Risk Factors for Rape, Physical Assault, and Posttraumatic Stress Disorder in Women

Pergamon

Journal of Anxiety Disorders, Vol. 13, No. 6, pp. 541–563, 1999 Copyright  2000 Elsevier Science Ltd Printed in the USA. All rights reserved 0887-6185/99 $–see front matter

PII S0887-6185(99)00030-4

RESEARCH PAPERS

Risk Factors for Rape, Physical Assault, and Posttraumatic Stress Disorder in Women: Examination of Differential Multivariate Relationships Ron Acierno, Ph.D., Heidi Resnick, Ph.D., Dean G. Kilpatrick, Ph.D., Benjamin Saunders, Ph.D., and Connie L. Best, Ph.D. National Crime Victims Research and Treatment Center, Medical University of South Carolina, Charleston, South Carolina, USA

Abstract—The National Women’s Study, a 2-year, three-wave longitudinal investigation, employed a national probability sample of 3,006 adult women to: (a) identify separate risk factors for rape and physical assault, and (b) identify separate risk factors associated with post-rape posttraumatic stress disorder (PTSD) and post-physical assault PTSD. This investigation differed from previous studies in that it prospectively examined risk factors at the multivariate, as opposed to univariate level. Overall, past victimization, young age, and a diagnosis of active PTSD increased women’s risk of being raped. By contrast, past victimization, minority ethnic status, active depression, and drug use were associated with increased risk of being physically assaulted. Risk factors for PTSD following rape included a history of depression, alcohol abuse, or experienced injury during the rape. However, risk factors for PTSD following physical assault included only a history of depression and lower education.  2000 Elsevier Science Ltd. All rights reserved. This research was supported by National Institute on Drug Abuse grant no. DA 05220, and preparation of this manuscript was partially supported by National Institute of Mental Health Training grant no. MH 18869. The authors express their thanks to John Boyle, Ph.D. of Schulman, Ronca, Bucuvalas, Inc. and Coryl Jones, Ph.D. of the National Institute on Drug Abuse. Requests for reprints should be sent to Ron Acierno, National Crime Victims Research and Treatment Center, Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, 171 Ashley Avenue, Charleston, SC 29425-0142, USA. E-mail: [email protected]

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Keywords: PTSD; Rape; Assault; Risk factors

The United States has the highest incidence of violent crime of any industrialized nation (Rosenberg & Fenley, 1991). More than one of every five Americans will suffer some form of serious physical or sexual assault during their lifetime (Kilpatrick, Acierno, Resnick, Saunders, & Best, 1997; Resnick, Falsetti, Kilpatrick, & Freedy, 1996). The extremely negative mental and physical health effects of violent crime have motivated state and federal agencies to sponsor research specifically devoted to violence prevention, with an emphasis on risk-factor specification. Identifying and subsequently modifying or eliminating risk factors for assaultive violence, such as rape or physical attack, may reduce both the incidence of assault and, in turn, that of post-assault psychopathology, such as posttraumatic stress disorder (PTSD). Similarly, identifying risk factors for PTSD following assault may permit early interventions with those victims at greatest risk of developing emotional problems. Unfortunately, very limited research has been conducted to clarify the relationship between multiple predisposing variables for either violence or PTSD. The majority of existing work in this area is confined to methodological and analytic strategies that examine individual relationships among selected variables and violence, with little consideration given to simultaneous effects of other related variables. That is, univariate identification and description of risk factors for violence and violence-related PTSD has characterized current knowledge in the field; however, it appears clear that one’s risk of being physically or sexually assaulted, or of developing PTSD is determined by multiple factors, which may or may not be related to one another. Thus, obtained univariate results identifying probable risk factors are potentially misleading. Research on race as a risk factor for assault is illustrative of this problem. Estimates of victimization rates associated with racial status have been mixed. Several crime surveys place African Americans at greatest risk for certain types of violent crime (Bachman & Salzman, 1994; Federal Bureau of Investigation, 1991; Hanson, Kilpatrick, Falsetti, & Resnick, 1995). Other studies hold that Caucasians are more likely to be assaulted (Burnam et al., 1988; Cottler, Compton, Mager, Spitznagel, & Janca, 1992; Norris, 1992). Still other studies have found no relationship between risk of violence and race (Breslau, Davis, Andreski, & Petersen, 1991). Discrepancies across studies may be attributed to confounding effects of income, education, age, past victimization status, substance abuse status, gender, and even assault type (physical assault vs. rape). Consequently, multivariate design and analyses are necessary to clarify risk relationships. This is not to imply that existing univariate studies have been fruitless. Several variables have been identified as potentially relevant to victimization risk, including age, income, victimization history, psychopathology, and substance

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use. Specifically, age appears to be negatively correlated with risk of sexual assault, but may be positively correlated with risk of physical assault within a limited range (i.e., through young adulthood) (Bachman & Salzman, 1994; Bureau of Justice Statistics, 1992; Kilpatrick, Edmunds, & Seymour, 1992; Norris, 1992). Thus, children and youth appear to be at greater risk of sexual assault, and youth and young adults are at greater risk of physical assault. Increased vulnerability and diminished likelihood of disclosure and prosecution appear to be primary reasons children suffer high rates of sexual assault. Physical assault in young adults is potentially related to situational behaviors that increase one’s risk for interpersonal violence (e.g., increased dating, elevated drug use in this age group, etc.). Not surprisingly, income appears to be inversely related to risk of violent assault (Bachman & Salzman, 1994; Kilpatrick, Resnick, Saunders, & Best, 1998; Reiss & Roth, 1993), particularly in women residing in households earning below $10,000 annually. In addition, past victimization also seems to greatly increases risk of future assault, and is perhaps the most potent predictor of interpersonal violence (Hanson et al., 1995; Kilpatrick et al., 1997; Koss & Dinero, 1989; Steketee & Foa, 1987; Zawitz, 1988). The relationship between both reduced income and past victimization status and assaultive violence may be a function of the combined effects of geographical residence (e.g., low socioeconomic status urban housing) and reduced availability of financial and social resources needed to avoid or escape from dangerous environments. Moreover, Byrne, Resnick, Kilpatrick, Saunders, and Best (1997) showed that the financial status of women who have been victimized actually diminishes, exacerbating the problem even further. The dilemma facing lowincome mothers suffering domestic violence highlights these points: despite repeated assaults, these women may be hesitant to leave their husbands because they feel unable to independently provide food and shelter for their families. The temporal relationship between psychopathology and victimization remains understudied, with each serving as a potential risk factor for the other. Nonetheless, existing research has demonstrated a strong relationship between depression, substance use disorders, antisocial personality disorder, and phobias and assault (Breslau et al., 1991; Burnam et al., 1988; Cottler et al., 1992; Kilpatrick et al., 1997). Increased risk of victimization in these groups probably varies as a function of psychopathology subtype. For example, substance abusers may be forced to repeatedly enter extremely dangerous situations in order to obtain drugs, or, once intoxicated, may experience impairment in their ability to detect and avoid potentially violent situations. By contrast, risk factors operating in depressed individuals may be associated with reduced social support and motivation for self-preservation or protection (e.g., depressed wives of abusive spouses).

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Risk factors for PTSD following interpersonal violence parallel many of the risk factors for assault. As was the case for exposure to crime, age is inversely related to incidence of PTSD, at least in those over 18 years old (Kilpatrick et al., 1989). Effects of race on risk of PTSD are mixed, partially because reported effects of race on risk of exposure to violence are also largely variable. A majority of studies have found no effects of race on development of PTSD following trauma (Breslau et al., 1991; Norris, 1992; Kilpatrick et al., 1989; Weaver & Clum, 1995). However, others (e.g., Green et al., 1990) have noted that African American survivors of disaster (not crime) evinced greater rates of PTSD than Caucasians. As noted above for assault, experience of prior victimization also appears to elevate risk of PTSD following new victimization. Several investigators report increased likelihood of PTSD in individuals with comorbid or preexisting psychological disorders, such as depression (Breslau et al., 1991; Kessler, Sonnega, Bromet, Hughes, & Nelson, 1995) or substance abuse (Cottler et al., 1992). Such preexisting conditions may serve to reduce the “threshold” at which an individual might develop the avoidance, hyperarousal, and reexperiencing symptoms of PTSD. Alternatively, comorbid psychopathology may contribute to maintenance of PTSD symptomatology. Moreover, diagnostic overlap between affective and anxiety disorders and PTSD is significant for some forms of psychopathology. Thus, vulnerability to one disorder may be strongly associated with vulnerability to other, related disorders. Qualitative aspects of assaultive violence also affect risk of developing PTSD. In univariate analyses, Kilpatrick et al. (1989) and Resnick, Kilpatrick, Dansky, Saunders, and Best (1993) found that women who were injured during assault or who perceived that their lives were in danger were more likely to develop PTSD than similarly victimized women without these crime characteristics. Experiencing actual physical harm, or perceiving real threat to one’s life is most certainly associated with cognitive and behavioral outcomes that differ from those produced by lessor forms of victimization. Clearly, recovery processes following physical injury (e.g., doctor’s visits, temporarily impaired ambulation) require alternate types of behaviors, and cognitive processes associated with catastrophic threat to one’s life might produce enduring cognitive changes (e.g., hopelessness) in some people. As mentioned, the true likelihood of being assaulted and of developing PTSD associated with each of the aforementioned risk factors remains unknown due to the univariate nature of most existing research. That is, does lower income independently increase one’s risk of being assaulted, or is this effect attributable to racial status? What are the unique effects of substance use on risk of assault and PTSD, over and above effects of demographic variables? Research is needed in which several demographic variables are examined in multivariate analyses in order to isolate independent effects of each on victimization risk. In addition to demographic variables, historical factors

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(such as past psychopathology and substance use, and past victimization status) must also be examined and controlled in multivariate analyses. In efforts to determine PTSD risk, study of these objective factors should be complemented with examination of multiple contextual factors, such as experienced injury or perceived life threat, that may determine psychological outcome of assaultive violence. Another essential consideration is the possibility that risk factors associated with rape differ from those associated with physical assault. The present study was designed to address these needs, and specific goals include the following: (a) to identify, through multivariate analyses, the unique contribution of demographic characteristics, history of psychopathology, and history of victimization to risk of being sexually assaulted in the form of rape; (b) to consider, in parallel multivariate analyses, effects of these factors to risk of being physically assaulted; and (c) to identify the contribution of these factors and assault characteristics to development of PTSD separately for rape and physical assault victims.

METHOD Participants Participants were enrolled in the National Women’s Study (NWS), a longitudinal telephone survey involving a national household probability sample of 4,009 women. Of this total, 2,009 were a national household probability sample of U.S. female adults (age 18 and older), and 2,000 were an oversample of women aged 18 to 34 years, the age at which victimization risk appears greatest (see Resnick et al., 1993 provide demographic characteristics of the original Wave I study sample, weighted by age and race to reflect national averages of these variables). The mean age of participants was 35.9 years (SD 5 14.5). Eighty-two percent were White; 8.2% were African American; 5.8% were Hispanic; 2.2% were Native American; and 1.8% were members of other racial groups. With respect to highest educational achievement, 3.5% did not graduate from high school; 75% were high school graduates; and 21.5% were college graduates. Procedure Households were selected based on random digit dialing methodology (The National Women’s Study methodology is described in considerable detail elsewhere; Resnick et al., 1993). In households with more than one adult woman, the most recent birthday method was used to select one woman for interview. If potential participants agreed to be interviewed, the survey was conducted. Following the initial interview, participants were informed according to the following script that they would be recontacted:

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As part of this three year study, we will be calling you again in about one year. The questions next year will be somewhat different. We will want to know the major events that have occurred in your life in the past year, how things are going, what types of services you have used or feel you need. The interviewer who will call next year will not know any of the answers you have given me today. However, we will need some information so that we can be sure to contact you next year, particularly in case you move.

Follow-up interviews were attempted both 1 year (Wave II) and 2 years (Wave III) after the initial interview (Wave I). One month prior to follow-up interviews, participants received a letter and a telephone call reminding them of our recontact intentions and informing them that they would be mailed a check for $20 following participation. Female interviewers collected all data using a computer-assisted telephone interview (CATI) procedure in which each question in the highly structured telephone interview appeared on a computer screen and was read verbatim to respondents. Measures The NWS employed a highly structured telephone interview designed to obtain information about several topics, including demographic characteristics, alcohol and drug use/abuse patterns, and history of rape and physical assault. Demographic variables were assessed using standard questions employed by the U.S. Bureau of the Census (1991) to catagorize age, education, and race. Alcohol use was investigated through a series of questions that inquired first about whether the respondent had ever ingested beer, wine, liquor, or any other alcoholic beverage. Next, respondents were asked whether they had consumed alcohol within the past 12 months. Participants who had consumed alcohol within the past 12 months were asked follow-up questions about frequency and impact of use, permitting diagnosis of alcohol abuse. Our criteria for alcohol abuse approximated those of the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV; American Psychiatric Association, 1994), which requires (a) presence of a maladaptive pattern of alcohol use resulting in clinically significant impairment or distress occurring within a 12-month period, as manifested by at least one of four symptoms of functional impairment, and (b) absence of alcohol dependence. Our modified diagnostic criteria differed in that we did not exclude persons from the alcohol abuse diagnosis who might have also met the alcohol dependence diagnosis, and we included a question in the alcohol abuse diagnosis that measured respondents’ unsuccessful attempts to reduce their alcohol consumption or to stop drinking (a DSM-IV dependence symptom). The net effect of these two modifications in DSM-IV criteria for alcohol abuse was to include some women who had symptoms of dependence as well as abuse.

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Drug use was measured by the query: “Have you ever used marijuana, cocaine, angel dust, LSD, or other hallucinogenics, heroin, methadone, or glue or other inhalants? Would you say you have used (item) on 1–3 occasions, 4–10 occasions, or more than 10 occasions?” Those participants who reported use of an illicit drug four or more times were designated as nonexperimental users. This level of usage was considered important because of the potential physical and legal hazards associated with acquisition and ingestion of an illicit substance. Moreover, this frequency of usage approximates that considered significant by the Diagnostic Interview Schedule (DIS; Robins, Helzer, Cottler, & Goldring, 1988) substance abuse screen. In this study, participants who abused alcohol but not drugs (designated as exclusive alcohol abusers) were differentiated from drug users (who may or may not have been alcohol abusers) for the following two reasons: (a) although alcohol and illicit drugs are psychoactive substances, purchase, possession, and consumption of alcohol are legal for adults, but all three are illegal in the case of drugs; and (b) a substantial proportion of respondents reported that they were exclusive alcohol abusers and did not use other illicit drugs. PTSD was measured, according to criteria of the Diagnostic and Statistical Manual of Mental Disorders, third edition, revised (DSM-III-R; American Psychiatric Association, 1987), by the NWS PTSD Module, a DIS-based structured interview with an added behaviorally specific, sensitive trauma screen. This modified interview comprehensively assesses lifetime occurrence of civilian crime, and includes a preface statement that provides contextual orientation to the trauma victim, along with accurate information regarding criterion A event prevalence. Moreover, the preface statement details the interviewer’s interest in any assault event, not just those perpetrated by strangers or reported to police or individuals in a position of authority. According to the DSM-III-R, PTSD is diagnosed when an individual has been exposed to a traumatic event that both presents actual or threatened death or serious injury to oneself or others, and elicits intense fear, helplessness, or horror. The basic symptoms of PTSD include reexperiencing, avoidance, and hyperarousal. These symptoms must persist for at least 1 month and cause functional impairment in interpersonal or vocational spheres. Major depression was measured by questions that assessed whether participants endorsed at least five of nine DSM-III-R symptoms of the disorder. Symptoms assessed included being depressed or down for at least a 2-week period, anhedonia for at least a 2-week period, feelings of worthlessness or guilt, concentration problems, self-injurious or suicidal thoughts, weight loss or gains, sleep disturbances, motor disturbances, and fatigue. Rape was measured using the following introduction and four screening questions: Another type of stressful event that many women have experienced is unwanted sexual advances. Women do not always report such experiences to

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the police or other authorities or discuss them with family or friends. The person making the advances isn’t always a stranger, but can be a friend, boyfriend, or even a family member. Such experiences can occur anytime in a woman’s life—even as a child. Regardless of how long ago it happened or who made the advances . . . 1. Has a man or boy ever made you have sex by using force or threatening to harm you or someone close to you? Just so there is no mistake, by sex we mean putting a penis in your vagina. 2. Has anyone, male or female, ever made you have oral sex by using force or threat of harm? Just so there is no mistake, by oral sex we mean that a man or a boy put his penis in your mouth or someone, male or female, penetrated your vagina or anus with their mouth or tongue. 3. Has anyone ever made you have anal sex by using force or threat of harm? Just so there is no mistake, by anal sex we mean that a man or boy put his penis in your anus. 4. Has anyone, male or female, ever put fingers or objects in your vagina or anus against your will by using force or threats?

Women responding affirmatively to one or more of these four questions were classified as rape victims. Physical assault was measured using the following introduction and two screening questions: Another type of stressful event women sometimes experience is being physically attacked by another person. 1. Not counting any incidents already described to me, has anyone—including family members or friends—ever attacked you with a gun, knife, or some other weapon, regardless of when it happened or whether you ever reported it or not? 2. Has anyone—including family members and friends—ever attacked you without a weapon, but with the intent to kill or seriously injure you?“

Women who responded affirmatively to one of these two questions were classified as having experienced a physical assault. Such assaults are defined as aggravated assault under the criminal statutes of most jurisdictions in the United States. Follow-up questions assessed when the incidents occurred, permitting us to determine whether women had been assaulted prior to the Wave I interview or between the Wave I and Wave III interviews. Variable Specifications The following definitions specify parameters of study variables: 1. Age: 18–34 years, 35–54 years, 55 years and over at Wave I interview. Range, 1–3.

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2. Educational achievement: less than a high school graduate, high school graduate, college graduate. Range, 1–3. 3. Race/ethnicity: a dichotomous variable in which African Americans, Hispanic Americans, Native Americans, Pacific Islanders, Native Alaskans, and Asian Americans were classified as Minorities and Whites were classified as nonminorities. Range, 0–1. 4. Income (annual): less than $10,000, $10,001–$25,000, over $25,000. Range, 1–3. 5. Active Wave I Exclusive Alcohol Abuse: met modified criteria for alcohol abuse as defined above, with symptoms reported during the preceding 12 months, but reported no drug use as defined above during 12 months preceding Wave I interview. Range, 0–1. 6. Lifetime exclusive alcohol abuse: met modified criteria at some point in their lifetime for alcohol abuse as defined above, but reported no history of drug use as defined above. Range, 0–1. 7. Active Wave I drug use: ingestion of illicit drugs by nonexperimental users (as defined above) during 12 months preceding Wave I interview. Range, 0–1. 8. Lifetime drug use: ingestion of illicit drugs by nonexperimental users (as defined above) at some point in their lifetime. Range, 0–1. 9. Active Wave I PTSD: met DSM-III-R criteria for PTSD over the 6 months prior to Wave I assessment. Range, 0–1. 10. Active Wave I depression: met DSM-III-R criteria for depression over the month prior to Wave I assessment. Range, 0–1. 11. Lifetime depression: met DSM-III-R criteria for major depression at some point in their lifetime. Range, 0–1. 12. New rape: reported rape in the 12 months preceding Wave II or Wave III interviews. Range, 0–1. 13. Lifetime rape: reported rape at some point during their lifetime measured at Wave I. Range, 0–1. 14. New physical assault: reported physical assault in 12 months preceding Wave II or Wave III interviews. Range, 0–1. 15. Lifetime physical assault: reported physical assault at some point during their lifetime measured at Wave I. Range, 0–1. 16. Lifetime victimization: reported history of rape or physical assault measured at Wave I. Range, 0–1. 17. Life threat during rape: rape victims reported that during any rape, they felt that they would be killed or seriously injured. Range, 0–1. 18. Life threat during physical assault: physical assault victims reported that during any rape, they felt that they would be killed or seriously injured. Range, 0–1. 19. Injury during rape: rape victims reported that they suffered physical injuries during any rape. Range, 0–1.

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20. Injury during physical assault: physical assault victims reported that they suffered physical injuries during any physical assault. Range, 0–1.

RESULTS Data are presented in terms of odds ratios (determined through hierarchical logistic regression using the SPSS statistical package for Windows, version 6. For all logistic regression analyses, an alpha level of .05 was chosen a priori. Attrition Of eligible respondents who completed Wave I interviews (n 5 4,008), 80% (n 5 3,220) completed Wave II follow-up interviews, and 75% (n 5 3,006) completed Wave III follow-up interviews. Of the 1,003 of women who completed Wave I but not Wave III interviews, 520 (51.8%) could not be located; 207 (20.6%) refused to participate or terminated the interview; 120 (12.0%) were located but could not be reached during the field period; 39 (3.9%) were deceased or had health problems that precluded their participation, 100 (10.0%) were still in call-back status at the conclusion of the field period, and 15 (1.5%) did not participate for some other reason. Wave III completers and noncompleters did not significantly differ in terms of Wave I lifetime assault, Wave I exclusive alcohol abuse, or Wave I drug use. However, a greater proportion of Whites (77.8%) than minorities (64.3%) completed Wave III, x2 5 63.6, df 5 1, p , .001. High school and college graduates (74.6% and 82.6%, respectively) were also more likely to be completers than women who had not graduated from high school (66.0%), x2 5 39.31, df 5 2, p , .001. Descriptive Data: Rates of New Rape and Physical Assault Of the 4,009 participants completing Wave I, 15.1% (n 5 607) reported that they had experienced a completed rape and 11.5% (n 5 463) indicated that they had been physically assaulted. Approximately 4.1% (n 5 166) reported that they had been both raped and physically assaulted (35.9% of physical assault victims were also rape victims, and 27.3% of rape victims were also physical assault victims). Table 1 presents longitudinal data that describe rates of new rape and physical assault (measured at Wave III) in terms of demographic variables (i.e., age, education, race, and income), substance use variables (i.e., active Wave I exclusive alcohol abuse and illicit drug use), psychopathology variables (active Wave I PTSD and major depression), and past victimization status. Because the emphasis of this article is on multivariate relationships, individual significance testing (e.g., chi-square analyses) of these relationships for recently experienced rape and physical assault was not conducted, and prevalence rates are presented for illustrative purposes only.

2.0 (n 5 44) 2.9 (n 5 12) 2.3a (n 5 11) 3.3 (n 5 15) 3.6 (n 5 6) 3.2 (n 5 7) 4.6 (n 5 7) 6.4 (n 5 12) 5.1 (n 5 38)

PTSD 5 posttraumatic stress disorder. a Non-White. b White.

Age Education Race Income Exclusive alcohol Drug use Major depression PTSD Past victimization

Variable

% W-III New Rape if Positive for Variable (or in Lowest Age, Education, or Income Range) 1.5 (n 5 10) 1.3 (n 5 29) – 1.3 (n 5 14) – – – – –

0.0 (n 5 0) 1.8 (n 5 13) 1.5b (n 5 43) 1.4 (n 5 23) 1.5 (n 5 48) 1.5 (n 5 47) 1.5 (n 5 47) 1.3 (n 5 42) 0.6 (n 5 16)

% W-III New Rape if Negative for % W-III New Rape Variable (or in if in Middle Age, Highest Age, Education, or Education, or Income Range Income Range) 2.8 (n 5 62) 2.6 (n 5 11) 4.9a (n 5 23) 3.5 (n 5 16) 2.4 (n 5 4) 6.0 (n 5 13) 7.3 (n 5 11) 5.9 (n 5 11) 5.9 (n 5 44)

% W-III New Physical Assault if Positive for Variable (or in Lowest Age, Education, or Income Range) 2.0 (n 5 14) 2.8 (n 5 62) – 2.5 (n 5 27) – – – – –

% W-III New Physical Assault if in Middle Age, Education, or Income Range

1.3 (n 5 6) 1.2 (n 5 9) 2.1b (n 5 60) 2.3 (n 5 37) 2.5 (n 5 79) 2.2 (n 5 70) 2.2 (n 5 72) 2.3 (n 5 72) 1.5 (n 5 39)

% W-III New Physical Assault if Negative for Variable (or in Highest Age, Education, or Income Range)

TABLE 1 Descriptive Data: Rates of New Physical Assault and Rape at Wave III (W-III) as a Function of Demographic Variables, Wave I Active Substance Use Variables, Wave I Active Major Depression, Wave I Active PTSD, and Lifetime Victimization Status

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TABLE 2 Longitudinal Analyses: Initial and Final Model Odds of (A) Wave III New Rape, and (B) Wave III New Physical Assault as a Function of Demographic Variables, Wave I Active Substance Use Variables, Wave I Active Major Depression, Wave I Active PTSD, and Lifetime Victimization Status (N 5 3,006) Step

Variable

b

SE

Wald

Step OR

Final OR

Final p

.304 .258 .358 .194 .469 .434 .483 .385 .321

3.86 0.29 1.03 2.09 1.19 0.03 0.16 2.97 37.10

0.47 ns ns ns ns ns ns 3.27 7.06

.55 ns ns ns ns ns ns ns 7.06

.049 .591 .310 .148 .276 .855 .688 .085 .000

Regression B. Odds of Wave III new physical assault 1 Age 2.218 .196 1.24 Education 2.251 .211 1.42 2.812 .265 9.52 Racea Income 2.018 .162 0.01 2 Exclusive alcohol abuse 2.356 .537 0.44 Drug use .568 .333 2.91 3 Major depression .783 .369 4.50 PTSD .201 .373 0.29 4 Past victimization 1.19 .242 24.41

ns ns 0.45 ns ns 2.55 2.52 ns 3.30

ns ns 0.44 ns ns ns 2.19 ns 3.30

.265 .234 .002 .911 .508 .088 .034 .589 .000

Regression A. Odds of Wave III new rape 1 Age 2.597 Education .138 2.363 Racea Income 2.280 2 Exclusive alcohol abuse .511 Drug use .079 3 Major depression .194 PTSD .663 4 Past victimization 1.955

PTSD 5 posttraumatic stress disorder; SE 5 standard error; OR 5 odds ratio; ns 5 not significant. a OR . 1 indicates increased risk for Whites; OR , 1 indicates increased risk for minorities.

Prediction of new rape and new physical assault by demographic variables, active substance use assessed at Wave I, active psychopathology assessed at Wave I, and lifetime victimization status. Four-step hierarchical logistic regressions predicted odds of a new rape and separately, odds of new physical assault. Groupings on steps were rationally derived. Demographic variables including age, education, race, and income were entered on Step 1 in order to isolate effects of these frequently cited objective factors on risk of assault. Substance use variables including exclusive alcohol abuse and drug use at Wave I were entered on Step 2; hence, odds ratios for these variables reflect effects over and above those of common demographic variables. We were also interested in effects of psychopathology on risk of assault, over and above aforementioned variables. Therefore, major depression and PTSD at Wave I were entered on Step 3. Finally, in order to ascertain that risk of future assault associated with past victimization was not simply a function of demographic, substance abuse, or psychopathology factors, past victimization status was entered on Step 4. Part A of Table 2 outlines the logistic regression predicting

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new rape while part B of Table 2 provides the logistic regression outline for predicting new physical assault. As is evident from inspection of odds ratios given in Table 2, predictors of new rape (measured prospectively) differed somewhat from predictors of new physical assault. The odds ratio associated with rape in the youngest age group was 1.82 (note that since there were three levels of this variable, risk associated with each sequential level is increased by a factor of 1.82, so that odds of rape in the youngest group compared to the oldest group was greater than 1.82). PTSD also increased risk of experiencing a new rape (odds ratio [OR] 5 3.27) if variance accounted for by past victimization was not considered. The most powerful predictor of new rape, however, was previous victimization (OR 5 7.06). Past victimization was also the strongest predictor of new physical assault (OR 5 3.30). Belonging to a minority group or presenting with major depression doubled risk of new physical assault (OR 5 2.22, and 2.19, respectively), and using drugs increased risk of new assault when diagnostic status or previous victimization history was not considered (OR 5 2.55). Descriptive Data: Rates of PTSD in Rape Victims and in Physical Assault Victims Table 3 presents data that describe rates of PTSD in the subsamples of rape victims and physical assault victims in terms of demographic variables (i.e., age, education, race, and income), lifetime substance use variables (i.e., lifetime exclusive alcohol abuse and illicit drug use), lifetime major depression status, and assault characteristics (i.e., perceived life threat during rape or physical assault and experienced serious injury during rape or physical assault). Prediction of Wave I active PTSD following rape and following assault by demographic variables, lifetime substance use variables, lifetime major depression, and assault characteristics. Four-step hierarchical logistic regressions predicted odds of PTSD in rape victims and in physical assault victims. Groupings on steps were rationally derived. As with prediction of victimization, age, education, race, and income were entered on Step 1. Behavior based variables, lifetime exclusive alcohol abuse and lifetime drug use status, were entered on Step 2. A psychopathology variable, lifetime major depression, was entered on Step 3. Finally, assault characteristics of perceived life threat and experienced injury (during the rape for rape victims and during the physical assault for physical assault victims) were entered on Step 4. Part A of Table 4 outlines the logistic regression predicting PTSD in rape victims, while part B of Table 4 outlines the logistic regression predicting PTSD in physical assault victims.

– 12.3 (n 5 13) 13.8 (n 5 57) – 15.7 (n 5 33) – – – – –

14.7 (n 5 89) 15.7 (n 5 73) 21.5 (n 5 20) 13.7a (n 5 14) 16.2 (n 5 18) 27.8 (n 5 15) 17.2 (n 5 46) 24.3 (n 5 79) 18.5 (n 5 68) 25.6 (n 5 52)

PTSD 5 posttraumatic stress disorder. a Non-White. b White.

Lifetime rape Age Education Race Income Lifetime experience of alcohol abuse Lifetime drug use Lifetime major depression Life threat Injury

Variable

% W-1 Active PTSD if in Middle Age Education, or Income Range

% W-1 Active PTSD if Positive for Variable (or in Lowest Age, Education, or Income Range)

3.5 (n 5 10) 8.8 (n 5 21) 9.2 (n 5 37)

13.4 (n 5 74) 12.7 (n 5 43)

4.1 (n 5 138) 2.9 (n 5 1) 11.9 (n 5 12) 14.9b (n 5 75) 13.6 (n 5 35)

% W-1 Active PTSD if Negative for Variable (or in Highest Age, Education, or Income Range)

Rape Victim Subsample (n 5 607)

29.1 (n 5 77) 22.0 (n 5 85) 21.3 (n 5 64)

26.9 (n 5 14) 20.3 (n 5 43)

20.3 (n 5 94) 21.4 (n 5 72) 27.1 (n 5 23) 19.6a (n 5 18) 25.5 (n 5 25)

% W-I Active PTSD if Positive for Variable (or in Lowest Age, Education, or Income Range)

– – –

– –

– 18.8 (n 5 18) 20.5 (n 5 60) – 18.4 (n 5 30)

% W-I Active PTSD if in Middle Age, Education, or Income Range

8.6 (n 5 17) 11.8 (n 5 9) 18.5 (n 5 30)

19.5 (n 5 80) 20.3 (n 5 51)

3.8 (n 5 133) 10.0 (n 5 3) 12.8 (n 5 11) 20.5b (n 5 76) 20.3 (n 5 37)

% W-I PTSD if Negative for Variable (or in Highest Age, Education, or Income Range)

Physical Assault Subsample (n 5 463)

TABLE 3 Descriptive Data: Rates of Active PTSD in Rape Victims and Physical Assault Victims at Wave I (W-I) as a Function of Demographic, Substance Use Psychopathology, and Assault Characteristic Variables

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TABLE 4 Initial and Final Model Odds of (A) Wave I Active PTSD in Rape Victims, and (B) Wave I Active PTSD in Physical Assault Victims as a Function of Demographic Variables, Lifetime Substance Use Variables, Lifetime Major Depression, Perceived Life Threat, and Experienced Injury (N 5 3,006) Step

Variable

b

Regression A. Odds of Wave I active PTSD 21.3 1 Age 2.44 Education 2.37 2.65 Racea Income .155 2 Lifetime experience of .973 alcohol abuse Lifetime drug use .216 3 Lifetime major 2.08 depression 4 Perceived life threat .423 Experienced injury 1.01

SE

Wald

in rape victims .3 2.3 .285 2.44 .240 2.36 .362 0.03 .181 0.73 .416 5.46

Step OR

Final OR

Final p

1.2 0.60 ns ns ns 3.88

1.2 ns ns ns ns 2.65

.300 .118 .856 .125 .392 .015

.288 .373

0.56 31.17

1.75 8.30

ns 8.04

.454 .000

.306 .270

1.91 14.06

ns 2.75

ns 2.75

.167 .000

ns 0.61 ns ns ns

.176 .025 .840 .812 .560

ns 4.73

.530 .000

ns ns

.077 .898

Regression B. Odds of Wave I active PTSD in physical assault victims 1 Age 2.329 .243 1.84 ns Education 2.488 .218 5.00 0.67 .065 .325 .041 ns Racea Income .040 .169 .056 ns 2 Lifetime experience of .233 .400 .340 ns alcohol abuse Lifetime drug use 2.174 .275 .398 ns 3 Lifetime major 1.55 .308 25.52 4.86 depression 4 Perceived life threat .749 .424 .312 ns Experienced injury 2.035 .270 .017 ns

PTSD 5 posttraumatic stress disorder; SE 5 standard error; OR 5 odds ratio; ns 5 not significant. a OR . 1 indicates increased risk for Whites; OR , 1 indicates increased risk for minorities.

Data in Table 4 reveal that risk factors for PTSD in rape victims differ from those in physical assault victims. For rape victims, a history of major depression increased odds of presenting with PTSD by a factor of 8, and a history of alcohol abuse increased risk of presenting with PTSD at Wave I interviews by a factor of almost 3. Rape victims who were injured during a rape were 2.75 times as likely to present with PTSD as those who reported no injury. For physical assault victims, history of major depression was also a salient risk factor for PTSD (OR 5 4.73). However, low education also significantly increased risk of presenting with PTSD following physical attack. Note that the aforementioned odds ratios represent increased risk unique to each variable. That is, increased risk attributable to these variables was over and above risk attributable to every other variable.

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DISCUSSION The major findings of this study were as follows: (a) with the exception of previous victimization, the risk factors for rape (i.e., lower age and active PTSD) differed from those associated with physical assault (i.e., minority ethnic status, active depression, and drug use). Moreover, effects of these factors on risk of victimization were evident over and above effects of other demographic factors and were independent, for the most part, of each other; (b) alcohol abuse, income level, and educational accomplishments had no effect on risk of rape or physical assault, once other factors were controlled; and (c) lifetime depression was a common risk factor for PTSD in rape and physical assault victims. However, injury during rape, classification as an exclusive alcohol abuser, and, to a limited extent, younger age were also risk factors for PTSD in rape victims, whereas depression was complemented only by low education as a risk factor for PTSD in physical assault victims. Our results differed somewhat from results of past studies that used univariate methodological and analytic strategies. Previously identified risk factors such as income did not consistently predict risk of new physical or sexual assault once the contribution of other variables was controlled, or when the type of assault under study was altered from sexual to physical. Obtained results, therefore, offer some clarification of assault-risk relationships. As mentioned, several specific risk factors for each form of assault were identified. In longitudinal analyses, prior victimization increased the risk of experiencing a new rape by a factor of 7, while belonging to a younger age group increased the risk of rape by a factor of 2. When past victimization status was not controlled, active (i.e., active Wave I) PTSD also increased the odds that one would experience a new rape. A somewhat different picture emerged when considering physical assault victims. Although prior history of victimization also increased risk of physical assault, being non-white, actively depressed, and, to a lessor extent being a drug user were also associated with increased likelihood of being physically assaulted. Risk of sexual and physical assault related to past victimization is well documented and may be a function of remaining in, or being unable to escape from dangerous situations. That is, women who have been assaulted may remain in high risk environments, perhaps because they are bound by familial or cultural ties, or perhaps because they possess limited motivation or problemsolving skills to leave. Importantly, our analyses controlled for effects of education and income on risk of new assault. Thus, one cannot simply state that this lack of mobility was due to economic deficiencies. Indeed, rape and domestic violence have been noted across the economic and educational range (Hotaling & Sugarman, 1990; Koss, Gidycz, & Wisniewski, 1987). Instead, the failure to extricate oneself from dangerous situations may result from lowered

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self-worth and self-blame associated with being the victim of physical and sexual assault. Fear of being blamed is common in assault victims, as is guilt about the assault (Resnick et al., 1996). Similar such arguments have formed the basis for explanations of the cycle of abuse typically cited in domestic violence summaries. Consistent with previous research, we found that younger adults were at significantly greater risk of being raped than middle-aged or older adults. Risk associated with age was independent of risk attributable to all other factors, and, as was the case with several other studied variables, risk varied according to assault type. That is, younger age groups, while at increased risk of sexual assault, were no more likely to be physically assaulted. However, definitive statements about the effects of age on assault risk are precluded by the restrictive lower age range (18 years) of our sample. Indeed, children and adolescents appear to be at even greater risk of some forms of assault, and when these age groups are considered, it is possible that risk of both forms of assault, not just rape, will be inversely related to age. Psychopathology in general, and depression in particular have been implicated as potential etiological agents in negative health behaviors, such as cigarette smoking and substance abuse (Acierno, Kilpatrick, Resnick, Saunders, & Best, 1996; Kilpatrick et al., 1997). Very little research has considered the impact of psychopathology on behaviors that affect risk of being assaulted (although these are also arguably negative health behaviors). In the present study, Wave I depression was unrelated to risk of new rape, after effects of demographic variables and substance use were controlled. However, being depressed did appear to significantly increase risk of new physical assault. Conversely, women with PTSD were at increased risk of a new rape (when past victimization status was not controlled), but were no more likely to experience a new physical assault. Therefore, it appears that different forms of psychopathology carry with them different forms of assaultive risk. Note that these were not spurious findings. Indeed, effects of psychopathology on victimization risk were independent of effects of all demographic and substance use variables and were quite pronounced. The question, therefore, becomes: Why does depression increase risk of physical assault (but not rape), whereas PTSD increases risk of rape (but not physical assault)? Depressed women, like women who have been previously assaulted, may lack the motivation, resources, or skills to extract themselves from physically assaultive situations (e.g., domestic violence), or may lack external concentration or contextual awareness necessary to perceive potentially violent situations. Behavior of depressed individuals (e.g., increased negativity) may also elicit physically aggressive behavior from others. By contrast, women with PTSD may exhibit extreme avoidance of situations resembling those in which assaultive violence has previously occurred, thereby limiting their risk of new physical assault (recall that avoidance is a hallmark symptom of PTSD, but not depression).

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However, they may be unable to avoid situations in which rape has occurred, since rape is more likely to be perpetrated by known others in or around one’s home environment (Kilpatrick et al., 1992). In addition, cognitive avoidance related directly to the rape event may prevent awareness of cues signifying increasing risk of sexual assault, preventing appropriate escape behavior. Alternatively, women in ongoing violent relationships may be more depressed. Obviously, further study along these parameters is needed. It is somewhat surprising that alcohol abuse had no effect on risk of either form of victimization. One would expect that alcohol abuse diminishes a woman’s ability to perceive danger in her environment, impairs her ability to escape danger should it be perceived, and reduces her potential to successfully extricate herself from dangerous residential situations (e.g., through lost employment). Recall that we classified these women according to their exclusive abuse of alcohol and nonuse of other drugs. Therefore, women who abuse only alcohol but not drugs may represent a subsample of substance abusers that effectively avoids dangerous situations, at least to the same extent as nonabusers. It is also not entirely clear why drug use increases one’s risk of physical assault, but not sexual assault. One possibility is that our sample size was too small to detect subtle differences. Another possibility is that a large percentage of severe physical assaults occurred in the context of drug use and other illicit and dangerous behaviors, such as drug purchase, whereas most rapes were perpetrated in situations that did not involve drugs. However, our data only partially supported this hypothesis: 52% of physical assault victims reported that their assailants were using drugs or alcohol at the time of the assault, compared to 37% of rape victims. Demographic factors other than age and race contributed little to longitudinal predictions of assault. As mentioned, lower age was associated with increased risk of rape, but not physical assault. Education level and income level were unrelated to victimization risk, once effects of age and race were controlled. This is somewhat counterintuitive, but underscores the finding that physical and sexual assaults are problems for women across the economic and educational ranges. Of great interest is the differential risk of physical, but not sexual assault associated with minority ethnic status. This finding may shed some light on previous contradictory results in which some investigators found African Americans at increased risk of assault and others found this ethnic group at decreased risk. Our results indicated that minority status did not affect likelihood of being raped, but more than doubled the risk experiencing a physical assault, over and above effects of income, substance use, psychopathology, and past victimization history. It is possible that minorities have a reporting bias against disclosure of sexual, but not physical assault. This is unlikely, however, because minority respondents did not report lower rates of sexual assault than Whites

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(2.3% vs. 1.5%, respectively); rather, minorities reported significantly higher rates physical assault than Whites (4.9% vs. 2.1%, respectively). To our knowledge, this is the first study to examine relative risk of both physical and sexual assault in terms of race, while controlling for a variety of other relevant factors. The fact that minorities are at increased risk of physical assault appears well founded, and is consistent with the criminal justice literature describing the most serious physical assault: murder. For example, 1995, the Federal Bureau of Investigation Uniform Crime Report statistics indicate that although they comprise only 13% of the population, African Americans represent fully 49% of homicide victims (Federal Bureau of Investigation, 1995). Analyses assessing risk factors for PTSD differed from those predicting new assaults in that the former involved prediction of active Wave I PTSD on the basis of demographic factors and lifetime substance use and psychopathology variables (i.e., retrospective analyses), whereas the latter predicted new assault on the basis of demographic factors and active Wave I substance use and psychopathology variables (longitudinal analyses). That is, two timeframes were used for analyses: Wave I active PTSD was studied in terms of lifetime psychopathology variables, whereas new assaults occurring between Waves I and III were studied in terms of active (at Wave I) psychopathology and substance use variables. This was justified because, in retrospective analyses, past history of depression and substance abuse are relevant to active PTSD, whereas active psychopathological status is inherently more relevant in longitudinal analyses predicting new assault. Data indicated that risk factors related to developing PTSD varied according to the type of assault experienced, with one exception. Both rape victims and physical assault victims were far more likely to develop PTSD if they had a history of major depression (OR 5 8.04 rape; 4.73 physical assault). However, rape victims with a history of alcohol abuse and rape victims who were injured during the assault were at almost three times the risk of developing PTSD compared to women without these characteristics. By contrast, these factors were not associated with increased risk of PTSD for physical assault victims. Only lower education and history of depression increased the odds that physical assault victims would present with PTSD. When only demographic variables were considered, lower age was associated with increased risk of PTSD in rape victims. However, this relationship did not hold when substance use and assault characteristics were also considered. As was the case with risk of new assault, lower household income did not increase one’s risk of developing PTSD. However, this analysis considered income from all members of a household. It is possible that the individual incomes of women in the sampled differed significantly from the household income. This difference in personal income may interact with assault type (e.g., domestic violence) to exacerbate psychopathology. That is, independently poorer women may be married to wealthy abusive men, but lack resources to leave the marriage. These women may then be exposed to repeated

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violence, which, in turn, increases risk of PTSD. Moreover, race was not related to development of PTSD following either form of assault. A history of major depression has been associated with a variety of negative psychopathological outcomes, including cigarette use (Acierno et al., 1996; Breslau, Kilbey, & Andreski, 1991; 1993a, 1993b), substance use, and anxiety disorders (Kessler et al., 1995). Consistent with this literature, we found that raped or physically assaulted women who had been depressed in the past were at increased risk of presenting with PTSD at Wave I assessment. While a portion of the variance in this finding may be related to the diagnostic overlap between the two disorders (e.g., concentration and sleep difficulties), it is also very likely that the impact of assault is intensified for previously depressed women. Existing research has demonstrated cognitive perceptual differences between depressed and nondepressed participants (e.g., Abramson, Seligman, & Teasdale, 1978). It is possible that depressed women perceive their assault as more destructive and distressing than non-depressed women, and have a lowered threshold for developing PTSD symptoms. Similarly, it is possible that the social support network of depressed women is weakened as a function of their affective disorder, and this diminished social support may serve to maintain PTSD. As mentioned above, alcohol abuse (and to a lesser extent, drug use) was not associated with increased risk of new assault, but did increase risk of PTSD in women who had been raped. No relationship between substance use and PTSD was observed in physical assault victims. It appears that substance use and abuse weaken women’s resistance to developing PTSD following a rape. This is, unfortunately, ironic in that victims appear to begin using substances following assault in order to cope with increased psychological distress (Kilpatrick et al., 1997). Therefore, while potentially effective in reducing anxiety symptomatology in the short term, substance use, and particularly alcohol abuse ultimately exacerbates the problems for which it was originally used. Assault characteristics were also related to development of PTSD in rape victims, although this relationship was not evident for physical assault victims. Women who were injured during rape were more likely to develop PTSD than victims with qualitatively different (i.e., no injury) rapes. However, the reduced ability to predict PTSD on the basis of assault characteristics for physical assault victims may be due to the fact that a greater proportion of physical assault victims actually experienced life threat and serious injury during assault. That is, any predictor variable common to a total group (i.e., physical assault victims with and without PTSD) will not be a good discriminator of subgroup (i.e., that group of physical assault victims with PTSD) membership. Analyses of assault characteristics within the groups of rape victims and assault victims supports this hypothesis. Fully 83.6% of physical assault victims (vs. 60.5% of rape victims) perceived that their lives were threatened during

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the attack, and 65.0% of assault victims (vs. 33.4% of rape victims) experienced injury. Overall, our data indicated that past victimization, lower age, and a diagnosis of active PTSD increase women’s risk of being raped. Furthermore, past victimization, minority ethnic status, and active depression and drug use increase women’s risk of being physically assaulted. Once assaulted, a somewhat different set of risk factors predicted development of PTSD. Victims of both physical assault and rape who had histories of major depression were at increased risk of developing PTSD. Moreover, rape victims with histories of alcohol abuse and rape victims who were injured, however severely, during their assault were also more likely to develop PTSD. For physical assault victims, only lower education complemented history of depression as a risk factor for PTSD. This study is unique in that it is the first to apply multivariate assessment and statistical techniques to examine, both independently and in terms of other predictors, contributions of demographic factors, substance use factors, assault characteristics, and psychopathology to risk of assault and to risk of developing PTSD once assaulted. This study is also the first to examine these variables separately in terms of both physical and sexual assault. As a result of this multivariate specificity, differential patterns of risk associated with rape and physical assault were identified, as were different factors important to the development of PTSD for each form of assault. A major weakness of this study, however, was its restricted age range. Only adults were included in the study sample, and although women were asked about lifetime assault and psychopathology, events occurring in childhood may have been subject to high levels of retrospective bias and memory degradation. In addition to a limited age range, this study assessed only women. Men are at equal or greater risk of physical assault compared to women, and factors that increase the likelihood that men will be assaulted or develop PTSD should be identified through multivariate analyses similar to those used in the present study with women. In addition to studies with child and male participants, research is also needed to more adequately explain differential impact of risk factors (e.g., substance use or abuse) on likelihood of being raped versus physically assaulted, and of developing PTSD following rape or physical assault.

REFERENCES Abramson, L. Y., Seligman, M., & Teasdale, J. (1978). Learned helplessness in humans. Critique and reformulation. Journal of Abnormal Psychology, 87, 49–74. Acierno, R., Kilpatrick, D. G., Resnick, H., Saunders, B., & Best, C. (1996). Violent assault, posttraumatic stress disorder, and depression: Risk factors for cigarette use among women. Behavior Modification, 20, 363–384. American Psychiatric Association. (1987). Diagnostic and statistical manual of mental disorders (3rd ed., Rev.). Washington DC: Author.

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R. ACIERNO ET AL.

American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4th ed.). Washington DC: Author. Bachman, R., & Salzman, L. E. (1994). Violence against women: Estimates from the redesigned survey (U.S. Department of Justice Special Report NCJ-154348). Washington, DC: Office of Justice Programs, Bureau of Justice Statistics. Breslau, N., Davis, G. C., Andreski, P., & Petersen, E. (1991). Traumatic events and posttraumatic stress disorder in an urban population of young adults. Archives of General Psychiatry, 48, 216– 222. Breslau, N., Kilbey, M. M., & Andreski, P. (1993a). Nicotine dependence and major depression: New evidence from a prospective investigation. Archives of General Psychiatry, 50, 31–35. Breslau, N., Kilbey, M. M., & Andreski, P. (1993b). Vulnerability to psychopathology in nicotinedependent smokers: An epidemiologic study of young adults. American Journal of Psychiatry, 150, 941–946. Bureau of Justice Statistics. (1992). Criminal victimization in the United States, 1990. Washington, DC: U.S. Government Printing Office. Burnam, M. A., Stein, J. A., Golding, J. M., Siegel, J. M., Sorenson, S. B., Forsythe, A. B., & Telles, C. A. (1988). Sexual assault and mental disorders in a community population. Journal of Consulting and Clinical Psychology, 56, 843–850. Byrne, C., Resnick, H., Kilpatrick, D., Saunders, B., & Best, C. (1997). The socioeconomic impact of rape and aggravated assault on women. Poster session presented at the 31st annual convention of the Assocation for the Advancement of Behavior Therapy, Miami, FL. Cottler, L. B., Compton, W. M., Mager, D., Spitznagel, E. L., & Janca, A. (1992). Posttraumatic stress disorder among substance users from the general population. American Journal of Psychiatry, 149, 664–670. Federal Bureau of Investigation. (1991). Uniform crime reports for the United States: 1990. Washington, DC: U.S. Government Printing Office. Federal Bureau of Investigation. (1995). Uniform crime reports for the United States: 1995. Washington, DC: U.S. Government Printing Office. Green, B. L., Lindy, J., Grace, M., Gleser, G., Leonard, A., Korol, M., & Winget, C. (1990). Buffalo Creek survivors in the second decade: Stability of stress symptoms. American Journal of Orthopsychiatry, 60, 43–54. Hanson, R. F., Kilpatrick, D. G., Falsetti, S. A., & Resnick, H. S. (1995). Violent crime and mental health. In J. R. Freedy & S. E. Hobfoll (Eds.), Traumatic stress: From theory to practice (pp. 129–161). New York: Plenum Press. Hotaling, G. T., & Sugarman, D. B. (1990). A risk marker analysis of assaulted wives. Journal of Family Violence, 5, 1–13. 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., Acierno, R., Resnick, H., Saunders, B., & Best, C. (1997). A two-year longitudinal analysis of the relationships among assault and alcohol and drug abuse in women. Journal of Consulting and Clinical Psychology, 65, 834–847. Kilpatrick, D. G., Edmunds, C. N., & Seymour, A. K. (1992). Rape in America: A report to the nation. Arlington, VA: National Victim Center and Medical University of South Carolina. Kilpatrick, D. G., Resnick, H. S., Saunders, B. E., & Best, C. L. (1998). Rape, other violence against women, and posttraumatic stress disorder: Critical issues in assessing the adversity-stresspsychopathology relationship. In B. P. Dohrenwend (Ed.), Adversity, stress, and psychopathology. Washington, DC: American Psychiatric Press. Kilpatrick, D. G., Saunders, B. E., Amick-McMullan, A., Best, C. L., Veronen, L. J., & Resnick, H. S. (1989). Victim and crime factors associated with the development of crime-related post-traumatic stress disorder. Behavior Therapy, 20, 199–214.

RISK FACTORS FOR RAPE, PHYSICAL ASSAULT, AND PTSD IN WOMEN

563

Koss, M. P., & Dinero, T. E. (1989). Discrimination analysis of risk factors for sexual victimization among a national sample of college women. Journal of Consulting and Clinical Psychology, 57, 242–250. Koss, M. P., Gidycz, C., & Wisniewski, N. (1987). The scope of rape: Incidence and prevalence of sexual aggression and victimization in a national sample of higher education students. Journal of Consulting and Clinical Psychology, 55, 162–170. Norris, F. H. (1992). Epidemiology of trauma: Frequency and impact of different potentially traumatic events on different demographic events. Journal of Consulting and Clinical Psychology, 60, 409–418. Reiss, A. J., & Roth, J. A. (1993). Understanding and preventing violence. Washington, DC: National Academy Press. Resnick, H. S., Falsetti, S. A., Kilpatrick, D. G., & Freedy, J. R. (1996). Assessment of rape and other civilian trauma-related PTSD: Emphasis on assessment of potentially traumatic events. In T. W. Miller (Ed.), Theory and assessment of stressful life events (pp. 235–271). Madison, CT: International Universities Press. Resnick, H. S., Kilpatrick, D. G., Dansky, B. S., Saunders, B. E., & Best, C. L. (1993). Prevalence of civilian trauma and PTSD in a representative national sample of women. Journal of Consulting and Clinical Psychology, 61, 984–991. Robins, L., Helzer, J., Cottler, L., & Goldring, E. (1988). NIMH diagnostic interview schedule, version III, revised (DIS-III-R). St. Louis: Washington University Press. Rosenberg, M. L., & Fenley, M. A. (1991). Violence in America: A public health approach. New York: Oxford University Press. Steketee, G., & Foa, E. B. (1987). Rape victims. Post-traumatic stress responses and their treatment: A review of the literature. Journal of Anxiety Disorders, 1, 69–86. U.S. Bureau of the Census. (1991). Statistical abstract of the United States: The national data book. (11th ed.). Washington, DC: Author. Weaver, T. L., & Clum, G. A. (1995). Psychological distress associated with interpersonal violence: A meta-analysis. Clinical Psychology Review, 15, 115–140. Zawitz, M. W. (Ed.). (1988). Report to the nation on crime and justice (2nd ed.). Washington, DC: U.S. Department of Justice.