This study analyzes 9 qualitative studies on how women label unwanted sexual experiences. It identifies 7 categories of factors that influence labeling: 1) Self-blame, 2) Normalization of violence, 3) Rejection of the term "sexual violence", 4) Understanding events based on rape scripts, 5) Ambivalence around labeling, 6) Labeling due to violence/impacts, 7) Labeling facilitated by social support/education. Results show labeling is complex, with women minimizing events, justifying perpetrators or avoiding labels due to rape myths and scripts. Seeking support or information can help with identification of sexual violence.

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Aggression and Violent Behavior
journal homepage:
www.elsevier.com/locate/aggviobe
h
Aggression and Violent Behavior 52 (2020) 10139
5
A metasynthesis of qualitative studies on girls' and women's
labeling of sexual violence
T
Catherine Rousseaua,⁎, Manon Bergerona, Sandrine Riccib
a Sexology Department, Université du Québec à Montréal,
Montréal, Québec, Canada b Sociology Department, Université
de Québec à Montréal, Montréal, Québec, Canada
A R T I C L E I N F O A B S T R A C T
Keywords:
Sexual violence
Labeling
Victims
Metasynthesis
Qualitative
Many women do not label their unwanted sexual experiences as
rape or sexual violence, but rather use various labels that
suggest a different understanding of the events. This
metasynthesis provides new insights and empirical evidence of
how girls and women discuss their unwanted sexual
experiences, and identifies factors that impede or promote such
labeling. Qualitative data of 9 studies were synthetized using

2. Noblit and Hare's (1988) framework. Results show that victims
can frame sexual violence within rape scripts that may lead to
minimization, normalization, self-blame or rationalization of
the event. Some participants hold an ambivalent discourse,
which suggests that labeling is a fluctuating process. Finally,
seeking social support, or receiving educational information
seem to facilitate the labeling of sexual violence. The
implications for intervention and sexual violence prevention
programs are discussed.
C. Rousseau, et al. Aggression and Violent Behavior 52 (2020)
101395
C. Rousseau, et al. Aggression and Violent Behavior 52 (2020)
101395
2
5Introduction
Sexual violence is a social problem, mainly affecting girls and
women, that can lead to significant psychosocial consequences
(Rhew, Stappenbeck, Bedard-Gilligan, Hughes, & Kaysen,
2017). In the United States, more than one-quarter of women
experienced unwanted sexual contact in their lifetime, while
one-third experienced some form of noncontact unwanted sexual
experience in their lifetime (Basile, Smith, Breiding, Black, &
Mahendra, 2014). The Centers for Disease Control and
Prevention defines sexual violence as “a sexual act that is
committed or attempted by another person without freely given
consent of the victim or against someone who is unable to
consent or refuse” (Basile et al., 2014, p. 11). Sexual violence
includes rape, attempted rape, sexual assault, sexual
harassment, sexual coercion without physical force and
unwanted sexual contact (Basile et al., 2014). This term is
inclusive of the various forms of sexual victimization that are
not necessarily criminalized, especially since legal frameworks
vary from one country to another. This definition allows for the

3. conception of sexual violence on a continuum, as many feminist
researchers have suggested, since the pioneering work of Kelly
(1987) and Hanmer
(1977).
While research confirms the high prevalence of sexual violence,
few events of sexual violence are reported to the authorities.
According to the Truman and Langton (2015), 34% of rape and
sexual assault crimes are reported to authorities in the United
States. One possible explanation for this under-reporting is that
victims may not identify or label the event as a form of sexual
violence. For several decades, researchers have been interested
in victims' unacknowledged sexual violence. Mary Koss was
one of the first to identify this phenomenon, which she termed
“hidden rape,” and developed the Sexual Experiences Survey,
which is an instrument capable of reflecting hidden cases of
rape (Koss, 1985, 2011). Her study, based on the Sexual
Experiences Survey, shows that 43% of women who reported
oral, anal, or vaginal non-consensual intercourse did not label
their experience as rape (Koss, 1985). More recently, Wilson
and Miller (2016) published a meta-analysis summarizing the
results of their empirical work and presenting estimates of the
prevalence of people who experienced rape, but did not label
their experiences as such. Based on 28 studies, regrouping 5917
female rape victims, the results show that an overall weighted
mean percentage of 60.4% of all victims do not understand their
experience as rape.
⁎ Corresponding author at: Université du Québec à Montréal,
Département de sexologie, CP 8888, succ. Centre-ville,
Montréal, Québec H3C 3P8, Canada. E-mail addresses:
[email protected] (C. Rousseau), [email protected] (M.
Bergeron), [email protected] (S. Ricci).
https://doi.org/10.1016/j.avb.2020.101395
Received 12 August 2019; Received in revised form 1 March
2020; Accepted 8 March 2020 Available online 12 March 2020
1359-1789/ © 2020 Elsevier Ltd. All rights reserved.

4. In this metasynthesis, we analyze the social vocabulary present
in victims' narratives (Hlavka, 2014; Kavanaugh, 2013). We
distinguish between elements that justify or excuse sexual
violence by allowing victims to interpret what happened to them
(Scott & Lyman, 1968). Because the labeling of sexual violence
is embedded in culture, it can reflect rape myths or gendered
stereotypes that make victims feel guilty and can take the blame
off the perpetrator. For example, victims can minimize the
severity of the experienced sexual violence. In fact, a study
reveals that women who have experienced rape are usually
considered responsible for the event in the current social
context (Peterson & Muehlenhard, 2004). Different factors can
influence the labeling of sexual violence. Some factors, as
named above, appear to prevent the identification of sexual
violence, while others may encourage it, such as verbally
expressing non-consent (Cleere & Lynn, 2013; Peterson &
Muehlenhard, 2007).
Many factors contribute to a social context that would denigrate
and blame women for experiences of sexual violence, such as
rape myths. These social discourses are understood as culturally
situated and socially learned ideologies that excuse rape.
Various rape myths have been documented, for example: the
belief that a husband cannot rape his wife, that women enjoy
rape, that women have asked to be raped and that women are
lying about having been raped (Edwards, Turchik, Dardis,
Reynolds, & Gidycz, 2011). It is possible to believe that these
rape myths are more closely interwoven with a narrow
conception of what sexual violence is and that this conception is
reiterated in dominant social discourses. Also, rape scripts may
influence victims' labeling of unwanted sexual experiences
(LeMaire, Oswald, & Russell, 2016). They are defined as a
social stereotype of what a “real” rape is and how victims and
perpetrators of rape are viewed (Ryan, 2011). For example, a
rape script usually implies a highly violent assault by a
stranger, in a public space, with forced intercourse (Kahn,
Mathie, & Torgler, 1994; Littleton, Tabernik, Canales, &

5. Backstrom, 2009). However, most sexual assaults are
perpetrated by a known man, in a private place, sometimes with
no physical force used (Cantor et al., 2015). In such situations,
there would be an inconsistency between the sexual
victimization and the rape script, which can lead to the non-
labeling of the event as sexual violence.
This metasynthesis is informed by feminist theory. We postulate
that rape myths or rape scripts come from a patriarchal system
discrediting women and girls' experience of sexual violence
(Brownmiller, 1975; Burt, 1980; Edwards et al., 2011; Gavey,
2005). By adopting this framework, we do not assume that girls
and women should immediately identify sexual violence after
being victimized, but we believe that greater recognition of
what is sexual violence would allow many girls and women to
avoid self-blame, minimization or justification of the violence
that they experience. It would also foster accountability for
perpetrators of sexual violence regarding their behaviors. The
way in which sexual violence is labeled is critical for the
survivor's experience because it guides the perception of the
event and its prevention. The social context, coming from
patriarchal tradition, leads many women to take responsibility
for the experienced sexual violence, which only accentuates the
invisibility of this form of genderbased violence and, at the
same time, dilutes the perpetrator's responsibility (Romito,
2006). This framework enables a more detailed and thorough
understanding of the imbrication of labeling and subscribing to
rape myths or scripts.
Studies on unacknowledged sexual violence mainly adopt
quantitative methods because of the ethical and methodological
challenges involved in interviewing people who have
difficulties identifying their non-consensual sexual experiences
as sexual violence (Johnstone, 2016). Although these
quantitative results can estimate the prevalence of the
phenomenon, they do not give us much information on how girls
and women qualify the unwanted sexual experience. They also
do not reflect the complex reality of this phenomenon and its

6. possible variations over time (Johnstone, 2016). Recently
however, there has been an increase in qualitative research on
unacknowledged sexual violence that suggests new insights and
useful in-depth information about how women label their
experiences. Nevertheless, a synthesis of qualitative studies on
the subject has not been published. This article aims to offer a
more complete understanding of labeling in victims' narratives.
We understand labeling both as women's acknowledgement of
unwanted sexual experiences, and as the process whereby
victims decide whether they label these experiences as sexual
violence. Our contribution is based on a metasynthesis, which is
a review of all qualitative studies published on the subject that
fit certain inclusion criteria. Qualitative metasyntheses entail a
systematic approach to the collection and analysis of qualitative
studies to allow the “enlarging of the interpretive possibilities
of findings and constructing larger narratives of general
theories” (Sandelowski, Docherty, & Emden, 1997, p. 369).
For this research, the objectives are: 1) to examine how girls
and women perceive their unwanted sexual experience and 2) to
identify a variety of factors that seem to impede the labeling of
sexual violence and factors that seem to encourage it.Method
This metasynthesis aims to provide a comprehensive and
qualitative overview of girls' and women's labeling of their
experienced sexual violence.
2.1. Procedure and sample
A review of qualitative studies on victims' labeling of sexual
violence was done using SAGE journals online, PsycINFO,
Taylor and Francis Online, Google Scholar and a review of
found articles' references. We searched qualitative papers in
April and May 2018, using keywords including: labeling,
accounts, normalizing, sexual violence, unacknowledged rape,
self-blame, qualitative, and mixed methods.
The inclusion criteria for studies were (a) to have a qualitative
component as structured, semi- or unstructured interviews or
focus groups, (b) to relate to the narrative of girls and women
who experienced sexual violence, (c) to address the issue of

7. unacknowledged sexual violence, (e) to have been carried out in
Western countries where rape myths and rape script are
similarly integrated and shared, and (f) to be written in English.
Thus, studies published before 2000 or that only addressed the
point of view of non-victims were excluded.
Nine studies were retained for this metasynthesis and 11 were
excluded because they did not meet the inclusion criteria. The
design of all the selected studies was exclusively or partially
qualitative and subscribed to different approaches to data
analysis. One is a phenomenological study, five are based on an
inductive approach, two have a descriptive approach and one is
outlined by the Listening Guide methodology. Demographic and
methodological characteristics of selected articles are shown in
Table 1. All studies were conducted in United States, except for
one in Canada and one in Australia. Participants' ages ranged
from 11 to 47 years old. Five studies focused on undergraduate
students. All the studies exclusively involved women who were
victimized by male perpetrators, most often someone they
knew.
2.2. Analysis
All studies were transferred to NVivo 11 (QSR International Pty
Ltd.) for synthesis and management of the emerging themes.
The approach used for this metasynthesis was based on Noblit
and Hare's framework (Noblit & Hare, 1988), which is divided
into seven phases. First, researchers choose a phenomenon and
must define it. In our case, we selected unacknowledged sexual
violence and labeling in girls and women narratives. Second,
researchers determine which qualitative studies are relevant to
their initial interest. Nine studies met our inclusion criteria.
Third, researchers read the qualitative studies several times to
identify keywords, themes or concepts. Fourth, they evaluate
how these studies are related to each other by synthetizing
previous keywords, themes or concepts. Fifth, researchers
transpose the studies into one another. This phase enables
comparison and maintains the central concepts of each label in
their relation to other concepts. An open coding then leads to

8. codes that are grouped to form conceptual categories. In line
with Glaser and Strauss' (2009) axial coding, we compared
conceptual categories to explore interactions between studies
and to build conceptual categories that are mutually exclusive.
These
Table 2
Categories, subcategories and data from studies that refer to
these categories.
Categories, subcategories and data from studies that refer to
these categories
Categories Subcategories Studies related
1. Self-blame occurring because of something done or not done
1.1 Feeling that sexual violence could have been stopped
1, 6, 7, 8, 9
1.2 Holding oneself at least partially responsible for the 1, 3, 5,
6, 7, 8, 9
event
2. Normalization of sexual violence 2.1 “The event was no big
deal”: reduction of severity 1, 2, 4, 7
2.2 “It happens all the time”: everyday behaviors 1, 2, 3, 6
2.3 “He didn't mean it”: perpetrators held unaccountable 1, 3, 4,
5, 6, 8, 9
3. Rejection of the term “sexual violence” 3.1 Recognizing
oneself as a victim goes against a strong 3, 5, 8
self-image
4. Understanding sexual violence according to rape scripts
4.1 Lack of behaviors deemed problematic blurs the 1,
2, 3, 5, 6, 8
labeling of sexual violence 1, 3, 5, 9
4.2 Perpetrators do not fit the victim's image of a 1, 5, 8, 9
perpetrator

9. 4.3 Believing that consent may not be withdrawn
5. Ambivalence: avoiding labels or using alternative terms
5.1 Evading a label that refers to sexual violence 1, 3, 4
5.2 The use of alternative terms to describe their 1, 3, 4, 5
experience
6. Labeling of sexual violence through the perpetrator's violent
behavior, the consequences 6.1 Physical violence and its
repetition 1, 3, 4, 9
suffered or the failure to comply with the consent 6.2
Negative psychological impacts 1, 2, 3
6.3 Not having consented and not being able to say no 1,
3, 4, 9
7. Seeking social support or having educational information 1,
4, 5
categories must allow for a better understanding of the
phenomenon, each of them taking into account the key concepts
identified in the source studies (Paillé, 1994). Each category
took into account the key concepts identified in the source
studies. However, the saturation of each category might not be
achieved because of the diverse topics covered in the corpus.
Generally, researchers would then synthesize transpositions by
producing an overview rather than simply analyzing them
individually and extracting separate conceptual categories
(Coffey, 2006). Sixth, translations are compared to find
similarities and differences. In this phase, conceptual categories
are linked together to develop a storyline or theory, according
to Glaser and Strauss' (2009) grounded theory. Nonetheless, this
was not the goal of this present metasynthesis. Seventh,
researchers adapt the synthesis to their audience. Thus, this
metasynthesis takes a written form and adopts a language that is
adapted to academics and practitioners so that they can benefit
from its results.Results
The analysis of our corpus resulted in the creation of seven
conceptual categories, each containing several sub-categories

10. (see Table 2). 3.1. Self-blame occurring because of something
done or not done
In this first category, sexual violence is not identified as such
because participants feel they have failed to have their non-
consent respected or to stop unwanted sexual behaviors. Some
believe that being intoxicated has put them in a position deemed
to be at risk, which leads them to consider that they are
responsible for unwanted sexual acts.
3.1.1. Feeling that sexual violence could have been stopped
Some participants felt like they failed to say they did not want
to engage in sexual activity. Two women in Harned's (2005)
study said: “[B]ecause [I] never told the person not to, even
though [I] didn't want them to”; “I should have been more
vocal” (p. 397). Another woman stated that she did not resist
enough to prevent the event: “…a young man who respondent
had met that night forced her into having sexual intercourse.
She said ‘no’ many times, but he physically forced himself on
her. He was much bigger than her. She was ashamed and felt she
was partly to blame because she couldn't stop him” (Weiss,
2009, p. 827). Weiss (2011) discussed that women can feel more
self-blame for the event and be more reluctant to label it as rape
when they consider themselves to have surrendered to sexual
activity.
3.1.2. Holding oneself at least partially responsible for the
event
Another reason evoked is the victim's intoxication: “I was drunk
and didn't put up a fight and gave in. Therefore, I feel I am
partially responsible for what happened” (Participant in Harned,
2005, p. 396); “I don't want to label it rape because I feel it was
my fault to be that intoxicated” (questionnaire response from
non-labeling participant in Peterson & Muehlenhard, 2011, p.
563). For some participants, they consider that they did not
communicate clearly enough: “I didn't really communicate that I
didn't want it to happen. I just kind of tensed up and didn't
move.” (Dardis, Kraft, & Gidycz, 2017, p. 13). Johnstone
(2016) states that the impact of self-blame is weighed in the

11. larger context of rape culture which holds the victim
responsible for what happened, instead of placing responsibility
and accountability on the perpetrator.
3.2. Normalization of sexual violence
The minimization of sexual violence is frequent among the
participants of the various studies. The frequency of these acts
of violence – such as sexual harassment, is sometimes reported
as being daily, to the point that participants and even some
friends see sexual violence as nothing serious or as not even
worth disclosing.
3.2.1. “The event was no big deal”: reduction of severity
Some participants consider the event as something that is not
very serious. For a participant in Hlavka's (2014) study, the
event deserved to be forgotten since “not much happened”:
“I was going to the bathroom and he wouldn't let me go in. He
put his foot in front of [the door], and he's a really strong
person, so I didn't really, like, I couldn't open the door. And he
said, ‘I'll let you in if you give me a kiss,’ and I said, ‘No.’ And
I was going back to the classroom and he pinned me against the
wall and tried to, like, lift up my shirt. And, like, touched me,
and then I… I got up… I started to scream, and I guess someone
heard, 'cause then, um, someone started coming. So he got away
from me, I just went back in the classroom and forgot about it. I
just didn't think it was really anything”.
(Hlavka, 2014, p. 346)
3.2.2. “It happens all the time”: everyday behaviors
3.2.2.1. Peer reactions can alter the inclination to recognize the
experience as rape. A participant in Johnstone's (2016) study
states that her friend's reaction lead her to reconsider the event
as something normal because her feelings were delegitimized:
“So yeah, I told my friend what happened and then, I don't
know, at first she started laughing and I was, I was like ‘this
isn't funny,’ and she's like, ‘it's happened to me so many
times’” (SchoolGirl [pseudonym], 20-year-old European-
Canadian, p. 280).
3.2.2.2. Unwanted sexual experiences are commonplace and

12. expected behaviors because they happen all the time. Sexual
harassment and violence appear to be a part of women's daily
lives. Thereby, unwanted sexual experiences are normalized
because of their frequency. Patricia (age 13), in Hlavka's (2014)
study, said: “They grab you, touch your butt and try to, like,
touch you in the front, and run away, but it's okay, I mean… I
never think it's a big thing because they do it to everyone” (p.
344). In addition, men are seen as natural perpetrators because
they appear unable to control their sexual drive and desires
(Phillips, 2000).
3.2.2.3. Sexual violence is seen as normal dating behavior
within heterosexual relationships. Violence against women is a
part of a continuum where the most extreme form is rape (Kelly,
1987). Some manifestations of violence tend to be normalized
because they are a part of what is expected in a heterosexual
relationship (Gavey, 2005). Such social representation is largely
informed by the naturalization of male desire, seen as
uncontrollable: “He'd just rub his hand across my butt, and then
one time I was sitting there and he—I was, like, laying on the
couch watching TV—and he came home. He was kinda drunk,
then he, like, literally just, like, laid on me. That's what he…
well, guys always try to get up on you, like just normal”
(participant in Hlavka, 2014, p. 347). Although coercive
experiences are unpleasant, some participants did not view them
as more than an aggravation, characterized as “annoying male
behavior” or “just an annoyance of a sexually energized young
man” (participants in Harned, 2005, p. 404). One young woman
perceives the event as a game with the boys, although she did
not like it (Weiss, 2009).
3.2.3. “He didn't mean it”: perpetrators held unaccountable
3.2.3.1. The event was accidental: denying their perpetrator's
intentions to harm them. Some participants referred to the
perpetrator's intentions to label their unwanted sexual
experience. They maintain that their partner's behavior was
accidental: “I just don't think he understood that I didn't want
him to keep on doing that and that it didn't feel good”

13. (participant in Harned, 2005, p. 398). Another participant refers
to the fact that the perpetrator was not aware of what he was
doing and therefore that it was not sexual violence:
“While riding in the car with several friends, one of the male
occupants in the car sexually assaulted the respondent. The
offender was grabbing and fondling her, and would not stop
when she asked him to. The respondent screamed and fought
him off. The other passengers were screaming at the offender to
stop. There was no actual rape but an attempt was made. The
respondent decided not to report it because she was not sure the
offender understood he was committing a crime.”
(Weiss, 2011, p. 453)
3.2.3.2. Blaming the effects of alcohol or drugs instead of the
perpetrator. An additional struggle that participants can face is
recognizing sexual violence when alcohol or drugs are involved.
The difficulty in identifying the violent character of the
unwanted sexual experience is exacerbated when the perpetrator
is intoxicated because it is seen as a mistake, as the report made
by this 18-year-old participant states: “At a friend's house, a
drunk male made unwanted sexual advances. He apologized and
said he didn't know what he was doing and it wouldn't happen
again. Respondent did not report since she did not want to get
him in trouble, and because he promised it wouldn't happen
again” (Weiss, 2009, p. 823). In Dardis et al. (2017), nearly half
of miscommunicationlabeled victims blame the consumption of
alcohol or substance: “I don't think he would have done it if he
was sober.” (p. 13).
3.3. Rejection of the term “sexual violence”
Being a victim of sexual violence seems to be incompatible, for
some participants, with being strong or perceiving oneself as
such. Thus, to name having been victim of sexual violence
negatively impacts their perception of themselves.
3.3.1. Recognizing oneself as a victim goes against a strong
self-image
Acknowledgement of having experienced sexual violence can
have several implications, particularly in terms of one's

14. identity. As Peterson and Muehlenhard (2011) state, not using
the label “rape” can allow participants to maintain their self-
image as proactive and strong:
“[If it had been rape] I would probably have done something
about it. I wouldn't have just let it go. I mean I don't think that's
right… I would have told my parents right away and gone to the
doctor to prove it. A lot of girls just let it go, and then 5 years
later they say, ‘Well, how are you going to prove it?’ So, it
wasn't rape, but if it was, I definitely would have done
something about it.” (interview response of a non-labeling
participant, Peterson & Muehlenhard, 2011, p. 565).
3.4. Understanding sexual violence according to rape scripts
Here, we deconstruct the rape script into three main themes.
First, the idea of rape is often associated with physical abuse,
vaginal/anal penetration, and injury. In the absence of these
components, many participants do not use the term “sexual
violence” to describe what happened. Furthermore, the rape
script usually portrays an unknown and scary perpetrator. If the
abuser is then a friend or partner – which is often statistically
the case (Fisher, Cullen, & Turner, 2000), this label seems
difficult to apply. Finally, consent is not usually a part of the
rape script. When sexual consent was given at the beginning of
sexual intercourse, some participants do not feel legitimized in
withdrawing it. They do not identify the situation as sexual
violence since they gave their consent at some point, even
though they may not have consented to each component of the
experience.
3.4.1. Lack of behaviors deemed problematic blurs the labeling
of sexual violence
If some elements are absent from the victim's unwanted sexual
experience, it may not be labeled as sexual violence because it
did not fit the rape script. This type of re-evaluation, as
discussed by Frohmann and Mertz (1994), may lead victims to
compare the event with an aggravated rape. This refers to the
rape script as socially designed: if the event did not match this
idea, it may not be labeled as rape.

15. 3.4.1.1. Absence of physical violence or physical harm. The
absence of physical violence committed by the perpetrator or
the absence of injury to the victim may move the event away
from the victim's rape script. The following narrative illustrates
the difficulty in defining what happened: “Although she did not
consent to sex with her exboyfriend, she claims there was no
violence and therefore does not see it as ‘rape exactly’” (In
Weiss, 2009, p. 824). Other participants in Weiss (2011) and
Peterson and Muehlenhard (2011) minimized their injuries by
comparing their situation to extreme crime scenarios with worse
outcomes. Grace (19-year-old, European-Canadian), a
participant in Johnstone's (2016) study, said: “So… just, when I
think of rape I think of maybe a weapon being used, like
something more like forceful than just alcohol, or like drugs…
kidnapping, like things like that. Like I think of much more
scarier things than whatever happened to me” (p. 281).
3.4.1.2. Absence of penetration. Concordant with the rape
script's presumption that rape implies a vaginal or anal
penetration, its absence blurs the identification of the violent
nature of the event. As Hlavka (2014) mentions: “Young women
constructed classic boundaries between “real rapes” and
everyday violence or “little rapes.”” (p. 346). Terri (age 11) was
interviewed because she told a friend she was forced to perform
oral sex on a 17-year-old neighbor: “He forced me, he, uh, he
grabbed me tighter, and he said if I didn't do it he was gonna
rape me” (Participant in Hlavka, 2014, p. 346). About 5% of
women of Harned's (2005) study did not consider the event as
rape because there was no intercourse.
3.4.1.3. Absence of psychological wound. For some
participants, the absence of psychological distress or trauma is
an indicator that the event was not severe enough and therefore
should not be considered as rape:
“I know it was kind of rape. I know in a general sense that is
kind of what it is, but I have a really hard time coming to
reality with that, like I have a hard time… cause I know people,
most people who have been raped, it's been a lot more

16. traumatic. So I can't really call it that because it didn't, like
affect me that badly in the long run, I don't think. Like it's
obviously really sucked at the time, but I'm ok now, like I don't
have a fear of men, or … like, I don't have any long-standing
problems from it…”
(Grace in Johnstone, 2016, p. 286)
3.4.2. Perpetrators do not fit the victim's image of a perpetrator
The perception of the perpetrator is often related to the image of
an unknown person. However, in the selected studies, a man
known to the victim committed much of the experienced sexual
violence. Acknowledging one's partner or friend as a rapist has
significant implications for the victim, as presented by this
participant: “I liked the person I was with. Although I
sometimes felt pressured into sexual intercourse, we were
friends and it wasn't a horrible situation” (Participant in
Harned, 2005, p. 399). In some cases, the image of the man is
not consistent with the stereotypic rapist image as cruel and
rough: “I don't think that he was that bad of a guy that he would
have just totally taken advantage of me. Because he really
wasn't that bad of a guy, just a mean, vindictive person or
anything. But … I mean, he should have known to back away. I
wouldn't consider it like exactly rape” (interview response by
nonlabeling participant in Peterson & Muehlenhard, 2011, p.
562). In some cases, participants do not consider the perpetrator
as a criminal: “He is a pig, but no rapist” (participant in Dardis
et al., 2017, p. 17).
3.4.3. Believing that consent may not be withdrawn
When girls and women make sexual advances, they are less
likely to acknowledge their legitimacy in wanting to stop sexual
intercourse. This leads some to believe that they put themselves
in a risky situation by agreeing to fondling with the man: “If I
hadn't been ‘messing around’ with him at all before, then I
would consider it rape, probably, but since I was kind of into it
in the beginning, then I just don't consider it rape” (interview
response from non-labeling participant in Peterson &
Muehlenhard, 2011, p. 563). Fear of worsening the situation

17. leads many women not to withdraw their consent: “I didn't want
to make him mad by saying no, so I did what he wanted”
(participant in Dardis et al., 2017, p. 18).
3.5. Ambivalence: avoiding labels or using alternative terms
This category refers to narratives suggesting ambivalence.
Participants do not know how to name the event, sometimes
because it does not seem to fit their idea of what sexual
violence is, and therefore must not be sexual violence per se.
For others, as previously stated, the term “sexual violence”
holds too much negative connotation and participants will
prefer using other words that appear less strong or may be less
connotated. This may act both as a result of being unwilling or
unable to characterize their experience as sexual violence or
rape, and as a way to minimize the event's impact and the
likelihood of it being understood as sexual violence or rape as
they reappraise the situation in the future.
3.5.1. Evading a label that refers to sexual violence
Madison and Minichiello's (2000) study reveals that evasive
strategies are used in participants' narratives when describing
the event. For example, a participant avoided labeling what
happened altogether. Some participants were unsure how to
label the event: “I'm not quite sure what to call what happened”;
“I don't really think it has a term”; “I don't know how I would
define this situation” (participants in Harned, 2005, p. 405).
3.5.2. The use of alternative terms to describe their experience
Some participants used synonyms to describe their experience.
These labels do often have a softer connotation: “[I] see it more
as emotional and psychological abuse and manipulation rather
than sexual abuse” (participant in Harned, 2005, p. 405). Also,
some participants avoid using the label “rape,” judged
negatively, too strong, and upsetting: “[It was] not rape, but [it
was] unwanted, forced sex… [R]ape is a strong word, but I
definitely did not want sex” (questionnaire response from non-
labeling participant in Peterson & Muehlenhard, 2011, p. 564).
The label “rape,” in these cases, is judged inappropriate for
their experience and participants consciously refuse to use it.

18. 3.6. Labeling of sexual violence through the perpetrator's
violent behavior, the consequences suffered or the failure to
comply with the consent
Some participants engage in a labeling process when they
clearly identify the perpetrator's problematic behaviors.
Alternatively, some recognize sexual violence due to the
experienced consequences. Lastly, some participants label the
situation as sexual violence because their consent was not
respected.
3.6.1. Physical violence and its repetition
Coherent with rape scripts, some participants labeled the event
as sexual violence because physical violence was involved:
“[B]ecause he used his physical strength to make me do
something that I didn't want to do” (participant in Harned, 2005,
p. 389); “He held down my arms and choked me so I would
cooperate” (participant in Dardis et al., 2017, p. 15). Injuries
resulting from the event also facilitate the labeling of sexual
assault: “[L]ooking at my bruises made me realize that there
had to be some force involved and that [I] was not just letting
him do it. There were bruises everywhere” (participant in
Harned, 2005, p. 392). The repetition of violent events
perpetrated by the same man is also a clue, for some
participants, that something was wrong: “At first it… appeared
to be accidental, but it wasn't accidental, because after a series
of the same sort of gestures you kind of get the picture that… it
was premeditated” (participant in Madison & Minichiello, 2000,
p. 408).
3.6.2. Negative psychological impacts
Participants can feel negative emotions following an unwanted
sexual experience, such as anxiety, fear, anger, and
disengagement. In some cases, these harmful psychological
impacts lead to the labeling of sexual assault. Negative impacts
can also affect sexual health and sexuality in general: “[T]hat
experience took away the meaning that sex used to have for me.
[N]ow, [I] don't feel it means as much, if anything, at all”
(participant in Harned, 2005, p. 390). For Sarah (18,

19. EuropeanCanadian), loss of control was a factor of distress:
“Well it's, uhh… I don't know, it's like, I think it's the whole
thing about, like, it's… your own body, and it's like… not
having… not having your say in what's going on” (Johnstone,
2016, p. 282).
3.6.3. Not having consented and not being able to say no
Issues of consent explain, for almost all labelers of Harned's
(2005) study, why they consider the event as sexual violence.
Some of them suggest the absence of consent as a determinant
component: “I was not consenting to what occurred. I was not
asked before penetration occurred if I wanted penetration to
occur” (participant in Harned, 2005, p. 387); “I said no and
tried to leave. Despite this he continued” (participant in Dardis
et al., 2017). For others, the inability to give consent because of
intoxication confirms the sexual violence: “I'd have to classify
it as rape because… if I was not conscious, you're not
consenting” (participant in Johnstone, 2016, p. 283). Finally,
some participants clearly state that they did not want sexual
activity: “[B]ecause [I] clearly said no and told him to stop, and
he continued with his actions and raped me” (participant in
Harned, 2005, p. 388).
3.7. Seeking social support or having educational information
External elements may also lead participants to redefine their
experiences. In Harned's (2005) study, seeking social support
triggered participants to label their victimization as sexual
assault: “[I] felt it was my fault, for drinking and flirting and
leaving the party, but a close male friend of mine convinced me
that it was sexual assault” (p. 390). Receiving a warning from a
colleague made a participant realize what was going on:
“Someone had said to me, ‘Don't get near that guy, he's a sleaze
bag,’ you know? ‘He's sleazy,’ or ‘he's strange,’ […]”
(participant in Madison & Minichiello, 2000, p. 407). Also,
being exposed to educational information facilitates the labeling
of the event: “I read an article on sexual assault or harassment,
and the situation I had been in was listed as a form of it”
(participant in Harned, 2005, p. 392).

20. The in-depth analysis of this corpus allowed us to expose a
variety of factors that lead a victim to label or to refuse to label
her experience as sexual violence. These factors predominantly
include self-blame, normalization, rejection of the term “sexual
violence”, adherence to rape scripts, ambivalence,
characteristics of the experience deemed problematic, and social
support or educational information.Discussion
The purpose of this study was to examine how girls and women
perceive their unwanted sexual experience and to identify a
variety of factors that seem to impede or promote the labeling
of the event. Results allowed the identification of three main
representations in participants' narratives: most would not label
the event as sexual violence (categories 1 to 4), others would be
ambivalent about it (category 5), and some would explicitly
label the event as sexual violence (categories 6 and 7). All
participants had experienced a situation that was concordant
with the Centers for Disease Control and Prevention's (2014)
definition of sexual violence, which includes sexual harassment,
sexual assault, attempted rape, rape, sexual coercion without
force, sexual contact and unwanted sexual advances.
The first group of categories (categories 1 to 4) portrays the
complexity of the labeling process as greatly influenced by the
social context in which these events occur. Analysis confirmed
that adherence to rape scripts and rape myths impact the
victims' propensity to label and understand the event as sexual
violence. Thus, not only does this adherence deny the presence
of sexual violence, but it also leads to types of labeling that
trivialize the violent nature of the interaction (Kavanaugh,
2013). This finding raises concerns since it suggests a tolerance
towards of forms of violence that can be modulated by
minimization, normalization, and rationalization of the
perpetrator's behavior, who is very often a man known to the
victim. Comprehension of these labels is illuminated when
understood in conjuncture with heterosexual relationships
(Rich, 1981). In the context of patriarchy, sexual assault in
heterosexual sex is not represented as a distinctive act of

21. violence, but rather as the end of a continuum of sexual
activities between men and women (Gavey, 2005). Social
representations often present the male sexual drive as
uncontrollable, prompting many men and women to adhere to
this idea of sexual violence as normal, banal, or commonplace
experiences. In this traditional sexual script, a man's role is to
initiate sexual activity, while a woman's responsibility is to
refuse his sexual advances if she is not willing (Wiederman,
2005). However, the masculine script further suggests
persistence despite protests or vocal non-consent (Harned,
2005; Littleton, Rhatigan, & Axsom, 2007).
As a result, it is not surprising to find that many events of
unwanted sexual experience are not represented as sexual
assault or rape by victims or by perpetrators. This
representation of unlabeled sexual violence or rape as natural or
expected is the most common discourse in this study. Rape
attribution research has shown that many unwanted sexual
events are not defined as sexual violence, particularly if they
contain elements that fit the traditional heteronormative sexual
script – within the context of intimate relationships, when there
is low physical force used by the perpetrator (Boyle &
McKinzie, 2015; Cleere & Lynn, 2013; Littleton et al., 2007) or
victim's low use of verbal or physical resistance (Harned, 2005;
Littleton, Axsom, Breitkopf, & Berenson, 2006).
The second type of representations (category 5), suggests that
labeling may be a process, as depicted by showing the
ambivalence in narratives. Results show that participants are
questioning the event by using terms that seems less threatening
than “rape.” These participants mainly reported recent
experiences of victimization. This is concordant with studies
that found that victims who do not label sexual violence as such
were more likely to relate a recent assault (Boyle & McKinzie,
2015; Cleere & Lynn, 2013; Littleton et al., 2006), which
suggest that time may influence labeling process. As reported
by Harned (2005), labeling seems to be a gradual process that is
influenced by different factors: seeking social support, thinking

22. about it, personal growth, sobering up (when the sexual
violence occurred while she was intoxicated), negative impact
suffered, educational information and repeat offender (when the
perpetrator has multiple victims). However, more studies need
to be done on this specific process since this interpretation
remains speculative in nature.
The third group of categories (categories 6 and 7) applies to
participants that do label the event as sexual violence. Results
show that some elements promote the labeling of sexual
violence: non-respect of consent, severity of consequences,
perpetrator' social behavior and educational information or
social support. These elements also seem to be linked to rape
scripts. As suggested by some researchers, women that report
emotional distress following sexual violence are more likely to
label the event as such because it fits the “real rape scenario,”
which states that a high level of physical violence and
psychological distress must have been experienced either during
or after the event (Boyle & McKinzie, 2015; Littleton et al.,
2006). However, a considerable proportion of the participants
rely on their lack of consent to label the event, more than they
rely on the perpetrators' behaviors in and of itself. It is
consistent with the many prevention programs in the United
States and Canada that promote communication of sexual
consent. Bedera and Nordmeyer (2015) have identified the
different prevention tips that are addressed to college students,
most common sexual violence prevention tip being to
“communicate sexual limits.” Although it seems to help some
women in labeling their experience as sexual violence, the fact
that these interventions place the emphasis on communication
(and, more specifically, on a victim's role in that
communication) leads some of them to blame themselves by
implying that they were not clear enough in their rejection of
sex, and therefore are responsible for being a victim of sexual
violence.
4.1. Limitations and future research
This metasynthesis has limitations. First, the data analysis did

23. not result in the achievement of theoretical saturation, since
there is a dearth of documentation regarding certain categories.
Unlike a typical qualitative research process based on research
interviews, this secondary analysis prevented a direct
conversation with the participants themselves to look for
missing elements in our analysis. Rather, it is better understood
as an exploratory study of the phenomenon.
Second, the internal diversity of the participants in this research
was limited to the characteristics of selected studies' samples.
Although there was a great diversity of age between the
participants, little racial diversity was observed. Thus, the
stakes of social class, racialization, or other forms of
marginalization are not represented. Populations from diverse
economic and racial backgrounds should be further studied to
document a broader and less ethnocentric comprehension of the
phenomenon.
Future research should validate, qualify and adapt labeling
categories with other under-represented groups, such as people
of sexual and gender diversity, and cultural, religious, ethnic or
racial diversity. It would also be necessary to explore labeling
regarding other forms of sexual violence such as online sexual
violence.
4.2. Practice implications
These results have implications for research, and for
intervention and prevention. In research studies, the
methodological operationalization of sexual violence appears to
be a feminist issue. It is important to study the labeling of
sexual violence in sociologically operational terms in an effort
to make it visible, allowing women to identify the violent nature
of the situation experienced. In order to obtain the most
comprehensive portrait of sexual violence, it is critical to adopt
a vocabulary that echoes women's experiences, while
identifying the indicators that reveal or obscure the presence of
violence.
In intervention and prevention, professionals working with
sexual violence victims must tackle rape myths and deconstruct

24. rape scripts that may be present in victims' narratives. Such
strategy may allow the victims to avoid feelings of shame or
guilt, and thus better process the events that they have
experienced. It is important to embrace the fact that some
people label sexual violence, while others do not. As Johnstone
(2016) states, the process of labeling an assault can come with
ambivalence. This ambivalence should be addressed to support
each victim in concordance with how she conceptualizes the
event.
Most importantly, we must aim for a better recognition of the
different manifestations of sexual violence among various
groups. By adopting an inclusive definition of the varied types
of sexual victimization, intervention programs will be able to
address myths more broadly. These programs should also
address more insidious and covert forms of sexual violence,
such as inappropriate sexual comments or sexual jokes, so as to
be in line with an approach that places sexual violence on a
continuum. Prevention programs must deconstruct rape myths
and different gender stereotypes that negatively affect
heterosexual relationships, from childhood to adulthood, for
both heterosexual individuals and those from sexual and gender
diverse communities. Intervention programs should criticize the
traditional gender socialization of women to enable them to
overcome emotional barriers that promote always being nice
(physically or emotionally) to others and to defer to men's
desires. Finally, prevention programs, such as the Enhanced
Assess Acknowledge Act Education program (Senn et al.,
2013), should focus on women's knowledge of sexual violence
to contrast it with positive and healthy sexualities and intimate
relationships. Acknowledgements
The authors thank Mylène Fernet for her helpful comments on
an earlier draft of the manuscript, Carl Rodrigue for the
guidelines needed to conduct a metasynthesis.Funding
information
This research was assisted by fellowships from the Fonds de
Recherche du Québec - Société et Culture (FRQSC).References

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http://www.sfgate.com/health/article/S-F-General-following-
Toyota-Way-to-efficiency-4879925.php

30. S.F. General following 'Toyota Way' to efficiency
By Victoria Colliver
Updated 8:02 pm, Thursday, October 10, 2013
At San Francisco General Hospital, clinicians, executives and
other staff members are peppering their
conversations with Japanese words like kaizen, which means
continuous improvement, and muda, for waste.
The dialogue is not part of a language program, but rather an
effort to infuse Japanese automaker Toyota's management
philosophy and practices into the way the hospital delivers
medicine to its patients. "The Toyota Way," as it is called, is
the
company's systematic approach to producing cars and trucks
efficiently, with the primary goal of pleasing the customer.
"A lot of people think, 'What does making cars have to do with
taking care of patients?' " said Iman Nazeeri-Simmons, the
hospital's chief quality officer.
IMAGE 1 OF 9
Dr. Ron Labuguen (right), an S.F. General Hospital continuous-i
mprovement team leader, records observations.
A lot, as it turns out.
San Francisco General is among a growing number of hospitals
in the U.S. taking Toyota's management principles to heart.
Behind the effort is a need to compete as greater scrutiny is
being placed on costs and hospital reimbursements are
shrinking.

31. Health law's impact
For public hospitals like San Francisco General, which is also
the city's designated trauma center, the federal Affordable Care
Act may further tighten financial constraints as the government
reduces payments earmarked for some uninsured patients.
As these patients become insured, they will also have greater
options in the hospital they choose to go to. And their choice
may
not be their nearest safety-net hospital. That realization is
putting these hospitals, including S.F. General, in the unusual
position of having to attract and retain "paying customers" to
survive.
"They're going to have to make themselves more attractive if
they're going to compete for those patients who no longer have
to
go there because they have to," said Dr. Mark Smith, chief
executive officer of the California HealthCare Foundation,
an Oakland philanthropy that has invested more than $2 million
over the past five years to help hospitals adopt Toyota's
techniques.
The foundation's grants have gone to a number of county health
systems - San Francisco, San Mateo, Alameda, Contra Costa,
Los Angeles - to help them re-engineer how they operate. That
could mean everything from how supplies are organized to how
many steps a nurse should take to reach essential equipment in
the operating room.
San Mateo Medical Center's chief executive officer, Dr.
Susan Ehrlich, described Toyota's method as "really focused on
the
small things. It's making a million small changes and making

32. sure everyone is doing those changes and sticking to them over
time."
Critical analysis
To make the system work, a team of employees is assigned to
analyze a particular area targeted for improvement. The group
immerses itself in what is typically a weeklong, hands-on
session, called a kaizen, and emerges with a plan to make
specific,
often seemingly small changes designed to have a big impact on
costs or the patient's experience.
Hospital administrators, doctors and nurses or any other staff
members could find themselves sitting in a waiting room for
hours with a patient or cleaning floors with the housekeeping
staff or watching a specific medical procedure. Suggestions can
become approved practice without the usual bureaucracy.
tation
For example, at San Francisco General, a recent kaizen focused
on the number of minutes it takes from the moment a patient
is wheeled into the operating room to when the first incision is
made. A team spent a week trying to come up with ways to
whittle 10 minutes off the hospital's average "wheels in" to
incision time of 40 minutes.
Ten minutes may not sound like a lot, but those minutes can add
up in wasted time and cost when a staff of nurses and
doctors has to wait for a piece of equipment or a patient to be
ready for them. Those delays also keep a patient in the
operating
room longer than necessary, reducing the number of procedures

33. that could be performed on other patients.
Working on change
Officials at San Francisco General, which started adopting
Toyota's methods in earnest a little more than a year ago,
admitted
that it's tough to get everyone on board and that change is often
met with some resistance.
"You generate these small wins - especially if they're visible -
and that's what changes people's attitudes real quickly," said Dr.
Ron Labuguen, medical director of San Francisco General's
Urgent Care Center, the first department to receive the Toyota
Way treatment.
The hospital's Urgent Care Center has already seen results. In
July 2012, the average wait - from arrival to discharge - was 4
to
6 hours. After going through the new process, the average wait
time is 2.5 hours.
During the improvement session in urgent care, team members
noticed that every time a patient needed a basic X-ray, they
had to leave the center, walk across the street to a different
building and then navigate a maze of hallways to the radiology
department. A patient who couldn't make the 15-minute walk
had to wait for a wheelchair escort, which could take hours at
the busy hospital.
They suggested a logical fix: create an on-site X-ray room.
"Having the X-ray here has revolutionized the patient
experience,"
said Ricardo Ballin, nurse manager in urgent care.
Toyota's techniques
The move toward applying Toyota's techniques in hospitals

34. started around 2000 when executives at Seattle's Virginia
Mason Medical Center became interested in seeing how they
could improve the hospital's quality, safety and patient
satisfaction. They looked at Toyota because several other
industries and companies, including Boeing, were using the
carmaker's established methods.
At first, the idea was resisted, executives leading the charge
said.
"When Boeing heard about Toyota, they said that's fine for a car
manufacturer, but we make airplanes," said Mike Rona,
Virginia Mason's former president who now runs his own
consulting businesses for hospitals converting to the system.
"Our
people, when they heard about Boeing, said that's fine for
Boeing, but we have processes that take care of people."
Rona said it doesn't really matter what any particular company
or industry does or produces. "Every organization has
processes to make whatever they make," he said, adding those
processes can always be improved.
Today, numerous hospitals around the nation, including many
private hospitals in the Bay Area, are using Toyota's techniques
in some of their practices.
San Mateo example
At San Mateo Medical Center, which is well on its way to full
adoption, administrators have trained 100 staff members to
teach the system to their colleagues, involved 300 employees in
52-week kaizens and made significant changes in nine
departments.
In one improvement session, hospital staff members looked at
operating room cancellations. They analyzed the reasons for

35. those cancellations - ranging from surgical scheduling conflicts
to patients not having their pre-op preparation done in time -
and recommended changes that reduced cancellations by 17
percent. That saved the hospital more than $200,000 between
October 2012 and July 2013, CEO Ehrlich said.
Another session targeted the infusion center, where patients
receive chemotherapy and other life-saving treatments. The
group focused on reducing time lost getting insurance
authorization for these very expensive drugs. Ehrlich said
reducing
muda, or waste, in that process saved the hospital $300,000
from February to August of this year.
Believers in Toyota's method say the key to making the system
more than just another management fad is to standardize the
new processes so that everyone does them the same way and
works to sustain the changes.
San Francisco General's quality officer, Nazeeri-Simmons,
admits that can be a challenge in a seemingly chaotic
atmosphere
of a major trauma center. But, she said, at least 80 percent of
the work done at the hospital every day is predictable or
routine.
That's where the changes can be made.

36. "You just can't act like everything we do is brand new, every
day," Nazeeri-Simmons said. "When you stabilize the 80
percent,
that gives you flexibility for the chaos."
Glossary
Toyota's production system, which focuses on reducing waste an
d inefficiencies while making customers happier, has been incre
asingly adopted by hospitals trying to improve medical
quality and increase patient satisfaction. Here are some of the s
ystem's frequently used Japanese terms, many of which do not h
ave a direct English translation:
Gemba: the place where work is performed
Hansei: a period of critical self reflection
Heijunka: a level production schedule that provides balance and
smooths day-to-day variation
Jidoka: using both human intelligence and technology to stop a
process at the first sign of a potential problem
Kaizen: continuous improvement
Kanban: a visual card or signal used to trigger the fulfillment of
need, such as restocking supplies
Muda: anything that consumes resources but provides no value
Poke-yoke: a mistake-proofing device that prevents errors
Source: Rona Consulting Group

37. Victoria Colliver is a San Francisco Chronicle staff writer. E-
mail: [email protected] Twitter: @vcolliver
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