Unit5Assign

Unit5Assign1TMHS

Due Aug 10th

Literature Review

Theories are important because they guide our human service practice. Theories enable us to see things from new angles and different perspectives. They help us to understand our social environment and explain behavior. Theories provide us a framework or lens through which we can view social problems.

For this assignment, you will select 2–3 human service theories that relate to your case study created in Unit 3. The theories selected should help to explain the scenario created in the case study. The paper should provide an analysis of the selected theories and how they support the case study.

Refer to the APA Style and Format link in the Resources for guidance on formatting all assignments in this course.

Requirements

Turnitin: Submit your assignment to Turnitin and upload your Report of Similarity along with your assignment.
Font: 12-point Times or Times New Roman, double-spaced.
Writing: Writing should be clear, organized, and free of errors; it should also follow professional standards.
Research: Use at least four academic sources; at least two of those sources should not be course materials.
Length: Your paper should be 3–4 pages, not including the cover page or reference page.
Format: Follow current APA style and formatting guidelines.

Make sure to review the scoring guide for this assignment to familiarize yourself with the criteria on which you will be assessed.

Sexual Violence Victimization and Associations with Health

in a Community Sample of African American Women

Kathleen C. Basile, Sharon G. Smith, Dawnovise N. Fowler, Mikel L. Walters,

and Merle E. Hamburger

Division of Violence Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia, USA

ABSTRACT

Limited information exists on the relationship between sexual

violence victimization and health among African American

women. Using data from a community sample of African

American women, we examine the association between current

health and lifetime experiences of sexual violence. Inperson

interviews were completed in 2010. Among interviewees,

53.7% of women reported rape victimization and 44.8%

reported

sexual coercion

in their lifetime. Victims of rape or

sexual coercion were significantly

likely to report depression

and posttraumatic stress disorder during their lifetime.

Among victims whose first unwanted sexual experience was

rape

or sexual coercion

, perpetrators were mostly acquaintances

and intimate partners, and over one third were injured

and needed services. More attention is needed on the health

needs of African American women and their association to

victimization status.

ARTICLE HISTORY

Received 15 September

2014

Revised 26 May 2015

Accepted 29 May 2015

KEYWORDS

Help-seeking; negative

health experiences; rape;

sexual coercion

Although sexual violence (SV) occurs across all ethnic and racial groups,

research has increasingly pointed to the prevalence and adverse health outcomes

of SV among specific groups, such as African American women and

other ethnic and racial minorities (Black et al., 2011; Bryant-Davis, Ullman,

Tsong, Tillman, & Smith, 2010; Lacey, McPherson, Samuel, Sears, & Head,

2013; Young & Boyd, 2000). Due to the limited number of studies and the

complex nature and consequences of SV victimization for African American

women, further research is needed.

There is a substantial literature focused on the health-related consequences

of SV (Lang et al., 2003; Smith & Breiding, 2011). Prior work has shown, for

example, that sexually victimized women are more likely to experience many

chronic health conditions, HIV risk factors, smoking, and excessive drinking

(Smith & Breiding, 2011). But most of the literature comes from population

samples that are not large enough to stratify by race or ethnicity. As a result,

less is known about the extent to which particular racial and ethnic groups,

CONTACT Kathleen C. Basile kbasile@cdc.gov Centers for Disease Control and Prevention, National Center

for Injury Prevention and Control, Division of Violence Prevention, Mailstop F64, 4770 Buford Highway, Atlanta, GA

30341-3724.

JOURNAL OF AGGRESSION, MALTREATMENT & TRAUMA

2016, VOL. 25, NO. 3, 231–253

http://dx.doi.org/10.1080/10926771.2015.1079283

This article not subject to US copyright law

including African American women SV

survivors

, experience these types of

negative health indicators. In this study, SV victimization status and specific

health associations are identified (e.g., mental, physical, and behavioral health

conditions, and postvictimization services received) in a community sample

of African American women.

Definitional components

The literature on SV uses various terms and definitions to examine this

public health problem, including sexual assault, sexual coercion, and rape.

These terms often overlap in definitions and are used interchangeably. For

the purpose of this study, SV includes physically forced nonconsensual

completed or attempted penetration, penetration when the victim was not

able to consent because she was passed out or asleep (rape), or unwanted

penetration that is not physically forced (sexual coercion; Basile, Smith,

Breiding, Black, & Mahendra, 2014).

The extent of SV among African American women

Despite the large body of literature examining SV, large nationally representative

studies focusing specifically on racial and ethnic minority women are limited.

Further, much of the previous scholarship that does exist on SV of African

American women is focused on rape and other penetrative SV acts (i.e., sexual

coercion), perhaps given the seriousness of these kinds of SV victimization and

their association with adverse health. Some national prevalence studies have

examined rape by racial and ethnic identity. For example, the National Violence

Against Women Survey (NVAWS) found that 18.8% of African American

women had experienced rape in their lifetime (Tjaden & Thoennes, 1998). A

study using data fromthe National Crime Victimization Survey found that from

2005 to 2010, approximately 3 African American women per 1,000 reported

experiencing sexual assault since age 12 (Planty, Langton, Krebs, Berzofsky, &

Smiley-McDonald, 2013). Kilpatrick, Resnick, Ruggiero, Conoscenti, and

McCauley (2007) conducted a national telephone study using both community

and college samples. These samples reported that African American women

reported higher rates of lifetime forcible rape than non-Hispanic White women,

Hispanic women, and Asian women. More recently, the National

Intimate

Partner and Sexual Violence survey (NISVS) found that 13.6% of Hispanic

women, 21.2% of non-Hispanic Black women, 20.5% of non-Hispanic White

women, and 27.5% of American Indian/Alaska Natives reported experiencing

rape during their lifetime (Breiding et al., 2014). Several smaller studies have also

focused on the differences in SV by race or ethnicity. Molitor, Ruiz, Klausner,

and McFarland (2000) recruited young women from a community sample of

low-income neighborhoods in five counties in California. Of more than 2,500

232 K. C. BASILE ET AL.

young women, 24.

reported they had experienced forced sex (30.0% of

African Americans, 32.0% of Whites, 14.4% of Hispanics, and 30.0% of multiracial

women). The aforementioned studies illustrate the range of SV prevalence

across samples of racial and

ethnic minority women.

Despite such variation,

findings consistently reveal a high burden of SV victimization among African

American women and other racial and ethnic minority groups. Given this

burden, it is imperative to explore the health of African American women SV

survivors as it can improve our understanding of the risks for this population,

and ultimately informthe development of effective interventions to address their

needs.

Health risks and adverse conditions for African American women SV

survivors

A substantial body of literature documents the risks of SV victimization to

physical, mental, and behavioral health, indicating that SV survivors are more

likely to experience adverse health compared to non-SV victims (Koss, Koss, &

Woodruff, 1991; McFarlane et al., 2005; Pico-Alfonso et al., 2006; Rivara et al.,

2007). Moderate to high rates of SV (e.g., 22%–100%) are reported in various

samples of predominantly African American women, including substance abuse

treatment recipients (Young & Boyd, 2000), low-income samples (Boyd,

Henderson, Ross-Durow, & Aspen, 1997; Bryant-Davis et al., 2010; Dailey,

Humphreys, Rankin, & Lee, 2011; Kalichman, Williams, Cherry, Belcher, &

Nachimson, 1998), and military veterans (Campbell, Greeson, Bybee, & Raja,

2008).

Adverse mental and behavioral health

Depression, posttraumatic stress disorder (PTSD), substance use disorders

(SUDs), and suicidality are common mental and behavioral health problems

among SV survivors in general (Alim et al., 2006; Caetano & Cunradi, 2003;

Iverson et al., 2013; Ramos, Carlson, & McNutt, 2004). In a U.S. national

sample, a history of SV has been found to be associated with anxiety

disorders, mood disorders, PTSD, SUDs, and suicide attempts (Iverson

et al., 2013). Studies focusing on the mental and behavioral health of

African American female SV survivors in particular are limited, and the

studies that exist usually rely on urban, low socioeconomic status (SES), or

drug-abusing samples (Boyd et al., 1997; Bryant-Davis, Chung, & Tillman,

2009; Bryant-Davis et al., 2010; Campbell et al., 2008; Vaszari, Bradford,

CallahanO’Leary, Ben Abdallah, & Cottler, 2011). For example, in a community

sample of low-income, ethnically diverse women (N = 835), Temple and

colleagues (2007) found that sexual assault by current partners and nonpartners

was a significant predictor of PTSD symptoms for African American

JOURNAL OF AGGRESSION, MALTREATMENT & TRAUMA 233

women. Depression is consistently found to be a health risk for African

American SV survivors (Alim et al., 2006; Ramos et al., 2004). Data from

462 women (87% African American) who were cocaine users showed that

43.3% reported sexual assault victimization. Among the African American

women in the sample, 85% reported suicidal ideation. Similarly, in terms of

comorbidity, in a sample of African American women recruited from an

urban hospital (n = 335), Thompson and colleagues (2000) found that

women with a history of child sexual abuse and current PTSD symptoms

were more likely than women without a child sexual abuse history or PTSD

to attempt suicide.

Although a concern for all survivors, adverse mental health and substance

use problems could be particularly problematic for African American women

SV survivors due to their risk for multiple, overlapping public health problems

and conditions (Bryant-Davis et al., 2010). For example, Bryant-Davis

and colleagues (2010) explored the relationship between poverty and mental

health outcomes in an urban community sample of African American female

SV survivors (N = 413). Positive relationships were found between poverty

and depression, PTSD, and illicit drug use in the sample.

Other adverse conditions and life consequences

A body of studies with samples of African American women either examined

the role of income or poverty as a correlate of SV (Bryant-Davis et al.,

2010; Ingram, Corning, & Schmidt, 1996), or included high numbers of

respondents with both low SES and high rates of SV victimization

(Kalichman et al., 1998; McFarlane et al., 2005; Temple et al., 2007;

Vaszari et al., 2011). Due to no or low income, African American women

with low SES are often resigned to homelessness or low-income housing in

communities where they are at increased risk for multiple violence exposures

(Abbey, Parkhill, Jacques-Tiura, & Saenz, 2009; Jenkins, 2002). In

addition to housing insecurity, food insecurity is another potentially related

adverse condition for impoverished African American women SV survivors.

Although food insecurity, as a factor of poverty, has not been directly

explored in the literature, it is related to women’s ability to meet their own

as well as their children’s basic needs. Overall, poverty and low SES are

associated with increased rates of SV among African American women

(Byrne, Resnick, Kilpatrick, Best, & Saunders, 1999; Honeycutt, Marshall,

& Weston, 2001; Kalichman et al., 1998).

Help-seeking and service needs

The help sources typically sought by SV survivors include reporting

assaults to police, obtaining protection orders (POs), receiving emergency

234 K. C. BASILE ET AL.

medical services (EMS) and emergency trauma department care, turning to

social support networks, and, in some cases, seeking mental health services

and victim shelter services (Bryant-Davis, Ullman, Tsong, & Gobin, 2011;

Kothari et al., 2012). Yet, the majority of all sexual assaults are not

reported or shared with social services or law enforcement (Hanson

et al., 2003), and often survivors who need medical care and counseling

do not receive it (Resnick et al., 2000). National data indicate that approximately

one fourth (26.2%) of adult rape survivors seek medical care after

the assault (Resnick et al., 2000). The National Crime Victimization Survey

(NCVS) estimates that in 2010 only 35% of the sexual assaults experienced

by women (regardless of their relationship to the perpetrator) were

reported to police (Planty et al., 2013).

Relatively few studies have investigated post-SV help-seeking characteristics

and correlates specifically among African American women SV survivors

(Zinzow, Resnick, Barr, Danielson, & Kilpatrick, 2012). A small number of

researchers have focused on increasing the attention in the literature on what

Bryant-Davis and colleagues (2011) called the “cultural context of sexual

assault recovery” (p. 1602). For example, Flicker et al. (2011) investigated

the differential impact of concomitant forms of violence (sexual violence,

stalking, and psychological aggression) and ethnicity on help-seeking behaviors

of female partner abuse survivors. The authors found racial differences

related to specific help-seeking behaviors. For example, African American

women survivors were more likely to seek police help and orders of protection

compared to White women, which appears to be consistent with other

findings (Bachman & Coker, 1995; Lipsky, Caetano, & Roy-Byrne, 2009;

Pearlman, Zierler, Gjelsvik, & Verhoek-Oftedahl, 2003). Yet, Kothari et al.

(2012) found, in a sample of women survivors of partner violence (including

SV) for which the police were involved, that African American women

survivors were less likely to obtain protective orders than White women

survivors. Such inconsistencies suggest the influence of contextual and cultural

factors on the help-seeking behaviors of women survivors (Bent-

Goodley, 2007; Boykins et al., 2010).

In terms of contextual factors, the nature of the rape experience seems to

matter. Boykins and colleagues (2010) found that Black women SV survivors

were more likely to have reported weapons used in their assaults and use of

illicit drugs when compared to White women survivors. The context of the

rape incident and experience could affect African American women survivors’

propensity to seek help from the emergency department as a primary

source of care for this population (Boykins et al., 2010; Koss et al., 1991) over

other types of help sources, as well as the experience of weapon-inflicted

injuries requiring such specific care.

Similarly, cultural factors and values can also influence help-seeking.

Culturally preferred sources of help, for example, for African American

JOURNAL OF AGGRESSION, MALTREATMENT & TRAUMA 235

women generally come from informal support networks of family and

friends, and faith-based resources and activities instead of more formal

help sources such as mental health counseling (Bent-Goodley & Fowler,

2006; Bryant-Davis et al., 2011; Henning & Klesges, 2002). Taken together,

more information is needed to better understand the victimization experiences,

related risks, and help-seeking characteristics (i.e., types of services

sought and obtained) for African American women SV survivors.

This study

The purpose of this study is to share findings from a community sample of

African American women about their rape and sexual coercion victimization

and its association with numerous negative mental and physical health

indicators as well as health-related behaviors. This study also builds on

previous studies that have addressed SV-related health risks in this population.

Findings from this study provide an in-depth examination of the health

burden associated with penetrative forms of SV victimization among a racial

and ethnic group of women for which little information is available on

health-related associations.

Methods

Participants

For this study, 168 African American women completed a face-to-face

paper-and-pencil interview. Eligibility requirements for this study were

being female, English-speaking, African American, and 18 years or older.

Descriptive analyses were conducted using the full sample. The women’s

ages ranged from 18 to 93 years old, with an average age of 48. Forty-two

percent (42.4%) of the sample was never married. Sixty-eight percent

(68.3%) completed high school or greater. The women’s total household

incomes varied, but tended to be low: 29.1% of participants reported an

annual income of less than $5,000; 12.7% reported an annual income of

$5,000 to $9,999; 12.1% reported annual income of $10,000 to $14,999,

17.6% reported earning between $15,000 and $24,999, 16.4% reported

annual income of $25,000 to $49,999, and 12.1% reported earnings of

$50,000 or greater.

Procedures

To ensure that interview questions were clearly interpreted and the instrument

was culturally appropriate, a pilot test of an African American sample

of women was conducted and the instrument was fine-tuned. To locate

236 K. C. BASILE ET AL.

African American women to complete the main study interviews, African

American urban neighborhoods in a Southeastern U.S. city and addresses

within those neighborhoods were randomly chosen and interviewers went

to those addresses to determine whether eligible women lived there. A total

of 322 women were screened for eligibility for the study, and 219 women

were deemed eligible. Of them, 168 women were interviewed for a completion

rate of 76.7%. Potential participants were initially told that the study

was about women’s health and well-being. As a safety precaution, interviewers

were instructed to reveal the specific nature of the survey—sexual

violence—only to the selected participant in a safe, private location.

Interviews were conducted between May and July 2010. The interviews

were conducted in person in a private location (most often at the participant’s

home) and lasted from 20 minutes to 2 hours, depending on the

participant’s experiences with SV. All women in the study received $20 as a

token of appreciation. Interviewers read the questions and response options

to participants or showed them a card with a list of the response options

pertaining to the question being asked.

Measures

Participants were asked a range of questions about their health and SV

victimization, including rape and sexual coercion. For all items, responses

of “don’t know” were recoded as missing.

History and tactics of SV

To determine their history of SV victimization, women were asked how

many times in their life they experienced a form of completed or attempted

sex (vaginal, anal, or oral) that was unwanted. Rape items consisted of

completed or attempted sex after a perpetrator used physical force or

threats of physical harm; gave the victim drugs or alcohol; or when the

sex occurred when the victim was passed out, asleep, drunk, or high (and

unable to provide consent to sex). Sexual coercion items consisted of

completed sex after a perpetrator did any of the following: told lies, made

false promises about the future, or threatened to end a relationship or

spread rumors; wore down the victim by repeatedly asking for sex; or

used his or her influence or authority to make the victim engage in

unwanted sex.

For all SV items, response options were never, 1 time, 2 to 5 times, 6 to 10

times, and more than 10 times. Responses were recoded into dichotomous

responses to indicate whether the respondent was ever victimized: 0 = never;

1 = 1 time, 2 to 5 times, 6 to 10 times, or more than 10 times.

JOURNAL OF AGGRESSION, MALTREATMENT & TRAUMA 237

Negative health behaviors and financial concerns

Alcohol and drug use

. All participants were asked (a) how often they

engaged in binge drinking and (b) how often they used illegal drugs or

misused prescription drugs in the past 12 months. Response options for

each question were 0 = never, 1 = less than monthly, 1 = monthly,

2 = weekly, 3 =

daily

or almost daily and recoded into 1 = yes, any use

and 0 = no use.

Food and housing insecurity

. All participants were asked questions

regarding how often they were worried or stressed about (a) their ability to

pay their rent or mortgage, and (b) to buy nutritious meals during the

previous 12 months. Response options for each question were always,

usually, sometimes,

rarely

, never, or don’t know and recoded into 1 = yes,

any worry and 0 = no worry.

Lifetime mental health conditions

Depression and suicidality. Participants were asked to indicate whether

they ever felt sad, down, or hopeless almost every day for 2 weeks or more,

had little interest or pleasure in doing things almost every day for 2 weeks or

more, seriously considered attempting suicide, or actually attempted suicide.

Response options were coded dichotomously:

1 = yes, 0 = no.

PTSD. Participants were asked to indicate whether they ever had an

experience that was so frightening, horrible, or upsetting that for at least

1 month they had nightmares about it or thought about it when they did not

want to; tried hard not to think about it or went out of their way to avoid

situations that reminded them of it; were constantly on guard, watchful, or

easily startled; or felt numb or distant from others, activities, or their

surroundings. Response options were coded

dichotomously: 1 = yes, 0 = no.

First unwanted sexual experience was rape or sexual coercion

Among participants who endorsed any item of rape or sexual coercion

during their lifetime, we focused on those victims whose first unwanted

sexual experience was rape or sexual coercion. Several variables were analyzed

for this subset.

Age of victim. Age at first rape or sexual coercion was measured using the

following response options: 12 or younger, 13 to 17, 18 to 29, 30 to 44, 45 to

59, 60 to 64, 65 or older, and don’t

know.

Age of perpetrator. Age of the perpetrator during the victim’s first rape or

sexual coercion was measured using the following response options: 12 or

238 K. C. BASILE ET AL.

younger, 13 to 17, 18 to 29, 30 to 44, 45 to 59, 60 to 64, 65 or older, and don’t

know.

Type of perpetrator. Participants were asked to indicate how they knew

the perpetrator. Four types of perpetrators were used to categorize responses:

(a) intimate partner: current or former boyfriend, girlfriend, romantic partner,

or significant other; current or former legal spouse, including common

law; or someone they were dating but who they would not label as a

boyfriend or girlfriend; (b) friend/acquaintance: friend; acquaintance; someone

they were on a first date with; someone in a position of power or trust

(e.g., employer, teacher, clergy, police officer); or someone else they knew; (c)

family member; and (d) stranger.

Physical

health conditions and services related to their first unwanted sexual

experience which resulted in rape or sexual coercion

Injury. Participants were asked to indicate whether they experienced

injuries from the rape or sexual coercion that resulted from their first

unwanted sexual experience.

Participants were specifically asked whether

they experienced minor bruises or scratches; cuts, major bruises, or black

eyes; broken bones or teeth; being knocked out after getting hit, slammed

against something, or choked; or other injuries. Response options for each

type of injury

were coded dichotomously: 1 = yes, 0 = no.

STD/HIV. In separate questions, participants were asked to indicate

whether they contracted a sexually transmitted disease or whether they

contracted HIV from the rape or sexual coercion that resulted from their

first unwanted sexual experience.

Response options were coded dichotomously:

1 = yes, 0 = no.

Pregnancy and outcome of pregnancy. Participants were asked to indicate

whether (yes–no) they got pregnant from the rape or sexual coercion that

resulted from their first unwanted sexual experience. If they answered yes,

they were asked what happened to the pregnancy. Response options were

birthed and kept the baby, birthed the baby and placed him or her for

adoption, had a miscarriage, had an abortion, or don’t know. In addition,

participants were asked whether they lost an existing pregnancy as a result of

their first experience of rape or sexual coercion; response options were coded

dichotomously: 1 = yes, 0 = no.

Rape kit exam. Participants were asked to indicate whether they underwent

a rape kit exam after the rape or sexual coercion that resulted from their

first unwanted sexual experience: Did a doctor or nurse take any physical

JOURNAL OF AGGRESSION, MALTREATMENT & TRAUMA 239

evidence from you (for example, samples of bodily fluid for a “rape kit”)?

Response options were coded dichotomously: 1 = yes, 0 = no.

Medical services, care, and hospitalization. Participants were asked to

indicate whether they needed medical care from a doctor or nurse due to

the rape or sexual coercion that resulted from their first unwanted sexual

experience. If they indicated yes, then they were asked if they were able to get

the medical care they needed. In addition, participants were asked to indicate

whether they have to stay at a hospital or get other inpatient medical care as a

result of their experience of rape or sexual coercion. Response options for all

questions were coded dichotomously: 1 = yes, 0 = no.

Mental health services. Participants were asked to indicate whether they

needed mental health care from a therapist, counselor, or other mental health

care provider due to the rape or sexual coercion that resulted from their first

unwanted sexual experience. If they indicated yes, then they were asked if

they were able to get the

mental health services they needed.

Response

options for all questions were coded dichotomously: 1 = yes, 0 = no.

Other services. Participants were asked to indicate whether they needed

housing services, community services, victim’s advocate services, and

whether someone contacted the police due to the rape or sexual coercion

that resulted from their first unwanted sexual experience. Response options

were coded dichotomously: 1 = yes, 0 = no.

Other consequences of the first unwanted sexual experience which was rape

or sexual coercion

Participants were asked to indicate whether they felt safe in the neighborhood

where they lived, whether they missed work, whether they stayed with

family members or friends, and whether they relocated from the area in

which they lived due to the rape or sexual coercion that resulted from their

first unwanted sexual experience. Response options were coded dichotomously:
1 = yes, 0 = no.

Analyses

First, we conducted descriptive analyses to verify racial identification. Three

participants were removed from the analysis sample because they did not

identify as African American, bringing the final sample to 165. Next, we

conducted analyses to determine the percentage of women from this community

sample who experienced rape, sexual coercion, or both in their

lifetime. Next, we performed chi-square analyses to test for a relationship

among mental health experiences, alcohol and drug use, and financial

240 K. C. BASILE ET AL.

concerns and lifetime rape or sexual coercion victim status. Second, we

examined more closely the use of alcohol and drugs, and financial concerns

among lifetime victims of rape or sexual coercion

. Finally, we provide

descriptive statistics regarding the characteristics and outcomes of women’s

first unwanted sexual experience that was rape or sexual coercion.

Results

Lifetime experiences of rape or sexual coercion in full sample

In the full sample, over half of participants indicated they were victims of

rape, sexual coercion, or both. More specifically, 53.7% of women reported

rape victimization and 44.8% reported sexual

coercion in their lifetime.

About 42% (42.3%) of the full sample experienced both rape and sexual

coercion in their lifetime.

Mental health experiences

Overall, 63.8% of the full sample experienced at least one symptom of PTSD,

and 50.0% experienced at least one symptom of depression during their lifetime.

Chi-square tests were performed, which revealed statistically significant

relationships between victimization status of lifetime experience of rape or

sexual coercion and individual symptoms of PTSD and depression (see

Table 1); lifetime experience of rape or sexual coercion and any symptom of

PTSD, χ2(1, N = 163) = 13.7986, p = .001; and lifetime experience of rape or

sexual coercion and any symptom of depression, χ2(1, N = 164) = 22.2826,

p = .001.

In addition, 20.9% of women in the full sample seriously considered

suicide during their lifetime; among those women, 88.2% also had a history

Table 1. Lifetime Mental Health Experiences by Victim Status of Rape or Sexual Coercion.

Participant has experienced

Victim Nonvictim Total

% n % n N Chi-square

PTSD symptoms (any) 67.31% 70 32.69% 34 104 13.7986*

Nightmares 72.41% 42 27.59% 16 58 9.3428**

Avoided situations that reminded her 68.67% 57 31.33% 26 83 9.7904**

Constantly on guard or easily startled 71.64% 48 28.36% 19 67 11.5359*

Felt numb or distant from others or activities 75.00% 45 25.00% 15 60 14.1523*

Depression symptoms (any) 74.39% 61 25.61% 21 82 22.2826*

Felt sad, down, or hopeless for 2 weeks or more 76.81% 53 23.19% 16 69 20.7523*

Little interest or pleasure in doing things for 2 weeks or

75.71% 53 24.29% 17 70 18.5358*

Note: Percentages represent proportion of victims or nonvictims of rape or sexual coercion who endorsed

the mental health experience. PTSD = posttraumatic stress disorder.

*p < .001. **p < .01.

JOURNAL OF AGGRESSION, MALTREATMENT & TRAUMA 241

of rape or sexual coercion in their lifetime. Among only the women who

seriously considered suicide, 41.2% actually attempted suicide. Among

women who both seriously considered and attempted suicide, 92.9% were

also victims of rape or sexual coercion in their lifetime.

Negative health behaviors and financial concerns in previous 12 months

Food and housing insecurity

In the full sample, 55.2% and 73.9% of participants indicated that they

worried about their ability to buy nutritious meals and pay their rent or

mortgage during the past 12 months, respectively. Chi-square tests revealed

significant relationships between rape or sexual coercion victimization

status and both food and housing insecurity: 66.3% of victims and 40.3%

of nonvictims were concerned about their ability to buy nutritious meals

during the previous year, χ2(1, N = 164) = 11.0490, p = .001. In addition, the

chi-square analysis indicated that 81.5% of victims and 63.9% of nonvictims

worried about their ability to pay their rent or mortgage during the

previous year, χ2(1, N = 164) = 6.4917, p = .011.

Alcohol and drug use

In the full sample, 42.9% and 14.0% of participants engaged in binge

drinking and illegal drug use or prescription drug misuse during the past

12 months, respectively. A chi-square test revealed a significant association

between rape or sexual coercion victimization status and binge drinking in

the past 12 months: 49.5% of victims and 33.8% of nonvictims engaged in

binge drinking during the previous 12 months, χ2(1, N = 162) = 3.9938,

p = .046. Chi-square tests were not performed on drug use due to low cell

sizes.

Experiences among victims of lifetime rape or sexual coercion

In this section the findings presented are among lifetime victims of rape or

sexual coercion only (n = 92).

Negative health behaviors and financial concerns in previous 12 months
among lifetime victims of rape or sexual coercion

Alcohol and drug use. Among lifetime victims of rape or sexual coercion,

a total of 49.5% indicated that they engaged in binge drinking (i.e., drank 4 or

more alcoholic beverages on one occasion) at some point in the previous

12 months on a monthly, weekly, or daily basis. Additionally, 10.9% reported

that they engaged in illegal drug use/prescription drug misuse on a daily or

almost daily basis in the last 12 months (see Figure 1).

242 K. C. BASILE ET AL.

Food and housing insecurity. Among lifetime victims of rape or sexual

coercion, 81.5% were concerned about paying their rent or mortgage, and

66.3% were concerned about their ability to pay for nutritious meals during

the previous 12 months (see Figure 2).

Characteristics of victims whose first unwanted sexual experience was rape

or sexual coercion

Victims were asked a series of questions about their first unwanted sexual

experience, such as their age when it happened and the person who victimized

them. Here, we focus on those whose first unwanted sexual experience

was rape or sexual coercion (n = 80).

Of the 80 women who reported that rape or sexual coercion occurred

during their first unwanted sexual experience, 73.4% (n = 58) reported that

10%

20%

30%

40%

50%

60%

70%

Never Sometimes or

rarely

Always or usually

Rent

Meals

Figure 2. Financial concerns among lifetime victims of rape or sexual coercion, previous 12

months (N = 92).

0%
10%
20%
30%
40%
50%
60%
70%

80%

Never Monthly or less Weekly Daily or almost

daily

Binge drinking

Drug use

Figure 1. Alcohol and drug use among lifetime victims of rape or sexual coercion, previous 12

months (N = 92).

JOURNAL OF AGGRESSION, MALTREATMENT & TRAUMA 243

the violence occurred when they were under the age of 18. In Figure 3 we

present the women’s ages at their first unwanted sexual experience resulting

in rape or sexual coercion.

Age and type of perpetrator. Among the women who reported a rape or

sexual coercion as their first unwanted sexual experience, perpetrators were

male (98.8%), the same race (96.3%), and known (90.0%) to the women in

some capacity. We examined the victims’ age and type of perpetrator

during their first unwanted sexual experience resulting in rape or sexual

coercion. Among victims who were 12 and younger, perpetrators were

mostly friends or acquaintances (46.2%) or family members (42.3%). Of

victims who were 13 to 17, perpetrators were mostly friends or acquaintances

(53.1%) or intimate partners (28.1%). Among those who were 18 to

29, perpetrators were mostly intimate partners (47.1%) or friends or

acquaintances (41.2%). Finally, among victims who were 30 to 44, perpetrators

were split between intimate partners (50.0%) and friends or

acquaintances (50.0%). See Table 2.

Consequences experienced by women whose first unwanted sexual

experience resulted in rape or sexual coercion

Physical health outcomes. Among women whose first unwanted sexual

experience resulted in rape or sexual coercion, 39.7% of victims suffered

injuries (ranging from minor cuts to being knocked out). Approximately 4%

(3.8%) and 8% (7.8%) reported contracting HIV or a sexually transmitted

disease, respectively. In addition, 17.9% of victims became pregnant as a

result of this experience (see Table 3).

32.9%

40.5%

21.5%

5.1%

12 & younger

13-17

18-29

30-44

Figure 3. Age at victim’s first unwanted sexual experience: Victims of rape or sexual coercion

(N = 79). One participant was excluded because she could not recall her age at the time of her

first unwanted sexual experience.

244 K. C. BASILE ET AL.

Table 3. Consequences of First Unwanted Sexual Experience (Rape or Sexual Coercion).

Yes No

Consequences % n % n

Physical

Injured 39.7% 31 60.3% 47

Minor bruises or scratches 93.6% 29 6.4% 2

Cuts, major bruises or black eyes, knocked out 40.0% 12 60.0% 18

Contracted HIV 3.8% 3 96.2% 76

Contracted a sexually transmitted disease 7.8% 6 92.2% 71

Lost existing pregnancy 3.0% 2 97.0% 65

Became pregnant 17.9% 12 82.1% 55

Birthed and kept the baby 58.3% 7 41.7% 5

Miscarriage 25.0% 3 75.0% 9

Abortion 16.7% 2 83.3% 10

Services

Needed medical services 35.1% 27 64.9% 50

Able to get medical services 55.6% 15 44.4% 12

Hospital stay 5.1% 4 94.9% 74

Rape kit exam was performed 15.4% 12 84.6% 66

Needed mental health services 36.2% 29 63.8% 51

Able to get mental health services 51.7% 15 48.3% 14

Needed community services 13.9% 11 86.1% 68

Needed housing services 12.8% 10 87.2% 68

Needed victim advocacy services 12.8% 10 87.2% 68

Police were contacted 26.3% 21 73.7% 59

Daily life

Stayed with family or friends afterward 38.0% 30 62.0% 49

Relocated or changed residence afterward 32.5% 26 67.5% 54

Missed work afterward 6.3% 5 93.7% 75

Felt unsafe in neighborhood afterward 42.3% 33 57.7% 45

Table 2. Victim Age and Perpetrator Type Among Those Whose First Unwanted Sexual

Experience was Rape or Sexual Coercion.

Intimate

partner Family

Friend or

acquaintance Stranger

n % n % n % n % Total N

12 and younger 1 3.9 11 42.3 12 46.2 2 7.7 26

13–17 9 28.1 2 6.3 17 53.1 4 12.5 32

18–29 8 47.1 0 0.0 7 41.2 2 11.8 17

30–44 2 50.0 0 0.0 2 50.0 0 0.0 4

Note: N = 79. One participant was excluded because she could not recall her age at the time of her first

unwanted sexual experience.

JOURNAL OF AGGRESSION, MALTREATMENT & TRAUMA 245

Services sought and obtained. The women whose first unwanted sexual

experience resulted in rape or sexual coercion sought a variety of services,

including medical care, mental health care, community services, housing,

victim advocacy, and police assistance. Findings revealed that 35.1% of

victims needed medical services, and of them, 55.6% were able to obtain

those services; 15.4% of all victims underwent a rape kit exam. Over one

quarter of victims (26.3%) stated that the police were contacted after the

incident. Moreover, 36.2% reported that they needed mental health services,

and about half (51.7%) of those were able to obtain them. Approximately

13% to 14% needed services provided by the community (13.9%), housing

(12.8%), or victim advocacy (12.8%; see Table 3).

Other consequences. Women whose first unwanted sexual experience

resulted in rape or sexual coercion were asked about other consequences

that affected their daily lives after this first unwanted experience. About 6%

(6.3%) of victims missed work because of the incident. Additionally, 42.3%

stated that they felt unsafe in their neighborhood afterward. Thirty-eight

percent of victims reported that they stayed with family or friends, and 32.5%

decided to relocate or move from their residence.

Discussion

African American women are victims of SV at high rates, as consistently

evidenced by previous national prevalence studies (Black et al., 2011;

Breiding et al., 2014; Tjaden & Thoennes, 1998). There is less information

available about the health associations linked to SV victimization for African

American women in particular. Understanding the physical and mental

health correlates and impact of SV among specific segments of the population

at high risk (i.e., African American women) is important to (a) better

contextualize the SV victimization experience, and (b) help inform and tailor

prevention efforts. Although the focus of this study is on a relatively small

community sample that is not representative of all African American women

in the United States, this sample is important because it provides a fuller

picture of the context and circumstances around SV victimization of a highrisk

urban sample of women. The findings help to highlight the high prevalence

of SV victimization and its health consequences for some racial and

ethnic minority women.

Findings from this study reveal a high prevalence of rape and sexual

coercion victimization among this community sample of African American

women (53.7% experienced rape and 44.8% experienced sexual coercion at

some point in their lives). These prevalence estimates are higher than previous

national survey estimates (Black et al., 2011; Breiding et al., 2014;

Tjaden & Thoennes, 1998), but are consistent with other community-based

246 K. C. BASILE ET AL.

studies of African American women (Bryant-Davis et al., 2010; Kalichman

et al., 1998). In addition, the face-to-face nature of data collection in this

study could have also increased disclosure (Tillman, Bryant-Davis, Smith, &

Marks, 2010). Results reveal that mental health conditions, alcohol use, and

financial concerns are associated with previous SV victimization. For example,

being a victim of rape or sexual coercion was associated with endorsing

at least one PTSD symptom and symptoms of depression in their lifetime. In

other findings, a high percentage of lifetime victims of rape or sexual coercion

engaged in binge drinking during the previous year, and over 10%

reported that they abused prescription drugs or used illegal drugs on a

daily or almost daily basis in the last 12 months.

Of those whose first unwanted sexual experience resulted in rape or sexual

coercion, the majority of victims were younger than 18 years of age, were the

same race as their perpetrator, and knew their perpetrators (intimate partners,

family members, or acquaintances) at the time of their assault. These

findings are consistent with results from previous studies of African

American women (Avegno, Mills, & Mills, 2009; Weist et al., 2007). The

consequences experienced by victims whose first unwanted sexual experience

resulted in rape or sexual coercion (e.g., physical consequences, service needs,

and impacts on daily living) are consistent with previous literature (Avegno

et al., 2009; Weist et al., 2007). Regarding the impact of rape or sexual

coercion on a victim’s daily life, many women no longer felt safe in their

neighborhood as a result of their assault. Others chose to stay with family or

friends after their attack and some chose to relocate or change residence

afterward. These findings are consistent with the work of Frazier and colleagues,

who found in their study of 171 sexual assault survivors that after their

assault women believed their world was no longer safe and they held negative

attitudes regarding fairness of life and goodness of people (Frazier, Conlon, &

Glaser, 2001).

In addition, various services were needed and sought by victims in this

sample whose first unwanted sexual experience was rape or sexual coercion.

These included medical care, mental health care, community services, housing,

victim advocacy services, and assistance from the police. Approximately

one third of victims needed either medical or mental health services.

However, only about half of those who required these services were able to

obtain the help they needed. In addition, only one quarter of victims whose

first unwanted sexual experience was rape or sexual coercion contacted the

police after their experience. These findings suggest the disinclination of

African American women to seek help from mental health services

(Henning & Klesges, 2002; Snowden, 2001) and, in some cases, from law

enforcement and the criminal justice system, which might reflect a cultural

tendency among this population to distrust helping professionals due to

historical mistreatment, and a lack of culturally competent services (Flicker

JOURNAL OF AGGRESSION, MALTREATMENT & TRAUMA 247

et al., 2011; Raj et al., 1999; Tillman et al., 2010). Compounded by increased

exposure to SV, racial and structural inequities, including the experience of

discrimination, might increase African American women survivors’ risk for

poor outcomes.

These findings as a whole support previous research suggesting the multiple

sociocultural hardships faced by African American women might be

exacerbated by SV victimization or might, in some cases, lead to SV victimization.

For example, the majority of the participants in our sample fell below

the poverty threshold for a family of two adults without children. In addition,

the majority of lifetime rape or sexual coercion victims expressed they had

financial concerns within the 12 months prior to the survey and they were

significantly more likely to have these concerns than nonvictims. These

included concerns about being able to pay their rent or mortgage and their

ability to afford healthy meals. Previous research has shown that women are

at increased risk of victimization when their income is below the poverty line,

and conversely, victimization increases women’s likelihood of unemployment

and reduced income (Byrne et al., 1999). In 2010, 46.6% of African American

female, single-parent households were impoverished (Entmacher, Robbins, &

Vogtman, 2014). African Americans live at disproportionately lower socioeconomic

levels with less access to resources than their White counterparts

(DeNavas-Walt, Proctor, & Smith, 2013). The added burden of traumatic SV

victimization for women living in poverty potentially exacerbates the need

for multiple services and resources to address various intersecting problems

(i.e., poverty, victimization, mental and physical health; Bryant-Davis et al.,

2009).

This study is a contribution to the literature on the impact of SV victimization

of African American women because it included many health associations

and circumstances of the violence, which enabled a well-rounded

picture of the SV experience. In addition, the measurement of SV victimization

included in this study was very detailed, including numerous tactics,

which likely improved disclosure. However, this study has some limitations.

First, the sample is from an urban neighborhood in a Southeastern U.S. city,

so the findings might not be generalizable to all African American women.

Second, the sample is relatively small, which limited our ability to conduct

more complex statistical testing. Also, the study only included one racial and

ethnic group of women so it did not enable comparisons to other groups. In

addition, the analyses conducted in this study only focused on rape and

sexual coercion, and other types of SV such as unwanted sexual contact are

not represented. The main SV variable used in this study combined rape and

sexual coercion. Ideally, we would have examined rape experiences and

sexual coercion victimization experiences separately so that we could determine

if there were differences in the health associations linked to these two

forms of sexual violence. However, the experiences of the women in our

248 K. C. BASILE ET AL.

sample did not enable us to examine rape and sexual coercion separately

because a relatively large subset of the women in our sample experienced

both rape and sexual coercion.

Overall, the findings from this study have important implications for

prevention, practice, and service response to African American victims of

SV. Given the alarming numbers of women in this study who experienced

rape and sexual coercion that caused injuries and other physical and

mental health problems, primary prevention of SV has the potential to

prevent numerous adverse health experiences and the costs associated with

them. In addition, the high rates of adverse physical and mental health

experiences among victims of SV in this sample suggest that African

American women are in particular need of ongoing health-related services,

whether or not they disclose their victimization status. Although our

findings suggest a need for these types of services, only a little more

than 50% of women in our sample were able to get the physical and

mental health services they needed.

Some have suggested that African American women’s SV-related health

risks, adverse conditions, and challenges with regard to seeking services are

intricately linked to race or ethnicity and culture (Bent-Goodley, 2007;

Boykins et al., 2010; Flicker et al., 2011; Tillman et al., 2010). This study

supports prior research suggesting an association between SV victimization

and numerous physical and mental health risks and behaviors. More scholarship

in this area with representative samples of African American women

and other racial and ethnic minority women are important to inform prevention

practice. Larger and more representative samples are needed for

future research on the health associations linked to SV victimization, and

to enable comparisons across different racial and ethnic groups. Further, the

important connections among adverse health, SV, and cultural differences

need further exploration to inform practice.

Acknowledgments

The findings and conclusions in this report are those of the authors and do not necessarily

represent the official position of the Centers for Disease

Control and Prevention.

The authors

acknowledge the passing of their coauthor, Dr. Merle E. Hamburger, before this article was

completed. This article is dedicated to his memory for his commitment and contributions to

youth violence and sexual violence research and prevention.

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JOURNAL OF AGGRESSION, MALTREATMENT & TRAUMA 253

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Rape Victimization and High Risk Sexual Behaviors: Longitudinal Study of African-American Adolescent Females

Delia L. Lang

, PhD, MPH,*

Jessica M. Sales

, PhD,*

Laura F. Salazar

, PhD,*

James W. Hardin

, PhD,†

Ralph J. DiClemente

, PhD,*

Gina M. Wingood

, ScD, MPH,* and

Eve Rose

, MSPH*

Author information ►

Article notes ►

Disclaimer

This article has been

cited by

Abstract

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Objectives:

African-American women are affected by disproportionately high rates of violence and sexually transmitted infections (STI)/human immunodeficiency virus (HIV) infection. It is imperative to address the intersection of these two urgent public health issues, particularly as these affect African-American adolescent girls. This study assessed the prevalence of rape victimization (RV) among a sample of African-American adolescent females and examined the extent to which participants with a history of RV engage in STI/HIV associated risk behaviors over a 12-month time period.

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Methods:

Three hundred sixty-seven African-American adolescent females ages 15–21, seeking sexual health services at three local teenager-oriented community health agencies in an urban area of the Southeastern United States, participated in this study. Participants were asked to complete an audio computer-assisted self-interview (ACASI) at baseline, 6- and 12-month follow-up. We assessed sociodemographics, history of RV and sexual practices. At baseline, participants indicating they had experienced forced sex were classified as having a history of RV.

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Results:

Twenty-five percent of participants reported a history of RV at baseline. At 6- and 12-months, victims of RV had significantly lower proportions of condom-protected sex (p=.008), higher frequency of sex while intoxicated (p=.005), more inconsistent condom use (p=.008), less condom use at last sex (p=.017), and more sex partners (p=.0001) than non-RV victims. Over the 12-month follow-up period, of those who did not report RV at baseline, 9.5% reported that they too had experienced RV at some point during the 12-month time frame.

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Conclusion:

African-American adolescent females who experience RV are engaging in more risky sexual behaviors over time than non-RV girls, thereby placing themselves at higher risk for contracting STIs. In light of the results from this unique longitudinal study, we discuss considerations for policies and guidelines targeting healthcare, law enforcement and educational and community settings. The complexities of RV screening in healthcare settings are examined as is the need for tighter collaboration between healthcare providers and law enforcement. Finally, we consider the role of prevention and intervention programs in increasing awareness about RV as well as serving as an additional safe environment for screening and referral.

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INTRODUCTION

Due to jeopardized health of adult and adolescent women, the intersection of gender-based violence and increased risk for acquiring sexually transmitted infections (STIs), including human immunodeficiency virus (HIV), has received increased attention in public health research.

The United Nations Declaration on Violence Against Women provides a broad basis for defining gender-based violence, which includes but is not limited to physical, sexual, and psychological violence, sexual abuse of female children, marital rape, non-spousal violence, sexual harassment, trafficking in women and forced prostitution. Globally, girls and women face systematic discrimination, leaving them highly vulnerable to being harmed physically, psychologically and moreover sexually by the men in their families and communities.2

In the United States (U.S.), women experience high rates of sexual violence. According to results from the National Violence Against Women Survey (NVAWS), nearly one in six women surveyed reported having been raped in their lifetime, a prevalence of 17.6%.

Furthermore, research suggests that in nearly two-thirds of cases, rape victimization (RV) was perpetrated by someone the victim knew (e.g. friends, acquaintances, or intimate partners) with over 50% of victims reporting that the rape occurred before age 18.
3
,

While RV rates are alarming, data also indicate that only one in five women reported their rape to authorities, suggesting that available data on RV represent a severe underestimate.3

Retrospective studies in the U.S. examining physical and/or sexual victimization have shown that women’s experiences of victimization during childhood and/or adolescence are associated with high-risk sexual practices in adulthood and the acquisition of STIs, including HIV.

–

Among African-American adult women specifically, experiences of SV in childhood and/or adolescence are associated with increased risk for abortion, re-experiencing abuse as an adult, acquiring an STI, earlier sexual debut, a greater number of lifetime sexual partners, and sex trading.

–16

Among adolescent females, studies examining the association between RV and STI/HIV-associated risk behaviors suggest a similar pattern of associations as those described for adult women. Studies based on representative samples of adolescent females report that approximately one in five girls has experienced some form of victimization.

Among sexually active adolescent girls, this rate increases to approximately one in three girls with African-American adolescent females reporting higher rates of physical or sexual victimization compared to other ethnic groups.

–

Many adverse psychological and physical health outcomes have been found to be associated with early experiences of RV, including eating disorders, decreased self-esteem and poor health-related quality of life.
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Adolescent females with a history of RV also report engaging in high risk sexual practices including having multiple sexual partners, earlier sexual debut, not using birth control at last intercourse, substance abuse, and exchanging sex for money or drugs.

–

Moreover, studies have reported a link between RV and self-reported STIs, whereas one recent study with female detained adolescents showed that victimization was related both directly and indirectly to biologically-confirmed chlamydia.
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Indirectly, physical or sexual victimization was related to chlamydia through condom failures and having sex while intoxicated.

Among adolescents, African-American females continue to represent a vulnerable group bearing the disproportionate burden of STI/HIV infection.

–

Specifically, the prevalence of chlamydia and gonorrhea is substantially higher among same-age African-American adolescent females compared to females from other ethnic groups.

Furthermore, previous studies have observed that among African-American females, even after adjusting for diverse behavioral and sociodemographic risk indices, the reinfection rate was threefold that among white peers.

–

This could be due to a combination of factors including lack of adoption of STI/HIV-preventive strategies, such as using condoms consistently or limiting number of sex partners and/or selecting partners from high risk sexual networks.
46
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,52

Taken together, these studies suggest that examining the intersection of RV and sexual risk taking among African-American females at high risk for STI/HIV acquisition is not only timely but also necessary given the scarce body of prospective research in this area. For purposes of this study, RV is defined as non-consensual sex during childhood or adolescence. RV is a particularly harmful type of gender-based violence associated with the most enduring health consequences, such as STI/HIV acquisition and associated risk behaviors.
5
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7
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The purpose of this study was to describe the prevalence of RV in a population of African-American adolescent females seeking STI services, and to longitudinally assess the extent to which African-American adolescent females with a history of RV engage in STI/HIV associated risk behaviors over a 12-month time period.

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METHODS

Participants

Participants in this study were part of a randomized controlled trial evaluating a sexual risk reduction intervention for young African-American females in an urban area of the Southeastern U.S. From March 2002 through August 2004, recruiters screened self-identified young African-American females seeking reproductive and sexual health services at three local teenager-oriented community health agencies. Eligibility criteria included being African-American, female, 15 to 21 years of age, and sexually active (reporting vaginal intercourse in the previous 60 days). The local institutional review board approved the study protocol before implementation.

Of 1,558 screened, 874 females met eligibility criteria. Of those who met eligibility criteria, 82% (n=715) agreed to participate, provided written informed consent, and completed a baseline assessment. Of those who agreed to participate, 348 (48.7%) were randomly assigned to the sexual risk reduction intervention condition while 367 (51.3%) were randomly assigned to a standard-of-care comparison condition. Analyses reported in this study addressed data from participants who were randomized to the standard-of-care comparison condition only to eliminate any effects of the intervention on high risk sexual behaviors. We obtained high retention rates (86%) at both 6- and 12-month follow ups for this sample.

Procedures

Data collection consisted of a 40-minute survey administered via audio computer-assisted self-interviewing (ACASI) technology at baseline, 6-month and 12-month follow-up time periods. Questions assessed sociodemographic information, history of RV, condom use behaviors and other variables describing participants’ sexual history. Participants were compensated $50 for their participation at each assessment time point.

Measures

History of Rape Victimization

History of RV was conceptualized as an index comprising two severe forms of abuse—forced vaginal intercourse or forced anal intercourse—and was assessed by asking two questions: “Has anyone ever forced you to have vaginal sex when you didn’t want to?” and “Has anyone ever forced you to have anal sex when you didn’t want to?” Response choices were yes (1) and no (0). Participants who endorsed either of these two questions were categorized as having a history of rape victimization. Participants who did not endorse either of these two questions were categorized as having no history of rape victimization.

Sociodemographic and Background Measures

We assessed highest grade completed in school by a single question, “What was the last grade that you completed in school?” Participants were also asked if they were currently attending school. Receiving federal assistance for living expenses was assessed by four yes-or-no questions. We summed responses to each question to create an index of family aid. Participants were also asked with whom they were living at the time of assessment (i.e. family members, boyfriend, other friends). We also assessed age at first willing vaginal sex.

Condom Use

We assessed several measures of condom use. First, condom use during the last episode of vaginal intercourse with a sex partner was assessed. Condom use at last intercourse provides an assessment of recent condom use that may be less susceptible to recall bias.

Participants were asked the question “Did you use a condom the last time you had vaginal sex with your boyfriend or steady partner?” Response choices were yes or no. Second, we assessed consistent condom use by asking participants the question “How many times did you have vaginal sex in the past 60 days?” Participants were then asked “How many of these times did you use a condom?” Based on these two questions we computed a continuous measure, proportion of condom use in the last 60 days, with possible values ranging from 0 to 100% condom use. Furthermore, we subsequently computed a dichotomous measure. Participants who indicated using condoms during every episode of vaginal intercourse in the past 60 days (100%) were defined as consistent condom users. Participants who indicated not using condoms during every episode of vaginal intercourse (0–99%) were defined as inconsistent condom users.

Unprotected Vaginal Sex

We assessed unprotected vaginal sex by subtracting the number of times a participant used condoms in the past 60 days from the number of times they reported having vaginal sex in the past 60 days.

Number of Sexual Partners

We assessed number of sexual partners by asking participants: “In the past 60 days, how many guys have you had vaginal sex with?” This measure was then dichotomized into participants who reported one sexual partner in the past 60 days and participants who reported two or more sexual partners.

Sex Under the Influence of Drugs or Alcohol

We assessed number of vaginal sex episodes while the participant and their sex partner were intoxicated by the following two questions: “In the past 60 days, how many times did you have sex while high on alcohol or drugs?” and “In the past 60 days, how many times did you have sex while your partner was high on alcohol or drugs?”

Statistical Methods

First, we used descriptive statistics to summarize sociodemographic variables, prevalence of sexual violence and high risk sexual behaviors. Subsequently, we conducted bivariate analyses consisting of Chi-square and independent Student’s t-tests to examine associations between RV and potential confounding variables. Finally, we estimated multivariable population-averaged generalized estimating equation (GEE) models to examine the longitudinal relationship between RV and high risk sexual behaviors.

We used the exchangeable correlation structure for the working correlation matrix based on an evaluation of the quasi-likelihood information criterion. A separate GEE model was constructed for each high risk sexual behavior considered.

Fitted GEE regression coefficients parameters can be interpreted as the odds or odds ratios (in logistic models analyzing dichotomous outcome variables) and means or mean differences (in linear regression models analyzing continuous outcome variables) over the entire 12-month period for an “average” participant. We computed the 95% confidence intervals around the adjusted odds ratios and adjusted mean differences and the corresponding P-value. To obtain adjusted means and mean differences, we repeatedly re-estimated models from bootstrap samples where samples were drawn with replacement at the level of the participant. For each model, we calculated adjusted means and standard errors from the collection of bootstrap results.

We computed percent relative difference for continuous variables as the difference (D) between the adjusted means for victimized participants divided by the adjusted mean for non-victimized participants. Percent relative difference provides a common metric for measuring the magnitude of the difference across the various measures relative to the baseline measure. We performed analyses using Stata statistical software, version 10.

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RESULTS

Descriptive and Bivariate Analyses

Three hundred sixty-seven participants between the ages of 15 and 21 participated in this study and provided baseline data (

Table 1

). The mean age of the participants was 17.8 (standard deviation [SD] =1.7) years. Most (67.9%) had not yet graduated from high school while the remaining 32% had completed high school and/or technical school. A total of 35.4% no longer attended school at the time of baseline assessment. Among this sample 53.4% reported that their family received some form of public assistance (i.e. welfare, Section 8 housing, food stamps). Most participants (82.3%) reported being in a current relationship with the average length of the relationship 15.11 months (SD=16.0). Ninety-two (25.1%) participants reported a history of RV at baseline. Of the participants who reported no RV at baseline, 26 (9.5%) reported RV incidence over the 12-month follow-up period. Of the participants who reported RV at baseline, 55 (59.8%) reported being re-victimized over the following 12-month period. Specifically, 14 (15.2%) reported being re-victimized at the 6-month follow up; eight (8.7%) reported being re-victimized at the 12-month follow up; and 33 (35.9%) reported being re-victimized at both the 6- and 12-month follow up.

Table 1.

Comparability of rape victimization (RV) and non-RV participants at baseline.

VARIABLES

RV (n=92)

Non-RV (n=275)

Mean (SD)

Percent (n)

Mean (SD)

Percent (n)

Age

17.98 (1.68)

17.71 (1.75)

0.20*

Age at first vaginal sex

14.23 (1.64)

14.68 (1.62)

0.02*

Less than high school

62.0% (57)

70.0% (191)

0.15*

Public assistance

56.5% (52)

52.4% (144)

0.49

Holding a paying job

29.3% (27)

28.0% (77)

0.80

Not living with family

30.8% (28)

19.8% (54)

0.03*

Currently in a relationship

82.6% (76)

82.2% (226)

0.93

Testing positive for an STI

23.9% (22)

27.3% (75)

0.53

Ever used marijuana

87.0% (80)

78.2% (215)

0.07*

Ever used alcohol

91.3% (84)

86.5% (238)

0.23

Number of days used alcohol

6.02 (10.71)

3.95 (8.75)

0.11*

*Covariates used in generalized estimating equation (GEE) models SD, standard deviation; STI, sexual transmitted infection.

We present descriptive statistics and bivariate associations between the predictor variable, history of RV, and demographic, as well as other potential confounding variables, in

Table 1
. We included only variables associated with history of RV at p≤.20 in bivariate analyses in the multivariate GEE models as confounders.

Furthermore, we present bivariate comparisons between RV history and sexual risk taking at each of the three time points (baseline, 6-months and 12-months) in

Table 2

Table 2.

Bivariate comparisons between rape victimization (RV) and non-RV participants and sexual risk taking at baseline, six and 12-month follow-up periods.

VARIABLES

RV (n=92)

Non-RV (n=275)

Mean (SD)

Percent (n)

Mean (SD)

Percent (n)

Baseline

Sex frequency while intoxicated

3.00 (6.82)

1.63 (4.18)

0.07

Sex frequency partner intoxicated

4.15 (7.90)

2.36 (4.90)

0.04

% condom use

40.0 (38.51)

56.3 (40.61)

0.002

Unprotected vaginal sex

10.2 (14.48)

5.2 (8.24)

0.006

Multiple sex partners

42.4% (39)

33.5% (92)

0.12

Inconsistent condom use

83.8% (67)

69.1% (163)

0.01

No condom use last sex

67.4% (62)

55.3 % (152)

0.04

Six-Month Follow-up

Sex frequency while intoxicated

1.68 (3.50)

1.21 (4.29)

0.33

Sex frequency partner intoxicated

2.91 (4.68)

1.68 (6.11)

0.07

% condom use

38.6 (39.41)

54.1 (42.59)

0.009

Unprotected vaginal sex

8.7 (11.15)

6.5 (10.60)

0.15

Multiple sex partners

39.5% (30)

24.8% (59)

0.01

Inconsistent condom use

84.3% (59)

66.2% (129)

0.004

No condom use last sex

69.7% (53)

51.7 % (122)

0.006

12- Month Follow-up

Sex frequency while intoxicated

2.22 (5.91)

0.65 (2.07)

0.02

Sex frequency partner intoxicated

3.34 (7.61)

1.11 (2.54)

0.01

% condom use

40.9 (39.54)

55.2 (43.13)

0.011

Unprotected vaginal sex

10.1 (14.55)

5.9 (12.64)

0.03

Multiple sex partners

38.8% (31)

20.8% (49)

0.001

Inconsistent condom use

79.5% (58)

65.3% (126)

0.03

No condom use last sex

66.2% (53)

54.3 % (127)

0.06

Open in a separate window

SD, standard deviation

Multivariate Analyses

We present results of GEE models constructed for continuous and dichotomous measures of sexual behaviors over the entire 12-month time period in

Table 3

. Analyses of continuous behavioral outcomes suggest that over the entire time period participants with a history of RV compared to participant without a history of RV reported significantly lower proportion condom use in the past 60 days (adjusted mean 21.45 vs. 31.57; p=.008), greater frequency of having sex while they were intoxicated (adjusted mean 2.30 vs. 1.30; p=.005) and greater frequency of having sex while their partner was intoxicated (adjusted mean 3.25 vs. 1.95; p=.005). Frequency of unprotected vaginal sex in the past 60 days was only marginally significant (p=.088).

Table 3.

Generalized estimating equation (GEE) results for behavioral outcomes.

GEE Models: Baseline – 12 Months

Adjusted Meana SV

Adjusted Meana Not SV

Differenceb(95% CI)

% Rel Differencec(95% CI)

AORd(95% CI)

Continuous Behavioral Outcomes

% Condom use past 60 days

21.5

31.6

–10.1 (–17.0;–3.7)

13.2 (13.2; 51.8)

n/a

0.008

Unprotected vaginal sex past 60 days

8.00

6.45

1.55 (–0.6; 3.4)

24.09 (–7.2; 55.6)

n/a

0.088

Frequency of sex while intoxicated

2.30

1.30

1.00 (0.25; 1.9)

77.90 (0.06; 162.9)

n/a

0.005

Frequency of sex while partner intoxicated

3.25

1.95

1.30 (0.40; 2.3)

66.69 (15.06; 124.2)

n/a

0.005

Dichotomous Behavioral Outcomes

Inconsistent condom use past 60 days

n/a

1.73 (1.2; 2.6)

0.008

No condom use at last sex

n/a

1.51 (1.1; 2.1)

0.017

Multiple sex partners

n/a

3.94 (3.0; 5.3)

0.0001

Open in a separate window

aAdjusted means for rape victimization (RV) and non-RV groups; means adjusted by participant age, age at first consensual sex, education, living arrangement, ever used marijuana and number of days alcohol use past 60 days.

bAdjusted mean difference between RV and non-RV groups reported for continuous outcomes

cRelative difference reported for continuous outcomes = adjusted mean difference/adjusted non-RV group mean x 100%.

dAdjusted odds ratios (OR) reported for dichotomous outcomes; adjusted by participant age, age at first consensual sex, education, living arrangement, ever used marijuana and number of days alcohol use past 60 days. Non-RV group is the referent for computing the OR.

Analyses of dichotomous behavioral outcomes suggest that over the entire 12-month time period, participants with a history of RV compared to participant without a history of RV were 1.7 times more likely to report using condoms inconsistently (95%CI =1.15, 2.60; p=.008), 1.5 times more likely to report using no condoms at last sex (95%CI = 1.08, 2.11; p=.017), and 3.94 times more likely to report having multiple partners (95%CI = 2.96, 5.26; p=.0001).

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DISCUSSION

In this sample of sexually active African-American adolescents one in four females reported a history of RV. These findings corroborate rates of RV reported in prior research with African-American adolescent females.

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Furthermore, results of this study show that African-American adolescent females seeking services at local STI clinics and who have a history of RV report an earlier age of consensual sex and are engaging in more risky sexual behaviors as they age than their counterparts who do not report a history of RV, thereby placing themselves at increased risk for contracting STIs, including HIV. These findings extend prior cross-sectional research reporting similar findings by underscoring the enduring adverse effects of RV on victims’ sexual risk taking over time.
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60
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Specifically, in this sample, African-American adolescent females with a history of RV reported less condom use with their sex partner, more frequent substance use during sexual intercourse, and multiple sex partners over a 12-month period. While we found no association in this sample between history of RV and testing positive for an STI, all of the risk behaviors aforementioned have been previously identified as antecedents to STI acquisition among African-American adolescent females.18

Understanding the relation between history of RV and risk behaviors has been hindered in previous research due to the cross-sectional nature of the study designs. As a result, two general explanations of this association have been offered in the literature: 1) following experiences of RV, women are more likely to engage in a pattern of risk behaviors and 2) engaging in risk behaviors may increase women’s risk of experiencing RV.

Although both explanations have received some support in the literature with regard to the association between RV and substance use behaviors, less is known about the temporal association between RV and sexual risk taking.

–

The longitudinal nature of our analyses, although not allowing for cause-effect conclusions to be drawn, lend some support to the explanation that experiences of RV are associated with a pattern of high risk sexual behaviors over time. This pathway is also consistent with a model designed to explain violence-related health problems which states that violent assaults, including sexual assaults, can lead to various adverse health outcomes, including acute physical injury, increased stress, psychological and emotional problems and subsequently high risk health behaviors.

For victims of RV particularly, studies have shown that the psychological sequelae may include low self-esteem, passivity, depression, post-traumatic stress disorder and feelings of powerlessness and helplessness.

–70

Taken together, these psychological problems, if unresolved through professional counseling, are likely to contribute to victims’ participation in high risk sexual behaviors, such as being less likely to communicate about sex and negotiate safer sex practices which may subsequently lead to inconsistent condom use out of fear that such assertiveness may provoke aggression and possibly repeat victimization.
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Moreover, following experiences of RV, sexual activity may become less pleasurable.

It is reasonable to assume that for victims of RV who view sexual activity as aversive, substance use may become a coping mechanism, allowing them to engage in sexual intercourse while alleviating negative emotions associated with RV.
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Unfortunately, this negative coping mechanism of using substances during sex may further exacerbate adolescent females’ risk for contracting an STI including HIV, as using substances during sex has been related to an increased risk of condom failures.
39
Condom failures, such as breakage and slippage, may be more important than other risk behaviors such as unprotected vaginal sex when examining predictors of STI acquisition. Findings from a recent study showed that biologically-confirmed STIs were not related to unprotected vaginal sex among a sample of adolescent females; however, after adjusting the measure of unprotected vaginal sex to account for imperfect condom use (i.e., controlling for breakage, leaking, and slippage), the association was significant.

In the present study, we did not find a relation between victimization and STIs; however, it may be possible that other factors could account for an indirect relation. Future research should examine more complex models that include indirect effects and measures of condom failures to account for STI outcomes. This line of research could help shed light on the complex relations among experiences of RV, sexual risk behaviors and STI/HIV outcomes.

Lastly, consistent with prior findings, our study suggests that victims of RV are more likely to report multiple sex partners than those without a history of RV.
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It is possible that because victims of RV initiate sexual activity earlier than non-victims, this may lead to exploring sexual behavior with a greater number of sexual partners during the course of adolescence. Additionally, several studies have found an association between history of RV and prostitution among 13–18-year-old predominantly African-American adolescents.76 Thus, transactional sex experiences may contribute to the higher number of sex partners reported by victims of RV in this sample.

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LIMITATIONS

This study has several noteworthy limitations. First, the conceptualization of RV used in this study is rather limited in scope, including only severe sexual violence (i.e. forced vaginal and anal intercourse) and not other forms of sexual violence, such as attempted rape, digital penetration or penetration with a foreign object. Therefore, it is possible that participants categorized as “not victimized” included some who may have experienced types of RV other than those assessed by this measure. Future studies should broaden this definition to assess the effects of a full range of RV on sexual risk taking over time. Second, this study did not assess the victim-perpetrator relationship; therefore, no comparisons could be made between RV perpetrated by a sexual partner vs. RV perpetrated by a family member or a stranger. Moreover, no data were available regarding the frequency, severity or chronology of victimization. Finally, although this study adds to the literature by assessing RV and risk behavior longitudinally, no cause-effect conclusions can be drawn from these findings.

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CONCLUSION

It is critically important to identify and intervene with girls who have experienced RV in an attempt to avoid a trajectory of sexual risk-taking and further re-victimization. To that end, policies and guidelines should be considered at several critical structural levels including: 1) healthcare, 2) law enforcement and 3) community education.

First, healthcare agencies, especially those serving adolescent female populations, should adopt screening guidelines for providers as standard practice. Having said that, it should be acknowledged that screening for RV, although a logical recommendation, could be complex in its implementation, especially among adolescent populations. For example, adolescent females may be accompanied to the clinic by the perpetrator in cases where RV or other types of violence are ongoing. In such cases, screening a victim may be ineffective at best and dangerous at worst. Furthermore, in the absence of being fully autonomous, adolescents’ ability to take advantage of available services targeting RV may be dependent on family members, who may or may not know about the victimization, and their level of support. However, despite its complexities, when implemented with caution, screening remains one of the best methods to protect adolescent females from ongoing RV and/or the sequelae of having experienced RV in the past. Agencies may consider implementing an overall health screening protocol that is conducted in private with only the patient and healthcare provider(s) in the consulting room. A thorough health screen would incorporate questions about both sexual risk behaviors, focusing particularly on condom use practices, frequency of sex while under the influence of substances and number of sex partners, as well as history of RV. Drawing on clinical judgment, providers may follow up with questions about current RV, should patients’ answers to previous inquiries be affirmative. Policies and guidelines must also be considered in the training of healthcare providers and their support staff. Resources should be readily available to make referrals; however, health agencies should consider implementing policies that place the adolescent female victim in a collaborative relationship with in-house staff who actively seek to connect her to targeted services for victims of RV in an effort to increase the likelihood of safe follow through. Additionally, training providers and staff to establish rapport with victims and adhere to strict confidentiality standards is a crucial consideration likely to impact both the probability of eliciting truthful responses as well as the safety of the patient. Finally, healthcare providers should also be linked to and collaborate with law enforcement agencies in instances where victims decide to report the victimization.

Second, policies and guidelines should address the needs of law enforcement agencies in an effort to expand services offered to victims of RV. Additional resources would allow enhanced training of law enforcement staff to work closely and collaboratively with healthcare agencies toward establishing sex crime reporting procedures designed to assure young women that they will be met with respect, sensitivity and timely consideration in reporting their experience(s) of victimization.

Third, policies and guidelines should be implemented in community educational settings to raise awareness of RV and associated consequences for adolescent females. Specifically, the implementation of existing sexual risk reduction and pregnancy prevention programs should incorporate sexual assault awareness into their protocols and offer treatment referrals to participants. Similarly, intervention programs for victims targeting the enduring effects of RV on sexual risk taking and the risk for re-victimization are needed and should be implemented within existing treatment plans addressing the needs of RV victims. As such, well designed intervention programs can serve a dual purpose: first, to raise awareness among both female and male adolescents in an attempt to prevent RV; and second, to serve as an additional safe environment where victims can feel comfortable reporting their experiences of RV. For many adolescent female victims of RV, such a setting may represent the first step toward prevention of increased sexual risk taking as well as possible re-victimization.

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Footnotes

Reprints available through open access at

http://escholarship.org/uc/uciem_westjem

Conflicts of Interest: By the WestJEM article submission agreement, all authors are required to disclose all affiliations, funding sources, and financial or management relationships that could be perceived as potential sources of bias. The authors disclosed none.

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Unit5Assign

Literature Review

Requirements

Rape Victimization and High Risk Sexual Behaviors: Longitudinal Study of African-American Adolescent Females

Abstract

Objectives:

Methods:

Results:

Conclusion:

INTRODUCTION

METHODS

Participants

Procedures

Measures

History of Rape Victimization

Sociodemographic and Background Measures

Condom Use

Unprotected Vaginal Sex

Number of Sexual Partners

Sex Under the Influence of Drugs or Alcohol

Statistical Methods

RESULTS

Descriptive and Bivariate Analyses

Table 1.

Table 2.

Multivariate Analyses

Table 3.

DISCUSSION

LIMITATIONS

CONCLUSION

Footnotes

REFERENCES

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