Sexual Violence Victimization of Women

Abstract

Sexual violence is a serious public health problem with devastating health-related consequences. In this article, the authors review the prevalence, characteristics, vulnerability factors for, and impacts of sexual violence victimization for women. Some key factors are reviewed that have been shown to increase vulnerability for victimization, including certain demographic characteristics, previous victimization, and use of drugs or alcohol. The impacts of rape and other sexual violence are described, including physical and sexual health; psychological, social, and societal impacts; as well as impact on risky health behaviors. The authors conclude with a discussion of the public health approach to sexual violence, primary prevention, the relevance of sexual violence research for health care practitioners, and recommendations for health care practice.

Sexual violence is a major public health problem with substantial impacts on the mental health, physical health, and social well-being of victims.^1-3 Although sexual violence is commonly conceived of as rape, and defined as completed or attempted penetration of some kind, it is much broader than rape alone. Sexual violence comes in many forms—some that involve physical contact and some that do not. The Centers for Disease Control and Prevention defines sexual violence as nonconsensual completed or attempted penetration, unwanted nonpenetrative sexual contact, or noncontact acts (eg, verbal sexual harassment, being flashed, being forced to look at sexual materials) by any perpetrator. ⁴ Other forms of sexual violence include sexual coercion during which the victim is pressured into sex. Perpetrators may use various kinds of pressure such as using one’s influence or authority to coerce a victim into sex, threatening to end their relationship, wearing them down by continually asking for sex, saying it is their spousal duty, or using threats of force.^5,6 Sexual violence also includes acts such as systematic rape during times of war, sexual trafficking (the buying and selling of people, mostly girls and women, into prostitution and sexual slavery), and female genital mutilation, ⁷ although the current review will not focus on these forms of sexual violence. Critical to the definition, sexual violence occurs when the survivor does not consent to the sexual activity, or when the survivor is unable to consent (eg, because of age, the influence of alcohol or drugs) or unable to refuse (eg, because of physical violence or threats). ⁴ Most of the national data that are available on sexual violence focus specifically on rape. For that reason and because of limited space, this review will focus primarily on rape victimization. For ease of reading, we use the terms victim and survivor interchangeably to describe the recipient of the violence.

“Rape affects a large number of Americans. The National Violence Against Women Survey (NVAWS), conducted in 1995 and 1996,indicated that approximately 1 in6 women (17.6%) and 1 in 33 men have been victims of attempted or completed rape during their lifetime.”

Rape affects a large number of Americans. The National Violence Against Women Survey (NVAWS), conducted in 1995 and 1996, indicated that approximately 1 in 6 women (17.6%) and 1 in 33 men have been victims of attempted or completed rape during their lifetime; 0.3% of women and 0.1% of men reported completed or attempted rape in the previous 12 months. These prevalence rates translate to an estimated 17.7 million women and 2.8 million men experiencing rape or attempted rape at some point in their lifetime and an estimated 302 091 women and 92 748 men experiencing rape or attempted rape each year. More recent national estimates of rape (not including attempted rape) from the 2nd Injury Control and Risk Survey (ICARIS-2) of 2001-2003 were similar and found that 10.6% of women and 2.1% of men experienced forced sex in their lifetime, which translates into 11.7 million women and 2.1 million men. ⁸ Studies have also shown that lifetime prevalence of marital rape, that is, rape specifically perpetrated by a spouse or intimate partner, ranges from 10% to 14% depending on the study.^5,9,10

Most Victims of Sexual Violence Are Young

The prevalence literature consistently indicates that sexual violence victimization begins early in the lifespan. Several US surveys studying rape, including the NVAWS, the National Women’s Study (NWS), the ICARIS-2, and the National College Health Risk Behavior Survey (NCHRBS), revealed that most rape victims are aged 18 years and younger. For example, the NCHRBS found that for 71% of victims the first rape occurred before the age of 18 years. ¹¹ Similarly, ICARIS-2 revealed that 60% of female and 69% of male rape victims experienced their first rape before their 18th birthday. ⁸ The NVAWS also found that the majority (54% for women and 71% for men) of all first rapes occurred before the age of 18 years, and for both sexes, almost half of these occurred before the age of 12 years. ¹² Comparable figures for women from the NWS were 62% (before 18 years) and 29% (before 12 years). ¹³ For more information on the prevalence of child sexual abuse, see Leeb, Lewis, and Zolotor, this issue. ¹⁴

Who Are the Perpetrators?

For both males and females, the perpetrator and victim know each other in the large majority of cases (>80% of cases). ¹² There is no clear consensus, however, on the most common relationship between the victim and perpetrator. This is partially because of differences in the definitions used to describe intimate partners. The NVAWS found that perpetrators of rape against adult women were most often intimate partners (62%), defined as a current or former spouse, cohabitating partner, boyfriend, or date. Twenty-one percent of rapists were acquaintances, 17% were strangers, and 7% were relatives. ¹² In the earlier NWS, however, the largest percentage of perpetrators (29%) were nonrelatives, such as friends or acquaintances, 27% were family members, 22% were strangers, and 19% were intimate partners (defined as a current or former spouse or boyfriend—not including dates). ¹³ When looking only at 12- to 17-year-old rape victims, the NVAWS found that perpetrators were mostly intimate partners (35%) and acquaintances (33.3%) for females and acquaintances (47%) for males. For child victims (aged 12 years and younger), the perpetrator was most commonly a nonintimate family member for females (67.8%) and an acquaintance for males (50%). ¹²

Vulnerability Factors for Sexual Violence Victimization

There are numerous factors that may make a person more vulnerable to sexual violence victimization. Vulnerability factors are those that may increase the likelihood for rape or other sexual violence victimization but are distinct from victim blaming, which mistakenly assigns responsibility for victimization to survivors. This section includes a summary of a few of the key vulnerability factors that have received substantial attention in the literature. The following review focuses on girls and women because the burden of rape is larger for females, as described previously, and most of the available literature concentrates on female samples.

Demographics

As the earlier prevalence estimates reveal, studies have consistently found that victims of rape and other sexual violence are most likely to be young and female. ¹² Other demographic variables have also been linked to sexual violence victimization. For example, national prevalence data from the NVAWS suggest that Black, Hispanic, and American Indian/Alaskan Native women are at greater risk for rape victimization (including rape by a partner) than white women. ⁴ Others have consistently found that being divorced or separated puts women at increased risk for sexual violence by a former partner.^15-18

Child Victimization and Revictimization

One of the most frequently replicated vulnerability factors for adult rape victimization is a previous history of child maltreatment, particularly child sexual abuse. Child sexual abuse survivors are 3 to 5 times more likely to experience subsequent adult sexual victimization than respondents who had not experienced any type of child abuse.^19-21A nationally representative study on intimate partner violence using NVAWS found that childhood physical and sexual abuse survivors were more likely to be in current physically violent relationships and to have experienced forced sex by a current intimate partner than women who did not experience child abuse. ²² In addition, findings from a review of marital rape ²³ show that women who experienced prior unwanted sexual experiences by a variety of perpetrators and under certain circumstances (eg, blood relatives, non–blood relatives, unwanted sexual experiences prior to age 14 years) were more likely to be victims of marital rape.

Some researchers have concluded that vulnerability to adult victimization is best understood as an after-effects of childhood victimization. For example, women who were sexually abused as children may be more likely to use drugs or alcohol habitually, which in turn, increases the likelihood for future victimization. Therefore, revictimization can be viewed as both a vulnerability factor for and a consequence of sexual violence. For many survivors, rape and other sexual violence are repeated multiple times at different life stages, and evidence suggests that women who experience childhood abuse followed by revictimization in adolescence are more vulnerable for future experiences of sexual violence than those who did not experience sexual violence in adolescence. ²⁴ Studies indicate that repeat victimization leads to more serious psychological damage than single victimization, possibly because repeated assault reinforces negative changes in central beliefs about the self and others. ²⁵

Substance Use and Abuse

Research is increasingly clarifying the relationships between alcohol and drug use and sexual victimization. Several studies have examined the relationship between alcohol use and rape, but they have produced mixed results in terms of whether women’s alcohol use actually predicts sexual victimization. ²⁶ Regarding the specific role that alcohol plays in one’s vulnerability to sexual violence, some experts have suggested that the use of alcohol may serve as cues to the perpetrator. For example, men may perceive women who drink alcohol as “easy,” or more interested in sex.^27,28 Engaging in alcohol or drug use may also put women in social settings where they are more likely to encounter a perpetrator.^29,30 On the other hand, the combination of alcohol and risky situations may be a better predictor of sexual assault than either factor acting alone. ³⁰

The influence of the perpetrator’s use of alcohol in sexual assault remains unclear. When substances are used, often both the victim and perpetrator are drinking; this pattern makes it difficult to disentangle the influence of alcohol for either the victim ³⁰ or perpetrator. However, some studies indicate that alcohol use may play a role in the characteristics of a sexual assault. The study by Testa ²⁶ indicated that penetration was more likely when the victim was drinking and less likely when the perpetrator was intoxicated. Furthermore, the victim’s level of intoxication can also influence the amount of aggression used by the perpetrator. Abbey and colleagues ³¹ found that men used less aggression when the victim was intoxicated and less able to physically resist, suggesting that when a woman is intoxicated, perpetrators may believe that less force is required to achieve sexual assault. ³² In essence, the use of alcohol may influence whether a woman is raped and the manner in which it occurs.

Alcohol/drug-facilitated sexual assault

Alcohol/drug-facilitated sexual assault occurs when a perpetrator engages in sexual behavior with a person who is unable to provide consent due to being intoxicated or incapacitated because of the effects of alcohol or drugs. This type of sexual assault can occur whether the victim’s consumption of alcohol or drugs is voluntary or involuntary, but some research suggests that voluntary consumption increases one’s vulnerability to sexual violence.^33,34 For example, after a woman has voluntarily consumed alcohol or drugs, a perpetrator may encourage her to become intoxicated or take advantage of her once she becomes intoxicated; this type of assault has been described as “opportunistic.” ³⁵

At a more sinister level, a “proactive” strategy ³⁵ is said to have occurred when a perpetrator covertly drugs or spikes the drink of an unknowing victim for the purpose of facilitating sex. A variety of drugs are used to commit sexual violence, such as cannabis and cocaine,^35,36 Rohypnol (“roofies”), ³⁷ gamma-hydroxybutyrate (known as “GHB”), ³⁷ amphetamines, ³⁶ heroin, ³⁶ ketamine,^36,37 and over-the-counter eye drops that contain tetrahydrozoline hydrochloride. ³⁸ Depending on the type of substance, the effects may, at minimum, reduce a woman’s inhibitions and facilitate sexual activity (eg, ecstasy) or, at worst, incapacitate her (eg, Rohypnol). ³³ For many of these drugs, the victim is unaware that she has consumed it (eg, it is slipped into her drink). Perpetrators choose these kinds of drugs to facilitate rape because they work quickly to relax muscles and significantly impair the victim’s memory for potentially several hours after ingesting the drug.^33,37 In some cases, alcohol and drugs are combined, which intensifies the intoxicating effects. ³⁵

Research in this area is in its early stages, but a few studies have attempted to estimate the prevalence of Alcohol/drug-facilitated sexual assault or distinguish between sexual assaults that were facilitated by alcohol versus drugs.A review of emergency department records over 6 years identified 12% as cases of suspected drug-facilitated sexual assault. ³⁹ However, in a recent nationally representative study ⁴⁰ of 1763 US adolescents (ages 12-17 years), 11.8% experienced some form of sexual assault, and of those, 18% were described as Alcohol/drug-facilitated sexual assault (both voluntary and involuntary use of alcohol or drugs), mostly occurring in girls aged 15 to 17 years. Among those reporting Alcohol/drug-facilitated sexual assault, 48.3% stated that they were “passed out” during their most recent sexual assault. ⁴⁰ Another study showed that among college students, 11% reported sexual assault while they were incapacitated. Of those, 1.7% were suspected cases of covert drug-facilitated sexual assault and 0.6% were confirmed cases of covert drug-facilitated sexual assault. ⁴¹ In general, findings indicate that the majority of these cases involve the use of alcohol instead of drugs, but they vary by the victim’s state of intoxication, such as being very intoxicated versus being passed out or unconscious.

Impacts of Sexual Violence

The impacts of sexual violence can occur at many levels. There are individual impacts that can be physical and also emotional or psychological. There can be impacts at a relational level such that survivors may have difficulty relating to others after victimization. Sexual violence can also have an impact on a survivor’s health-related behaviors. Finally, sexual violence has a broader impact in terms of its costs to society, many of which are health related. The literature on each of these areas of impact is summarized briefly below. Please note that much of the research in this area is specific to rape and child sexual abuse.

Physical and Sexual Health Impacts

There can be both immediate and long-term physical and sexual health impacts from rape. The immediate consequences may include injuries received during the rape, such as bruises, scrapes, broken bones, and genital trauma. Serious physical injury, particularly genital tearing, was believed to be more common among elderly survivors. ⁴² A recent review by Sommers, ⁴³ however, reports that new technologies and improvements in examination techniques are enabling better detection of genital injuries following rape and sexual assault. As a result, recent research reviewed by Sommers revealed that 50% to 90% of rape survivors have genital injuries. ⁴³ In addition, 4% to 30% of rape survivors contract sexually transmitted diseases (STDs) as a result of rape. ⁴⁴ Another study of African American women found that victims of childhood sexual abuse were more likely than nonvictims to report having an STD as an adult. ⁴⁵ The number of survivors contracting human immunodeficiency virus (HIV) after rape is unclear, but some cases have been documented.^46,47 A previous study estimated that 5% of rapes may result in pregnancy, mainly in adolescents. ⁴⁸ However, in the study by McFarlane et al, ⁴⁹ of women abused by their intimate partners, results showed that 26% of women reported rape-induced pregnancies.

Longer ranging physical symptoms and illnesses associated with rape and child sexual abuse are gastrointestinal disorder, irritable bowel syndrome, ⁵⁰ as well as chronic back, neck, head, and facial pain, including lower jaw discomfort.^27,29 Untreated STDs that result from rape can lead to pelvic inflammatory disease, which is a major cause of infertility. ⁵¹ Other gynecological problems that may result from rape and child sexual abuse are chronic pelvic pain,^52,53 irregular vaginal bleeding, painful menstrual periods, vaginal discharge,^54,55 urinary tract infections, ⁵³ and premenstrual syndrome, which affects 8% to 10% of menstruating women and causes physical, mood, and behavioral changes. ⁵⁶

Psychological Impacts

Rape can profoundly affect how a woman views the world in which she lives. The experience of rape can shatter a victim’s preexisting assumptions of life itself, ⁵⁷ such as her beliefs in the goodness of people and that the world is safe and fair. ⁵⁸ Negative changes in belief systems often are permanent consequences of rape and influence the meaning and interpretation of subsequent experiences. Following a rape, many victims experience psychological distress and disruptions to their daily routines. ²⁷ Emotional reactions to rape include shock, disbelief, denial, fear, confusion, anxiety, and withdrawal. ⁵⁹ Although serious physical injury or death resulting from rape is rare, victims may experience intense fear of their rapists, fear re-attack, and feel anxious about disclosing the assault to others. Following these initial reactions, victims frequently report low self-esteem, self-blame, ⁶⁰ shame, insomnia, dissociation, ⁶¹ and problems with sexual functioning. These problems may last for months, and for some victims, psychological distress may persist as long as 2 years.^62,63 Also common among female victims are sexual problems such as diminished interest or avoidance of sex, fear of sex, less frequent arousal and orgasms, ⁶⁴ and fear of contracting HIV.^45,65

Several psychiatric diagnoses are found among rape survivors including generalized anxiety, eating disorders, sleep disorders, ⁶⁶ depression, and posttraumatic stress disorder (PTSD).^67-70 PTSD is commonly diagnosed for trauma and widely studied among rape survivors. In fact, rape victims may be one of the largest groups of crime victims suffering from PTSD. ⁷¹ Symptoms of PTSD include emotional numbness, trouble sleeping, flashbacks or reliving the incident, feeling easily startled, and avoiding reminders of the traumatic event.^72,73 PTSD symptoms are often present within the first 2 weeks ⁶⁹ and usually by 3 months after rape. ⁷⁴ For many victims, the severity of PTSD symptoms improves within a month, but for others, symptoms may become chronic. ⁶⁹ Several factors appear to play a role in whether rape victims experience PTSD symptoms. These factors include duration of the assault, ⁷⁵ greater perceived life threat, ⁷⁶ rape tactic, ⁷⁷ history of trauma, ⁷⁸ and negative or unsupportive reactions after disclosing the rape to others.^78-80

Several studies have demonstrated a link between sexual assault and depression. A recent systematic review and meta-analysis ⁶⁸ revealed a significant association between rape and lifetime diagnosis of depression and suicide attempts. Studies indicate that postrape depression can last for approximately 3 months, and recurrent major depression over the lifetime is more prevalent in rape victims than in nonvictims. ⁷⁰ However, research indicates that depression and PTSD outcomes may vary by the rape tactic experienced by the victim. For example, a recent study revealed a stronger association between forcible rape (versus incapacitated rape) and PTSD and depression. ⁷⁷ Moreover, age at the time of the assault can play a role in psychological outcomes. Coid et al ⁸¹ compared experiences of rape having occurred as a child or adult; they found that rape experienced as an adult (but not as a child) was associated with depression, anxiety, and PTSD.

Research has consistently shown a strong association between suicidal thoughts and attempts and rape victimization.^68,75,82 However, the relationship between suicide and rape is complex and may be related to a variety of factors that include the characteristics of the sexual assault, the victim’s age, and her coping strategies. For example, Ullman ⁸³ found that victims who were raped by multiple perpetrators (ie, gang raped) reported more suicide attempts than single-offender rape victims. In addition, among adolescent female sexual assault victims, those who engaged in excessive drinking were more likely to experience suicidal ideation. ⁸⁴ For more information on factors that place individuals at risk for suicidal behavior, see Crosby, Buckner, and Taylor, this issue. ⁸⁵

Social and Relationship Impacts

Negative impacts on social adjustment after rape are usually short term. The majority of survivors find the strength to return to their roles as employees, students, mothers, intimate partners, and any other social roles. The quality and amount of social support the victim receives in the days, weeks, and months following the rape play an important role in recovery outcomes. However, positive social support does not appear to help victims as much as negative social support damages them. ⁸⁶ Studies indicate that negative reactions to sexual violence disclosure can prompt maladaptive coping in victims, ⁸⁰ and for some, negative or hurtful disclosure experiences can be worse for the victim than receiving no support at all. ⁸⁷

Social readjustment to the workplace seems to be the most difficult social impact of rape, and one study found productivity to suffer after rape for up to 8 months. ⁸⁸ Rape may be associated with deterioration of intimate relationships, ⁸⁹ which is often related to sexual problems or may stem from damage to beliefs such as those about the trustworthiness of others. Rape can also have a negative effect on the friends, family, and intimate partners of victims, which further strains relationships. ²⁹

Impacts on Risky Health-Related Behaviors

A major consequence of child sexual abuse and rape is that it increases the likelihood to engage in negative health behaviors. Some of these health behaviors include risky sexual behavior, such as having unprotected sex; having the first consensual sexual experience at an early age; having multiple sexual partners; trading sex for food, money, shelter, or drugs; and becoming pregnant as a teen, all of which may be traumatic aftereffects of early sexual violence victimization.^11,90,91 In one study, child sexual abuse survivors reported 1 or more of the following HIV-risk behaviors: intravenous drug use, treatment for an STD, testing positive for HIV, or having anal sex without a condom. ⁹² Child sexual abuse survivors in another study were more likely than those who were not sexually abused in childhood to become prostitutes. ⁹³ Among rape victims, one study found that they were more likely than nonvictims to contract an STD recently and be sex workers. ⁹⁴ In addition to high-risk sexual behavior, studies have found that survivors of child sexual abuse and rape are more likely than their counterparts to smoke cigarettes, overeat, drink alcohol, smoke crack cocaine, and be homeless ⁴⁶ and fail to engage in healthy behaviors like the use of motor vehicle seat belts.^95,96 A study focusing specifically on high school sexual dating violence in 1997 and 1999 in the state of Massachusetts found similar risks for unhealthy behavior among adolescent girls. Survivors of sexual dating violence were more likely than those who did not experience sexual dating violence to be heavy cigarette smokers, drive after drinking alcohol, use cocaine, use diet pills, start having sexual intercourse before the age of 15 years, and use substances before their most recent sexual intercourse. Analysis of data from the 1999 Massachusetts Youth Risk Behavior Survey showed that sexual dating violence was associated with binge drinking, anorexia nervosa, not using a condom during the last sexual intercourse, high numbers of sexual partners, and having been pregnant. ⁹⁷ Survivors also have reported self-mutilation, or deliberately cutting one’s own skin after rape. ⁹⁸ Just as alcohol and drugs were discussed as a vulnerability factor for sexual violence victimization, they may also be initiated or increased as a response to rape. ³⁴ Child sexual abuse history has also been linked in adulthood to the major causes of morbidity and mortality including extreme obesity and other eating disorders such as anorexia nervosa and bulimia, ⁹⁹ and rape victimization has been linked to hypertension and high cholesterol. ¹⁰⁰

Many of the long-term behavioral reactions to child sexual abuse and rape, such as alcohol and drug abuse, risky sexual behaviors, and smoking, have been characterized as coping strategies, or behavioral adaptations to the trauma. Finkelhor and Browne, ¹⁰¹ in their landmark article, proposed the process of traumatic sexualization to explain sex practices that may emerge as a result of child sexual abuse. A child can become traumatically sexualized after a perpetrator repeatedly rewards the child for sexual behavior; when the perpetrator exchanges affection, attention, or gifts for sexual behavior so that the child learns to use sex as a tool to get what he or she wants; or when a child associates fear and trauma with sexual activities. Traumatic sexualization as a result of child sexual abuse can lead to many of the physical, psychological, and health behavior impacts discussed above, such as repeated rape victimization, disinterest in and fear of sex, difficulty having orgasms, and high numbers of sexual partners. ¹⁰¹ The negative impact of having an early sexual initiation imposed by force also cannot be overlooked. In addition to the sexual violence literature, studies of first sexual experiences have revealed that almost 1 in 3 girls report that their first intercourse was not voluntary. ¹⁰²

Economic Impact and Cost to Society

Another major impact of rape is the economic cost resulting from survivor’s use of health care and other services. Rape survivors are more likely to seek medical care, whether from an emergency room or by visiting their primary care doctor in the year following their victimization, than they are to report to police or seek specialized victim services.^79,103 Studies have shown that the women with a history of victimization use more medical services in general than nonvictimized women. ¹ Specifically, the average number of primary care medical visits and the average cost of these visits were higher among rape victims than among women who were not victimized, and in one study medical visits increased by 56% in the second year after rape. ⁷⁹ It is important to note that taken symptom by symptom, assaulted persons are no more likely than nonassaulted persons to seek service. Thus, the excess medical services used by victims suggests that rape victimization may lead to poorer health, which results in greater medical care usage. ¹

The costs of rape to society also include the direct costs of other services, including specialized nurse examiner programs in emergency rooms, mental health services, criminal justice response, social services, and substance abuse treatment programs, as well as indirect costs such as estimates in dollars of the value of reduced quality of life for victims. Another direct economic cost of rape is lost hours at work for rape survivors and their loved ones, which contributes to decreases in productivity. A 1994 study found that the average rape in the United States was estimated to cost $5100 in direct, out-of-pocket expenses and $87 000 when a monetary value is attached to intangibles such as emotional distress and lost quality of life. ¹⁰⁴ A 2002 publication of a statewide study estimated that sexual violence costs more than $6.5 billion per year in direct and indirect expenses in the state of Michigan alone. ¹⁰⁵ The Centers for Disease Control and Prevention is beginning to embark on a project to estimate the costs of sexual violence at a national level. Quantifying the costs of rape and other forms of sexual violence for the nation as well as for communities and for survivors and their families will help raise awareness of the severity and widespread impact of sexual violence and can inform public policy directed at ending the violence.

The Relevance of Sexual Violence to Health Care

Why Sexual Violence Is a Public Health Problem

As evident from the previous review, sexual violence is a public health problem for a variety of reasons. First, sexual violence is a public health concern because of the sheer magnitude of the problem given the prevalence rates presented and the early onset of violence in the lifespan. Second, sexual violence is a public health concern because many, and arguably, most of the consequences of it are health related. A public health approach treats all forms of violence as health issues because there are quantifiable physical and psychological injuries and other long-term health impacts that result from them. ¹⁰⁶ Third, implicit in the public health focus is the idea that public health problems are preventable and more emphasis should be placed on reducing factors that put people at risk while increasing factors that protect people from the problem—in the case of violence, from becoming perpetrators of violence.

The Importance of Primary Prevention and the Current Debate on Assessment

Sexual violence is amenable to prevention. Public health underscores the importance of primary prevention, or preventing sexual violence before it occurs. ¹⁰⁷ The public health approach combines a diverse group of scientific disciplines (eg, sociology, psychology, medicine, education) to create a multidisciplinary approach to prevention. ¹⁰⁸ In the past 2 decades, the public health approach has been recognized as well suited in preventing multidimensional problems such as violence.^106,109 However, this approach can be a very challenging one for sexual violence prevention. Back in 1999, Mercy said a public health approach to sexual violence may require “new eyes” ¹¹⁰ to look at the issue with the significance in which other diseases are viewed. In other words, using this approach to address sexual violence involves considering it a disease of the same magnitude as other diseases for which the public health model was developed to address. While we have made progress in public health prevention of sexual violence, even in 2011, we still need “new eyes” to fully capitalize on what a public health approach can offer to the prevention of this problem. For example, given the deleterious impacts that rape and other sexual violence have on survivors, it seems like a missed opportunity to not use the health care setting to determine whether persons have experienced sexual violence when they present with signs or symptoms consistent with sexual violence victimization, in the same way that assessment and diagnosis of other public health problems (eg, diabetes, heart disease, or substance abuse) is conducted.

Some groups have pushed even further to recommend universal screening for sexual violence victimization. Universal screening for sexual violence and other forms of violence against women (ie, intimate partner violence) is not widely used, and in some cases where it is used, it is not done well. ¹¹¹ In 2004, the US Preventive Services Task Force concluded that there is insufficient empirical evidence to recommend for or against routine screening for intimate partner violence in a primary care setting. They cited reasons such as the lack of randomized controlled trials, the unavailability of efficacious treatment options, and the possibility of unintended negative consequences. ¹¹² For additional discussions of intimate partner violence universal screening recommendations, see Haegerich and Dahlberg (this issue) ¹¹³ and Black (this issue). ¹¹⁴

However, it should be noted that the Task Force’s recommendation did not refer explicitly to sexual violence screening. More research is clearly needed to know the benefits and possible unanticipated disadvantages of screening and assessment for violence against women, but particularly sexual violence in the health care setting. But even without a large evidence base, many scholars in the field have stressed the importance of assessment for violence against women, and sexual violence in particular^115,116 for several reasons, such as the numerous health impacts of sexual violence, the fact that the problem often goes undetected without assessment by health professionals, and the clinical importance of accounting for violence when treating someone medically. ¹¹⁵ The field awaits research to increase knowledge of the risks and benefits of universal screening for sexual violence in the health care setting. In the meantime, the sheer size of the problem and the magnitude of health-related impacts make it critical that routine inquiry about exposure to sexual violence takes place in the health care setting in patients who present with signs and symptoms consistent with sexual violence. ¹¹⁷ Below is a very brief discussion of some strategies informed by the literature that might be useful for identification of sexual violence in a health care setting, with particular focus on early identification and prevention.

Promising Health Care Assessment Strategies

The literature pointing to the relationship between sexual violence and health risk behaviors is particularly promising for assessment in health care settings. Short-term and long-term health consequences of sexual violence may be prevented by identifying sexual violence victims early by following up on signs and symptoms consistent with victimization and directly addressing victims’ health risk behaviors and use of health promotion strategies. Assessment of risky health behaviors frequently found among sexual victims in the health care setting and referral to interventions to influence those behaviors may prevent short-term and long-term health consequences. In addition, programs designed to enhance health promoting behaviors and reduce health risk behaviors among young people (eg, substance use, smoking, risky sexual behaviors, and risky dieting behaviors) may benefit from efforts to understand and address the needs of sexual violence victims.

Beyond addressing the needs of victims after the fact, education in a health care setting is important for primary prevention of perpetration, because it may prevent those at high risk for sexual violence perpetration from committing it in the first place. Although a review of the risk factors for sexual violence perpetration is beyond the scope of this article, certain risk factors that may be most relevant to health are worthy of a brief mention. Early sexual initiation^118-120 and sexual dysfunction or deviant sexual behavior such as a tendency toward paraphilia,^121,122 voyeurism, and atypical consensual sexual behaviors ¹²¹ have all been linked to sexual violence perpetration by males. Health care providers could talk about prevention strategies with male patients with signs and symptoms of these risk factors, especially teens and young adults given that sexual violence perpetration happens very early in the life-span. ¹²³ One promising strategy that health care providers may consider for male patients exhibiting risk factors for perpetration is bystander prevention programs ¹²⁴ that emphasize the importance of intervening with friends who may appear at risk for perpetration (eg, intoxicated male peer who walks off with an intoxicated female at a party). This may increase awareness of young males who have peers with attitudes that are supportive of sexual violence perpetration. Having male peer support for perpetration is also a significant risk factor for perpetrating sexual violence.^125,126 Another strategy with teens might be to focus on peer and partner perpetrated sexual violence and the links to alcohol. Because alcohol use is significantly associated with sexual violence in predominantly adult samples (A. L. Teten, L. A. Valle, S. DeGue, G. M. Massetti, J. L. Matjasko, Matjasko, K. Brookmeyer, unpublished review, 2010), medical professionals can address sexual violence prevention by addressing alcohol use with their adolescent patients. One possible strategy is to educate adolescent patients (potential victims and perpetrators) about the risks associated with alcohol use and sexual violence, along with the contexts in which it can occur, such as at parties where alcohol is being consumed. The importance of bystanders in sexual violence prevention could again be emphasized in this context. In addition, young women may feel more comfortable talking about sex or risky health behaviors with their physicians rather than their parents. Such conversations are good opportunities for discussing issues about how to clearly discuss consent with boyfriends and dates. It is important to note that a potential drawback to pursuing prevention strategies with boys in health care settings is that boys do not see physicians as often as girls. When boys do see the doctor, it is often for a sports physical. So, while physicians may be able to reach girls, they may not reach as many boys to prevent sexual violence perpetration.

Primary prevention of childhood sexual abuse would require education of parents and caregivers. A study by Flaherty and Stirling ¹²⁷ describes the role of pediatricians in preventing child maltreatment, which includes child sexual abuse. They discuss the importance of obtaining a thorough social history throughout a patient’s childhood as part of good medical practice and talking to parents about normal sexual development and how to prevent sexual abuse.

Beyond strategies at the individual level, the integration of sexual violence into the curricula of medical and nursing schools is an important strategy for sexual violence prevention. Many medical school curricula now include intimate partner violence, although it is often brief in scope (eg, 1-2 hours of instruction time). ¹²⁸ Child sexual abuse has also been a part of pediatricians’ medical school curricula for decades. ¹²⁸ However, it would be beneficial to prevention efforts if medical training about sexual violence extended beyond pediatricians’ training and beyond sexual violence in the context of childhood or intimate partner relationships. An additional strategy is for medical students to receive clinical training in actual situations versus classroom lecture formats. ¹²⁸

The Importance of Sexual Assault Nurse Examiner (SANE) Programs

When prevention efforts fail, it is critically important to have services in place for sexual violence victims. One part of these services is a medical program. Many communities have implemented programs to address the unique needs of recent rape victims. SANE programs emerged in the 1970s as a way to sensitively collect forensic evidence and address the physical and psychological needs of rape victims. ¹²⁹ The nurses who provide these services have undergone specialized training in the collection of forensic evidence, assessment and treatment of STDs and HIV, crisis intervention, and rape trauma syndrome. ¹²⁹ SANE nurses provide health-related services such as emergency contraception, assessment for injuries, information or treatment for STDs, and information about HIV and pregnancy risk, ¹²⁹ as well as practical assistance such as clothing, transportation, and safety planning. ¹³⁰

In 2005, there were more than 500 SANE programs in the United States. ¹³⁰ These programs exist in hospital and community-based settings (eg, rape crisis centers, free-standing clinics, criminal justice agencies). ¹³⁰ Health care–based treatment centers attract more sexual assault victims than forensic-based centers; ¹³¹ however, many hospitals conduct rape examinations without the use of SANEs, ¹²⁹ and emergency room staff often do not have training to provide the most comprehensive care to sexual assault victims (eg, referrals, appropriate drugs for sexually transmitted infections). ¹³¹

As discussed in this review, the experience and consequences of rape can severely affect victims’ psychological health. Enduring a rape examination and interactions with police and medical staff can be humiliating and stressful for victims ¹³² and result in “secondary victimization.” ¹³³ A review of health care–based interventions for sexual violence victims found that female providers are often preferred, and those who see rape as a problem tend to provide more quality care. ¹³¹ The significance of SANE programs and well-trained staff to implement them cannot be overemphasized. SANE programs seek to provide compassionate care to rape victims by addressing their immediate physical health needs and providing supportive care during the aftermath of rape, which can have long-term effects on their physical, sexual, and psychological health.

Conclusion

Sexual violence is a serious public health problem that has numerous short-term and long-term health impacts. Because of this, health care providers should be concerned and interested in this issue and should consider its impact on a patient’s overall health profile. Although this article has focused primarily on sexual violence victimization of women, it is important to reiterate, as the prevalence statistics indicate, that men and boys are also victims of sexual violence. Male sexual violence victims have some unique characteristics that are beyond the scope of this article, but the impact of their victimization and specific health care needs should not be overlooked (as discussed by Hall and Haegerich, this issue). ¹³⁴ It is also important to note that primary prevention of violence should focus on the source of the violence—namely, the perpetrators. Primary prevention strategies such as prevention of youth alcohol use is more likely to involve potential perpetrators, but more work is needed to focus efforts on identifying and preventing potential perpetrators from committing sexual violence based on what is known from the literature while at the same time assessing and addressing the needs of survivors when primary prevention is not possible.