Symptom Responses to a Continuum of Sexual Trauma [Violence and Victims]

This study reports the findings of an anonymous web-based survey to test differences in symptom presentation (depression, anxiety, posttraumatic stress disorder [PTSD]) among women who experienced different types of sexual trauma (forcible, pressured, sex stress). The study used a descriptive cross-sectional design with an online convenience sample of 243 adult females living primarily in the United States. The findings revealed that there was a statistically significant difference among type of sexual trauma groups for depression (p = .013) and PTSD (p = .044) but not for anxiety (p = .183). Post hoc analysis of the overall difference in depression revealed that the multiple rape type group (p = .010) and the forcible sex group (p = .016) had higher levels of depression.

Keywords: sexual abuse; sexual trauma; type of rape; depression; anxiety; PTSD

Rape statistics in the United States and the percentage of victim trauma symptoms have a very wide range. Although estimates suggest between 302,000 and 2.7 million women in the United States are raped yearly (Basile, Chen, Black, & Saltzman, 2007; Tjaden & Thoennes, 2006), findings suggest that only 19% (Tjaden & Thoennes, 2006) to 47% (Catalano, Smith, Snyder, & Rand, 2009) of rapes are reported (Kilpatrick, Edmunds, & Seymour, 1992). Victims of rape typically suffer from depression, anxiety, and posttraumatic stress disorder (PTSD). These psychological sequelae are collectively known as rape trauma (RT). Estimates of post rape symptoms of adult women's depression range from 12% to 87% (Brook, 1976; Lawrence, Chau, & Lennon, 2004; Miller, 1979; Shipley, Butt, & Horwitz, 1979), anxiety range from 28% to 90% (Brook, 1976; Gorsuch & Spielberger, 1966; Miller, 1979; Pico-Alfonso et al., 2006; Winfield, George, Swartz, & Blazer, 1990), and from 50% to 95% for PTSD (Bownes, O'Gorman, & Sayers, 1991a; Breslau, Chilcoat, Kessler, & Davis, 1999; Breslau et al., 1998; Darves-Bornoz, 1997; Shipley et al., 1979).

The extreme variance in RT symptoms for depression, anxiety, and PTSD suggest that the testing of a heterogeneous victim group for symptom response is too diverse to be meaningful. The early work of Burgess and Holmstrom (1974b) conceptualized a sexual trauma typology based on the issue of consent as a way to study symptom response in a 1-year sample of persons who entered the emergency ward of Boston City Hospital with the complaint of having been raped. The sample consisted of 146 patients: 109 adult women between ages 19 and 73 years, 34 female children aged 17 years and younger, and 3 male children younger than age 13 years.

The 109 adult women were divided into three categories based on the issue of consent: (a) victims of forcible rape (either completed or attempted), (b) victims who were unable to consent because of their age or mental status and were pressured into sex, and (c) victims of sexually stressful sexual encounters to which they had initially consented but that went beyond their expectations and control.

The purpose of this study was to first classify the type of sexual trauma experienced using the Burgess and Holmstrom (1974b) typology and then to test for differences in symptom responses (depression, anxiety, and PTSD) among groups of women who had experienced the continuum of sexual trauma (forcible, pressured sex, sex stress) via an anonymous web-based survey.

METHOD

This study used a descriptive cross-sectional design testing a convenience sample of 243 adult female victims of rape drawn from a population of females aged 18-64 years in the United States and abroad. The age range was determined based on being legally categorized as an adult but not having yet attained the status of older adult as defined by Social Security Income (SSI), Medicare, Medicaid, and state-county special assistance programs (Medicare Beneficiaries, 2011; Population Division, 2012; Social Security, 2012). The subjects recruited into the study met the following inclusion criteria: (a) female between the ages of 18 and 64 years, (b) 5 years or younger since their most recent incident of rape, (c) ability to understand English, (d) no recent report of psychosis, and (e) the ability to complete study instruments.

Size of Sample

A sample size of 100 was required for the planned analyses and was determined based on a power analysis specifying a moderate effect size (r = .30) for the proposed relationships among study variables, power of .80, and a two-tailed alpha level of .05 (Cohen, Cohen, West, & Aiken, 2003; Faul, Erdfelder, Lang, & Buchner, 2007; Munro, 2005).

Subject Recruitment

The sample was recruited using e-mail messages sent out through ResearchMatch as part of an opt in list of individuals who had previously given their contact information for that purpose, as well as via the clinical trials registry maintained by Vanderbilt University. Responses went directly into the REDCap survey system, designed and maintained by Vanderbilt University. Additional recruiting methods included informative advertisements placed on national screening and support online websites, and in domestic violence shelters, rape crisis centers, offices of professional staffs, public venues such as college bulletin boards, social media sites such as Facebook, police departments, posting informative public service announcements on local radio channels, and direct marketing of the study online to organizations in which the principal investigator is affiliated. Others referred participants to the study based on flyers supplied to their organizations.

Permission to conduct the research study was obtained from the Vanderbilt University Institutional Review Board (IRB). Protection of subjects was achieved through informed consent, obtained from the subjects prior to administration of questionnaires and initiation of data gathering. A waiver of documentation of consent was sought and authorized to protect the identity of the subjects. This ensured that there is no way to link a participant to a particular response.

Procedures

Potential participants were screened online. Once an exclusion criterion was met, no other information was gathered. If deemed eligible, the subjects were provided with informed consent. After they read and acknowledged understanding by answering three questions covering material contained within the consent, the participant was allowed to proceed to access the study online. All information was collected via participant self-report. Participants were allowed to save responses made directly online and return to finish the survey at their convenience. If the participant elected to log offand log back on to complete the study packet, the first thing the participant saw was reiteration of the fact that nobody would be able to contact him or her for any reason. All data collected from participants was kept online.

Measures

Screening for incidence of rape/sexual trauma and type experienced was measured by a modified version of the Sexual Experience Survey-Short Form Victimization (SES-SFV; Koss et al., 2007; Koss & Gidycz, 1985). The SES-SFV is a self-reported 10-item scale that uses a frequency assessment format, developed to ascertain the continuum and number of occurrences of sexual violence from the most severe form (rape) to no victimization. Rape was classified as a positive response to SES-SFV items specific to use of force, threats of harm to victim or others close to her, and/or unable to stop the event resulting in oral, vaginal, and/or anal sex, respectively. Pressured sex was classified as positive responses to SES-SFV items specific to threats to spread rumors, end the relationship, making false promises, and/or continuous verbal pressure for sex. Because there was no specific measure for sex stress on this instrument, a separate question was developed from the typology of sexual trauma: Did your unwanted sexual experience begin with a situation where you initially gave consent, then changed your mind for any reason, verbalizing to the other person/persons involved that you wanted the act to stop (e.g., just decided you no longer wanted to have sex, once sex began it moved beyond your comfort level and you changed your mind). The SES is reported to yield an internal consistency (Cronbach's alpha) of 0.74 and a test-retest reliability of 93% when administrations are 1 week apart (Koss & Gidycz, 1985; Koss, Gidycz, & Wisniewski, 1987).

Psychological Outcomes. Three instruments were used to assess psychological outcomes after the incidence of sexual trauma in the proposed research study.

Depression: Beck Depression Inventory (BDI-II). The BDI-II is a 21-item self-report instrument intended to assess the existence and severity of symptoms of depression (Beck, Steer, Ball, & Ranieri, 1996). Each item consists of four self-evaluative statements asking respondents to rate their symptoms from the last 2 weeks on a 4-point scale for each item ranging from 0 to 3. Questions include items on various feelings (e.g., sadness, loss of pleasure, self-dislike, indecisiveness, fatigue). Included is a question specifically on suicidal thoughts or wishes. Cronbach's alpha in this study was .95.

Anxiety: State-Trait Anxiety Inventory Form Y (STAI-Y). The STAI-Y (Spielberger & Gorsuch, 1966) is a 40-item self-report questionnaire. The most recent version differentiates temporary or emotional state anxiety from long-standing personality trait anxiety in adults. The scale is written to be used with adults older than 18 years who can read at a sixth-grade level. Range of scores is 20-80, with higher scores indicative of higher anxiety. For the purposes of this study, only trait anxiety was measured. Although state anxiety refers to a more short-term state (e.g., response to a more immediate stressor), trait anxiety attempts to measure more of a personality characteristic (e.g., the stable tendency to respond with state anxiety as an anticipatory mechanism). Because the study aims to assess anxiety and its respective associations to other sequelae (e.g., depression, PTSD) after incidence of rape within a 5-year period, it is appropriate to measure only the more long standing trait-oriented form of anxiety. Based on norming of the instrument in various populations, our sample experienced a mean level of anxiety (M = 51.3, SD = 13.73, range 23-79) that was higher than those found in a sample of general medical/surgical patients with a history of psychiatric complaints (n = 34, M = 44.6). Cronbach's alpha for this study was .95.

Posttraumatic Stress Disorder: Posttraumatic Stress Diagnostic Scale. The posttraumatic stress diagnostic scale (PDS; Foa, Cashman, Jaycox, & Perry, 1997) is a 49-item instrument that assesses all six Diagnostic and Statistical Manual of Mental Disorder, Fourth Edition (DSM-IV-TR) criteria for PTSD and is designed to aid in the detection and diagnosis of PTSD. The PDS uses the DSM-IV diagnostic criteria for PTSD and may be administered repeatedly over time to help monitor changes in symptoms. This instrument is designed to be used with adults aged 18-65 years and is written at an eighth-grade reading level. The normative base of this instrument is diverse and, thus, offers an advantage over other PTSD instruments that have been normed primarily on men suffering from combatrelated trauma. Initial norming was done with a group of 248 men and women between the ages of 18 and 65 years who had experienced a traumatic event at least 1 month before they took the test. The diversity of the sample was represented by individuals in women's shelters, PTSD treatment clinics, Veterans Affairs (VA) hospitals, and with staffof fire stations and ambulance corps. High internal consistency, good test-retest reliability, and good validity have been reported (Foa, 1997; Foa, Ehlers, Clark, Tolin, & Orsillo, 1999). Another more recent study compared the PDS to the Clinician Administered PTSD Scale (CAPS) in a sample of 138 women who were victims of domestic violence. Findings confirmed a high rate of PTSD in the sample with both instruments (Griffin, Uhlmansiek, Resick, & Mechanic, 2004).

RESULTS

There were 384 adult females who completed the study consent form and at least some portion of the study. Of those, 243 (63%) completed all of the study instruments sufficiently for inclusion in the analysis of the research questions. There were no statistically significant differences between the completers and noncompleters on any demographic factor.

The final convenience sample of participants included in this study (N = 243) ranged from 18 to 56 years of age with a median age of 27 years (25th-75th interquartile range [IQR]: 23.8-33.3). Multivariate analysis of variance (MANOVA) was used to test for differences in depression and anxiety among the three groups and the chi-square test of independence was used to test for those same differences among the distributions of PTSD.

Summaries of the depression and anxiety values (Table 1) as well as prevalence of PTSD for each type of trauma group are presented (Table 2). Findings revealed that there was a statistically significant difference among type of sexual trauma groups for depression (p = .013) but not for anxiety (p = .183). Post hoc analysis of the overall difference in depression revealed that the multiple rape type group (p = .010) and the forcible sex group (p = .016) had higher levels of depression than did the group experiencing sex stress.

There was also a statistically significant difference among the type of sexual trauma groups in the rates of PTSD (Likelihood chi-square p = .044). As displayed in Table 2, within the groups reporting forcible and multiple types of trauma, the distribution of those who did and did not meet the PTSD criteria were very similar. However, within the other types of trauma groups (pressured and sex stress), the rates meeting PTSD criteria were considerably less than the rate not meeting the criteria. Among those with PTSD, there were no statistically significant differences among the type of sexual trauma group for delayed onset (p = .767), symptom duration (p = .758), severity score (p = .160), or level of impairment (p = .812).

Sample Profile

This study profile of 243 adult women with a self-reported history of unwanted sexual experience(s) within the past 5 years identified characteristics similar to those of previous reported studies with a few unique differences. The mean age was 30.11 years, similar to the studies by Valentiner, Foa, Riggs, and Gershuny (1996) and Meadows, Kaslow, Thompson, and Jurkovic (2005) but higher than most other previous studies specific to rape and sexual abuse (Borja, Callahan, & Long, 2006; Bownes, O'Gorman, & Sayers, 1991b; Brown, Testa, & Messman-Moore, 2009; Clum, Calhoun, & Kimerling, 2000). The exceptions were the study by Basile, Arias, Desai, and Thompson (2004) in which multiple forms of abuse were examined relative to intimate partners and PTSD only (mean age is 39.6 years), and Bengtsson-Tops and Tops (2007) in which overall abuse in females seeking psychiatric services was examined (mean age is 39.0 years). Most participants in this study were single or not partnered (76.0%) and White (90%), a finding consistent with the latest 2010 American Community Survey (ACS) demographic and housing estimates set forth by the U.S. Census Bureau, related to race (current population is 50.8% female, 74.2% White), as well as previous studies in this populations (Clum et al., 2000; Fairbrother & Rachman, 2006) and similar to marital status, with slightly more than 50.0% of the U.S. female population (50.5%) reporting they are single (Amstadter, McCauley, Ruggiero, Resnick, & Kilpatrick, 2008; U.S. Census Bureau, Population Division, 2010). Unlike most studies on rape to date, this study recruited participants throughout the United States (91.0%) as well as abroad (9.0%) to analyze in the same study. Participants lived in all regions of the United States; Northeast (n = 41, 17.0%), Southeast (n = 18, 8.0%), Midwest (n = 40, 17.0%), South (n = 97, 41.0%), and West (n = 20, 9.0%). Outreach was also done to several countries, resulting in (n = 20) 9% of the sample.

Although most sample was well educated, and reported having at least a bachelor's (n = 100, 41.0%) or master's degree (n = 54, 23.0%), they were less affluent, with 70% of the sample reporting incomes of $60,000 or less (range from <$25,000 to >$100,000). These findings are similar to the study by Stein et al. (2004) but higher than the percentages reported in the current U.S. Census data (17.7% with a bachelor's degree; 10.4% with a graduate degree). Thus, the participants in this study appear to be more highly educated than those in the general population as well as in other studies (Meadows et al., 2005). This study evaluated income using slightly different cutoffs than those found in the U.S. Census report, however, income data appears to be proportionally equivalent, with 50.0% of participants in the 2010 U.S. Census reporting incomes of #$50,000 per year. Mean income figures reported in this study were similar to those of other studies (Amstadter et al., 2008; Masho & Ahmed, 2007). Any distinct variability is likely because many studies in this population have been done with college students (Clum et al., 2000) who, on average, earn less than those who are older and/or working full time.

Most sample in this study (n = 171, 71.0%) reported having no children, which is consistent with current U.S. population estimates, that 33.1% of households currently have one or more persons younger than age 18 years in the household. There were slightly more participants in this study who reported having nongovernmental health insurance (Point of Service [POS], Preferred Provider Organization [PPO], Health Maintenance Organization [HMO]; n = 143, 59.0%) than those having insurance that was government subsidized (Medicaid, Medicare, MediCal; n = 99, 41.0%). Although the trend is similar, participants in this study were more equally distributed in relation to the type of coverage than individuals in the general population (65.8% with private coverage, 29.7% with government-subsidized insurance). This finding is probably because of the =65-years-old inclusion criteria.

DISCUSSION

Symptom science, a critical research domain for nursing, was the focus of this study. The finding of no differences in respondents with PTSD over a 5-year period relative to delayed onset, symptom duration, or severity of symptoms suggests the permanency of the trauma narrative that it is encoded and stored in memory. Zinzow et al. (2010) also found in their sample of 2,000 college women that forcible rape, but not incapacitated rape or drug-alcohol facilitated rape, was positively associated with remembering the event well over time. Research on the psychobiology of trauma speaks to the memory dynamics of RT (Gaffney, 2011).

To the best of our knowledge, this was the first reported study that attempted to examine whether differences existed relative to a continuum of sexual trauma symptom response (depression, anxiety, PTSD) based on the type of sexual injury experienced, a model conceived by Burgess and Holmstrom (1974a, 1974b). The wide range of posttrauma symptoms reported in rape victimology research suggests that self-report tests are either not capturing the most distressing symptoms or the typology of RT is too inclusive. Burgess and Holmstrom used a hypothesis generating methodology in 1972 where after interviewing their sample, they personally did telephone follow-up for a year to document symptomatology. It became clear early in their research that the outcome symptom response of the rape incident differed significantly and thus designed the classification of a typology of sexual trauma based on the issue of consent. However, rape research on adult victims from the 1980s to current have not classified the type of sexual trauma but focused more on measuring symptoms based on rape dynamics.

In addition to the findings highlighted earlier, this study further identified a fourth category of sexual trauma; now classified as multiple rape type. Some participants acknowledged, for example, pressured oral sex and forcible vaginal rape in the same incident. This group had increased PTSD and depression.

Our study identified that although anxiety was not statistically significantly different among the groups experiencing the different types of sexual trauma (p = .183), both depression (p = .013), and PTSD (p = .044) were. This pattern is consistent with findings from the rape tactics classification study by Zinzow et al. (2010), which found that all three categories examined (forcible rape, incapacitated rape, drug or alcohol intoxication) were associated with increased risk of PTSD and depression. Our findings relative to overall depression and PTSD are consistent with findings from other studies that attempted to study comorbid sequelae in victims of rape (Lipsky, Field, Caetano, & Larkin, 2005; O'Campo et al., 2006; Stein et al., 2004). However, because anxiety and PTSD are related, it is somewhat surprising that there was no difference related to trait anxiety between the groups. Because our study only measured trait anxiety and unwanted sexual experiences within the past 5 years, it is possible that participants either do not suffer from a more long standing generalized overall anxiety or that there were historical differences relative to the nature and number of events that could be characterized as traumatic prior to the rape event-a concept beyond the scope of this study. These findings do, however, agree with a study by Stein and Kennedy (2001) examining comorbid depression and PTSD in female victims of interpersonal violence in that PTSD and depression were found to be the most common disorders and that generalized anxiety (lifetime) was the least common.

Respondents who experienced sex stress had less depression and PTSD than the other groups; however, the small sample size for the sex stress subgroup requires caution in interpreting these findings. This finding is not unexpected because those who experience sex stress initially gave their consent for the sexual interaction, and then something went wrong in the interaction. One hypothesis could be that although there was an initial willingness on the part of the victim for the contact, the sexual injury would be viewed as less distressing than for those who had never given consent to the interaction.

Finally, additional analyses from the measure of PTSD found no significant differences among the groups relative to delayed onset, symptom duration, or severity of PTSD symptoms. These findings agree with those by Borja et al. (2006) who found PTSD to be significantly associated only with the number of assaults. However, it should be noted that the Borja et al. study only examined acquaintance assault, and these findings differ with findings by Ullman, Filipas, Townsend, and Starzynski (2007) who found that delayed disclosure was related to more severe PTSD symptoms. Ullman and colleagues acknowledge that this finding may be caused by the overall issue of disclosure or other risk factors for PTSD (e.g., social support). Our study findings support that PTSD in groups resulting from one or more incidents of rape is a significant issue requiring intervention, and that issues specifically related to disclosure and PTSD warrant further exploration.

Limitations of the Study

There are several factors that limit our ability to suggest any causal linkages between symptom responses and sexual trauma typology including a cross-sectional design and a nonrandom convenience sample of adult participants who self-reported one or more incidents of rape within the past 5 years. Also, the measure of PTSD was distinctly different than the measures of depression and anxiety; PTSD was either a yes or a no, and depression and anxiety were ranked based on diagnostic cut-offscores. Finally, other confounding factors may exist. Retrospective self-report methodology may include recall and reporting bias and the use of an online survey excluded women who did not have access to the Internet. Also, because many participants reported that they had multiple rape incidents, it is unknown if this incident was actually the one participants referred to when answering the questionnaires. Furthermore, there were no controls put in place for those who had more than one incident of rape or for those who may have experienced other traumatic events. Despite these limitations, this study advances symptom science by type of sexual trauma to help direct resources and interventions.

Recommendations for Future Research

&lt;p>This study used a contemporary methodology of online anonymous surveys and classified the type of sexual trauma to highlight the importance of viewing victim responses years following a sexual trauma on a continuum of sexual injury. The finding that multiple incidents over a 5-year period produce an increase in symptomatology is not surprising and signals the need for further victimology research on symptom science of repeated sexually traumatic incidents. Although quantitative research methodology has advanced in major ways over the past 40 years, attention still needs to be given to traditional qualitative methods that produce spontaneous commentary about survivors' long-term issues following sexual trauma.

Future studies should attempt to obtain a more racially and gender diverse sample, and include lifetime experiences, controlling for time since the most recent experience. Longitudinal research will facilitate prediction of outcomes over time, which could contribute to clinicians' ability to classify the type of sexual injury and personalize intervention approaches aimed at addressing the depression and posttraumatic injury psychological sequelae associated with a sexual trauma syndrome.

REFERENCES

Amstadter, A. B., McCauley, J. L., Ruggiero, K. J., Resnick, H. S., & Kilpatrick, D. G. (2008). Service utilization and help seeking in a national sample of female rape victims. Psychiatric Services, 59(12), 1450-1457. http://dx.doi.org/10.1176/appi.ps.59.12.1450

Basile, K. C., Arias, I., Desai, S., & Thompson, M. P. (2004). The differential association of intimate partner physical, sexual, psychological, and stalking violence and posttraumatic stress symptoms in a nationally representative sample of women. Journal of Traumatic Stress, 17(5), 413-421. http://dx.doi.org/10.1023/B:JOTS.0000048954.50232.d8

Basile, K. C., Chen, J., Black, M. C., & Saltzman, L. E. (2007). Prevalence and characteristics of sexual violence victimization among U.S. adults, 2001-2003. Violence and Victims, 22(4), 437-448.

Beck, A. T., Steer, R. A., Ball, R., & Ranieri, W. (1996). Comparison of Beck Depression Inventories-IA and -II in psychiatric outpatients. Journal of Personality Assessment, 67(3), 588-597.

Bengtsson-Tops, A., & Tops, D. (2007). Self-reported consequences and needs for support associated with abuse in female users of psychiatric care. International Journal of Mental Health Nursing, 16(1), 35-43.

Borja, S. E., Callahan, J. L., & Long, P. J. (2006). Positive and negative adjustment and social support of sexual assault survivors. Journal of Traumatic Stress, 19(6), 905-914. http://dx.doi .org/10.1002/jts.20169

Bownes, I. T., O'Gorman, E. C., & Sayers, A. (1991a). Assault characteristics and posttraumatic stress disorder in rape victims. Acta Psychiatrica Scandinavica, 83(1), 27-30.

Bownes, I. T., O'Gorman, E. C., & Sayers, A. (1991b). Rape-a comparison of stranger and acquaintance assaults. Medicine, Science and the Law, 31(2), 102-109.

Breslau, N., Chilcoat, H. D., Kessler, R. C., & Davis, G. C. (1999). Previous exposure to trauma and PTSD effects of subsequent trauma: Results from the Detroit Area Survey of Trauma. American Journal of Psychiatry, 156(6), 902-907.

Breslau, N., Kessler, R. C., Chilcoat, H. D., Schultz, L. R., Davis, G. C., & Andreski, P. (1998). Trauma and posttraumatic stress disorder in the community: The 1996 Detroit Area Survey of Trauma. Archives of General Psychiatry, 55(7), 626-632.

Brook, R. M. (1976). Psychological evaluation stress on adolescents. Journal of Clinical Psychology, 32(3), 565-567.

Brown, A. L., Testa, M., & Messman-Moore, T. L. (2009). Psychological consequences of sexual victimization resulting from force, incapacitation, or verbal coercion. Violence Against Women, 15(8), 898-919. http://dx.doi.org/10.1177/1077801209335491

Burgess, A. W., & Holmstrom, L. L. (1974a). Crisis and counseling requests of rape victims. Nursing Research, 23(3), 196-202.

Burgess, A. W., & Holmstrom, L. L. (1974b). Rape trauma syndrome. American Journal of Psychiatry, 131(9), 981-986.

Catalano, S., Smith, E., Snyder, H., & Rand, M. (2009). Female victims of violence. Washington, DC: Bureau of Justice Statistics.

Clum, G. A., Calhoun, K. S., & Kimerling, R. (2000). Associations among symptoms of depression and posttraumatic stress disorder and self-reported health in sexually assaulted women. Journal of Nervous and Mental Disorders, 188(10), 671-678.

Cohen, J., Cohen, P., West, S., & Aiken, L. (2003). Applied multiple regression/correlation analysis for the behavioral sciences (3rd ed.). Mahway, NJ: Lawrence Erlbaum Associates.

Darves-Bornoz, J. M. (1997). Rape-related psychotraumatic syndromes. European Journal of Obstetrics, Gynecology, and Reproductive Biology, 71, 59-65.

Fairbrother, N., & Rachman, S. (2006). PTSD in victims of sexual assault: Test of a major component of the Ehlers-Clark theory. Journal of Behavior Therapy and Experimental Psychiatry, 37(2), 74-93. http://dx.doi.org/10.1016/j.jbtep.2004.08.004

Faul, F., Erdfelder, E., Lang, A. G., & Buchner, A. (2007). G*Power 3: A flexible statistical power analysis program for the social, behavioral, and biomedical sciences. Behavior Research Methods, 39(2), 175-191.

Foa, E. B. (1997). Psychological processes related to recovery from a trauma and an effective treatment for PTSD. Annals of the New York Academy of Sciences, 821, 410-424.

Foa, E. B., Cashman, L., Jaycox, L., & Perry, K. (1997). The validation of a self-report measure of posttraumatic stress disorder: The Posttraumatic Stress Diagnostic Scale. Psychological Assessment, 9, 445-451.

Foa, E. B., Ehlers, A., Clark, D. M., Tolin, D. F., & Orsillo, S. M. (1999). The Post-Traumatic Cognition Inventory (PTCI): Development and validation. Psychological Assessment, 11, 303-314.

Gaffney, D. A. (Ed.). (2011). The psychobiology of traumatic stress responses after sexual assault. St. Louis, MO: STM Learning.

Gorsuch, R. L., & Spielberger, C. D. (1966). Anxiety, threat, and awareness in verbal conditioning. Journal of Personality, 34(3), 336-347.

Griffin, M. G., Uhlmansiek, M. H., Resick, P. A., & Mechanic, M. B. (2004). Comparison of the posttraumatic stress disorder scale versus the clinician-administered posttraumatic stress disorder scale in domestic violence survivors. Journal of Traumatic Stress, 17(6), 497-503. http:// dx.doi.org/10.1007/s10960-004-5798-4

Kilpatrick, D. G., Edmunds, C. N., & Seymour, A. (1992). Rape in America: A report to the nation. Arlington, VA: National Victim Center.

Koss, M. P., Abbey, A., Campbell, R., Cook, S., Norris, J., Testa, M., . . . White, J. (2007). Revising the SES: A collaborative process to improve assessment of sexual agression and victimization. Psychology of Women Quarterly, 31, 357-370.

Koss, M. P., & Gidycz, C. A. (1985). Sexual experiences survey: Reliability and validity. Journal of Consulting Clinical Psychology, 53(3), 422-423.

Koss, M. P., Gidycz, C. A., & Wisniewski, N. (1987). The scope of rape: Incidence and prevalence of sexual aggression and victimization in a national sample of higher education students. Journal of Consulting Clinical Psychology, 55(2), 162-170.

Lawrence, S., Chau, M., & Lennon, M. C. (2004). Depression, substance abuse and domestic violence: Little is known about co-occurrence and comorbid effects on low income families (Mailman School of Public Health, Trans.). Columbia University: National Center for Children in Poverty.

Lipsky, S., Field, C. A., Caetano, R., & Larkin, G. L. (2005). Posttraumatic stress disorder symptomatology and comorbid depressive symptoms among abused women referred from emergency department care. Violence and Victims, 20(6), 645-659.

Masho, S. W., & Ahmed, G. (2007). Age at sexual assault and posttraumatic stress disorder among women: Prevalence, correlates, and implications for prevention. Journal of Womens Health, 16(2), 262-271. http://dx.doi.org/10.1089/jwh.2006.M076

Meadows, L. A., Kaslow, N. J., Thompson, M. P., & Jurkovic, G. J. (2005). Protective factors against suicide attempt risk among African American women experiencing intimate partner violence. American Journal of Community Psychology, 36(1-2), 109-121. http://dx.doi.org/10.1007/ s10464-005-6236-3

Medicare Beneficiaries. (2011). Retrieved from medicare.org

Miller, S. M. (1979). Coping with impending stress: Psychophysiological and cognitive correlates of choice. Psychophysiology, 16(6), 572-581.

Munro, B. (2005). Statistical methods for health care research (5th ed.). Philadelphia, PA: Lippincott Williams & Wilkins.

O'Campo, P., Kub, J., Woods, A., Garza, M., Jones, S., Gielen, A., . . . Campbell, J. (2006). Depression, PTSD, and comorbidity related intimate partner violence in civilian and military women. Brief Treatment and Crisis Intervention, 6(2), 99-110.

Pico-Alfonso, M. A., Garcia-Linares, M. I., Celda-Navarro, N., Blasco-Ros, C., Echeburua, E., & Martinez, M. (2006). The impact of physical, psychological, and sexual intimate male partner violence on women's mental health: Depressive symptoms, posttraumatic stress disorder, state anxiety, and suicide. The Journal of Womens Health, 15(5), 599-611. http://dx.doi.org/10.1089 /jwh.2006.15.599

Population Division. (2012). Projections of the population by selected age groups and sex for the United States: 2010-2050. (Table 2). Washington, DC: U.S. Census Bureau.

Shipley, R. H., Butt, J. H., & Horwitz, E. A. (1979). Preparation to reexperience a stressful medical examination: Effect of repetitious videotape exposure and coping style. Journal of Consulting and Clinical Psychology, 47(3), 485-492.

Social Security. (2012). Understanding Supplemental Security Income.

Spielberger, C. D., & Gorsuch, R. L. (1966). The development of the State-Trait Anxiety Inventory. In C. D. Spielberger & R. L. Gorsuch (Eds.), Mediating processes in verbal conditioning (Vol. Final report to the National Institutes of Health). Tampa, FL: University of South Florida.

Stein, M. B., & Kennedy, C. (2001). Major depressive and post-traumatic stress disorder comorbidity in female victims of intimate partner violence. Journal of Affective Disorders, 66(2-3), 133-138. http://dx.doi.org/10.1016/S0165032700003013

Stein, M. B., Lang, A. J., Laffaye, C., Satz, L. E., Lenox, R. J., & Dresselhaus, T. R. (2004). Relationship of sexual assault history to somatic symptoms and health anxiety in women. General Hospital Psychiatry, 26(3), 178-183. http://dx.doi.org/10.1016/j.genhosppsych.2003.11.003

Tjaden, P., & Thoennes, N. (2006). Extent, nature and consequences of rape victimization: Findings from the National Violence Against Women Survey. Washington: DC: U.S. Department of Justice.

Ullman, S. E., Filipas, H. H., Townsend, S. M., & Starzynski, L. L. (2007). Psychosocial correlates of PTSD symptom severity in sexual assault survivors. Journal of Traumatic Stress, 20(5), 821-831. http://dx.doi.org/10.1002/jts.20290

U.S. Census Bureau, Population Division. (2010). Table 2. Annual estimates of the resident population by sex and age for the United States, April 1, 2000 to July 1, 2009 (SC-EST2009-02-34). Retrieved from http://factfinder.census.gov/servlet/DTTable?_bm=y&-geo_id=01000US&-ds_ name=PEP_2009_EST&-_lang=en&-redoLog=false&-mt_name=PEP_2009_EST_G2009_ T008_2009&-format=&-CONTEXT=dt

Valentiner, D. P., Foa, EBDS, Riggs, D. S., & Gershuny, B. S. (1996). Coping strategies and posttraumatic stress disorder in female victims of sexual and nonsexual assault. Journal of Abnormal Psychology, 105(3), 455-458.

Winfield, I., George, L. K., Swartz, M., & Blazer, D. G. (1990). Sexual assault and psychiatric disorders among a community sample of women. American Journal of Psychiatry, 147(3), 335-341.

Zinzow, H. M., Resnick, H. S., McCauley, J. L., Amstadter, A. B., Ruggiero, K. J., & Kilpatrick, D. G. (2010). The role of rape tactics in risk for posttraumatic stress disorder and major depression: Results from a national sample of college women. Depression and Anxiety, 27(8), 708-715. http://dx.doi.org/10.1002/da.20719

Carrie M. Carretta, PhD, APN, AHN-BC, FPMHNP

University of Medicine and Dentistry of New Jersey

Ann W. Burgess, DNSc, APRN, FAAN

Connell School of Nursing, Boston College

Correspondence regarding this article should be directed to Carrie M. Carretta, PhD, APN, AHN-BC, FPMHNP, University of Medicine and Dentistry of New Jersey, Newark, 65 Bergen Street, SSB/GA 219, Newark, NJ 07101-1709. E-mail: [email protected] or [email protected]