, Mortensen H. Perceived control and adjustment to trauma: A comparison across events. Journal of Social and Clinical Psychology. 2004; 23 (3):303–324. [ Google Scholar ]
• Freedy JR, Magruder KM, Mainous AG, Frueh BC, Geesey ME, Carnemolla M. Gender differences in traumatic event exposure and mental health among veteran primary care patients. Military Medicine. 2010; 175 (10):750–758. [ PubMed ] [ Google Scholar ]
• Freedy JR, Magruder KM, Zoller JS, Hueston WJ, Carek PJ, Brock CD. Traumatic events and mental health in civilian primary care: Implications for training and practice. Family Medicine. 2010; 42 (3):185–192. [ PubMed ] [ Google Scholar ]
• Fusé T. Psychophysiological responses to sexual assault related imagery in sexual assault survivors with and without a history of tonic immobility. 2007 (Unpublished doctoral dissertation) [ Google Scholar ]
• Gidycz CA, Koss MP. Predictors of long-term sexual assault trauma among a national sample of victimized college women. Violence and Victims. 1991; 6 (3):175–190. [ PubMed ] [ Google Scholar ]
• Gidycz CA, Coble CN, Latham L, Layman MJ. Sexual assault experience in adulthood and prior victimization experiences: A prospective analysis. Psychology of Women Quarterly. 1993; 17 :151–168. [ Google Scholar ]
• Gidycz CA, Orchowski LM, King CR, Rich CL. Sexual victimization and health-risk behaviors: A prospective analysis of college women. Journal of Interpersonal Violence. 2008; 23 (6):744–763. doi: 10.1177/0886260507313944. [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Gilboa-Schechtman E, Foa EB. Patterns of recovery from trauma: The use of intraindividual analysis. Journal of Abnormal Psychology. 2001; 110 (3):392–400. doi: 10.1037//0021-843X.110.3.392. [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Goldmann E, Aiello A, Uddin M, Delva J, Koenen K, Gant LM, Galea S. Pervasive exposure to violence and posttraumatic stress disorder in a predominantly African American urban community: The Detroit neighborhood health study. Journal of Traumatic Stress. 2011; 24 (6):747–751. doi: 10.1002/jts. [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Gutner CA, Rizvi SL, Monson CM, Resick PA. Changes in coping strategies, relationship to the perpetrator, and posttraumatic distress in female crime victims. Journal of Traumatic Stress. 2006; 19 (6):813–823. doi: 10.1002/jts. [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Hagen KL. The impact of childhood maltreatment experiences, adult revictimization, history of traumatization symptoms, and racism on the psychological well-being of African-American women. 1998 (Unpublished doctoral dissertation) [ Google Scholar ]
• Halligan SL, Michael T, Clark DM, Ehlers A. Posttraumatic stress disorder following assault: The role of cognitive processing, trauma memory, and appraisals. Journal of Consulting and Clinical Psychology. 2003; 71 (3):419–431. doi: 10.1037/0022-006X.71.3.419. [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Hapke U, Schumann A, Rumpf HJ, John U, Meyer C. Post-traumatic stress disorder: The role of trauma, pre-existing psychiatric disorders, and gender. European Archives of Psychiatry and Clinical Neuroscience. 2006; 256 :299–306. doi: 10.1007/s00406-006-0654-6. [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Harris HN, Valentiner DP. World assumptions, sexual assault, depression, and fearful attitudes toward relationships. Journal of Interpersonal Violence. 2002; 17 (3):286–305. doi: 10.1177/0886260502017003004. [ CrossRef ] [ Google Scholar ]
• Heidt JM, Marx BP, Gold SD. Sexual revictimization among sexual minorities: A preliminary study. Journal of Traumatic Stress. 2005; 18 (5):533–540. [ PubMed ] [ Google Scholar ]
• Hidaka Y, Operario D, Tsuji H, Takenaka M, Kimura H, Kamakura M, Ichikawa S. Prevalence of sexual victimization and correlates of forced sex in Japanese men who have sex with men. PLoS ONE. 2014; 9 (5):1–6. doi: 10.1371/journal.pone.0095675. [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Hossain M, Zimmerman C, Abas M, Light M, Watts C. The relationship of trauma to mental disorders among trafficked and sexually exploited girls and women. American Journal of Public Health. 2010; 100 (12):2442–2449. [ PMC free article ] [ PubMed ] [ Google Scholar ]
• Johnson K, Scott J, Rughita B, Kisielewski M, Asher J, Ong R, Lawry L. Association of sexual violence and human rights violations with physical and mental health in territories of the Eastern Democratic Republic of the Congo. JAMA: The Journal of the American Medical Association. 2010; 304 (5):553–562. doi: 10.1001/jama.2010.1086. [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Kalichman SC, Benotsch E, Rompa D, Gore-Felton C, Austin J, Luke W, Simpson D. Unwanted sexual experiences and sexual risks in gay and bisexual men: Associations among revictimization, substance use, and psychiatric symptoms. Journal of Sex Research. 2001; 38 (1):1–9. [ Google Scholar ]
• Kaltman S, Krupnick J, Stockton P, Hooper L, Green BL. Psychological impact of types of sexual trauma among college women. Journal of Traumatic Stress. 2005; 18 (5):547–555. doi: 10.1002/jts.20063. [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Kaminer D, Grimsrud A, Myer L, Stein DJ, Williams DR. Risk for post-traumatic stress disorder associated with different forms of interpersonal violence in South Africa. Social Science & Medicine (1982) 2008; 67 (10):1589–1595. doi: 10.1016/j.socscimed.2008.07.023. [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Kaysen D, Atkins DC, Moore SA, Lindgren KP, Dillworth T, Simpson T. Alcohol use, problems, and the course of posttraumatic stress disorder: A prospective study of female crime victims. Journal of Dual Diagnosis. 2011; 7 (4):262–279. doi: 10.1080/15504263.2011.620449. [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Keller A, Lhewa D, Rosenfeld B, Sachs E, Aladjem A, Cohen L, Porterfield K. Traumatic experiences and psychological distress in an urban refugee population seeking treatment services. The Journal of Nervous and Mental Disease. 2006; 194 (3):188–194. doi: 10.1097/01.nmd.0000202494.75723.83. [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Kelley EL. Women’s conceptualization of their unwanted sexual experiences: A focus on labeling, time since assault, psychological functioning and risky sexual behavior. 2009 (Unpublished bachelor’s thesis) [ Google Scholar ]
• Kelley LP, Weathers FW, McDevitt-Murphy ME, Eakin DE, Flood AM. A comparison of PTSD symptom patterns in three types of civilian trauma. Journal of Traumatic Stress. 2009; 22 (3):227–235. doi: 10.1002/jts. [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Kendall-Tackett K, Cong Z, Hale TW. Depression, sleep quality, and maternal well-being in postpartum women with a history of sexual assault: A comparison of breastfeeding, mixed-feeding, and formula-feeding mothers. Breastfeeding Medicine. 2013; 8 (1):16–22. doi: 10.1089/bfm.2012.0024. [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Kennedy AC, Bybee D, Greeson MR. Examining cumulative victimization, community violence exposure, and stigma as contributors to PTSD symptoms among high-risk young women. The American Journal of Orthopsychiatry. 2014; 84 (3):284–294. doi: 10.1037/ort0000001. [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Kessler RC, Sonnega A, Bromet E, Hughes M, Nelson CB, Breslau N. Epidemiological risk factors for trauma and PTSD. In: Yehuda R, editor. Risk factors for posttraumatic stress disorder. Washington, D C: American Psychiatric Association; 1999. pp. 23–59. [ Google Scholar ]
• Kievit LW. Coping with rape: The relationship between context, resources, and outcome. 1999 (Unpublished doctoral dissertation) [ Google Scholar ]
• Kilpatrick DG, Edmunds CN, Seymour AK. Rape in America: A report to the nation. Charleston, SC: Crime Victims Research and Treatment Center; 1992. [ Google Scholar ]
• Kilpatrick DG, Resick PA, Veronen LJ. Effects of a rape experience: A longitudinal study. Journal of Social Issues. 1981; 37 (4):105–122. http://dx.doi.org/10.1111/j.1540-4560.1981.tb01073.x . [ Google Scholar ]
• Kilpatrick DG, Resnick HS, Ruggiero KJ, Conoscenti LM, McCauley J. Drug-facilitated, incapacitated, and forcible rape: A national study. Charleston, S C: 2007. [ Google Scholar ]
• Kimerling R, Alvarez J, Pavao J, Kaminski A, Baumrind N. Epidemiology and consequences of women’s revictimization. Women’s Health Issues. 2007; 17 :101–106. doi: 10.1016/j.whi.2006.12.002. [ PubMed ] [ CrossRef ] [ Google Scholar ]
• King C. The relationship between health risk behaviors and sexual assault: A prospective analysis. 2003 (Unpublished doctoral dissertation) [ Google Scholar ]
• Kunst MJJ, Winkel FW, Bogaerts S. Posttraumatic anger, recalled peritraumatic emotions, and PTSD in victims of violent crime. Journal of Interpersonal Violence. 2011; 26 (17):3561–3579. doi: 10.1177/0886260511403753. [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Lancaster SL, Melka SE, Rodriguez BF, Bryant AR. PTSD symptom patterns following traumatic and nontraumatic events. Journal of Aggression, Maltreatment & Trauma. 2014; 23 :414–429. [ Google Scholar ]
• Lang AJ, Rodgers CS, Laffaye C, Satz LE, Dresselhaus TR, Stein MB. Sexual trauma, posttraumatic stress disorder, and health behavior. Behavioral Medicine. 2003; 28 :150–158. [ PubMed ] [ Google Scholar ]
• Larimer ME, Lydum AR, Anderson BK, Turner AP. Male and female recipients of unwanted sexual contact in a college student sample: Prevalence rates, alcohol use, and depression symptoms. Sex Roles. 1999; 40 (3):295–308. [ Google Scholar ]
• Laura RK. Response to sexual trauma in relation to event centrality and objectified view of self. 2012 (Unpublished doctoral dissertation) [ Google Scholar ]
• Laws A, Golding JM. Sexual assault history and eating disorder symptoms among white, Hispanic, and African-American women and men. American Journal of Public Health. 1996; 86 (4):579–582. [ PMC free article ] [ PubMed ] [ Google Scholar ]
• Layman MJ, Gidycz Ca, Lynn SJ. Unacknowledged versus acknowledged rape victims: Situational factors and posttraumatic stress. Journal of Abnormal Psychology. 1996; 105 (1):124–131. [ PubMed ] [ Google Scholar ]
• Lexington JM. An examination of the relationship between tonic immobility and the psychophysiology, behaviors, and perceptions in response to a hypothetical date rape scenario. 2006 (Unpublished doctoral dissertation) [ Google Scholar ]
• Lindquist CH, Barrick K, Krebs C, Crosby CM, Lockard AJ, Sanders-Phillips K. The context and consequences of sexual assault among undergraduate women at Historically Black Colleges and Universities (HBCUs) Journal of Interpersonal Violence. 2013; 28 (12):2437–2461. doi: 10.1177/0886260513479032. [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Littleton HL, Grills-Taquechel AE, Buck KS, Rosman L, Dodd JC. Health risk behavior and sexual assault among ethnically diverse women. Psychology of Women Quarterly. 2012; 37 (1):7–21. doi: 10.1177/0361684312451842. [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Littleton HL, Grills AE, Drum KB. Predicting risky sexual behavior in emerging adulthood: Examination of a moderated mediation model among child sexual abuse and adult sexual assault victims. Violence and Victims. 2014; 29 (6):981–998. [ PubMed ] [ Google Scholar ]
• Logie CH, Alaggia R, Rwigema MJ. A social ecological approach to understanding correlates of lifetime sexual assault among sexual minority women in Toronto, Canada: Results from a cross-sectional internet-based survey. Health Education Research. 2014; 29 (4):671–682. doi: 10.1093/her/cyt119. [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Loshek EA. Predictors of sexual assertiveness in women: A comparative study of women during different life-stages. 2014 (Unpublished doctoral dissertation) [ Google Scholar ]
• Lown EA, Vega WA. Alcohol abuse or dependence among Mexican American women who report violence. Alcoholism: Clinical and Experimental Research. 2001; 25 (10) [ PubMed ] [ Google Scholar ]
• Lueger-Schuster B, Glück TM, Tran US, Zeilinger EL. Sexual violence by occupational forces during and after World War II: Influence of experiencing and witnessing of sexual violence on current mental health in a sample of elderly Austrians. International Psychogeriatrics. 2012; 24 (8):1354–1358. doi: 10.1017/S104161021200021X. [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Martin SL, Rentz ED, Chan RL, Givens J, Sanford CP, Kupper LL, Macy RJ. Physical and sexual violence among North Carolina women: Associations with physical health, mental health, and functional impairment. Women’s Health Issues. 2008; 18 :130–140. doi: 10.1016/j.whi.2007.12.008. [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Martinson AA. The impact of sexual trauma and posttraumatic stress disorder symptom severity on psychological and physiological reactivity to an intimacy induction task. 2013 (Unpublished doctoral dissertation) [ Google Scholar ]
• Masho SW, Ahmed G. Age at sexual assault and posttraumatic stress disorder among women: prevalence, correlates, and implications for prevention. Journal of Women’s Health. 2007; 16 (2):262–271. doi: 10.1089/jwh.2006.M076. [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Matich-Maroney J. Sexual exploitation and its aftereffects in developmentally disabled adults. 1996 (Unpublished doctoral dissertation) [ Google Scholar ]
• McAuslan P. After sexual assault: The relationship between women’s disclosure, the reactions of others, and health. 1998 (Unpublished doctoral dissertation) [ Google Scholar ]
• McCutcheon VV, Sartor CE, Pommer NE, Bucholz KK, Nelson EC, Madden PAF, Heath AC. Age at trauma exposure and PTSD risk in young adult women. Journal of Traumatic Stress. 2010; 23 (6):811–814. doi: 10.1002/jts. [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Messman-Moore TL, Brown AL, Koelsch LE. Posttraumatic symptoms and self-dysfunction as consequences and predictors of sexual revictimization. Journal of Traumatic Stress. 2005; 18 (3):253–261. doi: 10.1002/jts.20023. [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Messman-Moore TL, Coates AA, Gaffey KJ, Johnson CF. Sexuality, substance use, and susceptibility to victimization: Risk for rape and sexual coercion in a prospective study of college women. Journal of Interpersonal Violence. 2008; 23 (12):1730–1746. [ PubMed ] [ Google Scholar ]
• Messman-Moore TL, Long PJ, Siegfried NJ. The revictimization of child sexual abuse survivors: An examination of the adjustment of college women with child sexual abuse, adult sexual assault, and adult physical abuse. Child Maltreatment. 2000; 5 (1):18–27. doi: 10.1177/1077559500005001003. [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Meyerson LA. A prospective analysis of sexual assault and alcohol use among college women. 2002 (Unpublished doctoral dissertation) [ Google Scholar ]
• Miller BC, Monson BH, Norton MC. The effects of forced sexual intercourse on white female adolescents. Child Abuse & Neglect. 1995; 19 (10):1289–1301. [ PubMed ] [ Google Scholar ]
• Moss M, Frank E, Anderson BP. The effects of marital status and partner support on rape trauma. American Journal of Orthopsychiatry. 1990; 60 (3):379–391. [ PubMed ] [ Google Scholar ]
• Nayak MB, Lown EA, Bond JC, Greenfield TK. Lifetime victimization and past year alcohol use in a U.S. population sample of men and women drinkers. Drug and Alcohol Dependence. 2012; 123 (1):213–219. doi: 10.1016/j.drugalcdep.2011.11.016. [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Norris FH. Epidemiology of trauma: Frequency and impact of different potentially traumatic events on different demographic groups. Journal of Consulting and Clinical Psychology. 1992; 60 (3):409–418. [ PubMed ] [ Google Scholar ]
• Nosek MA, Hughes RB, Taylor HB. Disability, psychosocial, and demographic characteristics of abused women with physical disabilities. Violence Against Women. 2006; 12 (9):838–850. [ PubMed ] [ Google Scholar ]
• Orchowski LM. Disclosure of sexual victimization: A prospective study of social reactions and subsequent adjustment. 2009 (Unpublished doctoral dissertation) [ Google Scholar ]
• Orth U, Maercker A. Do trials of perpetrators retraumatize crime victims? Journal of Interpersonal Violence. 2004; 19 (2):212–227. [ PubMed ] [ Google Scholar ]
• Orth U, Cahill SP, Foa EB, Maercker A. Anger and posttraumatic stress disorder symptoms in crime victims: A longitudinal analysis. Journal of Consulting and Clinical Psychology. 2008; 76 (2):208–218. doi: 10.1037/0022-006X.76.2.208. [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Owens GP, Chard KM. PTSD severity and cognitive reactions to trauma among a college sample: An exploratory study. Journal of Aggression, Maltreatment & Trauma. 2006; 13 (2):23–36. doi: 10.1300/J146v13n02. [ CrossRef ] [ Google Scholar ]
• Palmer M. Evidence for persistent hypervigilance for sexual assault survivors. 2002 (Unpublished doctoral dissertation) [ Google Scholar ]
• Parks KA, Hsieh Y, Taggart C, Bradizza CM. A longitudinal analysis of drinking and victimization in college women: Is there a reciprocal relationship? Psychology of Addictive Behaviors. 2014; 28 (4):943–951. doi: 10.1037/a0036283. [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Pepper SE. Self blame in sexual assault survivors and attributions to other sexual assault survivors. 2009 (Unpublished master’s thesis) [ Google Scholar ]
• Phillips SR. The development of disordered eating among female undergraduates: A test of objectification theory. 2011 (Unpublished doctoral dissertation) [ Google Scholar ]
• Plichta SB, Falik M. Prevalence of violence and its implications for women’s health. Women’s Health Issues. 2001; 11 (3):244–258. doi: 10.1016/S1049-3867(01)00085-8. [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Preti A, Incani E, Camboni MV, Petretto DR, Masala C. Sexual abuse and eating disorder symptoms: The mediator role of bodily dissatisfaction. Comprehensive Psychiatry. 2006; 47 (6):475–481. doi: 10.1016/j.comppsych.2006.03.004. [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Price M, Kearns M, Houry D, Rothbaum BO. Emergency department predictors of posttraumatic stress reduction for trauma-exposed individuals with and without an early intervention. Journal of Consulting and Clinical Psychology. 2014; 82 (2):336–341. doi: 10.1037/a0035537. [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Prosser VL. The impact of sexual assault, sexual abuse, and physical violence on women. 1997 (Unpublished master’s thesis) [ Google Scholar ]
• Raja S. Secondary victimization among female veterans who have experienced sexual assault. 1999 (Unpublished doctoral dissertation) [ Google Scholar ]
• Ratner PA, Johnson JL, Shoveller JA, Chan K, Martin SL, Schilder AJ, Hogg RS. Non-consensual sex experienced by men who have sex with men: prevalence and association with mental health. Patient Education and Counseling. 2003; 49 (1):67–74. [ PubMed ] [ Google Scholar ]
• Read JP, Colder CR, Merrill JE, Ouimette P, White J, Swartout A. Trauma and posttraumatic stress symptoms predict alcohol and other drug consequence trajectories in the first year of college. Journal of Consulting and Clinical Psychology. 2012; 80 (3):426–439. doi: 10.1037/a0028210. [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Reed E, Raj A, Falbo G, Caminha F, Decker MR, Kaliel DC, Silverman JG. The prevalence of violence and relation to depression and illicit drug use among incarcerated women in Recife, Brazil. International Journal of Law and Psychiatry. 2009; 32 :323–328. doi: 10.1016/j.ijlp.2009.06.006. [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Resick PA. Reactions of female and male victims of rape or robbery. U.S Department of Justice, National Institute of Justice; 1988. [ Google Scholar ]
• Resick PA. Cognitive processes in PTSD-Etiology and treatment. 1991 Unpublished raw data. [ Google Scholar ]
• Resnick HS, Kilpatrick DG, Dansky BS, Saunders BE, Best CL. Prevalence of civilian trauma and posttraumatic stress disorder in a representative national sample of women. Journal of Consulting and Clinical Psychology. 1993; 61 (6):984–991. [ PubMed ] [ Google Scholar ]
• Rice T. Predicting sexually victimized women’s mental health and substance use help-seeking behavior. 2014 (Unpublished doctoral dissertation) [ Google Scholar ]
• Risser H, Hetzel-Riggin M, Thomsen C, McCanne T. PTSD as a mediator of sexual revictimization: The role of reexperiencing, avoidance, and arousal symptoms. Journal of Traumatic Stress. 2006; 19 (5):687–698. doi: 10.1002/jts.20156. [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Rizvi SL, Kaysen D, Gutner CA, Griffin MG, Resick PA. Beyond fear: The role of peritraumatic responses in posttraumatic stress among female crime victims. Journal of Interpersonal Violence. 2008; 23 (6):853–868. [ PubMed ] [ Google Scholar ]
• Roberts B, Ocaka KF, Browne J, Oyok T, Sondorp E. Factors associated with post-traumatic stress disorder and depression amongst internally displaced persons in northern Uganda. BMC Psychiatry. 2008; 8 :38–47. doi: 10.1186/1471-244X-8-38. [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Sachs-Ericsson N, Kendall-Tackett KA, Sheffler J, Arce D, Rushing NC, Corsentino E. The influence of prior rape on the psychological and physical health functioning of older adults. Aging & Mental Health. 2014:1–14. doi: 10.1080/13607863.2014.884538. [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Sadler AG, Mengeling MA, Fraley SS, Torner JC, Booth BM. Correlates of sexual functioning in women veterans: Mental health, gynecologic health, health status, and sexual assault history. International Journal of Sexual Health. 2012; 24 (1):60–77. [ Google Scholar ]
• Sandberg DA, Matorin AI, Lynn SJ. Dissociation, posttraumatic symptomatology, and sexual revictimization: A prospective examination of mediator and moderator effects. Journal of Traumatic Stress. 1999; 12 (1):127–138. doi: 10.1023/A:1024702501224. [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Santaularia J, Johnson M, Hart L, Haskett L, Welsh E, Faseru B. Relationships between sexual violence and chronic disease: A cross-sectional study. BMC Public Health. 2014; 14 (1):868–882. doi: 10.1186/1471-2458-14-1286. [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Sawtell CS. The victim-perpetrator relationship in the crime of rape: Victims’ mental well-being. 2008 (Unpublished doctoral dissertation) [ Google Scholar ]
• Saxon AJ, Davis TM, Sloan KL, McKnight KM, McFall ME, Kivlahan DR. Trauma, symptoms of posttraumatic stress disorder, and associated problems among incarcerated veterans. Psychiatric Services. 2001; 52 (7):959–964. doi: 10.1176/appi.ps.52.7.959. [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Schry AR, White SW. Social behaviors and psychological health study. 2013 Unpublished raw data. [ Google Scholar ]
• Schumm JA, Briggs-Phillips M, Hobfoll SE. Cumulative interpersonal traumas and social support as risk and resiliency factors in predicting PTSD and depression among inner-city women. Journal of Traumatic Stress. 2006; 19 (6):825–836. doi: 10.1002/jts. [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Shabalala N, Jasson A. PTSD symptoms in intellectually disabled victims of sexual assault. South African Journal of Psychology. 2011; 41 (4):424–436. doi: 10.1177/008124631104100403. [ CrossRef ] [ Google Scholar ]
• Shakespeare-Finch J, Armstrong D. Trauma type and posttrauma outcomes: Differences between survivors of motor vehicle accidents, sexual assault, and bereavement. Journal of Loss & Trauma. 2010; 15 (2):69–82. [ Google Scholar ]
• Smith CP, Freyd JJ. Dangerous safe havens: Institutional betrayal exacerbates sexual trauma. Journal of Traumatic Stress. 2013; 26 :119–124. doi: 10.1002/jts. [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Sorenson SB, Golding JM. Depressive sequelae of recent criminal victimization. Journal of Traumatic Stress. 1990; 3 (3):337–350. [ Google Scholar ]
• Stein MB, Walker JR, Forde DR. Gender differences in susceptibility to posttraumatic stress disorder. Behaviour Research and Therapy. 2000; 38 :619–628. [ PubMed ] [ Google Scholar ]
• Stepakoff S. Effects of sexual victimization on suicidal ideation and behavior in U.S. college women. Suicide and Life-Threatening Behavior. 1998; 28 (1):107–126. [ PubMed ] [ Google Scholar ]
• Temple JR, Weston R, Rodriguez BF, Marshall LL. Differing effects of partner and nonpartner sexual assault on women’s mental health. Violence Against Women. 2007; 13 (3):285–297. doi: 10.1177/1077801206297437. [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Testa M, Livingston JA, Hoffman JH. Does sexual victimization predict subsequent alcohol consumption? A prospective study among a community sample of women. Addictive Behaviors. 2007; 32 (12):2926–2939. doi: 10.1016/j.addbeh.2007.05.017. [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Teutscher JM. Victimization history and its effect on women’s use of rape avoidance behaviors. 2014 (Unpublished master’s thesis) [ Google Scholar ]
• Thelen MH, Sherman MD, Borst TS. Fear of intimacy and attachment among rape survivors. Behavior Modification. 1998; 22 (1):108–116. http://dx.doi.org/10.1177/01454455980221007 . [ PubMed ] [ Google Scholar ]
• Thompson KM, Crosby RD, Wonderlich S, Mitchell JE, Redlin J, Demuth G, Haseltine B. Psychopathology and sexual trauma in childhood and adulthood. Journal of Traumatic Stress. 2003; 16 (1):35–38. doi: 10.1023/A:1022007327077. [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Thompson MP, Kingree JB. Sexual victimization, negative cognitions, and adjustment in college women. American Journal of Health Behavior. 2010; 34 (1):54–59. [ PMC free article ] [ PubMed ] [ Google Scholar ]
• Turchik JA. Sexual victimization among male college students: Assault severity, sexual functioning, and health risk behaviors. Psychology of Men & Masculinity. 2011; 13 :243–255. doi: 10.1037/a0024605. [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Turchik JA, Hassija CM. Female sexual victimization among college students: Assault severity, health risk behaviors, and sexual functioning. Journal of Interpersonal Violence. 2014; 29 (13):2439–2457. doi: 10.1177/0886260513520230. [ PubMed ] [ CrossRef ] [ Google Scholar ]
• United States Department of Justice. Bureau of Justice Statistics. Survey of Inmates in State and Federal Correctional Facilities, 2004. Ann Arbor, MI: Inter-university Consortium for Political and Social Research; 2004. ICPSR04572-v1. [distributor] [ CrossRef ] [ Google Scholar ]
• Vaile Wright C, Collinsworth LL, Fitzgerald LF. Why did this happen to me? Cognitive schema disruption and posttraumatic stress disorder in victims of sexual trauma. Journal of Interpersonal Violence. 2010; 25 (10):1801–1814. doi: 10.1177/0886260509354500. [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Varma D, Chandra PS, Thomas T, Carey MP. Intimate partner violence and sexual coercion among pregnant women in India: Relationship with depression and post-traumatic stress disorder. Journal of Affective Disorders. 2007; 102 (1–3):227–235. doi: 10.1016/j.jad.2006.09.026. [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Veronen LJ, Kilpatrick DG. Self-reported fears of rape victims: A preliminary investigation. Behavior Modification. 1980; 4 (3):383–396. doi: 10.1177/014544558043007. [ CrossRef ] [ Google Scholar ]
• Walker EA, Gelfand AN, Gelfand MD, Koss MP, Katon WJ. Medical and psychiatric symptoms in female gastroenterology clinic patients with histories of sexual victimization. General Hospital Psychiatry. 1995; 17 (2):85–92. [ PubMed ] [ Google Scholar ]
• Walker J, Archer J, Davies M. Effects of male rape on psychological functioning. British Journal of Clinical Psychology. 2005; 44 :445–451. doi: 10.1348/014466505X52750. [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Wang B, Li X, Stanton B, Fang X, Yang H, Zhao R, Hong Y. Sexual coercion, HIV-related risk, and mental health among female sex workers in China. Health Care for Women International. 2007; 28 (8):745–762. doi: 10.1080/07399330701465226. [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Ward JA. Association of traumatic event, chronicity, and developmental level to posttraumatic symptomology. 1998 (Unpublished doctoral dissertation) [ Google Scholar ]
• Wasco SM. An ecological study of repeated sexual victimization among college women. 2004 (Unpublished doctoral dissertation) [ Google Scholar ]
• Weaver TL, Griffin MG, Mitchell ER. Symptoms of posttraumatic stress, depression, and body image distress in female victims of physical and sexual assault: Exploring integrated responses. Health Care For Women International. 2014; 35 :458–475. [ PMC free article ] [ PubMed ] [ Google Scholar ]
• Webb CL. Social support and the psychological outcome of rape. 1981 (Unpublished doctoral dissertation) [ Google Scholar ]
• Wenzel SL, Leake BD, Gelberg L. Health of homeless women with recent experience of rape. Journal of General Internal Medicine. 2000; 15 (4):265–268. [ PMC free article ] [ PubMed ] [ Google Scholar ]
• Winfield I, George LK, Swartz M, Blazer DG. Sexual assault and psychiatric disorders among a community sample of women. American Journal of Psychiatry. 1990; 147 (3):335–341. [ PubMed ] [ Google Scholar ]
• Wingood GM, DiClemente RJ. Rape among African American Women: Sexual, psychological, and social correlates predisposing survivors to risk of STD/HIV. Journal of Women’s Health. 1998; 7 (1):77–84. [ PubMed ] [ Google Scholar ]
• Wirtz PW, Harrell AV. Assaultive versus nonassaultive victimization: A profile analysis of psychological response. Journal of Interpersonal Violence. 1987; 2 (3):264–277. http://dx.doi.org/10.1177/088626087002003003 . [ Google Scholar ]
• Wolf EJ, Miller MW, Kilpatrick D, Resnick HS, Badour CL, Marx BP, Friedman MJ. ICD-11 complex PTSD in U.S. national and veteran samples: Prevalence and structural associations with PTSD. Clinical Psychological Science. 2014:1–15. doi: 10.1177/2167702614545480. [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Wonderlich SA, Crosby RD. Eating disturbance and sexual trauma in childhood and adulthood. International Journal of Eating Disorders. 2001; 30 :401–412. [ PubMed ] [ Google Scholar ]
• Wright LL. Negative sexual experiences and rape: Understanding the relationship between adult and childhood Sexual victimization and somatic complaints, psychological factors, and self-rated health in college women. 2014 (Unpublished doctoral dissertation) [ Google Scholar ]
• Xu Y, Olfson M, Villegas L, Okuda M, Wang S, Liu S, Blanco C. A characterization of adult victims of sexual violence: Results from the National Epidemiological Survey for Alcohol and Related Conditions. Psychiatry. 2013; 76 (3):223–240. doi: 10.1521/psyc.2013.76.3.223. [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Zayed MH. Effects of adult sexual assault types and tactics on cognitive appraisals and mental health symptoms. 2008 (Unpublished doctoral dissertation) [ Google Scholar ]
• Zinzow HM, Grubaugh AL, Frueh BC, Magruder KM. Sexual assault, mental health, and service use among male and female veterans seen in Veterans Affairs primary care clinics: A multi-site study. Psychiatry Research. 2008; 159 :226–236. doi: 10.1016/j.psychres.2007.04.008. [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Zinzow HM, Resnick HS, McCauley JL, Amstadter AB, Ruggiero KJ, Kilpatrick DG. Prevalence and risk of psychiatric disorders as a function of variant rape histories: Results from a National Survey of Women. Social Psychiatry and Psychiatric Epidemiology. 2012; 47 (6):893–902. doi: 10.1007/s00127-011-0397-1. [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Zlotnick C, Johnson J, Kohn R, Vicente B, Rioseco P, Saldivia S. Epidemiology of trauma, post-traumatic stress disorder (PTSD) and co-morbid disorders in Chile. Psychological Medicine. 2006; 36 :1523–1533. doi: 10.1017/S0033291706008282. [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Zweig JM, Barber BL, Eccles JS. Sexual coercion and well-being in young adulthood comparisons by gender and college status. Journal of Interpersonal Violence. 1997; 12 (2):291–308. [ Google Scholar ]
• Zweig JM, Crockett LJ, Sayer A, Vicary JR. A longitudinal examination of the consequences of sexual victimization for rural young adult women. Journal of Sex Research. 1999; 36 (4):396–409. [ Google Scholar ]
• Acierno R, Resnick HS, Kilpatrick DG. Health impact of interpersonal violence 1: Prevalence rates, case identification, and risk factors for sexual assault, physical assault, and domestic violence in men and women. Behavioral Medicine. 1997; 23 (2):53–64. [ PubMed ] [ Google Scholar ]
• American Psychiatric Association. Diagnostic and statistical manual (DSM-III) Washington, DC: Author; 1980. [ Google Scholar ]
• American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 5th. Washington, DC: Author; 2013. [ Google Scholar ]
• Atkeson BM, Calhoun KS, Resick PA, Ellis EM. Victims of rape: Repeated assessment of depressive symptoms. Journal of Consulting and Clinical Psychology. 1982; 50 :96–102. [ PubMed ] [ Google Scholar ]
• Black MC, Basile KC, Breiding MJ, Smith SG, Walters ML, Merrick MT, Stevens MR. National intimate partner and sexual violence survey(NISVS): 2010 summary report. Atlanta, GA: National Center for Injury Prevention and Control, Centers for Disease Control and Prevention; 2011. [ Google Scholar ]
• Borenstein M, Hedges L, Higgins J, Rothstein H. Comprehensive meta-analysis (Version 2)) [Computer software] Englewood, NJ: Biostat; 2005. [ Google Scholar ]
• Boudreaux E, Kilpatrick DG, Resnick HS, Best CL, Saunders BE. Criminal victimization, posttraumatic stress disorder, and comorbid psychopathology among a community sample of women. Journal of Traumatic Stress. 1998; 11 :665–678. [ PubMed ] [ Google Scholar ]
• Bower GH. Mood and memory. American Psychologist. 1981; 36 (2):129–148. [ PubMed ] [ Google Scholar ]
• Brewin CR, Andrews B, Valentine JD. Meta-analysis of risk factors for posttraumatic stress disorder in trauma-exposed adults. Journal of Consulting and Clinical Psychology. 2000; 68 :748–766. [ PubMed ] [ Google Scholar ]
• Burgess AW, Holmstrom LL. Rape trauma syndrome. The American Journal of Psychiatry. 1974; 131 :981–986. [ PubMed ] [ Google Scholar ]
• Burnam MA, Stein JA, Golding JM, Siegel JM, Sorenson SB, Forsythe AB, Telles CA. Sexual assault and mental disorders in a community population. Journal of Consulting and Clinical Psychology. 1988; 56 :843–850. [ PubMed ] [ Google Scholar ]
• Calhoun KS, Atkeson BM, Resick PA. A longitudinal examination of fear reactions in victims of rape. Journal of Counseling Psychology. 1982; 29 (6):655–661. [ Google Scholar ]
• Campbell R, Dworkin ER, Cabral G. An ecological model of the impact of sexual assault on women’s mental health. Trauma, Violence, & Abuse. 2009; 10 (3):225–246. [ PubMed ] [ Google Scholar ]
• Campbell R, Greeson MR, Bybee D, Raja S. The co-occurrence of childhood sexual abuse, adult sexual assault, intimate partner violence, and sexual harassment: A mediational model of posttraumatic stress disorder and physical health outcomes. Journal of Consulting and Clinical Psychology. 2008; 76 (2):194–207. [ PubMed ] [ Google Scholar ]
• Campbell R, Sefl T, Barnes HE, Ahrens CE, Wasco SM, Zaragoza-Diesfeld Y. Community services for rape survivors: Enhancing psychological well-being or increasing trauma? Journal of Consulting and Clinical Psychology. 1999; 67 (6):847–858. [ PubMed ] [ Google Scholar ]
• Carter-Snell CJ, Jakubec SL. Exploring women’s risks and resilience to mental illness after interpersonal violence. International Journal of Child Youth and Family Studies. 2013; 1 :72–99. [ Google Scholar ]
• Chen LP, Murad MH, Paras ML, Colbenson KM, Sattler AL, Goranson EN, Zirakzadeh A. Sexual abuse and lifetime diagnosis of psychiatric disorders: Systematic review and meta-analysis. Mayo Clinic Proceedings. 2010; 85 (7):618–629. [ PMC free article ] [ PubMed ] [ Google Scholar ]
• Chilcoat HD, Breslau N. Investigations of causal pathways between PTSD and drug use disorders. Addictive Behaviors. 1998; 23 (6):827–840. [ PubMed ] [ Google Scholar ]
• Classen CC, Palesh OG, Aggarwal R. Sexual revictimization: A review of the empirical literature. Trauma, Violence, & Abuse. 2005; 6 :103–129. [ PubMed ] [ Google Scholar ]
• Cohen J. Statistical power analysis for the behavioral sciences. 2nd. Hillsdale, NJ: Lawrence Erlbaum Associates; 1988. [ Google Scholar ]
• Conway CC, Hammen C, Brennan PA. Expanding stress generation theory: Test of a transdiagnostic model. Journal of Abnormal Psychology. 2012; 121 (3):754–766. [ PMC free article ] [ PubMed ] [ Google Scholar ]
• Cook SL, Gidycz CA, Koss MP, Murphy M. Emerging issues in the measurement of rape victimization. Violence Against Women. 2011; 17 :201–218. [ PubMed ] [ Google Scholar ]
• Cromer KR, Schmidt NB, Murphy DL. An investigation of traumatic life events and obsessive-compulsive disorder. Behaviour Research and Therapy. 2007; 45 (7):1683–1691. [ PubMed ] [ Google Scholar ]
• du Fort GG, Newman S, Bland R. Psychiatric comorbidity and treatment seeking: sources of selection bias in the study of clinical populations. Journal of Nervous and Mental Disease. 1993; 181 :464–474. [ PubMed ] [ Google Scholar ]
• Duval S, Tweedie R. Trim and fill: A simple funnel-plot-based method of testing and adjusting for publication bias in meta-analysis. Biometrics. 2000a; 56 :455–463. [ PubMed ] [ Google Scholar ]
• Duval S, Tweedie R. A nonparametric “trim and fill” method of accounting for publication bias in meta-analysis. Journal of the American Statistical Society. 2000b; 95 (449):89–98. [ Google Scholar ]
• [dataset] Dworkin ER, Menon S, Bystrynski J, Allen NE. Data for: Sexual assault victimization and psychopathology: A review and meta-analysis. Mendeley Data 2017 [ PMC free article ] [ PubMed ] [ Google Scholar ]
• Edwards KM, Turchik JA, Dardis CM, Reynolds N, Gidycz CA. Rape myths: History, individual and institutional-level presence, and implications for change. Sex Roles. 2011; 65 :761–773. [ Google Scholar ]
• Egger M, Davey Smith G, Schneider M, Minder C. Bias in meta-analysis detected by a simple, graphical test. British Medical Journal. 1997; 315 :629–634. [ PMC free article ] [ PubMed ] [ Google Scholar ]
• Ellard KK, Fairholme CP, Boisseau CL, Farchione TJ, Barlow DH. Unified Protocol for the Transdiagnostic Treatment of Emotional Disorders: Protocol development and initial outcome data. Cognitive and Behavioral Practice. 2010; 17 (1):88–101. [ PMC free article ] [ PubMed ] [ Google Scholar ]
• Etain B, Henry C, Bellivier F, Mathieu F, Leboyer M. Beyond genetics: Childhood affective trauma in bipolar disorder. Bipolar Disorders. 2008; 10 :867–876. [ PubMed ] [ Google Scholar ]
• Fisher BS, Cullen FT, Turner MG. The sexual victimization of college women. Washington, D C: National Institute of Justice; 2000. [ Google Scholar ]
• Friedman MJ, Resick PA, Bryant RA, Brewin CR. Considering PTSD for DSM-5. Depression and Anxiety. 2011; 28 :750–769. doi: 10.1002/da.20767. [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Gershuny BS, Baer L, Jenike MA, Minichiello WE, Wilhelm S. Comorbid posttraumatic stress disorder: Impact on treatment outcome for obsessive-compulsive disorder. American Journal of Psychiatry. 2002; 159 :852–854. doi: 10.1176/appi.ajp.159.5.852. [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Gilbert N. Examining the facts: Advocacy research overstates the incidence of date and acquaintance rape. In: Gelles RJ, Loseke DR, editors. Current controversies on family violence. Newbury Park, CA: SAGE; 1993. pp. 120–132. [ Google Scholar ]
• Gnambs T. The elusive general factor of personality: The acquaintance effect. European Journal of Personality. 2013; 27 :507–520. doi: 10.1002/per.1933. [ CrossRef ] [ Google Scholar ]
• Golding JM. Intimate partner violence as a risk factor for mental disorders: A meta-analysis. Journal of Family Violence. 1999; 14 (2):99–132. [ Google Scholar ]
• Goodman LA, Koss MP, Russo NF. Violence against women: Physical and mental health effects. Part I: Research findings. Applied & Preventive Psychology. 1993; 2 (2):79–89. [ Google Scholar ]
• Green BL, Goodman LA, Krupnick JL, Corcoran CB, Petty RM, Stockton P, Stern NM. Outcomes of single versus multiple trauma exposure in a screening sample. Journal of Traumatic Stress. 2000; 13 (2):271–286. doi: 10.1023/A:1007758711939. [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Harris EC, Barraclough B. Suicide as an outcome for mental disorders: A meta-analysis. British Journal of Psychiatry. 1997; 170 :205–228. doi: 10.1192/bjp.170.3.205. [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Hartung CM, Widiger TA. Gender differences in the diagnosis of mental disorders: Conclusions and controversies of the DSM-IV. Psychological Bulletin. 1998; 123 (3):260–278. [ PubMed ] [ Google Scholar ]
• Hernandez JM, Cordova MJ, Ruzek J, Reiser R, Gwizdowski IS, Suppes T, Ostacher MJ. Presentation and prevalence of PTSD in a bipolar disorder population: A STEP-BD examination. Journal of Affective Disorders. 2013; 150 :450–455. [ PubMed ] [ Google Scholar ]
• Hettema JM, Neale MC, Kendler KS. A review and meta-analysis of the genetic epidemiology of anxiety disorders. The American Journal of Psychiatry. 2001; 158 :1568–1578. [ PubMed ] [ Google Scholar ]
• Jewkes R. Violence against women: An emerging health problem. International Clinical Psychoparmacology. 2000; 15 (Supp3):S37–S45. [ PubMed ] [ Google Scholar ]
• Jordan CE, Campbell R, Follingstad D. Violence and women’s mental health: The impact of physical, sexual, and psychological aggression. Annual Review of Clinical Psychology. 2010; 6 :607–628. [ PubMed ] [ Google Scholar ]
• Kendler KS, Davis CG, Kessler RC. The familial aggregation of common psychiatric and substance use disorders in the National Comorbidity Survey: A family history study. The British Journal of Psychiatry. 1997; 170 :541–548. [ PubMed ] [ Google Scholar ]
• Kendler KS, Prescott CA, Myers J, Neale MC. The structure of genetic and environmental risk factors for common psychiatric and substance use disorders in men and women. Archives of General Psychiatry. 2003; 60 :929–937. [ PubMed ] [ Google Scholar ]
• Kennedy AC, Prock KA. “I still feel like I am not normal”: A review of the role of stigma and stigmatization among female survivors of child sexual abuse, sexual assault, and intimate partner violence. Trauma, Violence, & Abuse 2016 [ PubMed ] [ Google Scholar ]
• Kessler RC, Sonnega A, Bromet E, Hughes M, Nelson CB, Sonnega A, Nelson CB. Posttraumatic stress disorder in the National Comorbity Survey. Archives of General Psychiatry. 1995; 52 :1048–1060. [ PubMed ] [ Google Scholar ]
• Kilpatrick DG, Acierno R, Resnick HS, Saunders BE, Best CL. A 2-year longitudinal analysis of the relationships between violent assault and substance use in women. Journal of Consulting and Clinical Psychology. 1997; 65 (5):834–847. [ PubMed ] [ Google Scholar ]
• Kilpatrick DG, Resick PA, Veronen LJ. Effects of a rape experience: A longitudinal study. Journal of Social Issues. 1981; 37 (4):105–122. [ Google Scholar ]
• Koss MP. Hidden, unacknowledged, acquaintance, and date rape: Looking back, looking forward. Psychology of Women Quarterly. 2011; 35 :348–354. [ Google Scholar ]
• Koss MP, Abbey A, Campbell R, Cook S, Norris J, Testa M, White J. Revising the SES: A collaborative process to improve assessment of sexual aggression and victimization. Psychology of Women Quarterly. 2007; 31 :357–370. [ Google Scholar ]
• Koss MP, Gidycz CA, Wisniewski N. The scope of rape: Incidence and prevalence of sexual aggression and victimization in a national sample of higher education students. Journal of Consulting and Clinical Psychology. 1987; 55 (2):162–170. [ PubMed ] [ Google Scholar ]
• Koss MP, Heise L, Russo NF. The global health burden of rape. Psychology of Women Quarterly. 1994; 18 (4):509–537. [ Google Scholar ]
• Long LM, Ullman SE, Starzynski LL, Long SM, Mason GE. Age and educational differences in African American women’s sexual assault experiences. Feminist Criminology. 2007; 2 :117–136. [ Google Scholar ]
• Messman-Moore TL, Long PJ. The role of childhood sexual abuse sequelae in the sexual revictimization of women: An empirical review and theoretical reformulation. Clinical Psychology Review. 2003; 23 :537–571. [ PubMed ] [ Google Scholar ]
• Neville HA, Heppner MJ. Contextualizing rape: Reviewing sequelae and proposing a culturally inclusive ecological model of sexual assault recovery. Applied & Preventive Psychology. 1999; 8 :41–62. [ Google Scholar ]
• Orcutt HK, Erickson DJ, Wolfe J. A prospective analysis of trauma exposure: The mediating role of PTSD symptomatology. Journal of Traumatic Stress. 2002; 15 :259–266. [ PubMed ] [ Google Scholar ]
• Ozer EJ, Best SR, Lipsey TL, Weiss DS. Predictors of posttraumatic stress disorder and symptoms in adults: A meta-analysis. Psychological Bulletin. 2003; 129 (1):52–73. [ PubMed ] [ Google Scholar ]
• Panagioti M, Gooding PA, Tarrier N. A meta-analysis of the association between posttraumatic stress disorder and suicidality: The role of comorbid depression. Comprehensive Psychiatry. 2012; 53 (7):915–930. doi: 10.1016/j.comppsych.2012.02.009. [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Paolucci EO, Genuis ML. A meta-analysis of the published research on the effects of child sexual abuse. The Journal of Psychology. 2001; 135 (1):17–36. [ PubMed ] [ Google Scholar ]
• Pineles SL, Shipherd JC, Welch LP, Yovel I. The role of attentional biases in PTSD: Is it interference or facilitation? Behaviour Research and Therapy. 2007; 45 :1903–1913. [ PubMed ] [ Google Scholar ]
• Preti A, Rocchi MBL, Sisti D, Camboni MV, Miotto P. A comprehensive meta-analysis of the risk of suicide in eating disorders. Acta Psychiatrica Scandinavica. 2011; 124 (1):6–17. [ PubMed ] [ Google Scholar ]
• Resick PA. Psychological effects of victimization: Implications for the criminal justice system. Crime & Delinquency. 1987; 33 :468–478. doi: 10.1177/0011128787033004004. [ CrossRef ] [ Google Scholar ]
• Resick PA. The psychological impact of rape. Journal of Interpersonal Violence. 1993; 8 :223–255. [ Google Scholar ]
• Rosenthal R. The file drawer problem and tolerance for null results. Psychological Bulletin. 1979; 86 (3):638–641. doi: 10.1037/0033-2909.86.3.638. [ CrossRef ] [ Google Scholar ]
• Rothbaum BO, Foa EB, Riggs DS, Murdock T, Walsh W. A prospective examination of post-traumatic stress disorder in rape victims. Journal of Traumatic Stress. 1992; 5 (3):455–475. [ Google Scholar ]
• Rudd MD. Fluid vulnerability theory: a cognitive approach to understanding the process of acute and chronic suicide risk. In: Ellis TE, editor. Cognition and suicide: Theory, research, and therapy. Washington, DC: American Psychological Association; 2006. [ Google Scholar ]
• Sarkar NN, Sarkar R. Sexual assault on woman: Its impact on her life and living in society. Sexual and Relationship Therapy. 2005; 20 (4):407–419. [ Google Scholar ]
• Smolak L, Murnen SK. A meta-analytic examination of the relationship between child sexual abuse and eating disorders. International Journal of Eating Disorders. 2002; 31 (2):136–150. [ PubMed ] [ Google Scholar ]
• Stein DJ, Chiu WT, Hwang I, Kessler RC, Sampson N, Alonso J, Nock MK. Cross-national analysis of the associations between traumatic events and suicidal behavior: Findings from the WHO World Mental Health Surveys. PloS ONE. 2010; 5 (5):e10574. [ PMC free article ] [ PubMed ] [ Google Scholar ]
• Steketee G, Foa EB. Rape victims: Post-traumatic stress responses and their treatment: A review of the literature. Journal of Anxiety Disorders. 1987; 1 :69–86. [ Google Scholar ]
• Stewart SH, Conrod PJ. Psychosocial models of functional associations between posttraumatic stress disorder and substance use disorder. In: Ouimette P, Brown PJ, editors. Trauma and substance abuse: Causes, consequences, and treatment of comorbid disorders. Washington, DC: American Psychological Association; 2003. pp. 29–55. [ Google Scholar ]
• Sutherland S, Scherl DJ. Patterns of response among victims of rape. American Journal of Orthopsychiatry. 1970; 40 (3):503–511. [ PubMed ] [ Google Scholar ]
• Testa M, Livingston JA. Alcohol and sexual aggression: Reciprocal relationships over time in a sample of high-risk women. Journal of Interpersonal Violence. 2000; 15 (4):413–427. [ Google Scholar ]
• Tjaden P, Thoennes N. Prevalence and consequences of male-to-female and female-to-male intimate partner violence as measured by the National Violence Against Women Survey. Violence Against Women. 2000; 6 (2):142–161. doi: 10.1177/10778010022181769. [ CrossRef ] [ Google Scholar ]
• Tjaden P, Thoennes N. Extent, nature, and consequences of rape victimization: Findings from the National Violence Against Women Survey. Washington, D C: 2006. [ Google Scholar ]
• Tolin DF, Foa EB. Sex differences in trauma and posttraumatic stress disorder: A quantitative review of 25 years of research. Psychological Bulletin. 2006; 132 (6):959–992. [ PubMed ] [ Google Scholar ]
• Ullman SE, Brecklin LR. Sexual assault history and suicidal behavior in a national sample of women. Suicide and Life-Threatening Behavior. 2002; 32 :117–130. [ PubMed ] [ Google Scholar ]
• Ullman SE, Peter-Hagene LC. Longitudinal relationships of social reactions, PTSD, and revictimization in sexual assault survivors. Journal of Interpersonal Violence. 2014; 29 :1–21. [ PMC free article ] [ PubMed ] [ Google Scholar ]
• Ullman SE, Townsend SM, Filipas HH, Starzynski LL. Structural models of the relations of assault severity, social support, avoidance coping, self-blame, and PTSD among sexual assault survivors. Psychology of Women Quarterly. 2007; 31 (1):23–37. [ Google Scholar ]
• Viechtbauer W. Conducting meta-analyses in R with the metafor package. Journal of Statistical Software. 2010; 36 (3):1–48. URL: http://www.jstatsoft.org/v36/i03/ [ Google Scholar ]
• Viechtbauer W, Cheung MWL. Outlier and influence diagnostics for meta-analysis. Research Synthesis Methods. 2010; 1 :112–125. doi: 10.1002/jrsm.11. [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Xu Y, Olfson M, Villegas L, Okuda M, Wang S, Liu S, Blanco C. A characterization of adult victims of sexual violence: Results from the National Epidemiological Survey for Alcohol and Related Conditions. Psychiatry. 2013; 76 (3):223–240. [ PubMed ] [ Google Scholar ]
• Zinzow HM, Resnick HS, Amstadter AB, McCauley JL, Ruggiero KJ, Kilpatrick DG. Drug- or alcohol-facilitated, incapacitated, and forcible rape in relationship to mental health among a national sample of women. Journal of Interpersonal Violence. 2010; 25 :2217–2236. [ PMC free article ] [ PubMed ] [ Google Scholar ]
• Zweig JM, Crockett LJ, Sayer A, Vicary JR. A longitudinal examination of the consequences of sexual victimization for rural young adult women. Journal of Sex Research. 1999; 36 :396–409. [ Google Scholar ]

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Overview of Rape and Sexual Violence

The term "sexual violence" refers to a specific constellation of crimes including sexual harassment, sexual assault, and rape. The person who commits this crime may be a stranger, acquaintance, friend, family member, or intimate partner. Researchers, practitioners, and policymakers agree that all forms of sexual violence harm the individual, the family unit, and society and that much work remains to be done to enhance the criminal justice response to these crimes.

Sexual Violence Takes Many Forms

Sexual harassment ranges from degrading remarks, gestures, and jokes to indecent exposure, being touched, grabbed, pinched, or brushed against in a sexual way [1] . In employment settings, it has been defined as "unwelcome sexual advances, requests for sexual favors, and other verbal or physical conduct that enters into employment decisions or conduct that unreasonably interferes with an individual's work performance or creates an intimidating, hostile, or offensive working environment" [2] .

• Read more about civil rights and sexual harassment in an NIJ research report.
• See also  Sexual Harassment on the U.S. Equal Employment Opportunity Commission Web site .

Sexual assault covers a wide range of unwanted behaviors—up to but not including penetration—that are attempted or completed against a victim's will or when a victim cannot consent because of age, disability, or the influence of alcohol or drugs. Sexual assault may involve actual or threatened physical force, use of weapons, coercion, intimidation, or pressure and may include—

• Intentional touching of the victim's genitals, anus, groin, or breasts.
• Exposure to exhibitionism.
• Undesired exposure to pornography.
• Public display of images that were taken in a private context or when the victim was unaware.

Rape definitions vary by state and in response to legislative advocacy. Most statutes currently define rape as nonconsensual oral, anal, or vaginal penetration of the victim by body parts or objects using force, threats of bodily harm, or by taking advantage of a victim who is incapacitated or otherwise incapable of giving consent. Incapacitation may include mental or cognitive disability, self-induced or forced intoxication, status as minor, or any other condition defined by law that voids an individual's ability to give consent.

Not surprisingly, rates of rape also vary widely among studies according to how the crime is defined, what population is studied, and what methodology is used. Estimates range from as low as 2 percent [3] , as quoted in The Epidemic of Rape and Child Sexual Abuse in the United States [4] ,  to 56 percent [5] . The most recent and methodologically rigorous studies show that sexual assault still occurs at rates that approximate those first identified more than 20 years ago when Koss, Gidycz, and Wisiewski  [6] found that approximately 27.5% of college women reported experiences that met the legal criteria for rape.

Sexual assault and rape are generally defined as felonies. During the past 30 years, states have enacted rape shield laws to protect victims and criminal and civil legal remedies to punish those who commit this crime. The effectiveness of these laws in accomplishing their goals is a topic of concern.

Estimates also vary regarding how likely a victim is to report victimization. Traditionally, rape notification rates differed depending on whether the victim knew the person who committed the crime — those who knew the person were often less likely to report the crime. This gap, however, may be closing.

[note 1] Hill, C., and E. Silva. Drawing the Line: Sexual Harassment on Campus. Washington, DC: American Association of University Women, 2006.

[note 2] Rubin, P, 1995. Civil Rights and Criminal Justice: Primer on Sexual Harassment . Washington, DC: U.S. Department of Justice, National Institute of Justice, October 1995, NCJ 156663.

[note 3] Gordon, T., and S. Riger. Female Fear . New York: Free Press, 1989, NCJ 118492.

[note 4] Russell, D.E.H., and R.M. Bolen. The Epidemic of Rape and Child Sexual Abuse in the United States. Thousand Oaks, CA: Sage Publications, 2000: 247.

[note 5] Goodman, L.A. "Prevalence of Abuse Among Homeless and Housed Poor Mothers: A Comparison Study." American Journal of Orthopsychiatry 61(4)(October 1991): 489–500.

[note 6] Koss, M.P., C.A. Gidycz, and N. Wisiewski. " The Scope of Rape: Incidence and Prevalence of Sexual Aggression and Victimization in a National Sample of Higher Education Students ." Journal of Consulting and Clinical Psychology 55(2)(1987): 162–170, NCJ 108037.

Cite this Article

Read more about:.

Sexual assault and harassment

Sexual assault involves unwanted sexual activity, with perpetrators often using force, making threats, or taking advantage of victims not being able to give consent. Immediate reactions to sexual assault may include shock, fear, or disbelief. Long-term symptoms may include anxiety, fear, or posttraumatic stress disorder.

Sexual harassment involves conduct of a sexual nature that is unwelcome or considered offensive, particularly in the workplace.

Adapted from the Encyclopedia of Psychology and the APA Dictionary of Psychology

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The Stanford Sexual Assault Survivor Just Penned Another Powerful Essay

T he woman who was sexually assaulted by Brock Turner doesn’t want you to see her as a victim.

The survivor, who has not been publicly identified, wrote a powerful essay for Glamour ‘s “Women of the Year” issue about how she discovered a newfound strength after the public outrage at her assailant’s short sentence. Two witnesses saw Turner “thrusting” against an unconscious woman in January 2015 . In June 2016, Turner, a former Stanford student, was convicted of three felony counts of sexual assault and sentenced to six months in jail. He was released three months early in September for “good behavior .”

The short sentence — along with a letter written by Turner’s father that called the punishment “a steep price to pay for 20 minutes of action ” — drew broad furor from sexual assault prevention advocates, the general public and even Vice President Joe Biden. The case even led the California State Assembly to close a loophole in sentencing laws for sexual assault offenders.

At Turner’s sentencing in June, she read an emotional letter to Turner, which was later published on Buzzfeed and widely shared .

In her new essay, the survivor recalled being told by prosecutors before the trial that her case was “a best case scenario” — meaning that it had more evidence than a typical rape case, which are often considered difficult to successfully prosecute .

“I had everything, and I was still told it was not a slam dunk. I thought, if this is what having it good looks like, what other hells are survivors living? I’m barely getting through this but I am being told I’m the lucky one, some sort of VIP,” she wrote in Glamour. “It was like being checked into a hotel room for a year with stained sheets, rancid water, and a bucket with an attendant saying, No this is great! Most rooms don’t even have a bucket.”

“The violation of my body and my being added up to a few months out of his summer,” she wrote of Turner’s short sentence. “I began to panic; I thought, this can’t be the best case ­scenario. If this case was meant to set the bar, the bar had been set on the floor.”

She wrote in Glamour that she was initially hesitant to allow Buzzfeed to publish her letter, fearing that she was “making myself exposed and vulnerable again.” She was surprised when the reaction was overwhelmingly positive.

“But when my letter was published, no one turned away. No one said I’d rather not look, it’s too much, or too sad. Everyone pushed through the hard parts, saw me fully to the end, and embraced every feeling,” she wrote. “so now to the one who said, I hope my daughter never ends up like her , I am learning to say, I hope you end up like me, meaning, I hope you end up like me strong. I hope you end up like me proud of who I’m becoming. I hope you don’t “end up,” I hope you keep going. And I hope you grow up knowing that the world will no longer stand for this.”

“Victims are not victims, not some fragile, sorrowful aftermath,” she continued. “Victims are survivors, and survivors are going to be doing a hell of a lot more than surviving.”

Read her full essay in Glamour .

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Write to Samantha Cooney at [email protected]

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I Sought Treatment for a Terrible Sexual Assault. It Made Me Worse Off Than I Was Before.

For many problems, endless talk therapy isn’t the answer..

I met my new psychologist in Manhattan’s ugliest office building. “Hello,” she said, opening her door with a big smile. She introduced herself as “Doctor” followed by her last initial. Let’s call her Dr. M. Dr. M was beautiful—blond blow-out, charmingly snarled teeth—and I was desperate. I’d put off seeking help for years, scarred by bad experiences as an adolescent that involved too many drugs, punitive treatments, and clueless counselors. Finally, at 25, I was here, doing the thing we are all supposed to do to be healthy, high-functioning humans: I was going to therapy.

I’d had a crappy childhood, with enough drama and betrayal to fill a 384-page memoir . I’d walked into Dr. M’s office for help with something very specific, though: At 17, I’d been sexually assaulted. Now, I was haunted by the memory of a middle-aged man calling me a bitch and yelling at me to swallow his dick. I’d never shared the details with anyone; over time, the memories tormented me more instead of less. I told myself it didn’t bother me, but really I’d just contorted my life to avoid any reminders. Simply seeing the word “rape” made me feel like flames had engulfed my limbs. Only exercise could purge the horror, but my two or three hours of daily workouts aggravated my back until my doctor prescribed opioid painkillers. The cozy comfort of tramadol terrified me: I could easily see a future in which I succumbed to addiction. Other days, I fantasized about jumping off my office’s 14 th -floor terrace.

“Trauma is one of my specialties,” Dr. M. assured me, smiling, when I told her I’d been assaulted.

So, I began recalling everything. I told her about staying in a hostel in Budapest. I was traveling by myself and, surprisingly, there were no other guests, just two employees who made small talk and offered me alcohol that I declined and coffee that I accepted. Then, one man left to get cigarettes. The other man talked to me for a long time, and asked me to kiss him. Then, he stood up and unbuckled his belt.

When I got to that point, Dr. M announced that our time had run out. She explained her fee was $220 a session and suggested I come twice a week. My high-deductible insurance plan meant that would cost more than my rent—but I figured I wouldn’t need that many sessions. I Venmoed Dr. M, assuming that the next time we’d pick up where we left off. When I walked into the warm evening, I felt buoyed by the promise of imminent relief.

At the next appointment, I sat down, ready to begin. “So the man,” I started.

Dr. M flinched. “What about your family?” she asked, interrupting me. “You haven’t told me at all about your childhood.”

My childhood? I wondered. I wasn’t here to talk about that. But Dr. M was persistent. And she was a professional, with a Ph.D. and research papers in her name. She must have known what she was doing, I told myself. So, I told her about my childhood. And every Tuesday and Thursday evening, I obediently returned to her futon.

In the weeks that followed, I tried to contort the conversation back to the assault. Each time I mentioned it though, she gasped, recoiled, and changed the topic. Often, she monologued. Since I was attacked in Hungary, she shared her experience growing up in Eastern Europe. “That’s just the way it is there: You walk in a room and”—she clapped her hands—“someone rapes you.” Instead of helping me work through the shame, these conversations added to it.

Five thousand dollars’ worth of sessions later, I finally brought up the problem directly: “I feel like you don’t want me to tell you what happened.”

“Well,” Dr. M replied, “we don’t have the alliance.” She explained that sharing details would only “retraumatize” me—unless I could voice them without being upset. How, I wondered, could I ever describe crying while a man ejaculated on my cardigan without being upset?

I asked how long it would take to build said alliance.

“Maybe 10 years,” Dr. M said.

“I don’t have 10 years,” I responded.

I wasn’t even sure I had 10 months before it became unbearable. I thought, longingly, about diving into traffic on the West Side Highway. But what Dr. M had told me fit a dominant narrative around therapy—that we should all be in it, forever. Real relief takes time, the story goes: There are no quick fixes or simple cures. If you don’t feel better, it’s because you aren’t doing the work. Peace only comes from plumbing our inner depths.

I believed this, despite having had plenty of bad therapy experiences as a kid. My mom was a hoarder who, instead of dealing with her own issues, took me to doctors who prescribed increasingly intense drugs until I was on antipsychotics at 13. I spent time in a locked facility and in foster care. “Treatment” felt like punishment, focused on coercing my obedience while ignoring my emotions.

What shocked me about Dr. M was that, even as an adult with incredible privilege, my therapy experience could still be so bad. I was a software engineer at Google, earning six figures. I lived in New York City, a hotbed of psychology. In college, at Harvard, I minored in statistics and was mentored by a preeminent historian of psychiatry, equipping me to comb through hundreds of peer-reviewed papers to read about what might actually help me (though in the meantime, I kept seeing Dr. M—I had to do something).

It was clear that I had Post-Traumatic Stress Disorder. Despite the rhetoric about amorphous “trauma” living in the body forever and leading to unnamable malaise , my own dive into the research told me that PTSD was imminently treatable—quickly.

Several short-term treatments often provided relief to patients in 10 to 14 sessions. One, called prolonged exposure therapy, seemed to work particularly well. Premised on the idea that PTSD is caused by avoiding upsetting thoughts, patients expose themselves to trauma triggers in a highly structured setting. You talk about the moments that you can’t get over, again and again, until they lose their power. The sessions are longer than typical talk-therapy sessions , and there’s daily homework—the process is intense. The approach makes intuitive sense, summed up by the adage “face your fears.” But it also flies in the face of the warm fuzzies offered by many talk therapists. Part of the point of prolonged exposure is to become as upset as possible, so that you learn that memories cannot actually hurt you. This is essentially the opposite of Dr. M’s claim that I would be “retraumatized” by speaking about the assault too much.

Like many short-term, evidence-based therapies, it was almost impossible to access. While prolonged exposure is the go-to treatment for veterans seeking care at the VA, I’d searched extensively for someone in private practice who offered it and came up blank. Part of this was surely economics, since a short course of treatment was far less lucrative than billing private insurance indefinitely.

In the meantime, it’s not just that my sessions with Dr. M kept me in a holding pattern. I actually started to feel worse. I could no longer sleep through the night. I went on a starvation-level diet. I almost called off my wedding. I fantasized about tumbling into a freezing lake, my limp body finally finding peace at the bottom. Dr. M didn’t know what was going on, because she never asked; like most therapists, she didn’t track or even really ask about my symptoms. She probably thought I was doing great and that she was, too, since research shows that therapists overestimate their skills and their patient’s progress . Even the patient who inspired the so-called “talking cure” wasn’t cured by it: Contrary to Freud’s claims in a famous case study, historical records show that “Anna O.” got progressively worse until she wound up institutionalized. She only got better after quitting analysis and taking up activism, a transformation that took a while to occur.

But studies suggest that short-term treatments can be hugely beneficial, fast. It’s not just for PTSD—phobias, OCD, and social anxiety all respond well to exposure. Experiments show reductions in symptoms from a single session —or as little as two hours with a primary care provider . According to one analysis, after a 10-to-14-week course of prolonged exposure, two-thirds of sufferers no longer meet the diagnostic criteria for PTSD. In another, 83 percent no longer met the criteria six years later . The trouble is that these therapies can be difficult for patients to find.

I redoubled my search for exposure therapy, and learned that I could access it if I became a clinical research subject. In screening phone calls, young research assistants asked me questions like, “Can you tell me about what happened?” I would choke out my answer, only to have to them ask dozens more questions, about my sleep, my social life, and whether or not I could go to the grocery store or ride public transportation. These screening calls were exhausting, but when I hung up, I always felt better—in a way I absolutely had not after a session with my own therapist.

After several months, I was accepted into a study where I could receive prolonged exposure treatment—treatment that would change my life the way I’d once hoped talk therapy would. Having secured a new source of help, I finally broke up with Dr. M. In our last session, she informed me, “You are mad at the world and the people who hurt you. But I don’t see you trying to change.” I knew what she meant: I’d only gotten acupuncture once, despite her promise that bodywork could “unstick” the trauma; I refused to let Dr. M hypnotize me. I hadn’t upended my schedule to practice yoga or quit my job to attend silent meditation retreats. It wasn’t just Dr. M: It seemed like an entire culture told me that long-term therapy was morally good, no matter how much of an expensive slog it was. But I didn’t want to sacrifice my future to the pursuit of mental wellness. I wanted to heal. I wanted to get treatment, and then, to move on.

If you need to talk, or if you or someone you know is experiencing suicidal thoughts, call the  suicide lifeline  at 988 or text the  Crisis Text Line  at 741-741.