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Health complaints in acknowledged and unacknowledged rape victims
Anxiety Disorders 20 (2006) 372–379
Health complaints in acknowledged and unacknowledged rape victims§ Lauren M. Conoscenti *, Richard J. McNally Department of Psychology, Harvard University, 1240 William James Hall, 33 Kirkland St., Cambridge, MA 02138, USA Received 16 November 2004; received in revised form 11 February 2005; accepted 4 March 2005
Abstract Rape may have physical as well as mental health consequences. Previous studies on health complaints in sexual assault survivors have focused on women who acknowledged their assault as rape. Unacknowledged rape victims do not define their assault as ‘‘rape’’ despite meeting legal definitions. In this study, acknowledged victims, unacknowledged victims, and a control group reported the number of health complaints, the intensity of complaints, and how often they reported these complaints to health professionals. Rape alone, without acknowledgment, was associated with in an increase in the reported number and intensity of health complaints and the frequency at which these complaints are addressed to health professionals. Acknowledgment of rape was associated with an even greater increase in the number and intensity of health complaints. # 2005 Elsevier Inc. All rights reserved. Keywords: Rape; Health complaints; Posttraumatic stress disorder
More than 140,000 rapes are reported in the United States each year (Bureau of Justice Statistics, 2003). Epidemiological surveys show that between 30 and 65% of rape victims suffer from posttraumatic stress disorder (PTSD; Kessler, Sonnega, Bromet,Hughes,&Nelson,1995;Kilpatrick,Saunders,Veronen,Best,&Von,1987). Rape affects physical health as well as mental health. Sexual assault victims report more health complaints and utilize more health services than do nonvictims § These findings were presented at the annual meeting of the Association for Advancement of Behavior Therapy, November 2003, Boston, MA. * Corresponding author. E-mail address: [email protected] (L.M. Conoscenti).
0887-6185/$ – see front matter # 2005 Elsevier Inc. All rights reserved. doi:10.1016/j.janxdis.2005.03.001
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(e.g., Golding, 1994; Kimerling & Calhoun, 1994). In addition, the number of health complaints correlates positively with PTSD severity in sexual assault survivors (Kimerling & Calhoun, 1994; Zoellner, Goodwin, & Foa, 2000). Some victims, however, do not conceptualize their experience as rape, even when it meets the legal definition for the crime. Perhaps to reduce feelings of shame, these unacknowledged victims may resist viewing their experiences as rape. Unacknowledged rape victims may be especially common among women whose sexual assaults do not fit the stereotype (e.g., date rape). Indeed, relative to acknowledged rape victims, unacknowledged victims are more likely to have had previous and continuing relationships with their assailants (Koss, 1985; Layman, Gidycz, & Lynn, 1996). Studies show varying proportions of these acknowledged and unacknowledged victims. Koss, Dinero, Seibel, and Cox (1988) found that 77% of women raped by acquaintances and 45% of woman raped by strangers were unacknowledged. Layman et al. (1996) found 73% were unacknowledged, and a nationwide survey of college women reported 54% were unacknowledged (National Institute of Justice, 2000). Layman et al. (1996) found that acknowledged victims report more PTSD symptoms than do unacknowledged victims. Acknowledged victims often perceive a more forceful and resisted assault and report a greater willingness to press charges against the attacker than do unacknowledged victims. However, it is unclear whether acknowledged victims experience an objectively more severe rape, or if the acknowledgment process influences event perception. Studies assessing health complaints in rape victims have concerned women who identify themselves as victims. In this study, we investigated the relationship between acknowledgment and frequency and intensity of health complaints. Because increased PTSD severity is associated with both identity as a rape victim and greater health complaints, acknowledged rape victims should report more health complaints, report more intense complaints, and report more of these complaints to a health professional compared to unacknowledged victims, who in turn should report more complaints and more intense complaints, and report more to professionals, than nonvictim control participants. In addition, a greater proportion of acknowledged victims should meet criteria for PTSD compared to the unacknowledged group.
1. Method 1.1. Participants Participants were recruited from the community via advertisements in local newspapers, posters, and on a local website’s ‘‘classifieds’’ section. Advertisements read: ‘‘Have you had an unwanted sexual experience? Are you still troubled by it? Researchers seek women, ages 18–45, who have had an unwanted sexual
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experience and who are still experiencing distress related to the event to participate in a research study.’’ Because most rape victims do not develop chronic PTSD, we included the phrases ‘‘still troubled’’ and ‘‘still experiencing distress’’ to recruit women suffering from symptoms of PTSD. We also recruited women reporting no history of rape via advertisements that read: ‘‘Women needed! Researchers seek women ages 18–45 who have never experienced unwanted sexual contact to participate in a study.’’ Participants were first screened on the phone to determine whether they reported an experience meeting the legal definition of rape, and if so, when that experience took place. For this study, we defined rape as ‘‘an event that occurred without the woman’s consent that involved the use of force or threat of force, and that involved sexual penetration of the victim’s vagina, mouth, or rectum.’’ This meets legal definition of forcible rape throughout the United States. Screening questions were six items from the Sexual Experiences Survey (Koss & Oros, 1982; questions 1, 2, 4, 5, 10, and 11). Participants were asked to respond ‘‘yes’’ or ‘‘no’’ to questions assessing increasingly severe levels of sexual coercion, and were told that questions referred to vaginal, oral, or anal penetration. Questions 1 (‘‘Have you ever had sexual intercourse with a man when you both wanted to?’’) and 2 (‘‘Have you ever had a man misinterpret the level of sexual intimacy you desired?’’) acclimated the respondent to questions about sexual history. Questions 4, 5, 10, and 11 referred to experiences meeting the legal definition of rape (i.e., ‘‘Have you ever had sexual intercourse with a man when you didn’t want to because he threatened to use physical force if you didn’t cooperate?’’) but did not explicitly mention rape. We classified women who answered ‘‘yes’’ to questions 4, 5, 10, or 11 as rape victims. To rule out symptoms of Acute Stress Disorder related to the sexual assault, we excluded women from the study if they had been raped within the previous 3 months. Eligible participants provided written, informed consent, came to the Harvard campus to complete the study, filled out surveys, and were paid for their time. Participants reporting a history of rape were also given a list of community resources for survivors of sexual assault. Two hundred and eighteen women inquired about the study by phone or e-mail. Of this group, 20 women with no history of rape and 69 women reporting a history of rape participated. Of the remaining 129 women, 105 women declined participation. Typically, these women failed to arrive for appointments or to return phone calls or emails. In addition, 24 women were ineligible, usually because their ‘‘unwanted sexual experience’’ was sexual harassment or molestation, but not rape. Eighty-nine women participated. Sixty-nine reported unwanted oral, anal, or vaginal penetration. The Sexual Experiences Inventory (SEI; Koss, 1985) assessed how the 69 traumatized women defined their unwanted sexual experience. Of these 69 women, 29 were unacknowledged victims and 40 were acknowledged victims. Twenty women had never experienced unwanted sexual intercourse, and were designated as control participants.
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Table 1 Means and standard deviations for demographic variables
Age Education Percent nonwhite Percent with PTSD Months since rape
Acknowledged victims
Unacknowledged victims
Controls
30.6 (7.9) 15.2 (2.0) 36 61 159.5 (186.8)
27.0 (8.2) 15.8 (2.6) 44 67 93.2 (106.8)
23.3 (6.1) 15.3 (2.5) 25 – –
Note. Standard deviations are in parentheses.
The groups differed in age, F(2, 77) = 5.83, p < .01. Post hoc contrasts (least significant difference method) revealed that the control group was younger than both the acknowledged and unacknowledged victim groups ( p < .05), whereas the latter two groups did not differ in age (see Table 1). The proportion of nonwhite participants did not differ across groups, x2(2) = 1.10, p = .29. The groups did not differ in years of education, F(2, 73) = .44, p = .65, nor did the acknowledged and unacknowledged groups differ in months since the rape, t(57) = 1.57, p = .12. 1.2. Measures All participants completed the Pennebaker Inventory of Limbic LanguidnessModified (PILL; Pennebaker, Burnam, Schaeffer, & Harper, 1977; modified by Zoellner et al. (2000) to include gynecological and gastrointestinal problems common to sexual assault victims). The modified PILL is a 246-item self-report measure that measures frequency, intensity, and usage of medical services related to 82 medical complaints. Items on the PILL include routine health complaints, such as coughing, eyes watering, and sneezing, as well as more severe complaints, such as broken bones, vomiting, and blood in stool. Participants rated the frequency and intensity of symptoms they had experienced in the past 4 weeks, and whether they had mentioned the problem to a medical professional. Internal consistency for the original 54-item PILL (measuring frequency of symptoms only), as measured by Cronbach’s alpha, ranges from .88 (binary method) to .91 (summed method). Test–retest reliability for 177 subjects over a 2month period was .79 (binary method) and .83 (summed method; Pennebaker, 1982). Both acknowledged and unacknowledged victims completed two additional measures: the PTSD Symptom Scale (PSS-I; Foa, Riggs, Dancu, & Rothbaum, 1993) and the Sexual Experiences Inventory (SEI; Koss, 1985). The PSS-I is a 17-item measure assessing the presence and severity of each of the DSM-IV PTSD symptoms. Participants rate their symptoms on a 4-point scale ranging from 0 (‘‘not at all’’) to 3 (‘‘very much’’/‘‘five or more times per week’’). While the PSS-I is a continuous measure, it can also be used for a dichotomous
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cutoff. We used criteria matching the DSM-IV PTSD symptoms (endorsement of one re-experiencing symptom, three avoidance symptoms, and two increased arousal symptoms) to determine whether participants had or did not have PTSD. The PSS-I has high internal consistency (a = .85), high testretest reliability (r = .80), high interrater reliability (kappa = .91), and moderate to high correlations with other measures of psychopathology (Foa et al., 1993). The SEI distinguished acknowledged from unacknowledged rape victims by asking participants to respond ‘‘yes’’ or ‘‘no’’ to four questions. Participants who responded ‘‘no’’ to the fourth item, ‘‘Do you believe you were a victim of rape?’’ were classified as ‘‘unacknowledged.’’
2. Results Table 2 shows means and standard deviations for the variables. All t-tests reported are one-tailed. Sixty-one percent of the acknowledged group and 67% of the unacknowledged group met criteria for PTSD as measured by the PSS; no differences existed between victim groups for this variable, x2(1) = .21, p = .65. Victims reported more health complaints, t(85) = 2.28, p < .05, effect size r = .24, than did control participants. Relative to controls, victims experienced health complaints more intensely, t(87) = 3.46, p < .01, r = .34, and reported them to health professionals more frequently, t(87) = 2.19, p < .05, r = .23. Consistent with our hypothesis, acknowledged victims reported more intense health complaints than did unacknowledged victims, t = 2.00, p = .05, r = .25, and they tended to report more health complaints, t = 1.77, p = .08, effect size r = .23. However, acknowledged and unacknowledged victims did not differ in the reporting of health complaints to professionals, t = 1.15, p = .25. If sexual assault, especially that acknowledged as rape, is associated with physical health problems, then the acknowledged victim group should report more complaints, report more intense complaints, and report more complaints to health professionals than the unacknowledged group, whereas the unacknowledged group should report more complaints than the control group. We tested this prediction by applying contrast weights of 1, 0, and 1 to the means of the Table 2 Means and standard deviations for health-related variables
Number of health complaints Intensity of health complaints Number of consultations with medical professionals
Acknowledged victims
Unacknowledged victims
Controls
57.8 (33.1) 47.5 (37.5) 4.2 (6.4)
46.2 (25.3) 33.7 (23.2) 2.3 (3.4)
36.0 (25.1) 22.0 (18.4) 1.5 (2.7)
Note. Standard deviations are in parentheses.
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Table 3 Means and standard deviations for health-related variables for acknowledged victims with and without PTSD
Number of health complaints Intensity of health complaints Number of consultations with medical professionals
With PTSD
Without PTSD
78.7 (35.1) 66.4 (41.7) 6.2 (8.3)
35.6 (25.6) 25.2 (13.6) 1.2 (2.2)
Note. Standard deviations are in parentheses.
acknowledged, unacknowledged, and control groups, respectively.1 The results were in accord with this hypothesis, number of health complaints: t(84) = 2.73, p < .01, effect size r = .29; intensity complaints: t(86) = 3.13, p < .005, r = .32; number of complaints reported to health professional: t(86) = 2.04, p < .05, r = .21 (Table 3). Finally, because previous research showed a direct correlation between PTSD and health complaints, we examined the relationship between acknowledgment, PTSD, and health complaints. While the same proportion of participants in each victim group met criteria for PTSD, acknowledged victims with PTSD, compared to acknowledged victims without PTSD, reported more health complaints, t(31) = 3.88, p < .001, r = .57, and more intense complaints, t(28) = 3.16, p < .005, r = .51, and sought medical advice for more complaints, t(27) = 2.43, p < .05, r = .42. Unacknowledged victims with PTSD did not differ on health variables compared to unacknowledged victims.
3. Discussion Victims reported more health complaints and more intense complaints than did non-traumatized controls, and victims more often expressed these complaints to health professionals. This is consistent with previous research (Golding, 1994; Kimerling & Calhoun, 1994; Zoellner et al., 2000). The contrast analysis confirmed a relationship between acknowledgment and the health variables. Rape alone, without acknowledgment, is associated with in an increase in the reported number and intensity of health complaints and the frequency at which these complaints are mentioned to health professionals. Acknowledgment of rape is associated with an even greater increase in the number and intensity of health complaints. Interestingly, acknowledged and unacknowledged victims did not differ on levels of PTSD (cf. Layman et al., 1996), but among acknowledged victims only, PTSD was associated with greater 1 As Rosenthal and Rosnow (1991, p. 475) emphasize, assigning contrast weights of 1, 0, and 1 is precisely how one tests a linear contrast involving three groups that yields an effect size r. Appearances notwithstanding, the computational procedures do not ‘‘set aside’’ the middle group (see Koutstaal & Rosenthal, 1994).
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frequency and intensity of health complaints as well as increased frequency at which complaints are mentioned to healthcare professionals. While the effect sizes appear small, they are of practical importance in addressing the needs of rape victims. For example, the effect size associated with the finding that acknowledged victims report more intense health complaints than do unacknowledged victims is r = .25. Thus, out of 100 acknowledged victims, 25 additional victims will report having more intense health complaints compared to a sample of 100 unacknowledged victims (see Rosenthal, 1990 for further discussion of the practical implications of small effect sizes). Thus, identity as a rape victim has implications for somatic symptoms, but not necessarily psychiatric ones, after an assault. This has implications for health care. Medical professionals need to be aware of the increased frequency and intensity of health symptoms in both groups of victims. Unacknowledged victims, who are less likely to discuss the rape with their physicians, may not understand why they are experiencing more frequent and intense physical symptoms than they did prior to the assault. The meaning of sexual assault may also have profound emotional consequences. For example, nearly one-third of adults who reported recalling early episodes of childhood sexual abuse, after many years of not having thought about them, developed PTSD (Clancy & McNally, 2005). Likewise, understanding an unwanted sexual experience as rape may likewise affect the victim’s psychological adjustment. Because rape victims have so often experienced feelings of shame and guilt, thanks to social stigmatization associated with being a victim of this crime, those who acknowledge the assault as rape may be at greater risk for PTSD. It appears that not identifying oneself as a rape victim may be a protective factor against an increased number and intensity of somatic symptoms. On the other hand, Layman et al. (1996) warn that because unacknowledged victims do not label their experiences as rape, they risk revictimization because a high percentage of these victims have continued relationships with the perpetrator. Thus, not acknowledging a rape may lead to greater trauma. Three caveats limit the generalizability of these results. First, we did not assess whether control women in our study had experienced other kinds of traumatic experiences or if they suffered from PTSD or Acute Stress Disorder. Second, we did not assess male victims of sexual assault. Third, we did not obtain sufficiently detailed information about the assaults themselves. Accordingly, we were unable to compare acknowledged and unacknowledged victims in terms of objective measures of assault severity.
Acknowledgements This study was funded by a grant from the Harvard University Knox Fund awarded to the first author. The authors thank Lia Larson and Melissa Tanner for their assistance in data collection and analysis.
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References Bureau of Justice Statistics (2003). Criminal Victimization 2002. Washington, D.C.: U.S. Department of Justice, publication no. NCJ-199994. Clancy, S. A., & McNally, R. J. (2005). Recovered memories of childhood sexual abuse: forgetting as a consequence of voluntary suppression, submitted for publication. Foa, E. B., Riggs, D. S., Dancu, C., & Rothbaum, B. (1993). Reliability and validity of a brief instrument for assessing post-traumatic stress disorder. Journal of Traumatic Stress, 6, 459–473. Golding, J. M. (1994). Sexual assault history and physical health in randomly selected Los Angeles women. Health Psychology, 13, 130–138. Kessler, R. C., Sonnega, A., Bromet, E., Hughes, M., & Nelson, C. B. (1995). Posttraumatic stress disorder in the national comorbidity survey. Archives of General Psychiatry, 52, 1048–1060. Kilpatrick, D. G., Saunders, B. E., Veronen, L. J., Best, C. L., & Von, J. M. (1987). Criminal victimization: lifetime prevalence reporting to police, and psychological impact. Crime and Delinquency, 33, 479–489. Kimerling, R., & Calhoun, K. S. (1994). Somatic symptoms, social support, and treatment seeking among sexual assault victims. Journal of Consulting and Clinical Psychology, 62, 333–340. Koss, M. P. (1985). The hidden rape victim: personality, attitudinal, and situational characteristics. Psychology of Women Quarterly, 9, 193–212. Koss, M. P., Dinero, T. E., Seibel, C. A., & Cox, S. L. (1988). Stranger and acquaintance rape: are there differences in women’s experiences. Psychology of Women Quarterly, 12, 1–24. Koss, M. P., & Oros, C. J. (1982). Sexual experiences survey: a research instrument investigating sexual aggression and victimization. Journal of Consulting and Clinical Psychology, 50, 455–457. Koutstaal, W., & Rosenthal, R. (1994). Contrast analysis in behavioral research. In: Brezezinski, J. (Ed.). Probability in theory-building: experimental and non-experimental models of scientific research in behavioural sciences. 28 (pp.135–173). Rodopi: Amsterdam. Layman, M. J., Gidycz, C. A., & Lynn, S. J. (1996). Unacknowledged versus acknowledged rape victims: situational factors and posttraumatic stress. Journal of Abnormal Psychology, 105, 124– 131. National Institute of Justice (2000). The Sexual Victimization of College Women. Washington, D.C.: U.S. Department of Justice, publication no: NCJ-182369. Pennebaker, J. W. (1982). The psychology of physical symptoms. New York: Springer-Verlag. Pennebaker, J. W., Burnam, M. A., Schaeffer, M. A., & Harper, D. C. (1977). Lack of control as a determinant of perceived physical symptoms. Journal of Personality and Social Psychology, 35, 167–174. Rosenthal, R. (1990). How are we doing in soft psychology? American Psychologist, 45, 775–776. Rosenthal, R., & Rosnow, R. L. (1991). Essentials of behavioral research: Methods and data analysis (2nd ed.). New York: McGraw-Hill. Zoellner, L. A., Goodwin, M. L., & Foa, E. B. (2000). PTSD severity and health perceptions in female victims of sexual assault. Journal of Traumatic Stress, 13, 635–649.
Health complaints in acknowledged and unacknowledged rape victims§ Lauren M. Conoscenti *, Richard J. McNally Department of Psychology, Harvard University, 1240 William James Hall, 33 Kirkland St., Cambridge, MA 02138, USA Received 16 November 2004; received in revised form 11 February 2005; accepted 4 March 2005
Abstract Rape may have physical as well as mental health consequences. Previous studies on health complaints in sexual assault survivors have focused on women who acknowledged their assault as rape. Unacknowledged rape victims do not define their assault as ‘‘rape’’ despite meeting legal definitions. In this study, acknowledged victims, unacknowledged victims, and a control group reported the number of health complaints, the intensity of complaints, and how often they reported these complaints to health professionals. Rape alone, without acknowledgment, was associated with in an increase in the reported number and intensity of health complaints and the frequency at which these complaints are addressed to health professionals. Acknowledgment of rape was associated with an even greater increase in the number and intensity of health complaints. # 2005 Elsevier Inc. All rights reserved. Keywords: Rape; Health complaints; Posttraumatic stress disorder
More than 140,000 rapes are reported in the United States each year (Bureau of Justice Statistics, 2003). Epidemiological surveys show that between 30 and 65% of rape victims suffer from posttraumatic stress disorder (PTSD; Kessler, Sonnega, Bromet,Hughes,&Nelson,1995;Kilpatrick,Saunders,Veronen,Best,&Von,1987). Rape affects physical health as well as mental health. Sexual assault victims report more health complaints and utilize more health services than do nonvictims § These findings were presented at the annual meeting of the Association for Advancement of Behavior Therapy, November 2003, Boston, MA. * Corresponding author. E-mail address: [email protected] (L.M. Conoscenti).
0887-6185/$ – see front matter # 2005 Elsevier Inc. All rights reserved. doi:10.1016/j.janxdis.2005.03.001
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(e.g., Golding, 1994; Kimerling & Calhoun, 1994). In addition, the number of health complaints correlates positively with PTSD severity in sexual assault survivors (Kimerling & Calhoun, 1994; Zoellner, Goodwin, & Foa, 2000). Some victims, however, do not conceptualize their experience as rape, even when it meets the legal definition for the crime. Perhaps to reduce feelings of shame, these unacknowledged victims may resist viewing their experiences as rape. Unacknowledged rape victims may be especially common among women whose sexual assaults do not fit the stereotype (e.g., date rape). Indeed, relative to acknowledged rape victims, unacknowledged victims are more likely to have had previous and continuing relationships with their assailants (Koss, 1985; Layman, Gidycz, & Lynn, 1996). Studies show varying proportions of these acknowledged and unacknowledged victims. Koss, Dinero, Seibel, and Cox (1988) found that 77% of women raped by acquaintances and 45% of woman raped by strangers were unacknowledged. Layman et al. (1996) found 73% were unacknowledged, and a nationwide survey of college women reported 54% were unacknowledged (National Institute of Justice, 2000). Layman et al. (1996) found that acknowledged victims report more PTSD symptoms than do unacknowledged victims. Acknowledged victims often perceive a more forceful and resisted assault and report a greater willingness to press charges against the attacker than do unacknowledged victims. However, it is unclear whether acknowledged victims experience an objectively more severe rape, or if the acknowledgment process influences event perception. Studies assessing health complaints in rape victims have concerned women who identify themselves as victims. In this study, we investigated the relationship between acknowledgment and frequency and intensity of health complaints. Because increased PTSD severity is associated with both identity as a rape victim and greater health complaints, acknowledged rape victims should report more health complaints, report more intense complaints, and report more of these complaints to a health professional compared to unacknowledged victims, who in turn should report more complaints and more intense complaints, and report more to professionals, than nonvictim control participants. In addition, a greater proportion of acknowledged victims should meet criteria for PTSD compared to the unacknowledged group.
1. Method 1.1. Participants Participants were recruited from the community via advertisements in local newspapers, posters, and on a local website’s ‘‘classifieds’’ section. Advertisements read: ‘‘Have you had an unwanted sexual experience? Are you still troubled by it? Researchers seek women, ages 18–45, who have had an unwanted sexual
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experience and who are still experiencing distress related to the event to participate in a research study.’’ Because most rape victims do not develop chronic PTSD, we included the phrases ‘‘still troubled’’ and ‘‘still experiencing distress’’ to recruit women suffering from symptoms of PTSD. We also recruited women reporting no history of rape via advertisements that read: ‘‘Women needed! Researchers seek women ages 18–45 who have never experienced unwanted sexual contact to participate in a study.’’ Participants were first screened on the phone to determine whether they reported an experience meeting the legal definition of rape, and if so, when that experience took place. For this study, we defined rape as ‘‘an event that occurred without the woman’s consent that involved the use of force or threat of force, and that involved sexual penetration of the victim’s vagina, mouth, or rectum.’’ This meets legal definition of forcible rape throughout the United States. Screening questions were six items from the Sexual Experiences Survey (Koss & Oros, 1982; questions 1, 2, 4, 5, 10, and 11). Participants were asked to respond ‘‘yes’’ or ‘‘no’’ to questions assessing increasingly severe levels of sexual coercion, and were told that questions referred to vaginal, oral, or anal penetration. Questions 1 (‘‘Have you ever had sexual intercourse with a man when you both wanted to?’’) and 2 (‘‘Have you ever had a man misinterpret the level of sexual intimacy you desired?’’) acclimated the respondent to questions about sexual history. Questions 4, 5, 10, and 11 referred to experiences meeting the legal definition of rape (i.e., ‘‘Have you ever had sexual intercourse with a man when you didn’t want to because he threatened to use physical force if you didn’t cooperate?’’) but did not explicitly mention rape. We classified women who answered ‘‘yes’’ to questions 4, 5, 10, or 11 as rape victims. To rule out symptoms of Acute Stress Disorder related to the sexual assault, we excluded women from the study if they had been raped within the previous 3 months. Eligible participants provided written, informed consent, came to the Harvard campus to complete the study, filled out surveys, and were paid for their time. Participants reporting a history of rape were also given a list of community resources for survivors of sexual assault. Two hundred and eighteen women inquired about the study by phone or e-mail. Of this group, 20 women with no history of rape and 69 women reporting a history of rape participated. Of the remaining 129 women, 105 women declined participation. Typically, these women failed to arrive for appointments or to return phone calls or emails. In addition, 24 women were ineligible, usually because their ‘‘unwanted sexual experience’’ was sexual harassment or molestation, but not rape. Eighty-nine women participated. Sixty-nine reported unwanted oral, anal, or vaginal penetration. The Sexual Experiences Inventory (SEI; Koss, 1985) assessed how the 69 traumatized women defined their unwanted sexual experience. Of these 69 women, 29 were unacknowledged victims and 40 were acknowledged victims. Twenty women had never experienced unwanted sexual intercourse, and were designated as control participants.
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Table 1 Means and standard deviations for demographic variables
Age Education Percent nonwhite Percent with PTSD Months since rape
Acknowledged victims
Unacknowledged victims
Controls
30.6 (7.9) 15.2 (2.0) 36 61 159.5 (186.8)
27.0 (8.2) 15.8 (2.6) 44 67 93.2 (106.8)
23.3 (6.1) 15.3 (2.5) 25 – –
Note. Standard deviations are in parentheses.
The groups differed in age, F(2, 77) = 5.83, p < .01. Post hoc contrasts (least significant difference method) revealed that the control group was younger than both the acknowledged and unacknowledged victim groups ( p < .05), whereas the latter two groups did not differ in age (see Table 1). The proportion of nonwhite participants did not differ across groups, x2(2) = 1.10, p = .29. The groups did not differ in years of education, F(2, 73) = .44, p = .65, nor did the acknowledged and unacknowledged groups differ in months since the rape, t(57) = 1.57, p = .12. 1.2. Measures All participants completed the Pennebaker Inventory of Limbic LanguidnessModified (PILL; Pennebaker, Burnam, Schaeffer, & Harper, 1977; modified by Zoellner et al. (2000) to include gynecological and gastrointestinal problems common to sexual assault victims). The modified PILL is a 246-item self-report measure that measures frequency, intensity, and usage of medical services related to 82 medical complaints. Items on the PILL include routine health complaints, such as coughing, eyes watering, and sneezing, as well as more severe complaints, such as broken bones, vomiting, and blood in stool. Participants rated the frequency and intensity of symptoms they had experienced in the past 4 weeks, and whether they had mentioned the problem to a medical professional. Internal consistency for the original 54-item PILL (measuring frequency of symptoms only), as measured by Cronbach’s alpha, ranges from .88 (binary method) to .91 (summed method). Test–retest reliability for 177 subjects over a 2month period was .79 (binary method) and .83 (summed method; Pennebaker, 1982). Both acknowledged and unacknowledged victims completed two additional measures: the PTSD Symptom Scale (PSS-I; Foa, Riggs, Dancu, & Rothbaum, 1993) and the Sexual Experiences Inventory (SEI; Koss, 1985). The PSS-I is a 17-item measure assessing the presence and severity of each of the DSM-IV PTSD symptoms. Participants rate their symptoms on a 4-point scale ranging from 0 (‘‘not at all’’) to 3 (‘‘very much’’/‘‘five or more times per week’’). While the PSS-I is a continuous measure, it can also be used for a dichotomous
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cutoff. We used criteria matching the DSM-IV PTSD symptoms (endorsement of one re-experiencing symptom, three avoidance symptoms, and two increased arousal symptoms) to determine whether participants had or did not have PTSD. The PSS-I has high internal consistency (a = .85), high testretest reliability (r = .80), high interrater reliability (kappa = .91), and moderate to high correlations with other measures of psychopathology (Foa et al., 1993). The SEI distinguished acknowledged from unacknowledged rape victims by asking participants to respond ‘‘yes’’ or ‘‘no’’ to four questions. Participants who responded ‘‘no’’ to the fourth item, ‘‘Do you believe you were a victim of rape?’’ were classified as ‘‘unacknowledged.’’
2. Results Table 2 shows means and standard deviations for the variables. All t-tests reported are one-tailed. Sixty-one percent of the acknowledged group and 67% of the unacknowledged group met criteria for PTSD as measured by the PSS; no differences existed between victim groups for this variable, x2(1) = .21, p = .65. Victims reported more health complaints, t(85) = 2.28, p < .05, effect size r = .24, than did control participants. Relative to controls, victims experienced health complaints more intensely, t(87) = 3.46, p < .01, r = .34, and reported them to health professionals more frequently, t(87) = 2.19, p < .05, r = .23. Consistent with our hypothesis, acknowledged victims reported more intense health complaints than did unacknowledged victims, t = 2.00, p = .05, r = .25, and they tended to report more health complaints, t = 1.77, p = .08, effect size r = .23. However, acknowledged and unacknowledged victims did not differ in the reporting of health complaints to professionals, t = 1.15, p = .25. If sexual assault, especially that acknowledged as rape, is associated with physical health problems, then the acknowledged victim group should report more complaints, report more intense complaints, and report more complaints to health professionals than the unacknowledged group, whereas the unacknowledged group should report more complaints than the control group. We tested this prediction by applying contrast weights of 1, 0, and 1 to the means of the Table 2 Means and standard deviations for health-related variables
Number of health complaints Intensity of health complaints Number of consultations with medical professionals
Acknowledged victims
Unacknowledged victims
Controls
57.8 (33.1) 47.5 (37.5) 4.2 (6.4)
46.2 (25.3) 33.7 (23.2) 2.3 (3.4)
36.0 (25.1) 22.0 (18.4) 1.5 (2.7)
Note. Standard deviations are in parentheses.
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Table 3 Means and standard deviations for health-related variables for acknowledged victims with and without PTSD
Number of health complaints Intensity of health complaints Number of consultations with medical professionals
With PTSD
Without PTSD
78.7 (35.1) 66.4 (41.7) 6.2 (8.3)
35.6 (25.6) 25.2 (13.6) 1.2 (2.2)
Note. Standard deviations are in parentheses.
acknowledged, unacknowledged, and control groups, respectively.1 The results were in accord with this hypothesis, number of health complaints: t(84) = 2.73, p < .01, effect size r = .29; intensity complaints: t(86) = 3.13, p < .005, r = .32; number of complaints reported to health professional: t(86) = 2.04, p < .05, r = .21 (Table 3). Finally, because previous research showed a direct correlation between PTSD and health complaints, we examined the relationship between acknowledgment, PTSD, and health complaints. While the same proportion of participants in each victim group met criteria for PTSD, acknowledged victims with PTSD, compared to acknowledged victims without PTSD, reported more health complaints, t(31) = 3.88, p < .001, r = .57, and more intense complaints, t(28) = 3.16, p < .005, r = .51, and sought medical advice for more complaints, t(27) = 2.43, p < .05, r = .42. Unacknowledged victims with PTSD did not differ on health variables compared to unacknowledged victims.
3. Discussion Victims reported more health complaints and more intense complaints than did non-traumatized controls, and victims more often expressed these complaints to health professionals. This is consistent with previous research (Golding, 1994; Kimerling & Calhoun, 1994; Zoellner et al., 2000). The contrast analysis confirmed a relationship between acknowledgment and the health variables. Rape alone, without acknowledgment, is associated with in an increase in the reported number and intensity of health complaints and the frequency at which these complaints are mentioned to health professionals. Acknowledgment of rape is associated with an even greater increase in the number and intensity of health complaints. Interestingly, acknowledged and unacknowledged victims did not differ on levels of PTSD (cf. Layman et al., 1996), but among acknowledged victims only, PTSD was associated with greater 1 As Rosenthal and Rosnow (1991, p. 475) emphasize, assigning contrast weights of 1, 0, and 1 is precisely how one tests a linear contrast involving three groups that yields an effect size r. Appearances notwithstanding, the computational procedures do not ‘‘set aside’’ the middle group (see Koutstaal & Rosenthal, 1994).
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frequency and intensity of health complaints as well as increased frequency at which complaints are mentioned to healthcare professionals. While the effect sizes appear small, they are of practical importance in addressing the needs of rape victims. For example, the effect size associated with the finding that acknowledged victims report more intense health complaints than do unacknowledged victims is r = .25. Thus, out of 100 acknowledged victims, 25 additional victims will report having more intense health complaints compared to a sample of 100 unacknowledged victims (see Rosenthal, 1990 for further discussion of the practical implications of small effect sizes). Thus, identity as a rape victim has implications for somatic symptoms, but not necessarily psychiatric ones, after an assault. This has implications for health care. Medical professionals need to be aware of the increased frequency and intensity of health symptoms in both groups of victims. Unacknowledged victims, who are less likely to discuss the rape with their physicians, may not understand why they are experiencing more frequent and intense physical symptoms than they did prior to the assault. The meaning of sexual assault may also have profound emotional consequences. For example, nearly one-third of adults who reported recalling early episodes of childhood sexual abuse, after many years of not having thought about them, developed PTSD (Clancy & McNally, 2005). Likewise, understanding an unwanted sexual experience as rape may likewise affect the victim’s psychological adjustment. Because rape victims have so often experienced feelings of shame and guilt, thanks to social stigmatization associated with being a victim of this crime, those who acknowledge the assault as rape may be at greater risk for PTSD. It appears that not identifying oneself as a rape victim may be a protective factor against an increased number and intensity of somatic symptoms. On the other hand, Layman et al. (1996) warn that because unacknowledged victims do not label their experiences as rape, they risk revictimization because a high percentage of these victims have continued relationships with the perpetrator. Thus, not acknowledging a rape may lead to greater trauma. Three caveats limit the generalizability of these results. First, we did not assess whether control women in our study had experienced other kinds of traumatic experiences or if they suffered from PTSD or Acute Stress Disorder. Second, we did not assess male victims of sexual assault. Third, we did not obtain sufficiently detailed information about the assaults themselves. Accordingly, we were unable to compare acknowledged and unacknowledged victims in terms of objective measures of assault severity.
Acknowledgements This study was funded by a grant from the Harvard University Knox Fund awarded to the first author. The authors thank Lia Larson and Melissa Tanner for their assistance in data collection and analysis.
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References Bureau of Justice Statistics (2003). Criminal Victimization 2002. Washington, D.C.: U.S. Department of Justice, publication no. NCJ-199994. Clancy, S. A., & McNally, R. J. (2005). Recovered memories of childhood sexual abuse: forgetting as a consequence of voluntary suppression, submitted for publication. Foa, E. B., Riggs, D. S., Dancu, C., & Rothbaum, B. (1993). Reliability and validity of a brief instrument for assessing post-traumatic stress disorder. Journal of Traumatic Stress, 6, 459–473. Golding, J. M. (1994). Sexual assault history and physical health in randomly selected Los Angeles women. Health Psychology, 13, 130–138. Kessler, R. C., Sonnega, A., Bromet, E., Hughes, M., & Nelson, C. B. (1995). Posttraumatic stress disorder in the national comorbidity survey. Archives of General Psychiatry, 52, 1048–1060. Kilpatrick, D. G., Saunders, B. E., Veronen, L. J., Best, C. L., & Von, J. M. (1987). Criminal victimization: lifetime prevalence reporting to police, and psychological impact. Crime and Delinquency, 33, 479–489. Kimerling, R., & Calhoun, K. S. (1994). Somatic symptoms, social support, and treatment seeking among sexual assault victims. Journal of Consulting and Clinical Psychology, 62, 333–340. Koss, M. P. (1985). The hidden rape victim: personality, attitudinal, and situational characteristics. Psychology of Women Quarterly, 9, 193–212. Koss, M. P., Dinero, T. E., Seibel, C. A., & Cox, S. L. (1988). Stranger and acquaintance rape: are there differences in women’s experiences. Psychology of Women Quarterly, 12, 1–24. Koss, M. P., & Oros, C. J. (1982). Sexual experiences survey: a research instrument investigating sexual aggression and victimization. Journal of Consulting and Clinical Psychology, 50, 455–457. Koutstaal, W., & Rosenthal, R. (1994). Contrast analysis in behavioral research. In: Brezezinski, J. (Ed.). Probability in theory-building: experimental and non-experimental models of scientific research in behavioural sciences. 28 (pp.135–173). Rodopi: Amsterdam. Layman, M. J., Gidycz, C. A., & Lynn, S. J. (1996). Unacknowledged versus acknowledged rape victims: situational factors and posttraumatic stress. Journal of Abnormal Psychology, 105, 124– 131. National Institute of Justice (2000). The Sexual Victimization of College Women. Washington, D.C.: U.S. Department of Justice, publication no: NCJ-182369. Pennebaker, J. W. (1982). The psychology of physical symptoms. New York: Springer-Verlag. Pennebaker, J. W., Burnam, M. A., Schaeffer, M. A., & Harper, D. C. (1977). Lack of control as a determinant of perceived physical symptoms. Journal of Personality and Social Psychology, 35, 167–174. Rosenthal, R. (1990). How are we doing in soft psychology? American Psychologist, 45, 775–776. Rosenthal, R., & Rosnow, R. L. (1991). Essentials of behavioral research: Methods and data analysis (2nd ed.). New York: McGraw-Hill. Zoellner, L. A., Goodwin, M. L., & Foa, E. B. (2000). PTSD severity and health perceptions in female victims of sexual assault. Journal of Traumatic Stress, 13, 635–649.