Rape Victimization and High Risk Sexual Behaviors Longitudinal Stud.docx

Rape Victimization and High Risk Sexual Behaviors:
Longitudinal Study of African-American Adolescent Females
Delia L. Lang, PhD, MPH,* Jessica M. Sales, PhD,* Laura F.
Salazar, PhD,* James W. Hardin, PhD,†Ralph J. DiClemente,
PhD,* Gina M. Wingood, ScD, MPH,* and Eve Rose, MSPH*
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Go to:Abstract
Go to:
Go to:Objectives:
African-American women are affected by disproportionately
high rates of violence and sexually transmitted infections
(STI)/human immunodeficiency virus (HIV) infection. It is
imperative to address the intersection of these two urgent public
health issues, particularly as these affect African-American
adolescent girls. This study assessed the prevalence of rape
victimization (RV) among a sample of African-American
adolescent females and examined the extent to which
participants with a history of RV engage in STI/HIV associated
risk behaviors over a 12-month time period.
Go to:
Go to:Methods:
Three hundred sixty-seven African-American adolescent
females ages 15–21, seeking sexual health services at three
local teenager-oriented community health agencies in an urban
area of the Southeastern United States, participated in this
study. Participants were asked to complete an audio computer-
assisted self-interview (ACASI) at baseline, 6- and 12-month
follow-up. We assessed sociodemographics, history of RV and
sexual practices. At baseline, participants indicating they had
experienced forced sex were classified as having a history of
RV.
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Go to:Results:
Twenty-five percent of participants reported a history of RV at
baseline. At 6- and 12-months, victims of RV had significantly
lower proportions of condom-protected sex (p=.008), higher
frequency of sex while intoxicated (p=.005), more inconsistent
condom use (p=.008), less condom use at last sex (p=.017), and
more sex partners (p=.0001) than non-RV victims. Over the 12-
month follow-up period, of those who did not report RV at
baseline, 9.5% reported that they too had experienced RV at
some point during the 12-month time frame.
Go to:
Go to:Conclusion:
African-American adolescent females who experience RV are
engaging in more risky sexual behaviors over time than non-RV
girls, thereby placing themselves at higher risk for contracting
STIs. In light of the results from this unique longitudinal study,
we discuss considerations for policies and guidelines targeting
healthcare, law enforcement and educational and community
settings. The complexities of RV screening in healthcare
settings are examined as is the need for tighter collaboration
between healthcare providers and law enforcement. Finally, we
consider the role of prevention and intervention programs in
increasing awareness about RV as well as serving as an
additional safe environment for screening and referral.
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Go to:INTRODUCTION
Due to jeopardized health of adult and adolescent women, the
intersection of gender-based violence and increased risk for
acquiring sexually transmitted infections (STIs), including
human immunodeficiency virus (HIV), has received increased
attention in public health research.1 The United Nations
Declaration on Violence Against Women provides a broad basis
for defining gender-based violence, which includes but is not
limited to physical, sexual, and psychological violence, sexual
abuse of female children, marital rape, non-spousal violence,
sexual harassment, trafficking in women and forced

prostitution. Globally, girls and women face systematic
discrimination, leaving them highly vulnerable to being harmed
physically, psychologically and moreover sexually by the men
in their families and communities.2
In the United States (U.S.), women experience high rates of
sexual violence. According to results from the National
Violence Against Women Survey (NVAWS), nearly one in six
women surveyed reported having been raped in their lifetime, a
prevalence of 17.6%.3 Furthermore, research suggests that in
nearly two-thirds of cases, rape victimization (RV) was
perpetrated by someone the victim knew (e.g. friends,
acquaintances, or intimate partners) with over 50% of victims
reporting that the rape occurred before age 18.3,4 While RV
rates are alarming, data also indicate that only one in five
women reported their rape to authorities, suggesting that
available data on RV represent a severe underestimate.3
Retrospective studies in the U.S. examining physical and/or
sexual victimization have shown that women’s experiences of
victimization during childhood and/or adolescence are
associated with high-risk sexual practices in adulthood and the
acquisition of STIs, including HIV. 5–13 Among African-
American adult women specifically, experiences of SV in
childhood and/or adolescence are associated with increased risk
for abortion, re-experiencing abuse as an adult, acquiring an
STI, earlier sexual debut, a greater number of lifetime sexual
partners, and sex trading.7,8,14–16
Among adolescent females, studies examining the association
between RV and STI/HIV-associated risk behaviors suggest a
similar pattern of associations as those described for adult
women. Studies based on representative samples of adolescent
females report that approximately one in five girls has
experienced some form of victimization.17,18 Among sexually
active adolescent girls, this rate increases to approximately one
in three girls with African-American adolescent females
reporting higher rates of physical or sexual victimization
compared to other ethnic groups.19–23 Many adverse

psychological and physical health outcomes have been found to
be associated with early experiences of RV, including eating
disorders, decreased self-esteem and poor health-related quality
of life.17,24–27 Adolescent females with a history of RV also
report engaging in high risk sexual practices including having
multiple sexual partners, earlier sexual debut, not using birth
control at last intercourse, substance abuse, and exchanging sex
for money or drugs.16,20,28–39 Moreover, studies have
reported a link between RV and self-reported STIs, whereas one
recent study with female detained adolescents showed that
victimization was related both directly and indirectly to
biologically-confirmed chlamydia.18,19,32,40 Indirectly,
physical or sexual victimization was related to chlamydia
through condom failures and having sex while intoxicated.
Among adolescents, African-American females continue to
represent a vulnerable group bearing the disproportionate
burden of STI/HIV infection.41–44 Specifically, the prevalence
of chlamydia and gonorrhea is substantially higher among same-
age African-American adolescent females compared to females
from other ethnic groups.45,46 Furthermore, previous studies
have observed that among African-American females, even after
adjusting for diverse behavioral and sociodemographic risk
indices, the reinfection rate was threefold that among white
peers.42,47–50 This could be due to a combination of factors
including lack of adoption of STI/HIV-preventive strategies,
such as using condoms consistently or limiting number of sex
partners and/or selecting partners from high risk sexual
networks.46,51,52
Taken together, these studies suggest that examining the
intersection of RV and sexual risk taking among African-
American females at high risk for STI/HIV acquisition is not
only timely but also necessary given the scarce body of
prospective research in this area. For purposes of this study, RV
is defined as non-consensual sex during childhood or
adolescence. RV is a particularly harmful type of gender-based
violence associated with the most enduring health

consequences, such as STI/HIV acquisition and associated risk
behaviors.5,7,17,33,53,54 The purpose of this study was to
describe the prevalence of RV in a population of African-
American adolescent females seeking STI services, and to
longitudinally assess the extent to which African-American
adolescent females with a history of RV engage in STI/HIV
associated risk behaviors over a 12-month time period.
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Go to:METHODS
Participants
Participants in this study were part of a randomized controlled
trial evaluating a sexual risk reduction intervention for young
African-American females in an urban area of the Southeastern
U.S. From March 2002 through August 2004, recruiters
screened self-identified young African-American females
seeking reproductive and sexual health services at three local
teenager-oriented community health agencies. Eligibility
criteria included being African-American, female, 15 to 21
years of age, and sexually active (reporting vaginal intercourse
in the previous 60 days). The local institutional review board
approved the study protocol before implementation.
Of 1,558 screened, 874 females met eligibility criteria. Of those
who met eligibility criteria, 82% (n=715) agreed to participate,
provided written informed consent, and completed a baseline
assessment. Of those who agreed to participate, 348 (48.7%)
were randomly assigned to the sexual risk reduction
intervention condition while 367 (51.3%) were randomly
assigned to a standard-of-care comparison condition. Analyses
reported in this study addressed data from participants who
were randomized to the standard-of-care comparison condition
only to eliminate any effects of the intervention on high risk
sexual behaviors. We obtained high retention rates (86%) at
both 6- and 12-month follow ups for this sample.
Procedures

Data collection consisted of a 40-minute survey administered
via audio computer-assisted self-interviewing (ACASI)
technology at baseline, 6-month and 12-month follow-up time
periods. Questions assessed sociodemographic information,
history of RV, condom use behaviors and other variables
describing participants’ sexual history. Participants were
compensated $50 for their participation at each assessment time
point.
MeasuresHistory of Rape Victimization
History of RV was conceptualized as an index comprising two
severe forms of abuse—forced vaginal intercourse or forced
anal intercourse—and was assessed by asking two questions:
“Has anyone ever forced you to have vaginal sex when you
didn’t want to?” and “Has anyone ever forced you to have anal
sex when you didn’t want to?” Response choices were yes (1)
and no (0). Participants who endorsed either of these two
questions were categorized as having a history of rape
victimization. Participants who did not endorse either of these
two questions were categorized as having no history of rape
victimization.Sociodemographic and Background Measures
We assessed highest grade completed in school by a single
question, “What was the last grade that you completed in
school?” Participants were also asked if they were currently
attending school. Receiving federal assistance for living
expenses was assessed by four yes-or-no questions. We summed
responses to each question to create an index of family aid.
Participants were also asked with whom they were living at the
time of assessment (i.e. family members, boyfriend, other
friends). We also assessed age at first willing vaginal
sex.Condom Use
We assessed several measures of condom use. First, condom use
during the last episode of vaginal intercourse with a sex partner
was assessed. Condom use at last intercourse provides an
assessment of recent condom use that may be less susceptible to
recall bias.55 Participants were asked the question “Did you use

a condom the last time you had vaginal sex with your boyfriend
or steady partner?” Response choices were yes or no. Second,
we assessed consistent condom use by asking participants the
question “How many times did you have vaginal sex in the past
60 days?” Participants were then asked “How many of these
times did you use a condom?” Based on these two questions we
computed a continuous measure, proportion of condom use in
the last 60 days, with possible values ranging from 0 to 100%
condom use. Furthermore, we subsequently computed a
dichotomous measure. Participants who indicated using
condoms during every episode of vaginal intercourse in the past
60 days (100%) were defined as consistent condom users.
Participants who indicated not using condoms during every
episode of vaginal intercourse (0–99%) were defined as
inconsistent condom users.Unprotected Vaginal Sex
We assessed unprotected vaginal sex by subtracting the number
of times a participant used condoms in the past 60 days from the
number of times they reported having vaginal sex in the past 60
days.Number of Sexual Partners
We assessed number of sexual partners by asking participants:
“In the past 60 days, how many guys have you had vaginal sex
with?” This measure was then dichotomized into participants
who reported one sexual partner in the past 60 days and
participants who reported two or more sexual partners.Sex
Under the Influence of Drugs or Alcohol
We assessed number of vaginal sex episodes while the
participant and their sex partner were intoxicated by the
following two questions: “In the past 60 days, how many times
did you have sex while high on alcohol or drugs?” and “In the
past 60 days, how many times did you have sex while your
partner was high on alcohol or drugs?”
Statistical Methods
First, we used descriptive statistics to summarize
sociodemographic variables, prevalence of sexual violence and
high risk sexual behaviors. Subsequently, we conducted

bivariate analyses consisting of Chi-square and independent
Student’s t-tests to examine associations between RV and
potential confounding variables. Finally, we estimated
multivariable population-averaged generalized estimating
equation (GEE) models to examine the longitudinal relationship
between RV and high risk sexual behaviors.56 We used the
exchangeable correlation structure for the working correlation
matrix based on an evaluation of the quasi-likelihood
information criterion. A separate GEE model was constructed
for each high risk sexual behavior considered.
Fitted GEE regression coefficients parameters can be
interpreted as the odds or odds ratios (in logistic models
analyzing dichotomous outcome variables) and means or mean
differences (in linear regression models analyzing continuous
outcome variables) over the entire 12-month period for an
“average” participant. We computed the 95% confidence
intervals around the adjusted odds ratios and adjusted mean
differences and the corresponding P-value. To obtain adjusted
means and mean differences, we repeatedly re-estimated models
from bootstrap samples where samples were drawn with
replacement at the level of the participant. For each model, we
calculated adjusted means and standard errors from the
collection of bootstrap results.57,58 We computed percent
relative difference for continuous variables as the difference
(D) between the adjusted means for victimized participants
divided by the adjusted mean for non-victimized participants.
Percent relative difference provides a common metric for
measuring the magnitude of the difference across the various
measures relative to the baseline measure. We performed
analyses using Stata statistical software, version 10.
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Go to:RESULTS
Descriptive and Bivariate Analyses
Three hundred sixty-seven participants between the ages of 15
and 21 participated in this study and provided baseline data

(Table 1). The mean age of the participants was 17.8 (standard
deviation [SD] =1.7) years. Most (67.9%) had not yet graduated
from high school while the remaining 32% had completed high
school and/or technical school. A total of 35.4% no longer
attended school at the time of baseline assessment. Among this
sample 53.4% reported that their family received some form of
public assistance (i.e. welfare, Section 8 housing, food stamps).
Most participants (82.3%) reported being in a current
relationship with the average length of the relationship 15.11
months (SD=16.0). Ninety-two (25.1%) participants reported a
history of RV at baseline. Of the participants who reported no
RV at baseline, 26 (9.5%) reported RV incidence over the 12-
month follow-up period. Of the participants who reported RV at
baseline, 55 (59.8%) reported being re-victimized over the
following 12-month period. Specifically, 14 (15.2%) reported
being re-victimized at the 6-month follow up; eight (8.7%)
reported being re-victimized at the 12-month follow up; and 33
(35.9%) reported being re-victimized at both the 6- and 12-
month follow up.
Table 1.
Comparability of rape victimization (RV) and non-RV
participants at baseline.
VARIABLES
RV (n=92)
Non-RV (n=275)
Mean (SD)
Percent (n)
Mean (SD)
Percent (n)
P
Age
17.98 (1.68)

17.71 (1.75)
0.20*
Age at first vaginal sex
14.23 (1.64)
14.68 (1.62)
0.02*
Less than high school
62.0% (57)
70.0% (191)
0.15*
Public assistance
56.5% (52)
52.4% (144)
0.49
Holding a paying job
29.3% (27)
28.0% (77)
0.80
Not living with family
30.8% (28)
19.8% (54)
0.03*
Currently in a relationship
82.6% (76)

82.2% (226)
0.93
Testing positive for an STI
23.9% (22)
27.3% (75)
0.53
Ever used marijuana
87.0% (80)
78.2% (215)
0.07*
Ever used alcohol
91.3% (84)
86.5% (238)
0.23
Number of days used alcohol
6.02 (10.71)
3.95 (8.75)
0.11*
*Covariates used in generalized estimating equation (GEE)
models SD, standard deviation; STI, sexual transmitted
infection.
We present descriptive statistics and bivariate associations
between the predictor variable, history of RV, and demographic,
as well as other potential confounding variables, in Table 1. We
included only variables associated with history of RV at p≤.20
in bivariate analyses in the multivariate GEE models as
confounders.59 Furthermore, we present bivariate comparisons

between RV history and sexual risk taking at each of the three
time points (baseline, 6-months and 12-months) in Table 2.
Table 2.
Bivariate comparisons between rape victimization (RV) and
non-RV participants and sexual risk taking at baseline, six and
12-month follow-up periods.
VARIABLES
RV (n=92)
Non-RV (n=275)
Mean (SD)
Percent (n)
Mean (SD)
Percent (n)
P
Baseline
Sex frequency while intoxicated
3.00 (6.82)
1.63 (4.18)
0.07
Sex frequency partner intoxicated
4.15 (7.90)
2.36 (4.90)
0.04
% condom use
40.0 (38.51)
56.3 (40.61)
0.002

Unprotected vaginal sex
10.2 (14.48)
5.2 (8.24)
0.006
Multiple sex partners
42.4% (39)
33.5% (92)
0.12
Inconsistent condom use
83.8% (67)
69.1% (163)
0.01
No condom use last sex
67.4% (62)
55.3 % (152)
0.04
Six-Month Follow-up
1.68 (3.50)
1.21 (4.29)
0.33
2.91 (4.68)
1.68 (6.11)

0.07
% condom use
38.6 (39.41)
54.1 (42.59)
0.009
8.7 (11.15)
6.5 (10.60)
0.15
39.5% (30)
24.8% (59)
0.01
84.3% (59)
66.2% (129)
0.004
69.7% (53)
51.7 % (122)
0.006
12- Month Follow-up
2.22 (5.91)
0.65 (2.07)

0.02
3.34 (7.61)
1.11 (2.54)
0.01
% condom use
40.9 (39.54)
55.2 (43.13)
0.011
10.1 (14.55)
5.9 (12.64)
0.03
38.8% (31)
20.8% (49)
0.001
79.5% (58)
65.3% (126)
0.03
66.2% (53)

54.3 % (127)
0.06
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SD, standard deviation
Multivariate Analyses
We present results of GEE models constructed for continuous
and dichotomous measures of sexual behaviors over the entire
12-month time period in Table 3. Analyses of continuous
behavioral outcomes suggest that over the entire time period
participants with a history of RV compared to participant
without a history of RV reported significantly lower proportion
condom use in the past 60 days (adjusted mean 21.45 vs. 31.57;
p=.008), greater frequency of having sex while they were
intoxicated (adjusted mean 2.30 vs. 1.30; p=.005) and greater
frequency of having sex while their partner was intoxicated
(adjusted mean 3.25 vs. 1.95; p=.005). Frequency of
unprotected vaginal sex in the past 60 days was only marginally
significant (p=.088).
Table 3.
Generalized estimating equation (GEE) results for behavioral
outcomes.
GEE Models: Baseline – 12 Months
Adjusted Meana SV
Adjusted Meana Not SV
Differenceb(95% CI)
% Rel Differencec(95% CI)
AORd(95% CI)
P
Continuous Behavioral Outcomes
% Condom use past 60 days
21.5

31.6
–10.1 (–17.0;–3.7)
13.2 (13.2; 51.8)
n/a
0.008
Unprotected vaginal sex past 60 days
8.00
6.45
1.55 (–0.6; 3.4)
24.09 (–7.2; 55.6)
n/a
0.088
Frequency of sex while intoxicated
2.30
1.30
1.00 (0.25; 1.9)
77.90 (0.06; 162.9)
n/a
0.005
Frequency of sex while partner intoxicated
3.25
1.95
1.30 (0.40; 2.3)
66.69 (15.06; 124.2)
n/a
0.005
Dichotomous Behavioral Outcomes
Inconsistent condom use past 60 days
n/a
1.73 (1.2; 2.6)
0.008
No condom use at last sex

n/a
1.51 (1.1; 2.1)
0.017
n/a
3.94 (3.0; 5.3)
0.0001
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aAdjusted means for rape victimization (RV) and non-RV
groups; means adjusted by participant age, age at first
consensual sex, education, living arrangement, ever used
marijuana and number of days alcohol use past 60 days.
bAdjusted mean difference between RV and non-RV groups
reported for continuous outcomes
cRelative difference reported for continuous outcomes =
adjusted mean difference/adjusted non-RV group mean x 100%.
dAdjusted odds ratios (OR) reported for dichotomous outcomes;
adjusted by participant age, age at first consensual sex,
education, living arrangement, ever used marijuana and number
of days alcohol use past 60 days. Non-RV group is the referent
for computing the OR.
Analyses of dichotomous behavioral outcomes suggest that over
the entire 12-month time period, participants with a history of
RV compared to participant without a history of RV were 1.7
times more likely to report using condoms inconsistently
(95%CI =1.15, 2.60; p=.008), 1.5 times more likely to report
using no condoms at last sex (95%CI = 1.08, 2.11; p=.017), and
3.94 times more likely to report having multiple partners
(95%CI = 2.96, 5.26; p=.0001).
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Go to:DISCUSSION
In this sample of sexually active African-American adolescents
one in four females reported a history of RV. These findings

corroborate rates of RV reported in prior research with African-
American adolescent females.18,60,61 Furthermore, results of
this study show that African-American adolescent females
seeking services at local STI clinics and who have a history of
RV report an earlier age of consensual sex and are engaging in
more risky sexual behaviors as they age than their counterparts
who do not report a history of RV, thereby placing themselves
at increased risk for contracting STIs, including HIV. These
findings extend prior cross-sectional research reporting similar
findings by underscoring the enduring adverse effects of RV on
victims’ sexual risk taking over time.18,20,31,38,40, 60,61
Specifically, in this sample, African-American adolescent
females with a history of RV reported less condom use with
their sex partner, more frequent substance use during sexual
intercourse, and multiple sex partners over a 12-month period.
While we found no association in this sample between history of
RV and testing positive for an STI, all of the risk behaviors
aforementioned have been previously identified as antecedents
to STI acquisition among African-American adolescent
females.18
Understanding the relation between history of RV and risk
behaviors has been hindered in previous research due to the
cross-sectional nature of the study designs. As a result, two
general explanations of this association have been offered in the
literature: 1) following experiences of RV, women are more
likely to engage in a pattern of risk behaviors and 2) engaging
in risk behaviors may increase women’s risk of experiencing
RV.62 Although both explanations have received some support
in the literature with regard to the association between RV and
substance use behaviors, less is known about the temporal
association between RV and sexual risk taking.63–65 The
longitudinal nature of our analyses, although not allowing for
cause-effect conclusions to be drawn, lend some support to the
explanation that experiences of RV are associated with a pattern
of high risk sexual behaviors over time. This pathway is also
consistent with a model designed to explain violence-related

health problems which states that violent assaults, including
sexual assaults, can lead to various adverse health outcomes,
including acute physical injury, increased stress, psychological
and emotional problems and subsequently high risk health
behaviors.66 For victims of RV particularly, studies have shown
that the psychological sequelae may include low self-esteem,
passivity, depression, post-traumatic stress disorder and
feelings of powerlessness and helplessness.67–70
Taken together, these psychological problems, if unresolved
through professional counseling, are likely to contribute to
victims’ participation in high risk sexual behaviors, such as
being less likely to communicate about sex and negotiate safer
sex practices which may subsequently lead to inconsistent
condom use out of fear that such assertiveness may provoke
aggression and possibly repeat victimization.31,71 Moreover,
following experiences of RV, sexual activity may become less
pleasurable.72 It is reasonable to assume that for victims of RV
who view sexual activity as aversive, substance use may become
a coping mechanism, allowing them to engage in sexual
intercourse while alleviating negative emotions associated with
RV.18,62 Unfortunately, this negative coping mechanism of
using substances during sex may further exacerbate adolescent
females’ risk for contracting an STI including HIV, as using
substances during sex has been related to an increased risk of
condom failures.39Condom failures, such as breakage and
slippage, may be more important than other risk behaviors such
as unprotected vaginal sex when examining predictors of STI
acquisition. Findings from a recent study showed that
biologically-confirmed STIs were not related to unprotected
vaginal sex among a sample of adolescent females; however,
after adjusting the measure of unprotected vaginal sex to
account for imperfect condom use (i.e., controlling for
breakage, leaking, and slippage), the association was
significant.73 In the present study, we did not find a relation
between victimization and STIs; however, it may be possible
that other factors could account for an indirect relation. Future

research should examine more complex models that include
indirect effects and measures of condom failures to account for
STI outcomes. This line of research could help shed light on the
complex relations among experiences of RV, sexual risk
behaviors and STI/HIV outcomes.
Lastly, consistent with prior findings, our study suggests that
victims of RV are more likely to report multiple sex partners
than those without a history of RV.18,74,75 It is possible that
because victims of RV initiate sexual activity earlier than non-
victims, this may lead to exploring sexual behavior with a
greater number of sexual partners during the course of
adolescence. Additionally, several studies have found an
association between history of RV and prostitution among 13–
18-year-old predominantly African-American adolescents.76
Thus, transactional sex experiences may contribute to the higher
number of sex partners reported by victims of RV in this
sample.
Go to:
Go to:LIMITATIONS
This study has several noteworthy limitations. First, the
conceptualization of RV used in this study is rather limited in
scope, including only severe sexual violence (i.e. forced vaginal
and anal intercourse) and not other forms of sexual violence,
such as attempted rape, digital penetration or penetration with a
foreign object. Therefore, it is possible that participants
categorized as “not victimized” included some who may have
experienced types of RV other than those assessed by this
measure. Future studies should broaden this definition to assess
the effects of a full range of RV on sexual risk taking over time.
Second, this study did not assess the victim-perpetrator
relationship; therefore, no comparisons could be made between
RV perpetrated by a sexual partner vs. RV perpetrated by a
family member or a stranger. Moreover, no data were available
regarding the frequency, severity or chronology of
victimization. Finally, although this study adds to the literature
by assessing RV and risk behavior longitudinally, no cause-

effect conclusions can be drawn from these findings.
Go to:
Go to:CONCLUSION
It is critically important to identify and intervene with girls who
have experienced RV in an attempt to avoid a trajectory of
sexual risk-taking and further re-victimization. To that end,
policies and guidelines should be considered at several critical
structural levels including: 1) healthcare, 2) law enforcement
and 3) community education.
First, healthcare agencies, especially those serving adolescent
female populations, should adopt screening guidelines for
providers as standard practice. Having said that, it should be
acknowledged that screening for RV, although a logical
recommendation, could be complex in its implementation,
especially among adolescent populations. For example,
adolescent females may be accompanied to the clinic by the
perpetrator in cases where RV or other types of violence are
ongoing. In such cases, screening a victim may be ineffective at
best and dangerous at worst. Furthermore, in the absence of
being fully autonomous, adolescents’ ability to take advantage
of available services targeting RV may be dependent on family
members, who may or may not know about the victimization,
and their level of support. However, despite its complexities,
when implemented with caution, screening remains one of the
best methods to protect adolescent females from ongoing RV
and/or the sequelae of having experienced RV in the past.
Agencies may consider implementing an overall health
screening protocol that is conducted in private with only the
patient and healthcare provider(s) in the consulting room. A
thorough health screen would incorporate questions about both
sexual risk behaviors, focusing particularly on condom use
practices, frequency of sex while under the influence of
substances and number of sex partners, as well as history of RV.
Drawing on clinical judgment, providers may follow up with
questions about current RV, should patients’ answers to
previous inquiries be affirmative. Policies and guidelines must

also be considered in the training of healthcare providers and
their support staff. Resources should be readily available to
make referrals; however, health agencies should consider
implementing policies that place the adolescent female victim in
a collaborative relationship with in-house staff who actively
seek to connect her to targeted services for victims of RV in an
effort to increase the likelihood of safe follow through.
Additionally, training providers and staff to establish rapport
with victims and adhere to strict confidentiality standards is a
crucial consideration likely to impact both the probability of
eliciting truthful responses as well as the safety of the patient.
Finally, healthcare providers should also be linked to and
collaborate with law enforcement agencies in instances where
victims decide to report the victimization.
Second, policies and guidelines should address the needs of law
enforcement agencies in an effort to expand services offered to
victims of RV. Additional resources would allow enhanced
training of law enforcement staff to work closely and
collaboratively with healthcare agencies toward establishing sex
crime reporting procedures designed to assure young women
that they will be met with respect, sensitivity and timely
consideration in reporting their experience(s) of victimization.
Third, policies and guidelines should be implemented in
community educational settings to raise awareness of RV and
associated consequences for adolescent females. Specifically,
the implementation of existing sexual risk reduction and
pregnancy prevention programs should incorporate sexual
assault awareness into their protocols and offer treatment
referrals to participants. Similarly, intervention programs for
victims targeting the enduring effects of RV on sexual risk
taking and the risk for re-victimization are needed and should
be implemented within existing treatment plans addressing the
needs of RV victims. As such, well designed intervention
programs can serve a dual purpose: first, to raise awareness
among both female and male adolescents in an attempt to
prevent RV; and second, to serve as an additional safe

environment where victims can feel comfortable reporting their
experiences of RV. For many adolescent female victims of RV,
such a setting may represent the first step toward prevention of
increased sexual risk taking as well as possible re-victimization.
Go to:
Go to:Footnotes
Reprints available through open access at
http://escholarship.org/uc/uciem_westjem.
Conflicts of Interest: By the WestJEM article submission
agreement, all authors are required to disclose all affiliations,
funding sources, and financial or management relationships that
could be perceived as potential sources of bias. The authors
disclosed none.
Go to:
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Sexual Violence Victimization and Associations with Health
in a Community Sample of African American Women
Kathleen C. Basile, Sharon G. Smith, Dawnovise N. Fowler,
Mikel L. Walters,
and Merle E. Hamburger
Division of Violence Prevention, Centers for Disease Control
and Prevention, Atlanta, Georgia, USA
ABSTRACT
Limited information exists on the relationship between sexual

violence victimization and health among African American
women. Using data from a community sample of African
American women, we examine the association between current
health and lifetime experiences of sexual violence. Inperson
interviews were completed in 2010. Among interviewees,
53.7% of women reported rape victimization and 44.8%
reported sexual coercion in their lifetime. Victims of rape or
sexual coercion were significantly more likely to report
depression
and posttraumatic stress disorder during their lifetime.
Among victims whose first unwanted sexual experience was
rape or sexual coercion, perpetrators were mostly acquaintances
and intimate partners, and over one third were injured
and needed services. More attention is needed on the health
needs of African American women and their association to
victimization status.
ARTICLE HISTORY
Received 15 September
2014
Revised 26 May 2015
Accepted 29 May 2015
KEYWORDS
Help-seeking; negative
health experiences; rape;
sexual coercion
Although sexual violence (SV) occurs across all ethnic and
racial groups,
research has increasingly pointed to the prevalence and adverse
health outcomes
of SV among specific groups, such as African American women
and
other ethnic and racial minorities (Black et al., 2011; Bryant-
Davis, Ullman,
Tsong, Tillman, & Smith, 2010; Lacey, McPherson, Samuel,
Sears, & Head,
2013; Young & Boyd, 2000). Due to the limited number of

studies and the
complex nature and consequences of SV victimization for
African American
women, further research is needed.
There is a substantial literature focused on the health-related
consequences
of SV (Lang et al., 2003; Smith & Breiding, 2011). Prior work
has shown, for
example, that sexually victimized women are more likely to
experience many
chronic health conditions, HIV risk factors, smoking, and
excessive drinking
(Smith & Breiding, 2011). But most of the literature comes from
population
samples that are not large enough to stratify by race or
ethnicity. As a result,
less is known about the extent to which particular racial and
ethnic groups,
CONTACT Kathleen C. Basile [email protected] Centers for
Disease Control and Prevention, National Center
for Injury Prevention and Control, Division of Violence
Prevention, Mailstop F64, 4770 Buford Highway, Atlanta, GA
30341-3724.
JOURNAL OF AGGRESSION, MALTREATMENT & TRAUMA
2016, VOL. 25, NO. 3, 231–253
http://dx.doi.org/10.1080/10926771.2015.1079283
This article not subject to US copyright law
including African American women SV survivors, experience
these types of
negative health indicators. In this study, SV victimization status
and specific
health associations are identified (e.g., mental, physical, and
behavioral health
conditions, and postvictimization services received) in a
community sample
of African American women.

Definitional components
The literature on SV uses various terms and definitions to
examine this
public health problem, including sexual assault, sexual
coercion, and rape.
These terms often overlap in definitions and are used
interchangeably. For
the purpose of this study, SV includes physically forced
nonconsensual
completed or attempted penetration, penetration when the victim
was not
able to consent because she was passed out or asleep (rape), or
unwanted
penetration that is not physically forced (sexual coercion;
Basile, Smith,
Breiding, Black, & Mahendra, 2014).
The extent of SV among African American women
Despite the large body of literature examining SV, large
nationally representative
studies focusing specifically on racial and ethnic minority
women are limited.
Further, much of the previous scholarship that does exist on SV
of African
American women is focused on rape and other penetrative SV
acts (i.e., sexual
coercion), perhaps given the seriousness of these kinds of SV
victimization and
their association with adverse health. Some national prevalence
studies have
examined rape by racial and ethnic identity. For example, the
National Violence
Against Women Survey (NVAWS) found that 18.8% of African
American
women had experienced rape in their lifetime (Tjaden &
Thoennes, 1998). A
study using data fromthe National Crime Victimization Survey

found that from
2005 to 2010, approximately 3 African American women per
1,000 reported
experiencing sexual assault since age 12 (Planty, Langton,
Krebs, Berzofsky, &
Smiley-McDonald, 2013). Kilpatrick, Resnick, Ruggiero,
Conoscenti, and
McCauley (2007) conducted a national telephone study using
both community
and college samples. These samples reported that African
American women
reported higher rates of lifetime forcible rape than non-Hispanic
White women,
Hispanic women, and Asian women. More recently, the National
Intimate
Partner and Sexual Violence survey (NISVS) found that 13.6%
of Hispanic
women, 21.2% of non-Hispanic Black women, 20.5% of non-
Hispanic White
women, and 27.5% of American Indian/Alaska Natives reported
experiencing
rape during their lifetime (Breiding et al., 2014). Several
smaller studies have also
focused on the differences in SV by race or ethnicity. Molitor,
Ruiz, Klausner,
and McFarland (2000) recruited young women from a
community sample of
low-income neighborhoods in five counties in California. Of
more than 2,500
232 K. C. BASILE ET AL.
young women, 24.0% reported they had experienced forced sex
(30.0% of
African Americans, 32.0% of Whites, 14.4% of Hispanics, and
30.0% of multiracial
women). The aforementioned studies illustrate the range of SV
prevalence

across samples of racial and ethnic minority women. Despite
such variation,
findings consistently reveal a high burden of SV victimization
among African
American women and other racial and ethnic minority groups.
Given this
burden, it is imperative to explore the health of African
American women SV
survivors as it can improve our understanding of the risks for
this population,
and ultimately informthe development of effective interventions
to address their
needs.
Health risks and adverse conditions for African American
women SV
survivors
A substantial body of literature documents the risks of SV
victimization to
physical, mental, and behavioral health, indicating that SV
survivors are more
likely to experience adverse health compared to non-SV victims
(Koss, Koss, &
Woodruff, 1991; McFarlane et al., 2005; Pico-Alfonso et al.,
2006; Rivara et al.,
2007). Moderate to high rates of SV (e.g., 22%–100%) are
reported in various
samples of predominantly African American women, including
substance abuse
treatment recipients (Young & Boyd, 2000), low-income
samples (Boyd,
Henderson, Ross-Durow, & Aspen, 1997; Bryant-Davis et al.,
2010; Dailey,
Humphreys, Rankin, & Lee, 2011; Kalichman, Williams,
Cherry, Belcher, &
Nachimson, 1998), and military veterans (Campbell, Greeson,
Bybee, & Raja,

2008).
Adverse mental and behavioral health
Depression, posttraumatic stress disorder (PTSD), substance use
disorders
(SUDs), and suicidality are common mental and behavioral
health problems
among SV survivors in general (Alim et al., 2006; Caetano &
Cunradi, 2003;
Iverson et al., 2013; Ramos, Carlson, & McNutt, 2004). In a
U.S. national
sample, a history of SV has been found to be associated with
anxiety
disorders, mood disorders, PTSD, SUDs, and suicide attempts
(Iverson
et al., 2013). Studies focusing on the mental and behavioral
health of
African American female SV survivors in particular are limited,
and the
studies that exist usually rely on urban, low socioeconomic
status (SES), or
drug-abusing samples (Boyd et al., 1997; Bryant-Davis, Chung,
& Tillman,
2009; Bryant-Davis et al., 2010; Campbell et al., 2008; Vaszari,
Bradford,
CallahanO'Leary, Ben Abdallah, & Cottler, 2011). For example,
in a community
sample of low-income, ethnically diverse women (N = 835),
Temple and
colleagues (2007) found that sexual assault by current partners
and nonpartners
was a significant predictor of PTSD symptoms for African
American
233
women. Depression is consistently found to be a health risk for
African

American SV survivors (Alim et al., 2006; Ramos et al., 2004).
Data from
462 women (87% African American) who were cocaine users
showed that
43.3% reported sexual assault victimization. Among the African
American
women in the sample, 85% reported suicidal ideation. Similarly,
in terms of
comorbidity, in a sample of African American women recruited
from an
urban hospital (n = 335), Thompson and colleagues (2000)
found that
women with a history of child sexual abuse and current PTSD
symptoms
were more likely than women without a child sexual abuse
history or PTSD
to attempt suicide.
Although a concern for all survivors, adverse mental health and
substance
use problems could be particularly problematic for African
American women
SV survivors due to their risk for multiple, overlapping public
health problems
and conditions (Bryant-Davis et al., 2010). For example,
Bryant-Davis
and colleagues (2010) explored the relationship between
poverty and mental
health outcomes in an urban community sample of African
American female
SV survivors (N = 413). Positive relationships were found
between poverty
and depression, PTSD, and illicit drug use in the sample.
Other adverse conditions and life consequences
A body of studies with samples of African American women
either examined
the role of income or poverty as a correlate of SV (Bryant-Davis

et al.,
2010; Ingram, Corning, & Schmidt, 1996), or included high
numbers of
respondents with both low SES and high rates of SV
victimization
(Kalichman et al., 1998; McFarlane et al., 2005; Temple et al.,
2007;
Vaszari et al., 2011). Due to no or low income, African
American women
with low SES are often resigned to homelessness or low-income
housing in
communities where they are at increased risk for multiple
violence exposures
(Abbey, Parkhill, Jacques-Tiura, & Saenz, 2009; Jenkins, 2002).
In
addition to housing insecurity, food insecurity is another
potentially related
adverse condition for impoverished African American women
SV survivors.
Although food insecurity, as a factor of poverty, has not been
directly
explored in the literature, it is related to women’s ability to
meet their own
as well as their children’s basic needs. Overall, poverty and low
SES are
associated with increased rates of SV among African American
women
(Byrne, Resnick, Kilpatrick, Best, & Saunders, 1999;
Honeycutt, Marshall,
& Weston, 2001; Kalichman et al., 1998).
Help-seeking and service needs
The help sources typically sought by SV survivors include
reporting
assaults to police, obtaining protection orders (POs), receiving
emergency

medical services (EMS) and emergency trauma department care,
turning to
social support networks, and, in some cases, seeking mental
health services
and victim shelter services (Bryant-Davis, Ullman, Tsong, &
Gobin, 2011;
Kothari et al., 2012). Yet, the majority of all sexual assaults are
not
reported or shared with social services or law enforcement
(Hanson
et al., 2003), and often survivors who need medical care and
counseling
do not receive it (Resnick et al., 2000). National data indicate
that approximately
one fourth (26.2%) of adult rape survivors seek medical care
after
the assault (Resnick et al., 2000). The National Crime
Victimization Survey
(NCVS) estimates that in 2010 only 35% of the sexual assaults
experienced
by women (regardless of their relationship to the perpetrator)
were
reported to police (Planty et al., 2013).
Relatively few studies have investigated post-SV help-seeking
characteristics
and correlates specifically among African American women SV
survivors
(Zinzow, Resnick, Barr, Danielson, & Kilpatrick, 2012). A
small number of
researchers have focused on increasing the attention in the
literature on what
Bryant-Davis and colleagues (2011) called the “cultural context
of sexual
assault recovery” (p. 1602). For example, Flicker et al. (2011)
investigated
the differential impact of concomitant forms of violence (sexual

violence,
stalking, and psychological aggression) and ethnicity on help-
seeking behaviors
of female partner abuse survivors. The authors found racial
differences
related to specific help-seeking behaviors. For example, African
American
women survivors were more likely to seek police help and
orders of protection
compared to White women, which appears to be consistent with
other
findings (Bachman & Coker, 1995; Lipsky, Caetano, & Roy-
Byrne, 2009;
Pearlman, Zierler, Gjelsvik, & Verhoek-Oftedahl, 2003). Yet,
Kothari et al.
(2012) found, in a sample of women survivors of partner
violence (including
SV) for which the police were involved, that African American
women
survivors were less likely to obtain protective orders than White
women
survivors. Such inconsistencies suggest the influence of
contextual and cultural
factors on the help-seeking behaviors of women survivors
(Bent-
Goodley, 2007; Boykins et al., 2010).
In terms of contextual factors, the nature of the rape experience
seems to
matter. Boykins and colleagues (2010) found that Black women
SV survivors
were more likely to have reported weapons used in their
assaults and use of
illicit drugs when compared to White women survivors. The
context of the
rape incident and experience could affect African American
women survivors’

propensity to seek help from the emergency department as a
primary
source of care for this population (Boykins et al., 2010; Koss et
al., 1991) over
other types of help sources, as well as the experience of
weapon-inflicted
injuries requiring such specific care.
Similarly, cultural factors and values can also influence help-
seeking.
Culturally preferred sources of help, for example, for African
American
235
women generally come from informal support networks of
family and
friends, and faith-based resources and activities instead of more
formal
help sources such as mental health counseling (Bent-Goodley &
Fowler,
2006; Bryant-Davis et al., 2011; Henning & Klesges, 2002).
Taken together,
more information is needed to better understand the
victimization experiences,
related risks, and help-seeking characteristics (i.e., types of
services
sought and obtained) for African American women SV
survivors.
This study
The purpose of this study is to share findings from a community
sample of
African American women about their rape and sexual coercion
victimization
and its association with numerous negative mental and physical
health
indicators as well as health-related behaviors. This study also
builds on

previous studies that have addressed SV-related health risks in
this population.
Findings from this study provide an in-depth examination of the
health
burden associated with penetrative forms of SV victimization
among a racial
and ethnic group of women for which little information is
available on
health-related associations.
Methods
Participants
For this study, 168 African American women completed a face-
to-face
paper-and-pencil interview. Eligibility requirements for this
study were
being female, English-speaking, African American, and 18 years
or older.
Descriptive analyses were conducted using the full sample. The
women’s
ages ranged from 18 to 93 years old, with an average age of 48.
Forty-two
percent (42.4%) of the sample was never married. Sixty-eight
percent
(68.3%) completed high school or greater. The women’s total
household
incomes varied, but tended to be low: 29.1% of participants
reported an
annual income of less than $5,000; 12.7% reported an annual
income of
$5,000 to $9,999; 12.1% reported annual income of $10,000 to
$14,999,
17.6% reported earning between $15,000 and $24,999, 16.4%
reported
annual income of $25,000 to $49,999, and 12.1% reported
earnings of
$50,000 or greater.

Procedures
To ensure that interview questions were clearly interpreted and
the instrument
was culturally appropriate, a pilot test of an African American
sample
of women was conducted and the instrument was fine-tuned. To
locate
African American women to complete the main study
interviews, African
American urban neighborhoods in a Southeastern U.S. city and
addresses
within those neighborhoods were randomly chosen and
interviewers went
to those addresses to determine whether eligible women lived
there. A total
of 322 women were screened for eligibility for the study, and
219 women
were deemed eligible. Of them, 168 women were interviewed
for a completion
rate of 76.7%. Potential participants were initially told that the
study
was about women’s health and well-being. As a safety
precaution, interviewers
were instructed to reveal the specific nature of the survey—
sexual
violence—only to the selected participant in a safe, private
location.
Interviews were conducted between May and July 2010. The
interviews
were conducted in person in a private location (most often at the
participant’s
home) and lasted from 20 minutes to 2 hours, depending on the
participant’s experiences with SV. All women in the study
received $20 as a
token of appreciation. Interviewers read the questions and

response options
to participants or showed them a card with a list of the response
options
pertaining to the question being asked.
Measures
Participants were asked a range of questions about their health
and SV
victimization, including rape and sexual coercion. For all items,
responses
of “don’t know” were recoded as missing.
History and tactics of SV
To determine their history of SV victimization, women were
asked how
many times in their life they experienced a form of completed
or attempted
sex (vaginal, anal, or oral) that was unwanted. Rape items
consisted of
completed or attempted sex after a perpetrator used physical
force or
threats of physical harm; gave the victim drugs or alcohol; or
when the
sex occurred when the victim was passed out, asleep, drunk, or
high (and
unable to provide consent to sex). Sexual coercion items
consisted of
completed sex after a perpetrator did any of the following: told
lies, made
false promises about the future, or threatened to end a
relationship or
spread rumors; wore down the victim by repeatedly asking for
sex; or
used his or her influence or authority to make the victim engage
in
unwanted sex.
For all SV items, response options were never, 1 time, 2 to 5
times, 6 to 10

times, and more than 10 times. Responses were recoded into
dichotomous
responses to indicate whether the respondent was ever
victimized: 0 = never;
1 = 1 time, 2 to 5 times, 6 to 10 times, or more than 10 times.
237
Negative health behaviors and financial concerns
Alcohol and drug use. All participants were asked (a) how often
they
engaged in binge drinking and (b) how often they used illegal
drugs or
misused prescription drugs in the past 12 months. Response
options for
each question were 0 = never, 1 = less than monthly, 1 =
monthly,
2 = weekly, 3 = daily or almost daily and recoded into 1 = yes,
any use
and 0 = no use.
Food and housing insecurity. All participants were asked
questions
regarding how often they were worried or stressed about (a)
their ability to
pay their rent or mortgage, and (b) to buy nutritious meals
during the
previous 12 months. Response options for each question were
always,
usually, sometimes, rarely, never, or don’t know and recoded
into 1 = yes,
any worry and 0 = no worry.
Lifetime mental health conditions
Depression and suicidality. Participants were asked to indicate
whether
they ever felt sad, down, or hopeless almost every day for 2
weeks or more,
had little interest or pleasure in doing things almost every day

for 2 weeks or
more, seriously considered attempting suicide, or actually
attempted suicide.
Response options were coded dichotomously: 1 = yes, 0 = no.
PTSD. Participants were asked to indicate whether they ever
had an
experience that was so frightening, horrible, or upsetting that
for at least
1 month they had nightmares about it or thought about it when
they did not
want to; tried hard not to think about it or went out of their way
to avoid
situations that reminded them of it; were constantly on guard,
watchful, or
easily startled; or felt numb or distant from others, activities, or
their
surroundings. Response options were coded dichotomously: 1 =
yes, 0 = no.
First unwanted sexual experience was rape or sexual coercion
Among participants who endorsed any item of rape or sexual
coercion
during their lifetime, we focused on those victims whose first
unwanted
sexual experience was rape or sexual coercion. Several
variables were analyzed
for this subset.
Age of victim. Age at first rape or sexual coercion was
measured using the
following response options: 12 or younger, 13 to 17, 18 to 29,
30 to 44, 45 to
59, 60 to 64, 65 or older, and don’t know.
Age of perpetrator. Age of the perpetrator during the victim’s
first rape or
sexual coercion was measured using the following response
options: 12 or

younger, 13 to 17, 18 to 29, 30 to 44, 45 to 59, 60 to 64, 65 or
older, and don’t
know.
Type of perpetrator. Participants were asked to indicate how
they knew
the perpetrator. Four types of perpetrators were used to
categorize responses:
(a) intimate partner: current or former boyfriend, girlfriend,
romantic partner,
or significant other; current or former legal spouse, including
common
law; or someone they were dating but who they would not label
as a
boyfriend or girlfriend; (b) friend/acquaintance: friend;
acquaintance; someone
they were on a first date with; someone in a position of power
or trust
(e.g., employer, teacher, clergy, police officer); or someone else
they knew; (c)
family member; and (d) stranger.
Physical health conditions and services related to their first
unwanted sexual
experience which resulted in rape or sexual coercion
Injury. Participants were asked to indicate whether they
experienced
injuries from the rape or sexual coercion that resulted from their
first
unwanted sexual experience. Participants were specifically
asked whether
they experienced minor bruises or scratches; cuts, major
bruises, or black
eyes; broken bones or teeth; being knocked out after getting hit,
slammed
against something, or choked; or other injuries. Response
options for each
type of injury were coded dichotomously: 1 = yes, 0 = no.

STD/HIV. In separate questions, participants were asked to
indicate
whether they contracted a sexually transmitted disease or
whether they
contracted HIV from the rape or sexual coercion that resulted
from their
first unwanted sexual experience. Response options were coded
dichotomously:
1 = yes, 0 = no.
Pregnancy and outcome of pregnancy. Participants were asked
to indicate
whether (yes–no) they got pregnant from the rape or sexual
coercion that
resulted from their first unwanted sexual experience. If they
answered yes,
they were asked what happened to the pregnancy. Response
options were
birthed and kept the baby, birthed the baby and placed him or
her for
adoption, had a miscarriage, had an abortion, or don’t know. In
addition,
participants were asked whether they lost an existing pregnancy
as a result of
their first experience of rape or sexual coercion; response
options were coded
dichotomously: 1 = yes, 0 = no.
Rape kit exam. Participants were asked to indicate whether they
underwent
a rape kit exam after the rape or sexual coercion that resulted
from their
first unwanted sexual experience: Did a doctor or nurse take any
physical
239
evidence from you (for example, samples of bodily fluid for a
“rape kit”)?

Response options were coded dichotomously: 1 = yes, 0 = no.
Medical services, care, and hospitalization. Participants were
asked to
indicate whether they needed medical care from a doctor or
nurse due to
the rape or sexual coercion that resulted from their first
unwanted sexual
experience. If they indicated yes, then they were asked if they
were able to get
the medical care they needed. In addition, participants were
asked to indicate
whether they have to stay at a hospital or get other inpatient
medical care as a
result of their experience of rape or sexual coercion. Response
options for all
questions were coded dichotomously: 1 = yes, 0 = no.
Mental health services. Participants were asked to indicate
whether they
needed mental health care from a therapist, counselor, or other
mental health
care provider due to the rape or sexual coercion that resulted
from their first
unwanted sexual experience. If they indicated yes, then they
were asked if
they were able to get the mental health services they needed.
Response
options for all questions were coded dichotomously: 1 = yes, 0
= no.
Other services. Participants were asked to indicate whether they
needed
housing services, community services, victim’s advocate
services, and
whether someone contacted the police due to the rape or sexual
coercion
that resulted from their first unwanted sexual experience.
Response options

were coded dichotomously: 1 = yes, 0 = no.
Other consequences of the first unwanted sexual experience
which was rape
or sexual coercion
Participants were asked to indicate whether they felt safe in the
neighborhood
where they lived, whether they missed work, whether they
stayed with
family members or friends, and whether they relocated from the
area in
which they lived due to the rape or sexual coercion that resulted
from their
first unwanted sexual experience. Response options were coded
dichotomously:
1 = yes, 0 = no.
Analyses
First, we conducted descriptive analyses to verify racial
identification. Three
participants were removed from the analysis sample because
they did not
identify as African American, bringing the final sample to 165.
Next, we
conducted analyses to determine the percentage of women from
this community
sample who experienced rape, sexual coercion, or both in their
lifetime. Next, we performed chi-square analyses to test for a
relationship
among mental health experiences, alcohol and drug use, and
financial
concerns and lifetime rape or sexual coercion victim status.
Second, we
examined more closely the use of alcohol and drugs, and
financial concerns
among lifetime victims of rape or sexual coercion. Finally, we
provide

descriptive statistics regarding the characteristics and outcomes
of women’s
first unwanted sexual experience that was rape or sexual
coercion.
Results
Lifetime experiences of rape or sexual coercion in full sample
In the full sample, over half of participants indicated they were
victims of
rape, sexual coercion, or both. More specifically, 53.7% of
women reported
rape victimization and 44.8% reported sexual coercion in their
lifetime.
About 42% (42.3%) of the full sample experienced both rape
and sexual
coercion in their lifetime.
Mental health experiences
Overall, 63.8% of the full sample experienced at least one
symptom of PTSD,
and 50.0% experienced at least one symptom of depression
during their lifetime.
Chi-square tests were performed, which revealed statistically
significant
relationships between victimization status of lifetime
experience of rape or
sexual coercion and individual symptoms of PTSD and
depression (see
Table 1); lifetime experience of rape or sexual coercion and any
symptom of
PTSD, χ2(1, N = 163) = 13.7986, p = .001; and lifetime
experience of rape or
sexual coercion and any symptom of depression, χ2(1, N = 164)
= 22.2826,
p = .001.
In addition, 20.9% of women in the full sample seriously
considered
suicide during their lifetime; among those women, 88.2% also

had a history
Table 1. Lifetime Mental Health Experiences by Victim Status
of Rape or Sexual Coercion.
Participant has experienced
Victim Nonvictim Total
% n % n N Chi-square
PTSD symptoms (any) 67.31% 70 32.69% 34 104 13.7986*
Nightmares 72.41% 42 27.59% 16 58 9.3428**
Avoided situations that reminded her 68.67% 57 31.33% 26 83
9.7904**
Constantly on guard or easily startled 71.64% 48 28.36% 19 67
11.5359*
Felt numb or distant from others or activities 75.00% 45 25.00%
15 60 14.1523*
Depression symptoms (any) 74.39% 61 25.61% 21 82 22.2826*
Felt sad, down, or hopeless for 2 weeks or more 76.81% 53
23.19% 16 69 20.7523*
Little interest or pleasure in doing things for 2 weeks or
more
75.71% 53 24.29% 17 70 18.5358*
Note: Percentages represent proportion of victims or nonvictims
of rape or sexual coercion who endorsed
the mental health experience. PTSD = posttraumatic stress
disorder.
*p < .001. **p < .01.
241
of rape or sexual coercion in their lifetime. Among only the
women who
seriously considered suicide, 41.2% actually attempted suicide.
Among
women who both seriously considered and attempted suicide,
92.9% were
also victims of rape or sexual coercion in their lifetime.
Negative health behaviors and financial concerns in previous 12
months

Food and housing insecurity
In the full sample, 55.2% and 73.9% of participants indicated
that they
worried about their ability to buy nutritious meals and pay their
rent or
mortgage during the past 12 months, respectively. Chi-square
tests revealed
significant relationships between rape or sexual coercion
victimization
status and both food and housing insecurity: 66.3% of victims
and 40.3%
of nonvictims were concerned about their ability to buy
nutritious meals
during the previous year, χ2(1, N = 164) = 11.0490, p = .001. In
addition, the
chi-square analysis indicated that 81.5% of victims and 63.9%
of nonvictims
worried about their ability to pay their rent or mortgage during
the
previous year, χ2(1, N = 164) = 6.4917, p = .011.
Alcohol and drug use
In the full sample, 42.9% and 14.0% of participants engaged in
binge
drinking and illegal drug use or prescription drug misuse during
the past
12 months, respectively. A chi-square test revealed a significant
association
between rape or sexual coercion victimization status and binge
drinking in
the past 12 months: 49.5% of victims and 33.8% of nonvictims
engaged in
binge drinking during the previous 12 months, χ2(1, N = 162) =
3.9938,
p = .046. Chi-square tests were not performed on drug use due
to low cell
sizes.

Experiences among victims of lifetime rape or sexual coercion
In this section the findings presented are among lifetime victims
of rape or
sexual coercion only (n = 92).
Negative health behaviors and financial concerns in previous 12
months
among lifetime victims of rape or sexual coercion
Alcohol and drug use. Among lifetime victims of rape or sexual
coercion,
a total of 49.5% indicated that they engaged in binge drinking
(i.e., drank 4 or
more alcoholic beverages on one occasion) at some point in the
previous
12 months on a monthly, weekly, or daily basis. Additionally,
10.9% reported
that they engaged in illegal drug use/prescription drug misuse
on a daily or
almost daily basis in the last 12 months (see Figure 1).
Food and housing insecurity. Among lifetime victims of rape or
sexual
coercion, 81.5% were concerned about paying their rent or
mortgage, and
66.3% were concerned about their ability to pay for nutritious
meals during
the previous 12 months (see Figure 2).
Characteristics of victims whose first unwanted sexual
experience was rape
or sexual coercion
Victims were asked a series of questions about their first
unwanted sexual
experience, such as their age when it happened and the person
who victimized
them. Here, we focus on those whose first unwanted sexual
experience
was rape or sexual coercion (n = 80).

Of the 80 women who reported that rape or sexual coercion
occurred
during their first unwanted sexual experience, 73.4% (n = 58)
reported that
0%
10%
20%
30%
40%
50%
60%
70%
Never Sometimes or
rarely
Always or usually
Rent
Meals
Figure 2. Financial concerns among lifetime victims of rape or
sexual coercion, previous 12
months (N = 92).
0%
10%
20%
30%
40%
50%
60%
70%
80%
Never Monthly or less Weekly Daily or almost
daily
Binge drinking
Drug use
Figure 1. Alcohol and drug use among lifetime victims of rape
or sexual coercion, previous 12
months (N = 92).

243
the violence occurred when they were under the age of 18. In
Figure 3 we
present the women’s ages at their first unwanted sexual
experience resulting
in rape or sexual coercion.
Age and type of perpetrator. Among the women who reported a
rape or
sexual coercion as their first unwanted sexual experience,
perpetrators were
male (98.8%), the same race (96.3%), and known (90.0%) to the
women in
some capacity. We examined the victims’ age and type of
perpetrator
during their first unwanted sexual experience resulting in rape
or sexual
coercion. Among victims who were 12 and younger,
perpetrators were
mostly friends or acquaintances (46.2%) or family members
(42.3%). Of
victims who were 13 to 17, perpetrators were mostly friends or
acquaintances
(53.1%) or intimate partners (28.1%). Among those who were
18 to
29, perpetrators were mostly intimate partners (47.1%) or
friends or
acquaintances (41.2%). Finally, among victims who were 30 to
44, perpetrators
were split between intimate partners (50.0%) and friends or
acquaintances (50.0%). See Table 2.
Consequences experienced by women whose first unwanted
sexual
experience resulted in rape or sexual coercion
Physical health outcomes. Among women whose first unwanted
sexual

experience resulted in rape or sexual coercion, 39.7% of victims
suffered
injuries (ranging from minor cuts to being knocked out).
Approximately 4%
(3.8%) and 8% (7.8%) reported contracting HIV or a sexually
transmitted
disease, respectively. In addition, 17.9% of victims became
pregnant as a
result of this experience (see Table 3).
32.9%
40.5%
21.5%
5.1%
12 & younger
13-17
18-29
30-44
Figure 3. Age at victim’s first unwanted sexual experience:
Victims of rape or sexual coercion
(N = 79). One participant was excluded because she could not
recall her age at the time of her
first unwanted sexual experience.
Table 3. Consequences of First Unwanted Sexual Experience
(Rape or Sexual Coercion).
Yes No
Consequences % n % n
Physical
Injured 39.7% 31 60.3% 47
Minor bruises or scratches 93.6% 29 6.4% 2
Cuts, major bruises or black eyes, knocked out 40.0% 12 60.0%
18
Contracted HIV 3.8% 3 96.2% 76
Contracted a sexually transmitted disease 7.8% 6 92.2% 71
Lost existing pregnancy 3.0% 2 97.0% 65
Became pregnant 17.9% 12 82.1% 55

Birthed and kept the baby 58.3% 7 41.7% 5
Miscarriage 25.0% 3 75.0% 9
Abortion 16.7% 2 83.3% 10
Services
Needed medical services 35.1% 27 64.9% 50
Able to get medical services 55.6% 15 44.4% 12
Hospital stay 5.1% 4 94.9% 74
Rape kit exam was performed 15.4% 12 84.6% 66
Needed mental health services 36.2% 29 63.8% 51
Able to get mental health services 51.7% 15 48.3% 14
Needed community services 13.9% 11 86.1% 68
Needed housing services 12.8% 10 87.2% 68
Needed victim advocacy services 12.8% 10 87.2% 68
Police were contacted 26.3% 21 73.7% 59
Daily life
Stayed with family or friends afterward 38.0% 30 62.0% 49
Relocated or changed residence afterward 32.5% 26 67.5% 54
Missed work afterward 6.3% 5 93.7% 75
Felt unsafe in neighborhood afterward 42.3% 33 57.7% 45
Table 2. Victim Age and Perpetrator Type Among Those Whose
First Unwanted Sexual
Experience was Rape or Sexual Coercion.
Intimate
partner Family
Friend or
acquaintance Stranger
n % n % n % n % Total N
12 and younger 1 3.9 11 42.3 12 46.2 2 7.7 26
13–17 9 28.1 2 6.3 17 53.1 4 12.5 32
18–29 8 47.1 0 0.0 7 41.2 2 11.8 17
30–44 2 50.0 0 0.0 2 50.0 0 0.0 4
Note: N = 79. One participant was excluded because she could
not recall her age at the time of her first
unwanted sexual experience.
245

Services sought and obtained. The women whose first unwanted
sexual
experience resulted in rape or sexual coercion sought a variety
of services,
including medical care, mental health care, community services,
housing,
victim advocacy, and police assistance. Findings revealed that
35.1% of
victims needed medical services, and of them, 55.6% were able
to obtain
those services; 15.4% of all victims underwent a rape kit exam.
Over one
quarter of victims (26.3%) stated that the police were contacted
after the
incident. Moreover, 36.2% reported that they needed mental
health services,
and about half (51.7%) of those were able to obtain them.
Approximately
13% to 14% needed services provided by the community
(13.9%), housing
(12.8%), or victim advocacy (12.8%; see Table 3).
Other consequences. Women whose first unwanted sexual
experience
resulted in rape or sexual coercion were asked about other
consequences
that affected their daily lives after this first unwanted
experience. About 6%
(6.3%) of victims missed work because of the incident.
Additionally, 42.3%
stated that they felt unsafe in their neighborhood afterward.
Thirty-eight
percent of victims reported that they stayed with family or
friends, and 32.5%
decided to relocate or move from their residence.
Discussion
African American women are victims of SV at high rates, as

consistently
evidenced by previous national prevalence studies (Black et al.,
2011;
Breiding et al., 2014; Tjaden & Thoennes, 1998). There is less
information
available about the health associations linked to SV
victimization for African
American women in particular. Understanding the physical and
mental
health correlates and impact of SV among specific segments of
the population
at high risk (i.e., African American women) is important to (a)
better
contextualize the SV victimization experience, and (b) help
inform and tailor
prevention efforts. Although the focus of this study is on a
relatively small
community sample that is not representative of all African
American women
in the United States, this sample is important because it
provides a fuller
picture of the context and circumstances around SV
victimization of a highrisk
urban sample of women. The findings help to highlight the high
prevalence
of SV victimization and its health consequences for some racial
and
ethnic minority women.
Findings from this study reveal a high prevalence of rape and
sexual
coercion victimization among this community sample of African
American
women (53.7% experienced rape and 44.8% experienced sexual
coercion at
some point in their lives). These prevalence estimates are higher
than previous

national survey estimates (Black et al., 2011; Breiding et al.,
2014;
Tjaden & Thoennes, 1998), but are consistent with other
community-based
studies of African American women (Bryant-Davis et al., 2010;
Kalichman
et al., 1998). In addition, the face-to-face nature of data
collection in this
study could have also increased disclosure (Tillman, Bryant-
Davis, Smith, &
Marks, 2010). Results reveal that mental health conditions,
alcohol use, and
financial concerns are associated with previous SV
victimization. For example,
being a victim of rape or sexual coercion was associated with
endorsing
at least one PTSD symptom and symptoms of depression in their
lifetime. In
other findings, a high percentage of lifetime victims of rape or
sexual coercion
engaged in binge drinking during the previous year, and over
10%
reported that they abused prescription drugs or used illegal
drugs on a
daily or almost daily basis in the last 12 months.
Of those whose first unwanted sexual experience resulted in
rape or sexual
coercion, the majority of victims were younger than 18 years of
age, were the
same race as their perpetrator, and knew their perpetrators
(intimate partners,
family members, or acquaintances) at the time of their assault.
These
findings are consistent with results from previous studies of
African

American women (Avegno, Mills, & Mills, 2009; Weist et al.,
2007). The
consequences experienced by victims whose first unwanted
sexual experience
resulted in rape or sexual coercion (e.g., physical consequences,
service needs,
and impacts on daily living) are consistent with previous
literature (Avegno
et al., 2009; Weist et al., 2007). Regarding the impact of rape or
sexual
coercion on a victim’s daily life, many women no longer felt
safe in their
neighborhood as a result of their assault. Others chose to stay
with family or
friends after their attack and some chose to relocate or change
residence
afterward. These findings are consistent with the work of
Frazier and colleagues,
who found in their study of 171 sexual assault survivors that
after their
assault women believed their world was no longer safe and they
held negative
attitudes regarding fairness of life and goodness of people
(Frazier, Conlon, &
Glaser, 2001).
In addition, various services were needed and sought by victims
in this
sample whose first unwanted sexual experience was rape or
sexual coercion.
These included medical care, mental health care, community
services, housing,
victim advocacy services, and assistance from the police.
Approximately
one third of victims needed either medical or mental health
services.
However, only about half of those who required these services

were able to
obtain the help they needed. In addition, only one quarter of
victims whose
first unwanted sexual experience was rape or sexual coercion
contacted the
police after their experience. These findings suggest the
disinclination of
African American women to seek help from mental health
services
(Henning & Klesges, 2002; Snowden, 2001) and, in some cases,
from law
enforcement and the criminal justice system, which might
reflect a cultural
tendency among this population to distrust helping professionals
due to
historical mistreatment, and a lack of culturally competent
services (Flicker
247
et al., 2011; Raj et al., 1999; Tillman et al., 2010). Compounded
by increased
exposure to SV, racial and structural inequities, including the
experience of
discrimination, might increase African American women
survivors’ risk for
poor outcomes.
These findings as a whole support previous research suggesting
the multiple
sociocultural hardships faced by African American women
might be
exacerbated by SV victimization or might, in some cases, lead
to SV victimization.
For example, the majority of the participants in our sample fell
below
the poverty threshold for a family of two adults without
children. In addition,

the majority of lifetime rape or sexual coercion victims
expressed they had
financial concerns within the 12 months prior to the survey and
they were
significantly more likely to have these concerns than
nonvictims. These
included concerns about being able to pay their rent or
mortgage and their
ability to afford healthy meals. Previous research has shown
that women are
at increased risk of victimization when their income is below
the poverty line,
and conversely, victimization increases women’s likelihood of
unemployment
and reduced income (Byrne et al., 1999). In 2010, 46.6% of
African American
female, single-parent households were impoverished
(Entmacher, Robbins, &
Vogtman, 2014). African Americans live at disproportionately
lower socioeconomic
levels with less access to resources than their White
counterparts
(DeNavas-Walt, Proctor, & Smith, 2013). The added burden of
traumatic SV
victimization for women living in poverty potentially
exacerbates the need
for multiple services and resources to address various
intersecting problems
(i.e., poverty, victimization, mental and physical health; Bryant-
Davis et al.,
2009).
This study is a contribution to the literature on the impact of SV
victimization
of African American women because it included many health
associations
and circumstances of the violence, which enabled a well-

rounded
picture of the SV experience. In addition, the measurement of
SV victimization
included in this study was very detailed, including numerous
tactics,
which likely improved disclosure. However, this study has some
limitations.
First, the sample is from an urban neighborhood in a
Southeastern U.S. city,
so the findings might not be generalizable to all African
American women.
Second, the sample is relatively small, which limited our ability
to conduct
more complex statistical testing. Also, the study only included
one racial and
ethnic group of women so it did not enable comparisons to other
groups. In
addition, the analyses conducted in this study only focused on
rape and
sexual coercion, and other types of SV such as unwanted sexual
contact are
not represented. The main SV variable used in this study
combined rape and
sexual coercion. Ideally, we would have examined rape
experiences and
sexual coercion victimization experiences separately so that we
could determine
if there were differences in the health associations linked to
these two
forms of sexual violence. However, the experiences of the
women in our
sample did not enable us to examine rape and sexual coercion
separately
because a relatively large subset of the women in our sample
experienced

both rape and sexual coercion.
Overall, the findings from this study have important
implications for
prevention, practice, and service response to African American
victims of
SV. Given the alarming numbers of women in this study who
experienced
rape and sexual coercion that caused injuries and other physical
and
mental health problems, primary prevention of SV has the
potential to
prevent numerous adverse health experiences and the costs
associated with
them. In addition, the high rates of adverse physical and mental
health
experiences among victims of SV in this sample suggest that
African
American women are in particular need of ongoing health-
related services,
whether or not they disclose their victimization status. Although
our
findings suggest a need for these types of services, only a little
more
than 50% of women in our sample were able to get the physical
and
mental health services they needed.
Some have suggested that African American women’s SV-
related health
risks, adverse conditions, and challenges with regard to seeking
services are
intricately linked to race or ethnicity and culture (Bent-
Goodley, 2007;
Boykins et al., 2010; Flicker et al., 2011; Tillman et al., 2010).
This study
supports prior research suggesting an association between SV
victimization

and numerous physical and mental health risks and behaviors.
More scholarship
in this area with representative samples of African American
women
and other racial and ethnic minority women are important to
inform prevention
practice. Larger and more representative samples are needed for
future research on the health associations linked to SV
victimization, and
to enable comparisons across different racial and ethnic groups.
Further, the
important connections among adverse health, SV, and cultural
differences
need further exploration to inform practice.
Acknowledgments
The findings and conclusions in this report are those of the
authors and do not necessarily
represent the official position of the Centers for Disease
Control and Prevention. The authors
acknowledge the passing of their coauthor, Dr. Merle E.
Hamburger, before this article was
completed. This article is dedicated to his memory for his
commitment and contributions to
youth violence and sexual violence research and prevention.
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