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Perspectives in Psychiatric Care

ISSN 0031-5990

Sexual Assault: Where Are Mid-Life Women in the Research? Laura Thomas, MSN, RN, CNE, Donna Scott Tilley, PhD, RN, CNE, CA-SANE, and Karen Esquibel, PhD, RN, PNP Laura Thomas, MSN, RN, CNE, is an Assistant Professor, Texas Tech University Health Sciences Center School of Nursing, Lubbock, Texas, USA; Donna Scott Tilley, PhD, RN, CNE, CA-SANE, is a Professor and Interim Associate Dean, Texas Woman’s University College of Nursing, Denton, Texas, USA; and Karen Esquibel, PhD, RN, PNP is an Associate Professor, Texas Tech University Health Sciences Center School of Nursing, Lubbock, Texas, USA

Search terms: Sexual assault, date rape, rape, mid-life, middle age, older women Author contact: [email protected], with a copy to the Editor: [email protected] Conflict of Interest Statement The authors report no actual or potential conflicts of interest. First Received August 6, 2013; Final Revision received January 21, 2014; Accepted for publication February 6, 2014. doi: 10.1111/ppc.12067

PURPOSE: There is extensive literature related to the experience of sexual assault of women with a majority focused on younger women, college-aged women, or older women. There is little research about the experience of sexual assault of midlife women. DESIGN AND METHODS: This paper synthesizes the current literature associated with sexual assault by describing the increased number of single women in the population, defining terms associated with sexual assault, examining rape myths, characteristics of the victim, describing the relationship of victim to assailant, extent of victimization experienced by women, common physical injuries, age-related physiological changes, psychological considerations, and post-traumatic stress disorder specific to mid-life women. FINDINGS: The population of single women has increased across the life span. Current studies utilize varying definitions of sexual assault, examine results across variable age groups, and include the responses of single women with married women. Characteristics of victims demonstrate similarities by age group, relationship type, living conditions, and physical or mental capabilities that affect the occurrence of sexual assault. PRACTICE IMPLICATIONS: There are few studies that examine the sexual assault experiences of single mid-life women. Further research into the experiences of single mid-life women is warranted to provide direction for nursing education programs and clinical practice.

Sexual assault is a public health issue that affects millions of women and men each year. The Centers for Disease Control and Prevention estimates that one in five women and one in 71 men in the United States report that they have been sexually assaulted at least once during their lifetime (Black et al., 2011). In addition to these figures, it is noted in the literature that there is significant underreporting of sexual assault (Black et al., 2011; Harned, 2005; Rennison & Rand, 2003). Most studies describe the experiences of a large group of women from early teens to older adults without specific differentiation between age groups or marital status (Fanslow & Robinson, 2010; Grant & Ragsdale, 2008; Kalra, Wood, Desmarais, Verberg, & Senn, 1998; Rennison & Rand, 2003; Sormanti & Shibusawa, 2008). There are no studies dedicated specifically to single mid-life women who experience sexual assault (Del Bove, Stermac, & Bainbridge, 2005; Eckert & Sugar, 2008; Stermac, Del Bove, Brazeau, & Bainbridge, 2006). Societal bias about older women has led to the widely held belief that older women are not sexually attractive and 86

therefore not at risk for sexual assault (Del Bove et al., 2005). This bias demonstrates traditional gender role beliefs and perpetuates the secrecy that makes it difficult for single midlife women to report cases of sexual assault (Del Bove et al., 2005). An examination of the literature demonstrates the invisibility of this demographic of women in the research and the need to establish the incidence, prevalence, prevention methods, and needs of this age group. To identify relevant literature, a search was conducted using CINAHL, Medline, and PsychInfo databases. Limiters were used to include all articles in peer-reviewed journals in those databases from 2002 to 2013. An initial search using the keywords sexual assault, date rape, rape, mid-life, middle age, and older women yielded 57 citations. Of these, only five actually dealt specifically with sexual assault of mid-life women. None of the research results distinguished specifically between married, cohabitating, or single women. To provide a comprehensive view of the problem, selected articles (Table 1) about sexual assault in general were reviewed, along with white Perspectives in Psychiatric Care 51 (2015) 86–97 © 2014 Wiley Periodicals, Inc.

Perspectives in Psychiatric Care 51 (2015) 86–97 © 2014 Wiley Periodicals, Inc.

rape. The Canadian Journal of Human Sexuality, 9(3), 181–190.

Verberg, N., Desmarais, S., Wood, E., & Senn, C. (2000). Gender differences in survey respondents’ written definitions of date from recreational and leisure centers and through public advertisement.

102 women and 68 men age 18–85 years old living in a mid-sized city that were single and available to date. Participants were recruited

1992 and 2001.

350 women who sought medical treatment at an urban sexual assault care center between

Stermac, L., Del Bove, G., Brazeau, P., & Bainbridge, D. (2006). Patterns in sexual

assault violence as a function of victim perpetrator degree of relatedness. Journal of Aggression, Maltreatment & Trauma, 13(1), 41–58.

115 single, female participants age 18–85 years who were willing to date divided into two groups: women over 40 years old and women who were 39 years old or younger. Volunteers were recruited from university classes, retirement homes, dating services, community and single parent support groups.

Urban emergency room visits of 1,884 women 20 years of age or older.

Kalra, M., Wood, E., Desmarais, S., Verberg, N., Senn, C. Y. (1998). Exploring negative dating experiences and beliefs about rape among younger and older women. Archives of Sexual Behavior, 27(2), 145–153.

198(6), 688.e1–688.e7.

Eckert, L. O., & Sugar, N. F. (2008). Older victims of sexual assault: An underrecognized population. American Journal of Obstetrics and Gynecology,

Women who presented to a Sexual Assault Care Center in a large urban area in Canada. Three age groups were compared: Young women age 15–30 years, mid-age women

Del Bove, G., Stermac, L., & Bainbridge, D. (2005). Comparisons of sexual assault among older and younger women. Journal of Elder Abuse and Neglect, 17(3), 1–18. 31–54 years, and older women 55–87 years.

Sample

Citation

Table 1. Summary of Articles Reviewed

rape and gender, consent, force, and context of the rape.

and selective coding. Two coders with 95% agreement between coders. Quantitative: chi-square alpha .001 and .05 to assess the relationship between the definition of date

role of consent than men. Both women and men made a distinction between dating partners and acquaintances.

Most participants included consent and force in their definitions of rape. More women defined rape by gender and emphasized the

health issues were found commonly in stranger or acquaintance sexual assault.

Logistic regression analysis of risk of violence and severity of coercion related to the victim-assailant relationship used alpha level .05. Qualitative: constant comparative method to determine the relationship between gender, and the themes, open coding, axial coding,

committed by other perpetrators. The use of alcohol was related to acquaintance/dating partner assault than other types of perpetrators. Homelessness and mental

Sexual assaults by intimate partners were more severe with greater coercion than those

Women in this age group had more psychiatric disorders, including substance abuse, than the other age groups. The rate of homelessness was higher in the mid-life age group. Older women experienced more incidences of unwanted affection than younger women, no differences were found for date rape between the two groups, older women were not as concerned as becoming a victim of date rape as younger women, older women were found to support rape myth adherence more often than younger women.

in determining the severity of sexual abuse and type of coercion used by the assailant. The types of injuries sustained between the age groups were similar. Mid-life women were more violently and severely coerced physically and were more likely to have been raped by an acquaintance/dating partner or stranger.

Women were diverse in age, ethnicity, marital, and employment status. Most women arrived at the Center with the police. The victim- assailant relationship was significant

Findings

analysis of variance for continuous variables. More than 15% of data missing from variables was excluded from the study. Group comparisons used alpha level .001.

Quantitative: Administered a 15-question survey to examine negative dating experiences and the 18 statement R-Scale to assess adherence to rape myths. Analysis used to examine if there was a difference in the current dating rates between the two groups and negative dating experiences. Regression analysis was used to examine rape myth adherence and negative dating experiences between the two groups. Quantitative: group comparisons using chi-square for categorical variables and

Quantitative: chi-square analysis with dichotomous variables and Student t-test for continuous variables.

statistics using nominal data and analysis of variance. Alpha level .01.

Data collected from the Center’s database maintained between 1992 and 2004 with non-identifying information and coded information. Quantitative: chi-square

Methodology

improve education services and similarity in definitions used in future research.

Establishing clear definitions of date rape help researchers and readers understand how date rape is defined by the general public to

relationship between the assailant and victim to provide new information about the level of violence and injuries that result in specific types of relationships.

While this study did not focus on date rape of specific age groups, it did examine the

Negative dating experiences included unwanted attention, physical contact, and rape. Rape myth adherence is “prejudicial, stereotyped, or false beliefs about rape, rape victims, and rapists” (Kalra et al., 1998, p. 146).

women.

While the study was not limited to date rape the delineation of different age groups made this study one of the few that examined the experience of sexual assault in mid-life

examine the experiences of mid-life women who experienced sexual assault.

Women in all age groups were as likely to be sexually assaulted by a stranger as an acquaintance. The study did not specify a dating partner from an acquaintance but did

Date Rape

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papers from agencies such as the Centers for Disease Control and Prevention. In addition, a landmark study from 1998 wasincluded in the review. The 1998 study was one of the first studies that examined the experience of sexual assault by midlife women. The researchers compared the experiences of sexual assault and rape myth beliefs to a younger population to demonstrate the differences between the age groups and promote the need for further research. This paper will synthesize the current literature associated with sexual assault of single mid-life women by defining the terms associated with sexual assault, examining rape myths and describing the relationship between the victim and assailant. The trend toward an increased number of single mid-life women in the population will be examined. The increased number of single women at mid-life may increase the number of women involved in dating relationships, which may put them at higher risk for sexual assault (Eckert & Sugar, 2008; Rich, 2001; Sormanti & Shibusawa, 2008). Women who are divorced in mid-life are entering a dating scene that is significantly different from their previous experiences with the high risk of sexually transmitted infections, human immunodeficiency virus, and the high incidence of multiple partners among sexually active adults (Grant & Ragsdale, 2008; Sormanti & Shibusawa, 2008). Characteristics of the victim, a description of the extent of victimization experienced by mid-life women, and physiological considerations specific to mid-life women will be highlighted. A summary of the current knowledge about the sexual assault of mid-life women and areas for further research will conclude the paper.

Single Women The number of unmarried women is on the rise in the United States. The age of first marriage has increased by 4.5 years since 1970 while the chance that a first marriage will end in divorce has increased to “20% in five years, 33% within ten years, and 43% within fifteen years” (Liddon, Leichliter, Habel, & Aral, 2010, p. 1963). Even though the age of first marriage has increased, approximately 90% of women do marry (Elliott, Krivickas, Brault, & Kreider, 2010). The remarriage rate for a divorced woman has decreased from 65% in 1950 to 54% in 1995 with a high probability of second marriage failure (Liddon et al., 2010). The U.S. divorce rate for all women age 15 and older is 9.7%, which has increased from 6% in 1970 but decreased from 13% in 2003 (Liddon et al., 2010; U.S. Census Bureau, 2012). At age 65, men are more likely to be married than women as women tend to outlive men (Calasanti & Kiecolt, 2007). Sociobiological thought on mate selection supports the marriage hypergamy theory that men choose younger women as partners while women choose older men and that the primary attraction to a partner is related to reproduction (Alterovitz & Mendelsohn, 88

2009; Burrows, 2013). As men seem to seek younger women for dating relationships and men die younger than women, there are fewer opportunities for women to date or marry later in life (Levesque & Caron, 2004; McIntosh, Locker, Briley, Ryan, & Scott, 2011). Another factor that increases the number of single women in the population is the number of women who never marry. Approximately 11% of women over 40 years of age have never married either through their own choice or because they had not found a suitable partner (Elliott et al., 2010; McDill, Hall, & Turell, 2006). In the past, unmarried women were identified as spinsters who were lonely, unhappy, or dissatisfied with life (McDill et al., 2006). As education and employment opportunities have expanded women began to delay marriage. Although marriage is the accepted social norm for women, the women’s and civil rights movements created opportunities for women to engage in premarital sex, cohabitate, gain financial independence,and shift their focus from marriage to independence, decreasing the need to marry (McDill et al., 2006). Younger women are more often interested in marriage as a result of a dating relationship while many older women seek companionship, fun, and physical intimacy without the level of commitment marriage requires (Calasanti & Kiecolt, 2007; McIntosh et al., 2011; Watson & Stelle, 2011). Older women who are happier and have a strong support system are less likely to remarry than older women who do not have family or friends or who do not remain socially active (Moorman, Booth, & Fingerman, 2006; Watson & Stelle, 2011). Whether interested in marriage or not, mid-life and older women sought out male companions for dating or platonic relationships (Calasanti & Kiecolt, 2007; Moorman et al., 2006; Watson & Stelle, 2011). Definitions of Terms A discussion about sexual assault should begin with an examination of the various terms and definitions utilized by researchers to describe a woman’s experience of sexual assault. Rape, date rape, sexual violence, and sexual assault are defined differently between research studies. Some studies use the terms interchangeably, limiting the ability of the reader to grasp the depth to which the researcher has examined the woman’s experience. The National Intimate Partner and Sexual Violence Survey examined five types of sexual violence, including rape, forced penetration of another person, sexual coercion, unwanted sexual contact, and noncontact unwanted sexual experiences (Black et al., 2011). The National Intimate Partner and Sexual Violence Survey defines rape as “any completed or attempted unwanted vaginal, anal, or oral penetration through the use of physical force” (p. 17) or that occurs when a woman is threatened with physical harm or unable to consent due to ingestion of alcohol or drugs or is in a state of unconsciousness (Black et al., 2011). Perspectives in Psychiatric Care 51 (2015) 86–97 © 2014 Wiley Periodicals, Inc.

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Rape is further categorized as “completed forced penetration, attempted forced penetration, and completed drug or alcohol facilitated penetration” (Black et al., 2011, p. 17). Forced penetration of another person may occur when a person is physically forced, restrained, or threatened. Penetration of the vagina or anus may occur through the use of the penis, mouth, fingers or another object (Eckert & Sugar, 2008). Forced oral penetration may occur between two women via the vagina or anus or between a man and a woman when a woman forces a man to penetrate her (Black et al., 2011). Sexual coercion occurs when a woman is pressured to have sex through nonphysical means including repeated badgering from a partner for sex, psychological threats to end the relationship, threats from a person in authority, or when a partner made promises that were untrue (Black et al., 2011; Eckert & Sugar, 2008). Unwanted sexual contact is any unwanted sexual experience that involves touch but not penetration (Black et al., 2011). Sexual experiences that do not involve touch include exposure of sexual body parts, masturbating in front of the woman, coercing the woman into participation in sexual photographs or videos, publically displaying photographs or videos without the woman’s permission, voyeurism, or harassing the woman to the point where she feels unsafe (Black et al., 2011; National Institute of Justice, 2010). Date rape occurs when someone a woman knows socially forces her to participate in sexual activity against her will using force, intimidation, or coercion (New South Wales Government, 2002; Russo, 2000). The key terms in the definitions are the use of force, coercion, and unwanted sexual experiences. An analysis of the term “date rape” by 102 women and 68 men age 18–85 years old in a mid-sized Canadian city who were single and willing to date found even further variations in the participants’ understanding of date rape (Verberg, Desmarais, Wood, & Senn, 2000). Most but not all participants included force or refusal to participate in sexual activities as the main characteristics in defining date rape. As in a number of studies on date rape, participants used the term “acquaintance” and “dating” partner interchangeably. Penetration of the vagina or anus was identified in most definitions of rape (Verberg et al., 2000). However, 46.5% of participants included any unwanted sexual contact, expanding the definition of date rape further. Gender differences of the study participants identified women as most likely to associate gender with rape while men reported gender neutral definitions (Verberg et al., 2000). A majority of participants (72%) were under 40 years of age. Women over 40 years old may have different definitions of date rape related to previous experiences and generational differences than women under 40 years old; however, this study does shed light on how complex the definitions for sexual assault terms can be (Verberg et al., 2000). The terms “dating partner” and “acquaintance” are used interchangeably in some studies. The National Abuse Perspectives in Psychiatric Care 51 (2015) 86–97 © 2014 Wiley Periodicals, Inc.

Helpline and Break the Cycle define dating as two people in an intimate relationship (Love is Respect, 2013). A dating partner is considered a person who shares a relationship with another person (Love is Respect, 2013). In some studies, a dating partner is defined as someone with whom the victim is involved in a social relationship while an acquaintance is someone who is known to the victim (Eckert & Sugar, 2008; Verberg et al., 2000). Billy, Grady, and Sill’s (2009) examination of sexual risk taking among adults used the National Couples Survey definition of dating as “currently being in an unmarried, noncohabiting sexual relationship of at least one month’s duration” (p. 75). The numerous definitions across studies can make generalization of research difficult and comparison of results incongruous. Rape Myth Beliefs Women’s attitudes toward rape in dating relationships may have a basis in rape myths. Rape myths are established false beliefs about rape, rape victims, and assailants that are biased and stereotypical (Burt, 1980). The primary characteristic of rape myth beliefs is the woman’s belief that she is responsible for the rape because of her behavior, clothing choice when attacked, attractiveness, previous sexual history, use of alcohol or drugs, or a male partner’s expectation (Basow & Minieri, 2011; Harned, 2005). Typically, rape myths shift blame away from the perpetrator. Rape myth adherence among women over 40 years old is higher than that of women under 40 years old (Kalra et al., 1998). Even when coerced into unwanted sexual activity, mid-life women still tend to accept responsibility for unwanted physical attention or rape (Kalra et al., 1998). Many older women have been socialized to traditional gender roles, which include male dominance with an imbalance in power between the man and woman, subservience of the woman to the man, participation in sexual activity at the man’s request without regard for the woman’s desire for sex, dependency issues, poor social support, and the acceptance of previously violent relationships (Billy et al., 2009; Calasanti & Kiecolt, 2007; Harned, 2002; Kalra et al., 1998; Rennison & Rand, 2003; Simmons & Baxter, 2010; Sormanti & Shibusawa, 2008). Traditional roles leave women with low self-esteem and poor control over personal protection and health. A woman’s belief that violence happens in relationships and is a private issue may lead to fewer reports of rape, a higher occurrence of violence in dating relationships, and social isolation from those who could provide help (Kalra et al., 1998; Rennison & Rand, 2003; Simmons & Baxter, 2010). Men more frequently support rape myths beliefs than women, assigning more blame to the victim than the perpetrator (Basow & Minieri, 2011; Billy et al., 2009; Farmer & McMahon, 2005; Kelleher & McGilloway, 2009). However, most studies that have examined the rape myth beliefs of men 89

Sexual Assault: Where Are Mid-Life Women in the Research?

and women have been primarily carried out with college age participants (Basow & Minieri, 2011; Farmer & McMahon, 2005). Sormanti and Shibusawa (2008) found that mid-life and older women who were married and adhered to traditional gender roles felt obligated to submit to sexual demands from their husbands. A woman may have experienced violence as a result of refusing sex in the past, leaving her vulnerable to future intimidation and sexual assault (Sormanti & Shibusawa, 2008). The women in the study were recruited from emergency rooms and free standing clinics in an urban area of the United States that serves primarily underserved populations, which is not representative of the general population (Sormanti & Shibusawa, 2008). While the women’s movement may have gained ground for women in cases of sexual assault, rape myth beliefs are embedded into our culture and affect not only mid-life women but also adolescent and college-aged women. Researchers examined college-aged men’s beliefs about the expectation of sexual intercourse after a date. If the man paid for an expensive meal or the entire cost of the date, then the men and some of the women in the study stated that the woman should expect to have sexual intercourse after the date (Basow & Minieri, 2011). When the man paid for an inexpensive date or costs of the date were shared, men and women were less likely to presume a sexual outcome. Bias toward rape myths influenced male expectations of sexual intercourse (Basow & Minieri, 2011). The study participants were undergraduate students (n = 188) who supported the assertion that men assigned more blame to the victim no matter who paid for the date and still ascribed to the belief that when a woman says no she means yes (Basow & Minieri, 2011). Men with a higher rape myth acceptance tended to minimize the seriousness of rape and were more likely to justify acquaintance rape when the man paid the entire cost of the date (Basow & Minieri, 2011). While rape myth beliefs are higher among women over 40 years old than those of women under 40 years old, younger women may also accept responsibility for unwanted sexual experiences (Basow & Minieri, 2011; Harned, 2005; Kalra et al., 1998). Women who experience unwanted affection, physical or sexual abuse in a dating relationship and maintained a high rape myth adherence tended to assume responsibility for the abuse. The resultant loss of self-esteem may lead the woman to pull away from dating relationships, leading to isolation and depression (Kalra et al., 1998). Characteristics of Victims Researchers must proceed with caution when examining the characteristics of women who experience sexual assault to avoid assigning blame to women based on behavior or experiences. In a study of women aged 14 to 87 years old who presented to a large urban sexual assault care center in Canada, 90

researchers examined the differences in characteristics of victims between age groups (Stermac et al., 2006). Mid-life and older women (31–54 years old and 55–87 years old, respectively) were most likely to be divorced, separated, or widowed while younger women (15–30 years old) were more likely to be single at the time of the assault. The oldest age group was most likely to live alone and be assaulted in their home or living in a long-term care facility at the time of the assault (Stermac et al., 2006). Many of the older women who lived in long-term care facilities were assaulted by healthcare or service personnel. The mid-life and older women in the study had a higher number of preexisting psychiatric disorders that included bipolar disorder, depression, and schizophrenia than the general population (Stermac et al., 2006). The oldest age group had a higher incidence of dementia (Stermac et al., 2006). Women who were raped by intimate partners were more likely to be at home whereas women who were assaulted by acquaintances were more likely to be outdoors, at the assailant’s home, or in a vehicle (Del Bove et al., 2005; Eckert & Sugar, 2008; Stermac et al., 2006). In cases of acquaintance or dating partner rape, the victim was more likely to have consumed alcohol than in cases of intimate partner relationships. No data were collected about the assailant’s alcohol consumption (Del Bove et al., 2005; Stermac et al., 2006). A study conducted in an urban emergency room and a sexual assault clinic in the western United States examined the medical records of women who sought care for sexual assault. The researchers found approximately one third of the mid-life women were homeless, in jail, or disabled with high rates of preexisting psychiatric disorders (Eckert & Sugar, 2008). The characteristics of the women in Eckert and Sugar’s (2008) study were similar to those found by Stermac et al. (2006) and Del Bove et al. (2005). Relationship of Victim to Assailant The relationship between the victim and assailant can affect the type and extent of injuries sustained during rape. Women who were sexually assaulted by a current or former intimate partner were at risk for more severe injuries and coercion tactics than women who were assaulted by strangers, acquaintances, or dating partners (Del Bove et al., 2005; Stermac et al., 2006). In a study of women age 14 to 87 years old who presented to a large urban sexual assault care center in Canada, one third of the sexual assaults were committed by acquaintances or dating partners (Stermac et al., 2006). An acquaintance in the study was defined as a person the victim knew or was dating for greater than 24 hr (Stermac et al., 2006). One quarter of the participants in the study identified as ethnic minorities, 13% lived on the street or in a shelter and 26% had a history of psychiatric diagnoses prior to the assault. The study did not divide or compare the participant groups by age or marital Perspectives in Psychiatric Care 51 (2015) 86–97 © 2014 Wiley Periodicals, Inc.

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status (Stermac et al., 2006). The results represent all participants with an average age of 27 years old. More Caucasian women in the study were sexually assaulted by a stranger or an acquaintance while women of ethnic minorities were sexually assaulted by a husband or boyfriend (Stermac et al., 2006). Women who were sexually assaulted by an acquaintance or dating partner were more likely to be in the assailant’s home at the time of the assault. Approximately 44% of the women in the study had used alcohol prior to the assault (Stermac et al., 2006). Using the same data, the researchers examined the victim to assailant relationship between three age groups of women (55–87 years, n = 61; 31–54 years, n = 73; 15–30 years, n = 78) (Del Bove et al., 2005). The type of sexual assault was similar among age groups. Vaginal assault was the most common type of sexual assault experienced by the participants across age groups. Physical restraint was the most common method of coercion, followed by physical violence and verbal threats (Del Bove et al., 2005). All age groups were most often assaulted by a stranger or acquaintance. Mid-life women were assaulted most frequently either in their own home (20%) or outside (28.6%), in contrast to the younger women in the study, who were assaulted in their own home (19.2%), the assailant’s home (19.2%), a vehicle (17.9%), or outside (20.5%), with a small number of mid-life and older women assaulted in an institution (Del Bove et al., 2005). Although Eckert and Sugar (2008) did not use the same age ranges as Del Bove et al. (2005), they found similar results. Women 20 years old and older were recruited from an urban emergency room in the United States. The researchers divided the participants into three age groups: 20–39 years (n = 1742), 40–55 years old (n = 554), and over 55 years old (n = 102) (Eckert & Sugar, 2008). The mid-life women had the highest rate of homelessness (16.6%) and preexisting psychiatric diagnoses (52.3%) and were more often assaulted by a stranger (22.7%) or an acquaintance (43.1%) than the younger or older age groups. The mid-life women experienced the most assaults in their own home (22%), another person’s home (23.8%), or outside (21.1%) compared with the younger women, who experienced assault in their own home (19.7%), another person’s home (30.5%), in a vehicle (11.2%), or outside (16.3%) (Eckert & Sugar, 2008). A small number of women in the mid-life group were assaulted in a care facility (2.3%), but the women in the older age group experienced significantly higher rates of assault (33.3%) in a care facility. A majority of the assaults in care facilities were perpetrated by a service provider. Consistent with Del Bove et al. (2005), most assailants were strangers or acquaintances across all age groups (Eckert & Sugar, 2008). Researchers conducted a study in west central Michigan to examine the experience of women (n = 1,917) who were sexually assaulted and sought emergency room care. The participants were divided into two age groups; 18 to 39 years old (n = 1,610) and 50 years old and older (n = 72) (Jones, Perspectives in Psychiatric Care 51 (2015) 86–97 © 2014 Wiley Periodicals, Inc.

Rossman, Diegel, Van Order, & Wynn, 2009). Most women in the older age group were married (69.3%) rather than single (30.6%). Consistent with Del Bove et al. (2005) and Eckert and Sugar (2008), a majority of older women were assaulted by a stranger (Jones et al., 2009). Most of the assaults took place in the older women’s homes (73.6%) or in a care facility (8.3%) and most of the older women had existing physical or cognitive deficits. The few sexual assaults that occurred in care facilities were perpetrated by service providers (Jones et al., 2009). Extent of Victimization Relationship Between Victim and Assailant The extent of victimization has been identified as relative to the relationship between the woman and her assailant. Perineal and anal injuries were more commonly inflicted in cases of intimate partner, acquaintance, or dating partner sexual assault (Stermac et al., 2006). The extent of coercion used by boyfriends and spouses was more severe than acquaintance or stranger sexual assault. Stermac et al. (2006) found that the most common methods of coercion were physical restraint (50%), verbal threats (39.8%), physical violence (26.7%), drug or alcohol use (9.6%), and sexually assaulting a sleeping woman (7.4%). The use of drugs as a means of coercion was used most commonly by strangers or dating partners (Stermac et al., 2006). Weapons were used to coerce younger women more often than mid-life or older women and were more often used during assault by a stranger rather than a dating partner (Del Bove et al., 2005; Stermac et al., 2006). Women who were assaulted by a boyfriend or spouse suffered more severe physical trauma and a broader range of injuries than women who were assaulted by strangers (Stermac et al., 2006). Common Physical Injuries The most common injuries discovered on examination of women after sexual assault included soft tissue injuries and lacerations on the head, neck or face, vagina, and perineal or anal area (Del Bove et al., 2005; Eckert & Sugar, 2008; Stermac et al., 2006). Injuries did not differ between age groups except that older women experienced more vaginal injuries than younger or mid-life women (Del Bove et al., 2005; Eckert & Sugar, 2008; Jones et al., 2009). The extent of vaginal tearing and lacerations were more severe in older women, most likely because of the changes in elasticity and thinning of tissue in the genital area (Eckert & Sugar, 2008; Jones et al., 2009). Eckert and Sugar (2008) found that the specific types of sexual assault experienced by mid-life women included penis to vagina (72%), penis to mouth (25%), penis to anus (17.7%), and hand to vagina (20.7%). There were rare 91

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instances of the use of a foreign object during the rape (Eckert & Sugar, 2008; Jones et al., 2009). Physical coercion of midlife women (40–55 years old) was more violent than other age groups, with the use of choking (14.3%), hitting (35.9%), restraints (50.9%), and verbal threats (31.9%) (Eckert & Sugar, 2008). Eckert and Sugar (2008) found that mid-life women were less likely to be assaulted by an intimate partner than younger women. The results of the study by Jones et al. (2009) support those results. Physical Examination Colposcopic examinations are extremely useful to visualize genital abrasions, bruises, and tears, which can be minute and not visible to the naked eye (Frank, 1996; Slaughter & Brown, 1992). These injuries are often a result of tightened pelvic muscles, and a lack of pelvic tilt or lubrication during forced penetration (Ledray, 2006). Most injuries from an assault are located on the posterior fourchette, labia minora, and fossa navicularis (Slaughter, 2006). These small injuries can heal within 48–72 hr in healthy individuals (Ledray, 2006). Colposcopy has lengthened the window of opportunity to detect trauma or trace evidence in these victims (Slaughter, 2006). Age-Related Physiological Changes Normal changes of aging, anatomical and hormonal changes in mid-life women impact a woman’s physical response to sexual activity, consensual or otherwise. As estrogen levels begin to diminish in mid-life, genital tissues become less elastic and thinner, while the vagina narrows and shortens (Eckert & Sugar, 2008; Poulos & Sheridan, 2008). The vaginal glands also produce fewer secretions (Sommers et al., 2006). The external genitalia demonstrate changes with age as the labia lose fat and elastic tissue and the vulva thins and flattens. The epidermal growth rate decreases and collagen content/ thickness diminish with age (Sommers et al., 2006). These changes make the genitalia more susceptible to injury during the attack and possible bleeding when introducing a speculum for the colposcopic exam (Poulos & Sheridan, 2008). Genital trauma, vaginal lacerations, and vaginal and bladder infections in victims of sexual assault are more common in women over age 55 compared with younger women (Dyer, Connolly, & McFeely, 2003; Eckert & Sugar, 2008). If new injuries occur during the genital or vaginal exam, the healthcare provider should document this clearly. Several investigators have found that older women sustain a higher prevalence of genital injury caused by rape than younger women (Sommers et al., 2006). Nongenital physical injury is a realistic possibility following a sexual assault. Most studies indicate that approximately 3–5% of significant physical injuries result from rape (Ledray, 2006). However, 92

when this happens it must be addressed appropriately. Eckert and Sugar (2008) found that mid-life women were more violently victimized than their younger counterparts, resulting in injuries more widespread and more severe to include body trauma and intracranial injury. Every body system has the potential to be affected by sexual assault. Physical effects can range from irritable bowel syndrome and headaches to chronic pain and obesity (Dole, 2006). Other possible effects include fatigue, cystitis, hearing loss, and dyspepsia (Dole, 2006). Psychological and physical side effects may impact the victims’ lifestyle, leading to unemployment, homelessness, incarceration, or increased risk taking behaviors (Dole, 2006). Follow-up care can help stop the cycle of victimization. Psychological Considerations In addition to physical differences, mid-life and older women’s responses to trauma differ based on the number of traumatic experiences and the context of those experiences when they present with psychological symptoms (Bright & Bowland, 2008). Mid-life and older women who were sexually abused as children, have lived in an abusive situation for several years, have been involved in many abusive relationships, or have suffered more than one traumatic event may be at higher risk for complicated and severe psychological distress (Bright & Bowland, 2008). This impact can last for years following an assault, and typically includes depression, anxiety, fears, post-traumatic stress disorder (PTSD) symptoms, self-blame, and shame (Ledray, 2006). In order to accurately assess responses to trauma, the clinical interview is an essential element in the care of adult women who have experienced sexual assault (Bright & Bowland, 2008). Mid-life women may exhibit symptoms of PTSD from one or more experiences with sexual assault or other types of intimate partner violence (IPV). It is important for clinicians to recognize symptoms of PTSD and provide appropriate referrals and treatment for women who seek healthcare services. PTSD PTSD is a complex, multifaceted anxiety disorder that occurs after a person experiences a traumatic event including sexual assault (Scott-Tilley, Tilton, & Sandel, 2010; U.S. Department of Veterans Affairs, 2013). The diagnostic criteria identified as triggers for PTSD include exposure to a traumatic event, witnessing a traumatic event, having a family member or friend threatened with a traumatic event, or repeated exposure either directly or indirectly to a traumatic event through the media (American Psychological Association [APA], 2013). The Diagnostic and Statistical Manual of Mental Disorders (DSM-5) defines traumatic events as serious injury, actual or threatened death, or sexual violence (APA, 2013). Women Perspectives in Psychiatric Care 51 (2015) 86–97 © 2014 Wiley Periodicals, Inc.

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develop PTSD and related consequences at about twice the rate of men, most likely because of the greater prevalence of sexual violence experienced by women (Bright & Bowland, 2008). The integration of emotional and physical symptoms can lead to long-term chronic health conditions, including suppressed immune function, sleep disturbances, depression, increased risk of suicide, increased risk for type II diabetes, increased insulin resistance, substance abuse, atherosclerotic heart disease, obesity, increased severity of premenstrual syndrome symptoms, and chronic pain (Gill, Szanton, & Page, 2005; Scott-Tilley et al., 2010; U.S. Department of Veterans Affairs, 2013), including headaches (Gerber, Fried, Pineles, Shipherd, & Bernstein, 2012). Biological changes associated with PTSD include neuroendocrine changes that alter hormone levels of epinephrine, norepinephrine, and cortisol in response to stress (Gill et al., 2005; Symes et al., 2010). Symptoms of PTSD are grouped into four categories: re-experiencing the event, avoiding situations or places that are reminders of the trauma, fear, guilt and/or shame, and hyperarousal (U.S. Department of Veterans Affairs, 2013). Not everyone who experiences sexual assault develops PTSD. Researchers estimate that PTSD symptomatology occurs in 52% to 85% of IPV cases including sexual assault (Lipsky, Caetano, Field, & Larkin, 2005). Researchers have found genetic susceptibility and previous experiences of traumatic events as possible precursors to the development of PTSD (APA, 2013; Campbell, Dworkin, & Cabral, 2009). A study of 182 women 18 years old and older who received emergency department care for injuries related to IPV with PTSD symptoms in an underserved, metropolitan area of Texas found that women who were abused were four times more likely to be married, have been depressed, have experienced more severe physical types of IPV, have been sexually assaulted, and have had partners who abused alcohol than women who were not abused (Lipsky et al., 2005). Over 60% of the study population was under 35 years of age while 35.1% of the women were 35 years old or older. Few of the women in the study were single (4.2%) compared with those who were married (40%) or living with a partner (55.8%). The participants included a higher proportion of African American and Hispanic women than Caucasian women. One half of the women in the study described PTSD symptoms while 85% reported depressive symptoms including somatic complaints and decreased activity (Lipsky et al., 2005). When PTSD symptoms were present, women were four times more likely to be depressed, and twice as likely to be married, experienced sexual assault, and be exposed to six or more types of IPV. The severity of IPV was correlated to the occurrence of PTSD symptoms; however, participants were not diagnosed with PTSD. The continuous exposure to violence may contribute to worsening depression, decreased self-esteem, and a sense of hopelessness (Lipsky et al., 2005). Women who were exposed to IPV developed increased severity of depression and more Perspectives in Psychiatric Care 51 (2015) 86–97 © 2014 Wiley Periodicals, Inc.

anxiety symptoms than women who were not abused (Lipsky et al., 2005; Scott-Tilley et al., 2010). The study results showed that women who experienced severe IPV or sexual abuse were more likely to develop PTSD. Continued exposure to the risk of IPV may contribute to further psychological repercussions. The women in the study showed a high rate of alcohol and drug abuse even though substance abuse did not seem to contribute to a PTSD diagnosis (Lipsky et al., 2005). In another study of the association between IPV and psychological sequela, a group health plan in the western United States examined the diagnosis codes submitted by primary care and specialty providers for women 18 to 64 years old who had been enrolled in the plan for at least 3 years (Bonomi et al., 2009). The use of office visit diagnosis codes distinguishes this study from others that use emergency room data from women who sought out healthcare services. The broader demographic includes women who may not seek acute care services and provides a different context for the data. Mid-life women (45 to 65 years old) comprised 49.4% of the study population (Bonomi et al., 2009). No data on marital status was provided. The women in the study were not representative of the U.S. population because of increased age, higher income, and more education than the general population. The researchers compared the diagnosis codes on claims for 242 women who experienced abuse within the past year to 1,686 women who had never experienced IPV (Bonomi et al., 2009). The researchers identified a significant increase in mental health disorders in abused women when compared with women who were never abused. The women in the abused group showed a higher relative risk of developing mental health disorders, including a 6-fold increase in substance abuse, a 5-fold increase in family/social issues, a 3-fold increase in depressive disorders, and twice as many incidences of anxiety and tobacco use (Bonomi et al., 2009). The types of abuse and related psychological issues were not correlated by type of IPV but reported in general as IPV (Bonomi et al., 2009). A review of the research literature about the relationship between sexual assault and mental health outcomes showed increased PTSD symptoms when women experienced secondary victimization because of adverse responses from legal and medical providers (Campbell et al., 2009). PTSD symptoms were reduced when women received assistance from mental health providers and rape crisis centers (Campbell et al., 2009). Healthcare Services Response of Healthcare Providers Many women report negative experiences with healthcare providers when reporting sexual assault and other types of IPV (Beaulaurier, Seff, Newman, & Dunlop, 2007; Fanslow & Robinson, 2010; Ismail, Berman, & Ward-Griffin, 2007; 93

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Tower, 2007). A nontherapeutic response from the nurse may make a woman feel like she will not be believed, or will be judged or blamed for the violence (Beaulaurier et al., 2007; Campbell et al., 2009; Fanslow & Robinson, 2010; Ismail et al., 2007; Ting & Panchanadeswaran, 2009). Factors that may prevent an empathetic response from the nurse include personal values and attitude toward violence or relationships, lack of knowledge about IPV, limited education, time constraints, and a misunderstanding about IPV (Tower, 2007). Healthcare professionals may address IPV as a mental health issue rather than a public health issue, which may make a woman feel stigmatized. Research shows that women want nonjudgmental attitudes from healthcare providers, acknowledgment of the violence, and for their stories to be heard and believed; however, the literature shows that women are not experiencing these responses when seeking treatment (Campbell et al., 2009; Fanslow & Robinson, 2010; Ting & Panchanadeswaran, 2009; Tower, 2007). The available research evaluates the responses of healthcare providers as a group but does not address the response of nurses separately except in studies of women’s experiences with sexual assault nurse examiners (SANEs) (Beaulaurier et al., 2007; Bonomi et al., 2009; Fanslow & Robinson, 2010; Ting & Panchanadeswaran, 2009; Tower, 2007). SANEs have bridged the gap between women who were sexually assaulted and healthcare providers, but many areas do not have access to SANEs. Adolescents who had experienced sexual assault and were treated by SANEs stated that the nurses were sensitive to their needs, compassionate, caring, and personable, and that the nurses validated and believed their story of the assault (Campbell, Greeson, & Fehler-Cabral, 2013). Studies have found that women were disappointed with caregivers’ responses to their needs after abuse, which left women feeling bad about themselves, guilty, depressed, violated, distrustful of others, and unlikely to seek help in the future (Campbell et al., 2009; Fanslow & Robinson, 2010; Flinck, Paavilainen, & Asted-Kurki, 2005; Ismail et al., 2007; Ting & Panchanadeswaran, 2009; Tower, 2007). Women interpreted nonverbal cues of facial expression and body language as lacking in authenticity and synchronicity with the providers’ words (Flinck et al., 2005). Women wanted empathetic, outspoken, nonprejudicial responses from healthcare providers who were willing to listen (Fanslow & Robinson, 2010; Flinck et al., 2005; Ismail et al., 2007). Validation of the woman’s experience and a helpful response from the healthcare provider were important to women who were abused (Bonomi et al., 2009; Campbell et al., 2009; Fanslow & Robinson, 2010; Flinck et al., 2005; Kelleher & McGilloway, 2009). Adolescents who did not receive strong support from family or healthcare providers and community agencies found that they returned to the abusive partner because they felt they had no other options for support, which perpetuated the abuse and placed them a higher risk for future abuse (Ismail et al., 2007). 94

Researchers have found that when women reported violence only one half to one third of healthcare professionals had helpful responses (Fanslow & Robinson, 2010). While ranking the responses of healthcare providers low in traditional medical systems, women reported more positive outcomes from mental health providers, rape crisis centers, violence shelter workers, and SANEs (Campbell et al., 2009; Ismail et al., 2007). Healthcare Provider Recommendations Mid-life women demonstrated differences in their presentation with sexual assault, making it appropriate to utilize a SANE who has been educated specifically in the care of victims of sexual assault across the life span. Since 1992, the Joint Commission has required emergency and ambulatory care facilities to have protocols on rape, sexual molestation, and domestic abuse (Ledray, 2001). In 1997, the Joint Commission required healthcare facilities to develop and train staff to use criteria, which identifies possible victims. Due to these efforts, healthcare facilities are more aware of the needs of sexual assault victims and the unique set of problems associated with their varying demographics. Despite the physiological changes that occur as women age, the protocols for sexual assault examination are not varied based on age (U.S. Department of Justice Office on Violence Against Women, 2013). Understanding age differences remains a key to effectively treating sexual assault. SANEs, the largest group of forensic nurse examiners, have received the specialized training necessary to support the needs of all sexual assault victims and have the nursing background in development to support changes in care (Ledray, 2006). The SANE or healthcare provider should also pay close attention to medications taken by the victim daily.Some medications can slow the healing process in the victim, or create circumstances that promote further injury. For example, a victim who takes an anticoagulant daily may be more prone to bleeding from the assault and physical assessment. Future Directions for Research More information is needed on the sexual assault experiences of single mid-life women. The studies discussed in this article all examine varying age ranges, marital status, and use inconsistent definitions of sexual assault terms. The study populations are limited by socioeconomic status, race, or recruitment sites. Most studies recruited participants from emergency rooms or sexual assault centers in primarily urban areas. It may be that these are the principal areas in which to find the highest proportion of women who have experienced sexual assault; however, primary care clinics and urgent care centers may also identify cases of sexual assault. The use of emergency room and sexual assault clinics in urban areas Perspectives in Psychiatric Care 51 (2015) 86–97 © 2014 Wiley Periodicals, Inc.

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limits the ability of the researcher to generalize results to the larger population. A wider range of recruitment sites in rural as well as urban areas may yield differences in participant responses. The responses of single women should be separated from the responses of married and cohabitating women to identify differences in experiences, physiological injury, psychological distress, and community resource needs. As the number of single mid-life women continues to increase in the population, healthcare providers need to screen single mid-life women for the occurrence of sexual assault. They also need to be aware of the psychological impact of sexual assault on a woman’s health and recognize that single women in mid-life who date and are sexually active may need encouragement to talk about their sexual assault experiences. Many women in the studies reviewed were diagnosed with preexisting psychiatric diagnoses. A further examination of the relationship between mental health diagnoses and sexual assault may contribute to the development of interventions for single mid-life women who are sexually assaulted. Evaluation of long-term physical and psychological effects of sexual assault and the patterns of violence related to the type of relationship between the victim and assailant would provide more information to improve the responses of healthcare providers to the woman’s needs and lead to the development of specific community resources (Stermac et al., 2006). The available resources that describe the physiological consequences of sexual assault are outdated. The most current study that reported physiological injuries from the sexual assault of mid-life women was published in 2008. Additional research to determine the adequacy of the previous research and the availability of new information should be carried out with this population. The additional research may reduce bias among healthcare providers toward women who experience sexual assault. Examination of the effects of traditional roles and socialization on women’s perceptions of the experience of sexual assault should be studied to improve the ability of healthcare professionals to provide care (Kalra et al., 1998). The history of traditional gender roles, rape myth beliefs, and sociocultural norms may prevent mid-life women from discussing sexual assault experiences and approaching the topic with healthcare providers. More research needs to be conducted to determine the origins of a woman’s traditional role beliefs and the adherence to rape myths to change the harmful effects of these beliefs. Although there is research that identifies the response women want from healthcare providers, reinforcement of nonjudgmental responses to mid-life women who report sexual assault may need to occur in prelicensure nursing education programs and advanced practice nursing education programs to ensure appropriate responses in the clinical setting. There is little research that focuses on the nurse’s response to women who report sexual assault, with the exception of SANEs. Most Perspectives in Psychiatric Care 51 (2015) 86–97 © 2014 Wiley Periodicals, Inc.

research examines the responses of healthcare providers as one group. Research into the nurse’s responses and nurse practitioner responses will provide direction for nursing education programs and clinical practice.

Conclusion There are few studies that examine sexual assault as experienced by single mid-life women. The current studies tend to group participants in age groups from adolescents to older women, do not address study results by age and marital status, or do not separate participant responses by age and marital status (Bonomi et al., 2009; Fanslow & Robinson, 2010; Lipsky et al., 2005; Stermac et al., 2006; Symes et al., 2010). None of the studies reviewed exclusively examined sexual assault of single mid-life women. As the research evaluated for this paper found differences in experiences for women who experienced sexual assault, examining the experiences of single mid-life women would add significantly to the research literature by contributing insight to nursing education programs, improving clinical practice, and developing community resources for women.

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