Obstetrics & Gynecology:
Intimate Partner Sexual Assault Against Women: Frequency, Health Consequences, and Treatment Outcomes
McFarlane, Judith RN, DrPH*; Malecha, Ann RN, PhD*; Watson, Kathy MS†; Gist, Julia RN, PhD*; Batten, Elizabeth‡; Hall, Iva RN, PhD§; Smith, Sheila RNC, PhD§
From the *Texas Woman's University, College of Nursing, Houston, Texas; †Baylor College of Medicine, Houston, Texas; ‡Harris County District Attorney's Office, Houston, Texas; §Lamar University, Department of Nursing, Beaumont, Texas.
Supported by Grant No. 2002-WG-BX-0003 awarded by the National Institute of Justice, Office of Justice Programs, U.S. Department of Justice. Points of view in this document are those of the authors and do not necessarily represent the official position or policies of the U.S. Department of Justice.
Reprints are not availale. Address correspondence to: Dr. Judith McFarlane, Texas Woman's University, 1130 John Freeman Boulevard, Houston, TX; e-mail: firstname.lastname@example.org.
Received June 15, 2004. Received in revised form August 15, 2004. Accepted August 25, 2004.
OBJECTIVE: To describe the characteristics and consequences of sexual assault within intimate relationships specific to racial or ethnic group, compare the findings to a similar group of physically assaulted–only women, and measure the risk of reassault after victim contact with justice and health services
METHODS: A personal interview survey of 148 African-American, Hispanic, and white English- and Spanish-speaking abused women seeking a protection order. Extent of sexual assault, prevalence of rape-related sexually transmitted diseases and pregnancy, symptoms of posttraumatic stress disorder (PTSD) and depression, and risk of reassault after treatment were measured
RESULTS: Sixty-eight percent of the physically abused women reported sexual assault. Fifteen percent of the women attributed 1 or more sexually-transmitted diseases to sexual assault, and 20% of the women experienced a rape-related pregnancy. Sexually assaulted women reported significantly (P = .02) more PTSD symptoms compared with nonsexually assaulted women. One significant (P = .003) difference occurred between ethnic groups and PTSD scores. Regardless of sexual assault or no assault, Hispanic women reported significantly higher mean PTSD scores compared with African-American women (P = .005) and White women (P = .012). The risk of sexual reassault was decreased by 59% and 70% for women who contacted the police, or applied for a protection order, after the first sexual assault. Receiving medical care decreased the woman's risk of further sexual assault by 32%
CONCLUSION: Sexual assault is experienced by most physically abused women and associated with significantly higher levels of PTSD compared with women physically abused only. The risk of reassault is decreased if contact is made with health or justice agencies.
LEVEL OF EVIDENCE: III
The prevalence and health effects of intimate partner physical assault against women are well chronicled.1 Conversely, the occurrence, health consequences and, especially, treatment outcomes of intimate partner sexual assault are virtually unknown. The few studies that measure sexual assault separate from physical assault consistently report 40 to 50% of battered women are also sexually assaulted,2–4 a rate of sexual assault 4 to 5 times higher than the 9 to 13% reported by women from community and national samples.5–7
Although intimate partner sexual assault is not exclusively found in battering relationships, it is nearly impossible to find a large enough sample of women to study who have experienced sexual assault yet have not been physically assaulted by their intimates as well. The time sequencing of physical and sexual assault within intimate relationships is unknown, as are the associated physical and psychological disorders. Correct sequencing is essential for developing a causal model of victimization and reactions, and to establish the relative effects of physical and sexual assault in predicting symptomatology, such as depression and posttraumatic stress disorder (PTSD). For example, if sexual assault severity is uniquely related to PTSD severity, then professionals who care for these women will need to focus on sexual assault treatment. Furthermore, outcome data after treatments, such as victim use of health and justice services, and the risk of reassault are unknown. When we understand the unique contribution of sexual assault to women's health, professionals can better tailor their services for, and validate the experiences of, this often underserved and silent population.
The purpose of our study was to describe the frequency, sequencing, and consequences of sexual assault within intimate relationships specific to racial or ethnic group and compare the findings to a similar group of physically-assaulted-only women. Treatments used by the women to end the sexual assault are described, along with the risk of reassault after women contact health or justice agencies.
MATERIALS AND METHODS
After institutional review board approval, our first study began in January 2001, at a special family violence unit of a District Attorney's office that serves an ethnically diverse population of 3 million citizens. The objective was to test a safety intervention for abused women and evaluate the effectiveness of protection orders. Predicting a moderate effect size of 0.45 for the safety intervention with 80% power and allowing for 25% attrition, a total of 150 abused women were required for the study. All women who presented to this special family violence unit to apply for a8–10 protection order and who and met our inclusion criteria (eg, female, 18 years or older, English or Spanish speaker) were invited by one of 6 investigators into the study until 150 women entered the study. A total of 154 women qualified for the study and were invited to participate; 4 women refused. One woman committed suicide 6 weeks into the study. All of the remaining 149 women completed the 18-month study, the results of which have been published.8–10
Our second study began in January 2003, after a second institutional review board approval specific to sexual assault. Because justice services are used by upwards of 50% of abused women11,12 and because of the rapport established between the women in the first study and the 6 investigators, the initial cohort of 150 abused women were invited to participate in the second study on intimate partner sexual assault. Among the initial cohort of 150 women, 148 women were alive in January 2003. A second woman died of cancer. All remaining 148 women signed informed consent specific to the present study on intimate partner sexual assault. Sexual assault was defined as a positive response to any one of the 5 questions on the Severity of Abuse against Women, Sexual Assault Subscale.13 The 5 questions asked were “During the relationship, did (name of abuser)
* make you have sexual intercourse against your will?”
* physically force you to have sex?”
* make you have oral sex against your will?”
* make you have anal sex against your will?”
* use an object on you in a sexual way?”
Additional questions asked about the sexual violence that occurred before the women applied for the protection order in January 2001. Specifically, the women were asked about the perpetrator's behavior at the time of the first and subsequent sexual assaults, as well as her help-seeking and health problems she attributed to the sexual assault(s). Scored instruments were administered to measure posttraumatic stress disorder (PTSD) and depression. All instruments were offered in English or Spanish, according to the woman's preference, and completed during a personal interview in a private setting, at a time and location convenient and safe for the woman. All women were offered $50 at the completion of the interview.
The Demographic Data Form was used to document information on the woman's age, education, income, self-identified race or ethnicity, employment status, relationship to the abuser, and primary language. The Severity of Violence against Women Scales (SAVAWS), Sexual Abuse Sub-Scale is a 46-item instrument designed to measure threats of physical violence (19 items) and physical assault (27 items).11 For each item, respondents use a 4-point scale to indicate how often the behavior occurred (0 = never, 1= once, 2 = 2–3 times, 3 = 4 or more times). The higher the score, the more violence reported. Internal consistency reliability estimates in studies of abused women have ranged from 0.89 to 0.91 for the threat of abuse dimension and from 0.91 to 0.94 for the physical abuse dimension.14–16 Five of the 27 items on the physical assault scale assess sexual assault. Sexual assault scores ranged from 1 to 15. In the present study, reliability (measured by Cronbach alpha coefficient) was 0.92 for the 5-item sexual assault subscale.
The Brief Symptom Inventory (BSI) is an 18-item instrument designed to measure 3 psychological dimensions, including depression, anxiety, and somatization, as well as providing a Global Severity Index.17 Internal consistency reliability ranges from 0.74 to 0.89 for the subscales. Test-retest reliability over 2 weeks ranges from 0.68 to 0.91. A global index score of 63 or greater places a person at risk of psychological distress, as does a score of 63 or greater or any 2 of the 3 scales. In this study, reliabilities (Cronbach alpha coefficients) were 0.88 for depression, 0.85 for anxiety, and 0.85 for somatization.
The Posttraumatic Stress Disorder Scale (PTSD) is a 7-item symptom scale used to screen for posttraumatic stress disorder. The instrument is a subset of items from the National Institutes of Mental Health Diagnostic Screening Interview Schedule for DSM-IV18 Scores of greater than 4 indicate posttraumatic stress disorder with a sensitivity of 80% and a specificity of 97%, a positive predictive value of 71%, and a negative predictive value of 98%. In this study, reliability (Cronbach alpha coefficient) was 0.78
Data analysis began with independent t tests and χ2 analyses used to determine whether the physically and sexually abused women differed significantly from women physically abused only with respect to demographic characteristics. Descriptive statistics were used to document perpetrator behaviors at the time of the sexual assaults as well as health conditions the women attributed to the sexual assault and actions the women took to end the abuse. To determine whether specific treatments, such as contacting the police or receiving medical care, after the first sexual assault decreased a woman's likelihood of reassault we completed relative risk analyses. Analyses of variance and multivariate analyses were completed to test for differences in mean scores for mental health functioning according to the woman's racial or ethnic group and experience with sexual assault. When a significant difference was detected between racial or ethnic groups, pair-wise comparisons were completed to determine the specific racial or ethnic groups affected (ie, Hispanic and whites, Hispanic and African American, etc.). Finally, to determine whether a relationship existed between PTSD scores and sexual assault scores, a Pearson correlation was computed.
One hundred women, 68% of the sample, reported sexual assault 1 or more times during the relationship. The demographics of the women sexually assaulted and not sexually assaulted appear in Table 1. There were no significant demographic differences between the 2 groups.
The type and frequency of sexual assault appear in Table 2. Sixty-two percent (95% confidence interval [CI] 52.5–71.5%) of the women reported forced sexual intercourse 4 or more times, with 37% (95% CI 27.5–46.5%) and 27% (95% CI 18.3–35.7%) of the women reporting forced oral and anal sex, respectively. Seventy-nine percent of the women reported more than 1 episode of sexual assault, with more than half (55%) of these women reporting the second assault occurred within 1 month of the first assault. To determine whether the frequency of sexual assault varied by racial or ethnic group a 1-way analysis of variance was completed on the mean sexual assault scores. White women had the highest mean score of 7.22 (standard deviation [SD] ± 3.5) compared with African-American women at 5.37 (SD ± 2.3), and Hispanic women at 5.92 (SD ± 3.4). There were no statistically significant differences among ethnic groups. When asked about temporal sequencing of physical and sexual assault, 30% of the women reported sexual assault preceded the physical assault. Several women explained the sequencing in this way, “When I began to resist the forced sex by kicking or pushing him away, he began to hit, punch, and hold me down.” None of the women reported sexual assault only.
Fifty percent of the women reported that the abusers consumed alcohol immediately before the first and subsequent sexual assaults, and 40% of the women reported illicit drug use by the abuser during the first and subsequent sexual assaults, with 60% of the illicit drug use reported as crack or cocaine. Forty and 50% of the women stated the abuser physically assaulted them immediately before the first and subsequent sexual assaults, respectively. Thirty and 35% of the women reported physical abuse immediately after the first and subsequent sexual assaults, respectively.
Women were asked whether they told someone about the sexual assault, contacted the police, applied for a protection order, or received medical care or counseling. If the woman responded “yes” to contacting the police or applying for a protection order, she was asked whether she received the order of protection and was the abuser arrested. Help-seeking behaviors were stratified by women who were and were not reassaulted after seeking help. This information appears in Table 3, along with the test statistic. The behaviors of telling someone, contacting the police, and applying for a protection order were significantly (P < .05) associated with a decreased risk of reassault, with the largest reduction in risk associated with application for a protection order.
The relative risk and 95% CI of specific help-seeking behaviors compared with not seeking help after the first sexual assault and risk of reassault are presented in Table 4. Women who contacted the police, irrespective of whether the abuser was arrested, were 59% less likely to experience reassault. Women who applied for a protection order, irrespective of whether the order was received, were 70% less likely to experience reassault. Stated another way, women who did not contact the police were 2.4 times more likely to be reassaulted, and women who did not apply for a protection order were 3.3 times more likely to be reassaulted when compared with women who sought help. Receiving medical care decreased the woman's risk of further sexual assault by 32%. Help-seeking behaviors increased from the first to subsequent assaults. After the second sexual assault, 46% of the women told someone after the assault, 15% contacted the police, 19% applied for a protection order, 14% received medical care, and 9% received counseling.
The women were provided with a list of gynecologic conditions and asked whether they had experienced any of them because of forced sex. The women's responses, according to whether they reported 1 or repeated sexual assaults, are listed in Table 5. Repeated sexual assaults were associated with significantly more gynecologic conditions, with 15% of the women reporting 1 or more sexually transmitted diseases after sexual assault.
Twenty women reported 32 pregnancies after sexual assault. Outcomes for these 32 rape-related pregnancies were 26 (81%) live birth, 5 (16%) elective abortion, and 1 (3%) stillbirth. When asked whether the abuser forced sex during pregnancy, 24 women (31% of the women who had experienced a pregnancy) reported a total of 52 pregnancies accompanied by one or more episodes of sexual assault. Outcomes of these 52 pregnancies were 46 (88%) live births, 3 (6%) elective abortions, and 3 (6%) spontaneous abortions.
Means and standard deviations for scores on the Brief Symptom Inventory and PTSD scale were calculated for sexually assaulted and nonassaulted women by racial or ethnic group and appear in Table 6. Posttraumatic stress was the only measure that showed a significant difference between sexually assaulted and nonsexually assaulted women. Sexually assaulted women reported significantly (P = .02) more PTSD symptoms compared with nonsexually assaulted women. There was one significant (P = .003) difference between racial or ethnic groups. Regardless of sexually assaulted or not assaulted, Hispanic women reported significantly higher mean PTSD scores compared with African-American (P = .005) and white women (P = .012). The Pearson correlation computed between PTSD and sexual assault scores yielded a value of .16 (P = .104) which indicates the greater the frequency of sexual assault, the more symptoms of PTSD in this sample.
Over two-thirds (68%) of women in our study reported sexual assault by their intimate partners, a rate appreciably higher than comparable reports of 40–50%.2–4 For women in this study, sexual assault began within 2 years of consensual sex, reoccurred for 79% of the women, usually within 1 month of the first assault, and was most frequently experienced by white women. Our reassault rate of 79% is higher than the National Crime Victimization Survey, which found 65% of marital sexual assault survivors report a similar attack within a 6-month period.19
A few descriptive studies exist that chronicle the characteristics and consequences of intimate partner sexual assault. One survey of 1,000 women living in battered women's shelters yielded a response rate of 12% (115 women), among which 44% reported physical assault during sex, and 51% reported forced sex after a physical assault.2 Another study found 58% of a sample of 33 raped wives reported physical assault during the rape.20 These figures are comparable to our findings that 40–50% of the women reported physical assault at the time of the sexual assault.
Bennice and Resick21 suggest 2 explanations for the concurrent occurrence of physical and sexual assault. One possibility is that sexual assault is used by the abuser as another form of assault during a physically abusive episode, similar to reaching for a weapon. A second possibility is that sexual assault intimates do not view forced sex as assault, and instead, they are attempting to have sex as a form of apologizing for the physical assault. The second possibility is consistent with Walker's 3-phase Cycle of Violence with the honeymoon and making-up behaviors as the phase after the assault.22–24 Our findings support the first explanation of extended violence, especially because 30% of the women in our sample reported physical assault after sexual assault.
Only 16–25% of sexual assaults are reported to the police, with the reporting rate lowest when the woman knows the assailant.25,26 In our study only 6% of the women contacted the police after the first assault and 15% after the second assault. Similarly, most victims of sexual assault do not receive medical attention after the event.25 National estimates are that only 26% of women receive medical care after sexual assault, with women who report sexual assault to the police 9 times more likely to seek medical care.26 Another study reports that 50% of injured female victims of sexual assault who report the crime to the police also received medical treatment compared with a fifth of those women not reporting to police.25 In our study, 50% of women reporting to the police after the first sexual assault also received medical care, whereas only 33% of the women in our study contacting the police after the second assault also received medical care. We do not know how many of our women had sustained injuries.
Reporting to police initiates the protocol to collect forensic evidence, which is performed by a medical provider. Alternatively, sexual assault victims who go directly to a medical care facility for treatment may be asked to report to police to receive emergency forensic medical care that may be funded by the state.27 In our study, 9% of the women received medical care after the first sexual assault and 14% after the second assault. Although contact with the police and medical care increased from the first to second assault, only 50% of the women in our study who contacted the police also received medical care. Anonymity is a frequently cited reason for women not contacting the police and medicine.26 A cooperative medical and justice system model that encourages and perhaps even subsidizes medical care for all sexual assault victims and also allows for anonymity as an option for sexual assault victims receiving forensic examinations, is recommended as a strategy for facilitating sexual assault victims’ use of justice and health services.
Finally, 8% of the women applied for a civil protection order after the first assault and 19% of the women applied after the second assault. It is known that abused women often seek civil protection orders to end the violence.28 A collaborative model of justice and health care that encourages women seeking orders of protection after assault to also seek medical care is highly recommended.
Contacting the police, irrespective of whether the abuser was arrested, and applying for a protection order, irrespective of whether the order was received, was associated with up to a 70% risk reduction for reassault. However, women who did not contact the police after the first sexual assault were twice as likely to be reassaulted, and women who did not apply for a protection order were 3 times more likely to be reassaulted. These results agree with those of other longitudinal studies reporting significantly lower levels of violence experienced by women seeking assistance from the justice system, irrespective of the justice system outcome.10,14,28
How can contact with justice or health services, irrespective of the outcome, reduce the likelihood of further violence? A qualitative study focusing on why women seek orders of protection revealed a desire among women to regain some measure of control in their lives by making the abuse public.29 The women discussed using the justice system as a “loudspeaker” to notify the abuser that the law knew about his behavior. They viewed the legal system as a force larger than themselves and as having power over the abuser that they themselves had lost as a result of the abuse. The protection order becomes an announcement that the abused woman refused to “take it” anymore and was acting on her own behalf. When an abused woman decides to contact justice, health, or social service agencies, information about the abuse is shared, and contact is made. Just as the privatization of violence contributes to its continuation, perhaps the contact and information with health and justice agencies can prevent reoccurrence of violence.
Gynecologic problems are the most frequently reported physical health difference between abused and nonabused women. Conditions of sexually transmitted diseases, vaginal bleeding or infection, pain on intercourse, urinary-tract infections, and pelvic pain and inflammatory disease are far more likely to be reported by abused women.30–33 In one U.S. population-based study of self-reported data, the odds of having a gynecologic problem were 3 times greater than average for victims of spouse abuse.34 One of the few studies to separate physical from sexual abuse found 30% of sexually abused women reported 3 or more gynecologic health problems, compared with only 8% of women who experienced physical abuse alone, and 6% of women never abused.32 The same study reports the incidence of gynecologic health problems among physically abused–only women not appreciably different from the incidence of the nonabused women.
Sexual assault and associated consequences may explain these gynecologic differences. For example, vaginal, anal, and urethral trauma from forced sex (blunt force and lack of lubrication) can lead to increased transmission of microorganisms through direct transmission into the bloodstream or back flow of bacteria in the urethra. We found one other study that asked abused women whether a sexually transmitted disease was contracted as a result of, and after, sexual assault. Among a shelter sample of 115 women, 6.5% of the women reported contracting a sexually transmitted disease as a direct result of forced sex,2 compared with the 15% of women in our study who attributed 1 or more sexually transmitted diseases to sexual assault.
Unintended pregnancies account for about half of all pregnancies in the US.35 Some of these unintended pregnancies follow sexual assault. To determine the national rape-related pregnancy rate, a national probability sample surveyed 4,008 women for a period of three years and found a rape-related rate of 5%, with a disproportionate number of pregnancy rapes among adolescents.36 The rape-related pregnancy rate of 20% found in our study is four times the national rate. For our women the sexual assault continued into pregnancy, with 31% of the women who experiencing a pregnancy, whether or not rape-related, reporting sexual assault during the pregnancy.
There is evidence to suggest that sexually assaulted women may be more likely to terminate pregnancies as a strategy to eliminate this source of power and control within the relationship.37 In our study, 16% of the rape-related pregnancies were ended with an elective abortion. However, we did not ask the percentage of consensual sex pregnancies terminated with an elective abortion. Latest statistics from our state Department of Health38 document 19% of reported pregnancies end with an elective abortion. How many elective abortions follow rape-related pregnancies is unknown. No other research was identified that documented the associations between sexual assault, pregnancy, and elective or spontaneous abortion.
A recent study compared intimate partner sexual assault victims to women who have experienced physical assault alone and found that women who have experienced both physical and sexual assault tend to have higher levels of PTSD and depression.39 However, severity of physical assault did not predict severity of PTSD. Rather, intimate partner sexual assault continued to significantly predict PTSD even after controlling for the severity of physical violence. We found a positive relationship between PTSD and sexual assault scores among our sample of 148 women, indicating the greater the frequency and severity of sexual assault, the more symptoms of PTSD. The association of PTSD and sexual assault frequency and severity requires further study.
Does sexual assault predict PTSD, or does the threat of physical or sexual assault used by the perpetrator to gain sexual access to the victim occur more often, thus increasing the frequency of sexual assault overall in the relationship? Perhaps both phenomena occur. Several studies have associated intimate partner sexual assault with more severe physical assault.39–41 Additionally, the act of sexual assault itself may account for an increase in PTSD symptoms. Consistent with this explanation, a survey of women who reported rape to be their most upsetting trauma found 45.9% of the women developed PTSD. In contrast, for women who considered physical attacks to be most upsetting trauma, only 21.3% of the women developed PTSD.42 These findings support the notion that there indeed may be something unique to the experience of sexual assault that increases the likelihood of developing PTSD.
Many researchers consider PTSD the most appropriate diagnostic category for experiences associated with intimate partner violence, even though symptoms of other disorders, such as depression, may be present.43,44 Because PTSD and depression overlap, depression detected in some studies may represent symptoms of PTSD.45 Because the essential feature of PTSD is the development of certain symptoms (ie, sleep disturbances, hypervigilance) after exposure to an extreme traumatic stressor,46 experiences after the stress of intimate partner violence can be interpreted as representing PTSD. Conceptualizing abused women's symptoms as reflecting PTSD depathologizes the woman. Because PTSD connects trauma and certain symptoms, it can facilitate understanding and meaningful treatments for abused women.
Finally, the higher PTSD scores among Hispanic women may be related to immigrant status and associated acculturation, because 28% of the women in this study were non–U.S.-born. In a previous study we found first-generation immigrant women experience levels of abuse no different from U.S.-born women, but they lack the resources of English proficiency and education with which to deal with the abuse.47 Further research is needed to explain the connections of acculturation, abuse, and PTSD.
There are limitations of the study that are important in generalizing the findings. The sample was from one urban agency of women who were actively seeking assistance from the justice system. How abused women who use justice services differ from women that do not is unknown and requires further study. Furthermore, the study relied on self-reports that may underreport or overreport due to lack of adequate recall or lack of voluntary disclosure. None of the information on use of justice or medical services was validated with service providers, as were none of the health problems the women attributed to sexual assault.
Additionally, when considering the health outcome data, our study is limited by an absence of information about the women's physical or sexual assault during childhood. Childhood abuse represents a potential confounding factor for later health problems. One study found that abused women in a primary care setting who were abused as children had long-term health consequences over and above what could be attributed to intimate partner violence.34 Another limitation of our study is an absence of trauma history data over the woman's lifetime. Similar to intimate partner violence, all traumas that a woman experiences will affect her physical health. Another study found that 10% of 1,456 adults interviewed in a primary care clinic had experienced a traumatic event in the last year and that 57% experienced at least 1 event in their lifetime.48 This same study documented the traumatic event history, female sex and non-Hispanic ethnicity associated with more psychiatric conditions. Future studies must separate physical from sexual assault and examine the interconnections among childhood abuse, lifetime trauma and violence, intimate partner violence, and physical health problems to better understand the effects of these factors on a woman's health and functioning.
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