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Examining Sexual Assault Survival of Adult Women: Responses, Mediators, and Current Theories

Hellman, Ann MSN, RN

doi: 10.1097/JFN.0000000000000037
Review Article

ABSTRACT The purpose of this article is to examine the state of the science of sexual assault research to direct future research in three key areas: responses, mediators, and current theory with a religious or spiritual focus addressing recovery. Three research questions guided the investigation of literature and the formation of this article: (a) What are common survivor responses to, and long-term effects of, sexual assault?; (b) What are mediators for recovery after sexual assault?; and (c) What theory with a religious or spiritual focus exists to address recovery from sexual assault? This research identifies significant gaps in the literature underscoring the importance of future research that examines responses to and long-term effects of sexual assault, need for mediators during recovery, and need to develop theory using religious and spiritual tenets aiding in recovery from sexual assault. Further research is necessary to develop this science, expand understanding, and support sexual assault survivors on their recovery journey.

Author Affiliations: PhD candidate, East Tennessee State University and Assistant Professor, East Tennessee State University.

The author declares no conflict of interest.

Correspondence: Ann H. Hellman, MSN, RN, 3789 Brookwood Drive, Cookeville, TN 38501. E-mail:

Received December 6, 2013; accepted for publication on July 3, 2014.

Sexual assault (SA), also known as rape and sexual violence, affects thousands of women each year. The 2006–2010 U.S. Department of Justice National Crime Victimization Survey reports that an average of 207,754 victims, aged 12 years and older, experience rape and SA yearly (Bureau of Justice Statistics, 2013). When considering the national female population at large, one in five experiences SA during her lifetime (Centers for Disease Control [CDC], 2013b). Because SA is severely underreported, survivors in the United States likely number greater than 25% of the female population.

SA, in its broadest context, is a widely studied phenomenon; thus, a significant amount of SA literature features studies in areas of forensic examinations (Boykins, 2005; Johnson, Peterson, Sommers, & Baskin, 2012). Campbell (2005, 2006, 2008, 2011, 2012) has published extensively about Sexual Assault Nurse Examiners (refer to reference list for a complete listing of references). Sexual Assault Response Teams received some attention in the literature (Cole, 2011). Additional research has addressed drug-facilitated SA, SA in the military, and posttraumatic stress disorder (PTSD; Bedard-Gilligan, Kaysen, Desai & Lee, 2011; Beynon, Sumnall, McVeigh, Cole, & Bellis, 2006; Clinton-Sherrod, Morgan-Lopez, Brown, McMillen, & Cowell, 2011; DuBosc et al., 2012; Eadie, Runtz, & Spencer-Rodgers, 2008; Ferguson, 2008; Houser, 2007).

Understanding the state of the science of SA research underpins this endeavor and is imperative in guiding future research and directing nurses exploring this phenomenon. The purpose of this article is to examine the state of the science of SA research to direct future research in this area. In congruence with this purpose, three questions guided the literature review: (a) What are the common survivor responses to, and long-term effects of, SA?; (b) What are mediators for recovery after SA?; and (c) What current theories with a religious or spiritual focus address recovery from SA?

The terminology attributed to SA is varied; as such, the following terms were included in the literature search: rape, sexual violence, intimate partner violence, sexual coercion, sexual aggression, and interpersonal violence. The World Health Organization (2014) places the terms “rape” and “sexual violence” under the “violence against women” category. As per the CDC (2014), the term “sexual violence” encompasses rape, SA, sexual abuse, and unwanted sexual contact. Examination of SA, the focus of this article, is viewed separately from the term “intimate partner violence” as it may or may not include the act(s) of SA. Although multiple definitions of SA exist, commonalities among definitions include a sexual act by a person or persons committed upon another without that person’s consent, a sexual act occurring between persons of the same or opposite sex, the existence or absence of a relationship between the perpetrator and survivor at the time of the sexual act, and a list of behaviors that comprise the sexual act (Spohn & Tellis, 2012).

Throughout this article, the term “survivor” is used. The term “survivor” is defined as “a person who continues to function or prosper in spite of opposition, hardship, or setbacks” (, 2013). Moreover, as this article focuses on recovery of individuals who have been sexually assaulted, the term “survivor” is used intentionally as it lends a longitudinal perspective to the discussion and supports the mediating factor of regaining control. For SA survivors, long-term physical, mental, and emotional effects abound. Psychological conditions and behaviors include anxiety, aggression, isolation, and poor self-esteem (Borja, Callahan, & Long, 2006; Creighton & Jones, 2012; Kaukinen & DeMaris, 2005; Littleton, 2007; Miller, Handley, Markman, & Miller, 2010; Ullman & Najdowski, 2011, 2009; Vidal & Petrak, 2007). Additional responses to and long-term effects of SA include avoidance coping, PTSD, depression, suidical ideation, and changes in religious perception. Survivors experience psychosocial issues as manifested in relationship difficulties and the ability to trust themselves and others and experience intimacy issues (Herman, 2001). Multiple physical conditions may follow SA and include chronic diseases; headache; eating disorders; gynecological symptoms; irritable bowel syndrome; and damage to the vagina, urethra, and anus (Morrison, Quadara, & Boyd, 2007). To cope with the aftereffects, many survivors turn to substance use resulting in additional treatment issues (Kaukinen & DeMaris, 2005; Ullman, Starzynski, Long, Mason, & Long, 2008.).

Multiple factors mediate physical, mental, and emotional effects on survivors’ futures. These factors include religious coping, spousal support, social support and reactions, personal beliefs, perceived control, and coping patterns. Of particular interest is the influence of religious coping on recovery. Positive religious coping is germane to SA research. Positive religious coping refers to possessing an understanding of a life plan; viewing their God and church congregation as a source of comfort, acceptance, support, and strength; and using religious practices such as prayer and singing as a means of emotional release (Pargament, Feuille & Burdzy, 2011). Survivors of faith traditions rely on religious coping measures as strongly as other coping measures of cognitive restructuring, denial, reinterpretation, and repression (Frazier, Tashiro, Berman, Stegar, & Long, 2004).

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This literature review examined peer-reviewed, full-text articles in English accessed through multidiscipline databases such as CINAHL, Applied Science and Technology, Criminal Justice Abstracts, Dissertations and Thesis Databases, Health Source: Nursing/Academic Edition, Nursing & Allied Health Collection: Comprehensive, PsycARTICLES, PsycINFO, PubMed, and Women’s Studies International. These articles were published in 2003 and later.

Using the keywords “sexual assault,” “rape,” “recovery,” “religious coping,” “religion,” and “spirituality,” applied in multiple combinations, resulted in 497 different articles. Although the Adverse Childhood Experiences Study conducted by the CDC (2013a) shows that many childhood abuse victims also experience SA, articles failing to isolate participants with only a SA history (i.e., participants with additional traumatic life events such as child abuse, motor vehicle accident, simple assault, etc.), and with populations involving children or men were not included, as the focus of this review was to study the phenomenon of SA specific to adult women. Each article was evaluated for its contributions to the understanding of SA, examinations of survivor responses, effects of SA, mediators for recovery, and references to theories of recovery focusing on religious or spiritual influences, resulting in 23 articles.

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Identified articles were separated into three themes to align with the research questions. Although overlapping of themes occurred, the primary focus of each determined their categorization. Articles were analyzed by author(s) and area of expertise, discipline, publication source, methods used, measures, findings, and contribution to the science.

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Responses and Long-Term Effects

Articles meeting the inclusion criteria and focusing on responses to, and long-term effects of, SA are few (see Table 1). Most focused on use of avoidance coping with many demonstrating how use of avoidance coping, negative belief systems, and negative social reactions contributes to PTSD. With the exception of one qualitative study (Patterson, Greeson & Campbell, 2009), all studies examining long-term effects were retrospective, cross-sectional, and quantitative in design and are from psychology and sociology. With the exception of the Ben-Ezra et al.’s (2010) study, which examined a population of Jewish women, all articles included ethnically diverse research participant samples. All studies used widely accepted and established measures such as Koss and Gidycz’ (1985) Sexual Experiences Survey (Ullman & Najdowski, 2009; Ullman et al., 2007); Goodman, Corcoran, Turner, Yuan, and Green’s (1998) Stressful Life Experiences Survey (Ullman & Najdowski, 2009; Ullman et al., 2007); Donald and Wares’ (1984) Social Reactions Questionnaire of the Rand Health Insurance Experiment (Ullman & Najdowski, 2009; Ullman et al., 2007); and Carver, Scheier and Wentraub (1989) Brief COPE among others (Ullman & Najdowski, 2009; Ullman et al., 2007).



Responses and long-term effects present in studies include anxiety, depression, PTSD, avoidance coping, decreased self-esteem, substance use, and suicidal ideation and attempts. Such responses and long-term effects were influenced by social support (including religious support), others’ perceptions, and the presence of additional traumas and drug use. Overall, the more negative social reactions experienced and more avoidance coping used correlated to higher levels of distress and PTSD.

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Studies focusing on mediators for recovery form the bulk of this article (see Table 2). Most explored the role of social support and perceived control as mediating factors of recovery with moderate assessment of coping and self-blame. Additional coping mechanisms of assimilation, accommodation, and belief in a just world received minimal attention.



Many studies featured an ethnically diverse population. Three studies demonstrated a White majority population, and one study focused on Blacks only (Bryant-Davis et al., 2011; Frazier, 2003; Frazier et al., 2004). Included studies have sample sizes of 62–413 female participants with a median age of 32 years. Both sample size and age range sufficiently addressed the focus population.

Study designs offered little variation. Most studies were retrospective, quantitative, and cross-sectional and arose from psychology and sociology. Gaps in the literature included studies in nursing and those of qualitative and longitudinal design. Other gaps included studies examining the effects of attack disclosure and seeking justice through the justice system. Sample sizes range from 3 to 413. Several studies offered ethnically diverse samples, whereas the Bryant-Davis et al. (2011) study focused on Black survivors (Ahrens et al., 2010; Campbell et al., 2010). No other studies focused on a single ethnic population.

Throughout the studies, mediators centered on four basic themes: positive support (religious, spousal, family, and social), belief in a just world, perceived control, and number of coping strategies used. Overall, the greater amount of positive support resulted in greater psychological well-being with less distress and symptoms of PTSD. Survivors with strong beliefs in a just world attributed their attack to situational circumstances rather than character and behavioral circumstances (Fetchenhauer et al., 2005). The perceived amount of control held by survivors was instrumental in postexperience adjustment. Survivors using a greater number of coping strategies showed lower levels of distress (Littleton, 2007; Littleton et al., 2011).

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Religious- or Spiritual-Focused Theories

When searching for theories with a religious or spiritual focus, only one study matched the inclusion criteria. Whereas others examined both men and women, Duma, Mekwa, and Denny (2007) alone explored the recovery of women during the first 6 months after SA. A grounded theory emerged providing a series of concepts pertaining to spirituality, including awakening, pragmatic acceptance, turning point, reclaiming what was lost, defining own landmarks for healing, and readiness for closure.

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Studies included in this anaysis primarily addressed survivor responses of avoidance coping, use of poor coping mechanisms, and changes in religious beliefs. Study design, tools, and results of the studies supported widely held beliefs regarding SA survivor responses. Social withdrawal, denial, and failing to seek help are all classified as avoidance coping behaviors. Survivors exhibited avoidance coping behaviors when they feared potential harm and negative social reactions and when they possessed a significant amount of self-blame for the assault (Patterson et al., 2009). Such avoidance coping behaviors led to greater PTSD symptoms (Ullman et al., 2007).

Poor coping mechanisms manifested in suicidal ideation and self-harm postassault, presenting challenges to patient care. Multiple factors influenced suicidal ideation: age, ethnicity, sexual identity, amount of trauma, presence of drug use, disclosure of the assault, and perceived control. According to the literature, younger, minority survivors; bisexuals; those experiencing greater overall trauma from the event; and those with histories of drug use showed greater suicidal ideation (Ullman & Najdowski, 2009).

Approximately half of the participants in the study by Ben-Ezra et al. (2010) became less religious after SA. Changes in religious beliefs occurred from shattering of core beliefs of a benevolent, controlled, and just world. This study’s participants comprised one religious group (Jewish women), excluding those with differing religious beliefs. Other research studies focusing on specific religious groups were absent in the literature.

Additional gaps in the literature included religious-specific measuring tools and studies focused on suburban and rural populations. As unique beliefs comprise the worlds’ religions, development of tools to adequately assess changes in belief systems after SA is needed. Religious-specific research is a means to identify survivor responses unique to religious identities and guide creation of appropriate interventions. The study by Patterson et al. (2009) focused on urban populations; thus, its results are not transferable to suburban and rural populations. As belief systems differ between religions, they may also differ between community cultures and geographical locations and need to be assessed. Additional areas of survivor responses lacking in the literature included continued consequences of physical injuries; coping through substance use; changes in belief patterns of self, others, and the world; and effects of SA on sexuality beliefs and practices.

Of studies examining mediators of recovery, sample sizes ranged from 3 to 413. Several studies offered ethnically diverse samples, whereas the study by Bryant-Davis et al. (2011) focused on Black SA survivors (Ahrens et al., 2010). Established tools included Koss and Gidycz’s (1985) Sexual Experiences Survey (Ahrens et al., 2010; Borja et al., 2006; Fetchenhauer et al., 2005; Koss & Figueredo, 2004; Littleton, 2007; Littleton et al., 2011; Miller et al., 2010); Donald and Ware’s (1984) Social Reactions Questionnaire of the Rand Health Insurance Experiment (Ahrens et al., 2010); and the Brief COPE by Carver et al. (1989), among others (Ullman & Najdowski, 2009; Ullman et al., 2007).

Most showed the mediating effects of positive social support, perceived control, and positive religious support. As survivors divulged their attack, how listeners responded determined future incidence sharing, affected relationships, and guided survivors’ feelings of self-blame. If met with support, acceptance, and lack of judgment, survivors showed greater help-seeking behaviors. Thereby, lessening the prevalence and severity of PTSD decreased self-blame, depression, anxiety, and suicidal ideation. Positive social support greatly mitigated detrimental effects of SA.

Positive religious coping behaviors are assessed using the measures of Pargament, Koenig, and Perez’s (2000) RCOPE (Ahrens et al., 2010); Pargament et al.’s (1990) Religious Coping Activities Scale and Pargament et al.’s (1988) Religious Problem-Solving Styles Questionnaire (Frazier et al., 2004); and the Religious Coping subscale of Carver et al.’s (1989) COPE (Bryant-Davis et al., 2011; Frazier et al., 2004; Ullman & Najdowski, 2011). Most religious coping studies featured widely used tools proven valid and reliable with this population. Some lesser-known measures such as Kammann and Flett’s (1983) Positive Affect Subscale of the Affectometer 2, Pearlman’s (1996) McPearl Belief Scale-Revision D, and Resick et al.’s (1986) Veronen–Kilpatrick Modified Fear Survey were also present in the literature (Koss & Figueredo, 2004; Littleton, 2007).

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Multidisciplinary research is necessary to identify common survivor responses, assist survivors in help-seeking behaviors, and guide treatment decisions to facilitate maximum recovery. Collaborative research between healthcare providers and religious leaders would explore more fully the influence of religious coping on recovery. Research with nurses encountering SA survivors has the potential to explore the influence of religious and faith practices on recovery research, as nurses may be the first point of contact when survivors seek help. At present, theory development with religious and spiritual foci and fostering a survivor’s recovery is largely unexplored.

Although the studies included in this review were few, they provided an insight into common responses of adult female survivors. The literature reviewed represents studies exploring avoidance coping, PTSD, depression, and suicidal ideation. Additional research studies are needed to explore the consequences of physical injuries, isolation, self-esteem issues, changes in relationships, and sexuality issues. As most studies were quantitative, qualitative studies would enrich data obtained from survivors. Studies of specific religious groups would contribute information regarding changes in beliefs distinctive to those groups. Studies on specific community and geographic populations are also needed.

Because survivors often feel powerless, regaining control of body, life, and environment diminishes the ill effects and promotes positive recovery. In her seminal study, Frazier (2003) examined evolving perceptions of control postattack. The degree of regaining control varied among participants and warrants further research to identify methods encouraging earlier regaining of control. In addition, Frazier corroborated the relationship between perceived control and positive social support. Increased perceptions of control over recovery arose from positive social support, decreasing avoidance coping, depression, anxiety, suicidal ideation, and PTSD.

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During the past 10 years, studies investigating mediating factors of recovery from SA number greater than studies examining survivor’s responses. However, additional research for other mediators is needed in this area. Additional qualitative studies will contribute to further exploration of this phenomenon. Because recovery is a linear and time-burdened process, longitudinal studies are needed to examine the recovery process. As most studies presented in this article are cross-sectional, longitudinal assessments of the mediating factors of social support, perceived control, and religious coping are warranted.

Researchers must address the role of religious coping as used by survivors of multiple religions to gain a better understanding of the influence of religion on recovery. Given that the limited research that is available regarding the role of religion in mediating the effects of SA is strongly supported, validation of its use must be proven to facilitate widespread application.

The state of the science of SA reveals a small body of literature with significant gaps. The few articles meeting the inclusion criteria underscore the importance of future research examining responses to, and long-term effects of, SA. To isolate the phenomenon of SA of adult women, studies that featured mixed gender populations and those experiencing multiple or mixed traumas were excluded. Future research focusing on female-only populations with appropriate research designs investigating the isolated phenomenon of SA is profoundly needed.

As noted, significant gaps in the literature exist. The mediating factors of perceived control and social support are not fully explored. Theory exploring spirituality and religious contributors to recovery is lacking as only one theory specifically addressing this mediator was identified. Numbers of longitudinal and qualitative studies are few. Ethnic-specific inquiries are limited and important with such studies offering insight into whether particular survivor groups respond in unique ways.

Although the research questions guiding this state of the science were addressed, it is apparent that multiple trajectories of SA research remain. The need for additional researchers to further explore this phenomenon is paramount. To increase our understanding of survivors’ recovery after SA, and to best support them on their recovery, further research is warranted.

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                        long-term effects; mediators; sexual assault; state of the science; theory

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