Violence and Victims, Volume 30, Number 4, 2015

The Role of Sexual Orientation in the Victimization and Recovery of Sexual Assault Survivors Rannveig Sigurvinsdottir, MA Sarah E. Ullman, PhD University of Illinois at Chicago Few studies examine the sexual violence victimization and recovery of nonheterosexuals. Limited available research suggests that lesbian and bisexual women are at increased risk for sexual violence and experience more recovery problems following assault than heterosexuals. We examine differences by sexual orientation in victimization, recovery, and social reactions as well as whether racial differences relate to recovery in female sexual assault survivors (N 5 1,863) from the community. Bisexual women emerged as a distinct group from heterosexual women with greater recovery problems and experienced greater impact of social reactions. Black sexual minority women also had more negative outcomes than White sexual minority women. Results suggest that differences in sexual orientation and race relate to poorer recovery, especially for survivors with multiple marginalized identities.

Keywords: sexual assault; sexual orientation; victimization; recovery

S

exual violence victimization and recovery of nonheterosexuals remains understudied (Balsam, Beauchaine, & Rothblum, 2005), although lesbian and bisexual women are at higher risk for sexual victimization than heterosexual women (Drabble, Trocki, Hughes, Korcha, & Lown, 2013; National Center for Injury Prevention and Control, 2013). A nationally representative study showed that lifetime sexual violence victimization is 79.6% for bisexual women, 59.1% for lesbian women, and 43.2% for heterosexual women (Drabble et al., 2013), with 46.1%, 13.1%, and 17.4% having lifetime completed rape, respectively (National Center for Injury Prevention and Control, 2013). Furthermore, a review of 75 studies showed lifetime victimization rates of 16%–85% for lesbian and bisexual women (Rothman, Exner, & Baughman, 2011). For women in general, the lifetime prevalence of sexual assault has been estimated at around 20% (Tjaden & Thoennes, 2000). As these statistics show, the limited studies available have yielded highly varying results. Some of this variability may be explained by different definitions of sexual assault (some assess only completed rapes, whereas others use broader definitions), and some studies used nonrepresentative samples. Regardless, the overall trend seems to be that lesbians and bisexual women are at higher risk for sexual violence than heterosexual women. Lesbian and bisexual women are at increased risk throughout their lifetime, both as children or as adults (Friedman et al., 2011; Hughes, McCabe, Wilsnack, West, & Boyd, 2010; Morris & Balsam, 2003; Roberts, Austin, Corliss, Vandermorris, & Koenen, 2010; 636

© 2015 Springer Publishing Company http://dx.doi.org/10.1891/0886-6708.VV-D-13-00066

Sexual Orientation of Sexual Assault Survivors637

Rothman et al., 2011). However, one study of adult sexual assault found no differences in victimization rates between groups with differing sexual orientations (Hughes et al., 2010). Childhood sexual abuse is more commonly reported by lesbian and bisexual women (Balsam et al., 2005; Gentlewarrior & Fountain, 2009; Hughes, Johnson, & Wilsnack, 2001) and even among heterosexual-identified women with same-sex partners (Roberts et al., 2010) than heterosexual women without same-sex partners. Sexual orientation predicts increased risk of victimization even when other known risk factors have been controlled (e.g., gender, age education, prior sexual victimization experiences; Balsam et al., 2005).

VICTIMIZATION HISTORY AND ASSAULT CHARACTERISTICS Victimization characteristics differ by sexual orientation, such as the relationship between survivor and perpetrator. Intimate partner victimization is most common for bisexual women (all violence 5 63.1%, severe violence 5 49.3%), followed by lesbians (all violence 5 43.8%, severe violence 5 29.4%) and heterosexual women (all violence 5 35.0%, severe violence 5 23.6%; National Center for Injury Prevention and Control, 2013). Lesbians are most likely to be victimized by a relative (Long, Ullman, Long, Mason, & Starzynski, 2007). Second, men are more likely to be perpetrators of sexual assault, regardless of survivor sexual orientation (Balsam et al., 2005; Bradford, Ryan, & Rothblum, 1994; Brand & Kidd, 1986; Moore & Waterman, 1999; Morris & Balsam, 2003). For example, for violence other than rape, 85.2% of lesbians, 87.5% of bisexual women, and 94.7% of heterosexual women were only victimized by men (National Center for Injury Prevention and Control, 2013). It is important to note, however, that in depth research on lesbian women specifically indicates that same-sex partner violence including sexual assault are serious problems in this population (see Girshick, 2002, for a review).

PSYCHOSOCIAL IMPACT Sexual assault survivors may experience problems, such as alcohol or drug abuse, posttraumatic stress disorder (PTSD), and depression (Campbell, Dworkin, & Cabral, 2009). The negative impact of victimization is disproportionately high for sexual minorities, with 57.4% of bisexual women and 33.5% of lesbian women reporting at least one negative impact (e.g., feeling afraid, missing work, PTSD symptoms), compared to 28.2% of heterosexual women (National Center for Injury Prevention and Control, 2013). Nonheterosexual women are also more likely to report hazardous drinking than heterosexual women, even after controlling for victimization and demographics (Drabble et al., 2013). Bisexual women also experience greater PTSD symptoms following their victimization than lesbian or heterosexual women (Long et al., 2007). Existing studies are very limited and need to be expanded on to better understand the nature and consequences for survivors of different sexual orientations.

SOCIAL REACTIONS When survivors disclose their unwanted sexual experiences, the other person’s reaction can affect the survivor’s recovery. Negative social reactions predict a negative impact on

638

Sigurvinsdottir and Ullman

health and well-being (Ullman, 1996; Ullman & Siegel, 1995), whereas the impact of positive reactions is smaller (Campbell, Ahrens, Sefl, Wasco, & Barnes, 2001). Only one study has examined the impact of social reactions on lesbian and bisexual women and found no differences in negative reactions but that lesbian women receive the fewest positive reactions (Long et al., 2007).

RACE Our knowledge of the intersection of race and sexual orientation in the context of sexual assault is extremely limited. Studies do suggest that sexual minorities of color may experience even greater prejudice than White sexual minorities (Reed & Valenti, 2012). This effect may be especially strong for female sexual minorities of color because they experience racism, sexism, and heterosexism simultaneously (Bowleg, Huang, Brooks, Black, & Burkholder, 2003). Intersecting identities can therefore have a greater detrimental effect on those who are marginalized (National Coalition of Anti-Violence Programs, 2011).

PRESENT STUDY This exploratory study looks at the impact of sexual assault on lesbian and bisexual women. We address gaps in the literature by examining whether there are sexual orientation differences in victimization history, assault characteristics, post-assault recovery, social reactions, and the role of race as it intersects with sexual orientation on these outcomes. Based on past research, we expect lesbian and bisexual women to be more likely to have experienced child sexual abuse than heterosexual women. We will also test for differences in child sexual abuse severity. We also expect bisexual women to be more likely to be victimized by intimate partners in adult sexual assaults and lesbian women to be related to the perpetrator, as suggested by previous research (Long et al., 2007). For perpetrator gender, we predict that survivors are more likely to have been victimized by a man but will also test differences by survivor sexual orientation for female perpetrators. Finally, very little is known about differences by sexual orientation in assault severity or injury severity as well as differences in completed and attempted rape. All of the variables described here are important in the recovery of survivors in general, so they may play a role among sexual minorities as well. Gaps also exist about the psychosocial impact of sexual violence on lesbian and bisexual women. For example, we know nothing about differences in drug abuse or depression symptoms by sexual orientation. Regarding alcohol use, we predict that lesbian and bisexual women will report more drinking than heterosexual women (Drabble, Midanik, & Trocki, 2005). We also predict that bisexual women will report the greatest PTSD symptoms (Long et al., 2007). Social reactions to survivors also need to be examined more closely, including both positive and negative reactions, as well as whether the relationship between reactions and recovery outcomes differs by sexual orientation. We predict that bisexual women will receive the fewest positive social reactions. Lastly, more information is needed to explore the relationship between race and sexual orientation on recovery outcomes. We predict that being non-White and a sexual minority predicts increased psychosocial problems.

Sexual Orientation of Sexual Assault Survivors639

METHOD Participants A volunteer sample of women (N 5 1,863) from the greater Chicago area, ranging in age from 18 to 71 years (M 5 31.1, SD 5 12.2) was recruited for a mail survey of unwanted sexual experiences. The response rate was 85%. The sample was ethnically diverse (45% African American, 35% White, 2% Asian, 8.1% other; 14% Hispanic, assessed separately). The sample was well educated with 34.6% having a college degree or higher, 43.5% having some college education, and 21.9% having a high school education or less. Just under half of the sample (46.8%) was currently employed, although income levels were relatively low, with 68% of women having household incomes of less than $30,000. The largest group of participants identified as heterosexual, 83%, whereas 11% identified as bisexual and 6% as lesbian. Although the percentage of bisexual and lesbian women was much lower, given the large sample, the groups are large enough for the descriptive exploratory analyses.

Procedure Participants completed a paid mail survey about their unwanted sexual experiences as part of a study on the impact of sexual assault on adult community-residing women in the Chicago metropolitan area. Recruitment was accomplished via weekly advertisements in local newspapers, on craigslist, and through university mass mail. In addition, fliers were posted in the community, at other Chicago colleges and universities, as well as at agencies that cater to community members in general and victims of violence against women specifically (e.g., community centers, cultural centers, substance abuse clinics, and domestic violence and rape crisis centers). Interested women called the research office and were screened for eligibility using the following criteria: (a) had an unwanted sexual experience at the age of 14 years or older, (b) were 18 years or older at the time of participation, and (c) had previously told someone about their unwanted sexual experience. We sent eligible participants packets containing the survey, an informed consent sheet, a list of community resources for dealing with victimization, and a stamped return envelope for the completed survey. Participants were paid $25 for their participation. The university’s institutional review board approved all study procedures and documents.

Measures Sexual Victimization. Sexual victimization in both childhood (prior to age 14 years) and adulthood (at age 14 years or older) was assessed using a modified version of the Sexual Experiences Survey (SES; Koss, Gidycz, & Wisniewski, 1987). The revised measure (Testa, VanZile-Tamsen, Livingston, & Koss, 2004) assesses various forms of sexual assault including unwanted sexual contact, verbally coerced intercourse, attempted rape, and rape resulting from force or incapacitation (e.g., from alcohol or drugs). The revised 11-item SES measure has good reliability (a 5 .73); similar reliability was found in our sample (a 5 .78). Both child sexual abuse and adult sexual assault were assessed with the SES measure in the survey, but no measure of adult sexual assault was included in the analyses because all women had experienced a sexual assault in adulthood, most of which were completed rape (74.2%).

640

Sigurvinsdottir and Ullman

Childhood Sexual Abuse Severity. Responses to the SES prior to age 14 years were used to code a five-level ordinal variable indicating child sexual abuse severity ranging from (1) fondling/kissing through (5) completed rape (M 5 1.88, SD 5 1.72, a 5 .89). Childhood sexual abuse was assessed separately from other traumatic events, with the SES, because this trauma requires multiple specific behavioral questions. Posttraumatic Stress Symptoms. PTSD symptoms were assessed with the Posttraumatic Stress Diagnostic Scale (PDS; Foa, 1995), a standardized 17-item instrument based on Diagnostic and Statistical Manual of Mental Disorders (4th ed.; DSM-IV) criteria. On a scale ranging from 0 (not at all) to 3 (almost always), women rated how often each symptom (i.e., reexperiencing/intrusion, avoidance/numbing, hyperarousal) bothered them in relation to the sexual assault during the past 12 months. If women had more than one assault, PTSD symptoms were assessed with respect to the most serious assault. The PDS has acceptable test–retest reliability for a PTSD diagnosis in assault survivors over 2 weeks (k 5 .74; Foa, Cashman, Jaycox, & Perry 1997). The 17 items were summed to assess the extent of posttraumatic symptomatology (M 5 21.13, SD 5 12.93, a 5 .93 in this sample). Depression. Depression was measured using a seven-item version of the Center of Epidemiologic Studies Depression Scale (CESD-7) modified by Mirowsky and Ross (1990). Participants were asked to rate their symptoms over the past 12 months using a 5-point Likert scale from 0 (never) to 5 (always). In this sample, a 5 .86 (M 5 2.01, SD 5 .75). Problem Drinking. Past-year problem drinking was assessed with the Michigan Alcoholism Screening Test (Selzer, 1971), a widely used 25-item standardized self-report screening instrument for alcohol abuse and dependence that is valid and reliable (Gibbs, 1983). The number of alcohol-related problems during the past year was coded as a continuous measure (M 5 2.90, SD 5 4.22, a 5 .80 in this sample) and indicates a low level of alcohol problems, with only 20% problem drinkers, compared to 38% in another similar study of sexual assault victims (Ullman, Starzynski, Long, Mason, & Long, 2008). Problem Drug Use. Problem drug use was measured with a modified, shortened version of the Drug Abuse Screening Test, the DAST-10 (McCabe, Boyd, Cranford, Morales, & Slayden, 2006). The DAST-10 has good internal consistency (a 5 .86) and temporal stability (test–retest intraclass correlation coefficient 5 .71) and can identify individuals needing more intensive assessment for drug abuse problems (Cocco & Carey, 1998). The scale was also reliable for our sample, a 5 .86. We found a low level of problem drug use according to Skinner’s (1982) DAST screening guidelines (M 5 2.02, SD 5 2.68), with 29% meeting the criteria for problem drug use, a greater level of problem symptoms in comparison to other samples of women (McCabe et al., 2006). Social Reactions. The Social Reactions Questionnaire has 48 items which are answered on a 5-point Likert scale. Items ask how other people reacted to survivors when they disclosed their victimization. The measure has positive (M 5 2.22, SD 5 0.95) and negative (M 5 0.96, SD 5 0.80) overall summary computed scales which will be used to compare groups on the social reactions received (Ullman, 2000). Previous studies have confirmed the reliability and validity of this measure (Ullman, 2000). In addition to these measures, participants were asked about the gender of the perpetrator (male or female) and their relationship to the perpetrator (spouse, partner, relative, acquaintance, or a stranger). Participants were also asked about what injuries they sustained during their unwanted experience (cuts, bruises, etc.) as well as how and whether they resisted the perpetrator (e.g., pushing away, asking the perpetrator to stop).

Sexual Orientation of Sexual Assault Survivors641

Analysis We first examined whether differences exist in victimization by sexual orientation using a chi-square test to see whether child sexual abuse is more common for lesbian and bisexual women than heterosexual women. Between-groups ANOVAs were used to examine differences in child sexual abuse severity, differences in perpetrator gender, and whether relationship to the perpetrator differs by sexual orientation. Between-groups ANOVAs were also used to explore differences in assault severity and injury severity by sexual orientation. Between-groups ANOVAs were performed to examine whether lesbian and bisexual women have greater PTSD symptoms, more depressive symptoms, and more problem drinking and drug use than heterosexual women. Differences in social reactions were examined using between-groups ANOVAs and multiple regressions to examine the relationship between social reactions and recovery outcomes. Lastly, a between-groups ANOVA was used to examine racial differences in recovery of survivors by sexual orientation.

RESULTS Victimization History and Assault Characteristics We examined the frequency of childhood sexual abuse (CSA); CSA severity; and adult sexual assault characteristics of relationship to perpetrator, gender of perpetrator, assault severity, and injury severity. When examining whether participants had experienced CSA, a chi-square test found significant differences by sexual orientation, x2 (2, N 5 1664) 5 6.75, p 5 .03. A follow-up t test showed that lesbian and bisexual women were equally likely to have CSA victimization (M 5 0.73) and heterosexual women were significantly lower (M 5 0.65). For CSA severity, a between-groups ANOVA performed showed a significant difference in CSA severity between lesbian, bisexual, and heterosexual women, F(2, 1661) 5 6.42, p 5 .002. A follow-up Bonferroni test showed that bisexual women (M 5 2.27) had significantly higher CSA severity than heterosexual women (M 5 1.82), mean difference 5 20.45, p 5 .004. No significant difference exists between lesbian women (M 5 2.14) and bisexual women or between heterosexual and lesbian women for CSA severity. When examining relationship to perpetrator, there was no difference between lesbian, bisexual, and heterosexual women when the perpetrator was a stranger, nonromantic acquaintance, casual or first date, romantic acquaintance, or husband. However, there was a significant difference for victimization by relatives, F(2, 1846) 5 6.39, p 5 .006. A follow-up test showed that as expected, lesbian women (M 5 0.24) were significantly more likely to be victimized by relatives than bisexual (M 5 0.09) or heterosexual women (M 5 0.13), mean difference 5 0.15, p 5 .001 and mean difference 5 20.11, p 5 .005, respectively. Lesbians were therefore most likely to be victimized by relatives. An ANOVA was done to test whether all three groups were more likely to be sexually assaulted by men than women. This hypothesis was confirmed as all groups were more likely to be victimized by men than women. Heterosexual women had the highest proportion of male perpetrators, with 96.5% victimized by men, 1.1% by women, and 2.4% by both men and women. Bisexual women had male perpetrators in 92.6% of cases, female perpetrators in 3.2% of cases, and perpetrators of both genders in 4.2% of cases. Lesbian women were victimized by men in 89.4% of cases, by women 6.7% of cases, and both

642

Sigurvinsdottir and Ullman

in 3.8% of cases. When comparing perpetrator gender and survivor sexual orientation, a between-groups ANOVA was significant, F(2, 1851) 5 5.07, p 5 .006. A follow-up test showed that lesbian women (M 5 1.14) were significantly more likely to have female perpetrators or perpetrators of both genders than heterosexual women (M 5 1.09), mean difference 5 0.09, p 5 .04. There was no difference between lesbian and bisexual women (M 5 1.12) or between lesbian and heterosexual women in perpetrator gender. We tested for sexual orientation differences in assault severity, injury severity, and completed versus attempted rape. There were no differences for assault severity either for violence in general or sexual abuse. There was also no significant difference between groups on injury severity. There were no differences by sexual orientation in completed rape except for rapes when the perpetrator gave the survivor alcohol or drugs, F(2, 1754) 5 5.13, p 5 .006. A follow-up test with Bonferroni correction showed that bisexual women were significantly more likely to endorse this item (M 5 0.46) than heterosexual women (M 5 0.34), mean difference 5 20.12, p 5 .004. There was no significant difference between lesbian women (M 5 0.35) and the other groups. For attempted rape, there was no clear pattern of differences between groups by sexual orientation.

Survivor Recovery Outcomes A summary of results for recovery outcomes and social reactions can be seen in Table 1. Recovery outcomes included were PTSD symptomatology, depression symptoms, problem drinking, and drug use. A between-groups ANOVA showed a significant difference in PTSD symptoms between lesbian, bisexual, and heterosexual women, F(2, 1734) 5 12.45, p , .001. Follow-up tests showed that bisexual women (M 5 24.89) reported significantly greater PTSD symptoms than heterosexual women (M 5 20.46), mean difference 5 24.43, p , .001. Lesbian women (M 5 24.15) also reported greater PTSD symptoms than heterosexual women, mean difference 5 23.69, p 5 .02. There was no significant difference between lesbian and bisexual women. Therefore, lesbian and bisexual women reported significantly greater PTSD symptoms than heterosexual women. These results partially confirm the hypothesis, with bisexual women reporting greater PTSD symptoms than heterosexual women, but lesbian women reported similar levels as bisexual women. TABLE 1.  Psychosocial Outcomes and Social Reactions by Sexual Orientation Variable

Heterosexual

Bisexual

Lesbian

Problem drinking

2.77a

4.09a

3.31a

Drug abuse

2.23a

3.10a

2.46

Depression symptoms

1.98a

2.21a

2.15

PTSD symptoms

20.34a

24.89a

24.15b

Positive reactions

2.21

2.26a

2.25

Negative reactions

0.93b

1.14b

1.06

Note. PTSD 5 posttraumatic stress disorder. aDifference between groups significant at the p , .001 level. bDifference between groups significant at the p , .05 level.

Sexual Orientation of Sexual Assault Survivors643

To test whether sexual minority women had greater depression symptoms, a betweengroups ANOVA showed a significant difference, F(2, 1847) 5 9.94, p , .001. A follow-up Bonferroni test revealed that bisexual women (M 5 2.21) reported significantly more depression symptoms than heterosexual women (M 5 1.98), mean difference 5 20.23, p , .001. However, there was no significant difference between lesbian (M 5 2.15) and bisexual women or between heterosexual and lesbian women. Therefore, depression symptoms are elevated for bisexual women compared to heterosexual women but not for lesbian women. As expected, a between-groups ANOVA showed a significant difference in problem drinking between lesbian, bisexual, and heterosexual women, F(2, 1747) 5 9.14, p , .001. A follow-up Bonferroni correction showed greater problem drinking in bisexual women (M 5 4.09) than heterosexual women (M 5 2.72), mean difference 5 21.37, p , .001. There was no significant difference between lesbian and bisexual women or between heterosexual and lesbian women. To examine whether sexual minority women had more problem drug use, a betweengroups ANOVA was done, which showed a significant difference in problem drug use between lesbian, bisexual, and heterosexual women, F(2, 1465) 5 6.62, p 5 .001. A follow-up test showed that bisexual women (M 5 3.10) reported significantly more problem drug use than heterosexual women (M 5 2.28), mean difference 5 20.81, p 5 .001. There was no significant difference between lesbian (M 5 2.72) and bisexual women or between heterosexual and lesbian women. Post-Assault Social Reactions. A between-groups ANOVA showed no significant differences between groups on positive reactions, F(2, 1609) 5 0.22, p 5 .81. For negative reactions, a between-groups ANOVA showed a significant difference between groups, F(2, 1603) 5 5.52, p 5 .004. A follow-up test revealed that bisexual women (M 5 1.14) received significantly greater negative reactions than heterosexual women (M 5 0.93), mean difference 5 20.20, p 5 .006. There was no significant difference between lesbian (M 5 1.06) and bisexual women or between lesbian and heterosexual women. Moderation of Negative Reactions: Recovery Outcome Relationships by Sexual Orientation. To explore whether sexual minority status moderated the association between negative reactions and recovery, we conducted a multiple linear regression analysis with PTSD symptoms as the dependent variable. Sexual orientation significantly moderated the relationship between negative reactions and PTSD symptoms, such that bisexual women have a stronger relationship between negative reactions and PTSD symptoms than heterosexual women, B 5 2.66, t(1502) 5 2.27, p 5 .007, and the same is true for lesbians when compared to heterosexual women, B 5 2.86, t(1502) 5 2.22, p 5 .03. Negative reactions and sexual orientation explained a significant portion of the variance in PTSD symptoms, R2 5 0.20, F(3, 1502) 5 125.14, p , .001. For problem drinking, sexual orientation showed a stronger relationship between negative reactions and problem drinking for bisexual women, B 5 1.04, t(1512), p 5 .003. This relationship did not emerge for lesbian women. Together, negative social reactions and sexual orientation explain comparatively less variance in problem drinking than they do for PTSD (although the model is still significant), R2 5 0.03, F(3, 1512) 5 15.01, p , .001. Finally, only bisexual women had a stronger relationship between negative reactions and problem drug use, B 5 0.68, t(1286) 5 2.91, p 5 .004. As with problem drinking, explained variance was low but still significant, R25 0.04, F(3, 1286) 5 17.54, p , .001. These results show that negative reactions can play a larger role for bisexual women on all of the recovery outcomes considered here and that lesbian women show the same pattern only for PTSD symptoms.

644

Sigurvinsdottir and Ullman

Race by Sexual Orientation. Lastly, we compared Black and White women in our sample of different sexual orientations. We wanted to know whether Black sexual minority women exhibit poorer recovery outcomes than White women, possibly because of multiple marginalization. Thus, we conducted two-way between-groups ANOVAs testing for main effects of sexual orientation and race as well as interaction between them. Table 2 shows the mean results of each recovery outcome by sexual orientation and race. We found a significant interaction only for problem drinking, F(11, 1631) 5 2.03, p 5 .02, and a significant main effect for sexual orientation, F(2, 1642) 5 8.27, p , .001, but not a main effect for race. For problem drug use, there was no interaction but significant main effects for both sexual orientation, F(2, 1381) 5 7.73, p , .001, and race, F(5, 1381) 5 2.68, p 5 .01. For PTSD, there was no significant interaction but significant main effects of sexual orientation, F(2, 1633) 5 13.19, p , .001, and race, F(6, 1633) 5 2.49, p 5 .02. Finally, for depression symptoms, there was no significant interaction or main effect for race, but there was a significant main effect for sexual orientation, F(2, 1738) 5 10.41, p , .001. Among bisexual women, there were no race differences for PTSD, depression symptoms, or problem drug use. However, Black bisexual women (M 5 5.12) reported greater problem drinking than White bisexual women (M 5 3.29), t(135) 5 2.12, p 5 .04. Lesbian women had no race differences in depression symptoms or problem drug use, but Black lesbians (M 5 25.39) reported greater PTSD symptoms than White lesbians (M 5 19.45), t(77) 5 2.01, p 5 .05. Black women (M 5 4.43) also had significantly higher problem drinking than White women (M 5 1.86), t(76) 5 2.84, p 5 .01. For heterosexual women, Black women (M 5 21.02) reported significantly greater PTSD symptoms than White women (M 5 19.30), t(1166) 5 2.30, p 5 .02, but there were no differences in depression symptoms, problem drinking, or problem drug use. These results show that for lesbian and bisexual women, problem drinking is greater among Black women than White women. Black lesbian and heterosexual women also report greater PTSD symptoms than White women across sexual orientation. Next, sexual minorities were compared within each race. Among Black women, there was a significant difference in depression symptoms, F(2, 828) 5 4.30, p 5 .01. A followup Bonferroni correction showed that bisexual women (M 5 2.24) reported significantly more depressive symptoms than heterosexual women (M 5 1.99), mean difference 5 20.25, p 5 .02. Lesbian women (M 5 2.11) did not differ from the other groups. Black women also reported differences in PTSD symptoms by sexual orientation, F(2, 757) 5 7.37, p 5 .001. Bisexual women (M 5 26.44) reported significantly greater PTSD sympTABLE 2.  Recovery Outcomes by Sexual Orientation and Race Black

White

Heterosexual Bisexual Lesbian Heterosexual Bisexual Lesbian Problem drinking

 2.68

 5.12

 4.44

 2.99

 3.29

 1.86

Drug abuse

 2.51

 3.24

 3.11

 2.21

 2.88

 1.89

Depression symptoms

 1.99

 2.24

 2.11

 1.94

 2.15

 1.97

PTSD symptoms

21.02

26.44

25.39

19.3

22.44

19.45

Note. PTSD 5 posttraumatic stress disorder.

Sexual Orientation of Sexual Assault Survivors645

toms than heterosexual women (M 5 21.02), mean difference 5 25.43, p 5 .002. Again, lesbians did not differ from the other groups (M 5 25.39). For problem drinking, a between-groups ANOVA showed a significant difference by sexual orientation, F(2, 775) 5 12.20, p , .001. Lesbian women (M 5 4.44) were significantly more likely to report problem drinking than heterosexual women (M 5 2.68), mean difference 5 21.76, p 5 .04. Bisexual women (M 5 5.12) were also more likely to report problem drinking than heterosexual women, mean difference 5 22.44, p , .001. There were no differences in problem drug use by sexual orientation for Black women. These results show that when comparing outcomes for sexual minority Black women to heterosexual Black women, they have worse depression, PTSD, and problem drinking, but not problem drug use symptoms. Among White women, there were no significant differences by sexual orientation for depressive symptoms, PTSD symptoms, problem drinking, or problem drug use.

DISCUSSION We examined the role of sexual orientation on victimization history, assault characteristics, social reactions, and psychological and problem substance use outcomes for sexual assault survivors in a large sample of survivors recruited from a large urban area. As in other past research (Rothman et al., 2011), we found slight differences in CSA frequency which seems to indicate that lesbian and bisexual women are at increased risk compared to heterosexual women. As predicted, lesbian women were more likely to be victimized by relatives, replicating Long et al. (2007), and men are overall more likely to be perpetrators than women. We have also expanded current knowledge on the topic by finding more severe CSA in bisexual women than in heterosexuals and that lesbian women are more likely to be assaulted by females than were heterosexual women. For survivor recovery, as expected, we found elevated rates of PTSD symptoms in bisexual women when compared to heterosexual women, as in one past study (Long et al., 2007), and the same pattern for lesbian women, in contrast to Long et al. (2007) who found no difference for lesbians from other groups. We found greater problem drinking only for bisexual women but had expected elevated drinking for lesbians as well (Drabble et al., 2005). Adding to the literature on this topic, we found that only bisexual women reported more depression symptoms and problem drug use than heterosexual women. Across recovery outcomes, bisexual women therefore have more problems than heterosexual women. Lesbian women are similar to heterosexual women, except they have elevated PTSD symptoms. We found no differences in post-assault positive social reactions, but bisexual women had significantly greater negative social reactions than heterosexual women. Because past research shows that negative social reactions predict PTSD symptoms, problem drinking, and drug use (Ullman, 2000; Ullman et al., 2008; Ullman, Townsend, Starzynski, & Long, 2006), we examined whether this relationship was moderated by sexual orientation. Being bisexual or lesbian predicted a stronger relationship between negative reactions and PTSD. However, only bisexual women experienced a stronger relationship between negative reactions and each of the following outcomes: problem drinking, drug use, and depression. The results suggest that when bisexual women receive negative reactions, they play a greater role in their recovery than negative reactions for heterosexual women. The same is true for lesbian women regarding PTSD symptoms. However, we do not know whether these groups are getting worse reactions, whether they are qualitatively different

646

Sigurvinsdottir and Ullman

from other reactions, or whether these reactions just influence these survivors more. Future research is needed to explore why such differences exist. The results indicate that within each racial group, there are greater differences in negative outcomes for Black women than for White women, which may be evidence of the detrimental effects of multiple marginalization. Race also interacted with sexual orientation such that overall, Black sexual minority women had more negative outcomes than White sexual minority women. More specifically, Black bisexual women reported more problem drinking than White bisexual women. Among lesbian women, Black survivors reported more problem drinking and greater PTSD symptoms than White survivors. Heterosexual Black women reported more PTSD symptoms than heterosexual White women. When sexual minority groups were compared within races, there were no differences in outcomes for White women. However, Black bisexual women reported more depression and PTSD symptoms than Black heterosexual women. For problem drinking, both Black bisexual and lesbian women had higher scores than Black heterosexual women. These results underscore the importance of considering the intersection of race and sexual minority status on recovery outcomes in sexual assault survivors. Interventions and services for sexual assault survivors need not only to be sensitive to sexual minority women but also to different racial groups within those sexual minorities. Survivors who experience prejudice because of their sex, race, and sexual orientation simultaneously may have very different needs from people who have not experienced multiple marginalization. This is consistent with previous ideas of the compounding effects of sexual and racial prejudice (Bowleg et al., 2003). Overall, these results suggest that bisexual women may be a distinct group when it comes to sexual assault, as suggested by some past research (Drabble et al., 2013; Long et al., 2007; National Center for Injury Prevention and Control, 2013). Bisexual women experienced more severe child abuse and greater PTSD symptoms than heterosexual women, consistent with Long et al. (2007), and greater problem drinking, problem drug use, and negative social reactions than heterosexual women. Furthermore, the impact of negative reactions on PTSD symptoms, problem drinking, and problem drug use was greater for bisexual women than for other groups. Limitations of the study include the use of a convenience sample and retrospective survey methods. Also, group sizes were very different, so low power may have produced fewer significant differences than expected. This is most likely the case for lesbian women who were the smallest group and were expected to differ more from heterosexual women. More research is needed with larger samples of lesbians in particular because this group is likely to be more hidden in sexual violence research, even though in-depth research with lesbians clearly shows that such violence occurs and has harmful impacts (Girshick, 2002). Our study was not designed to fully account for female perpetrators as we only had one question on gender of the perpetrator, so it likely underestimates female-perpetrated sexual assault. Another limitation is that when asked about relationship to perpetrator, one of the options was “husband,” which should probably be worded as “romantic partner” to include women of different sexual orientations. These findings do not take into account sexual attraction and/or sexual histories/number of partners, which also may differ by sexual orientation and perhaps influence sexual victimization experiences and their associated outcomes. Future research is needed to evaluate a broader range of constructs to better understand group differences, particularly in representatively sampled women. This study is an important addition to the sparse literature available on the victimization and recovery of lesbian and bisexual women following sexual assault. These results may help in the development of services that are sensitive to the needs of sexual minorities.

Sexual Orientation of Sexual Assault Survivors647

REFERENCES Balsam, K. F., Beauchaine, T. P., & Rothblum, E. D. (2005). Victimization over the life span: A comparison of lesbian, gay, bisexual and heterosexual siblings. Journal of Consulting and Clinical Psychology, 73(3), 477–487. Bowleg, L., Huang, J., Brooks, K., Black, A., & Burkholder, G. (2003). Triple jeopardy and beyond: Multiple minority stress and resilience among Black lesbians. Journal of Lesbian Studies, 7(4), 87–108. Bradford, J., Ryan, C., & Rothblum, E. (1994). National Lesbian Health Care Survey: Implications for mental health care. Journal of Consulting and Clinical Psychology, 62, 228–242. Brand, P., & Kidd, A. (1986). Frequency of physical aggression in heterosexual and female homosexual dyads. Psychological Reports, 59, 1307–1313. Campbell, R., Ahrens, C. E., Sefl, T., Wasco, S. M., & Barnes, H. E. (2001). Social reactions to rape victims: Healing and hurtful effects of psychological and physical health outcomes. Violence and Victims, 16(3), 287–302. Campbell, R., Dworkin, E., & Cabral, G. (2009). An ecological model of the impact of sexual assault on women’s mental health. Trauma, Violence, and Abuse, 10, 225–246. Cocco, K. M., & Carey, K. B. (1998). Psychometric properties of the Drug Abuse Screening Test in psychiatric outpatients. Psychological Assessment, 10, 408–414. Drabble, L., Midanik, L. T., & Trocki, K. (2005). Reports of alcohol consumption and alcoholrelated problems among homosexual, bisexual, and heterosexual respondents: Results from the 2000 National Alcohol Survey. Journal of Studies on Alcohol, 66, 111–120. Drabble, L., Trocki, K. F., Hughes, T. L., Korcha, R. A., & Lown, A. E. (2013). Sexual orientation differences in the relationship between victimization and hazardous drinking among women in the National Alcohol Survey. Psychology of Addictive Behaviors, 27(3), 639–648. Foa, E. B. (1995). Posttraumatic Stress Diagnostic Scale manual. Minneapolis, MN: National Computer Systems. Foa, E. B., Cashman, L., Jaycox, L., & Perry, K. (1997). The validation of a self-report measure of posttraumatic stress disorder: The Posttraumatic Diagnostic Scale. Psychological Assessment, 9(4), 445–451. Friedman, M. S., Marshal, M. P., Guadamuz, T. E., Wei, C., Wong, C. F., Saewyc, E., & Stall, R. (2011). A meta-analysis of disparities in childhood sexual abuse, parental physical abuse, and peer victimization among sexual minority and sexual nonminority individuals. American Journal of Public Health, 101(8), 1481–1494. Gentlewarrior, S., & Fountain, K. (2009). Culturally competent service provision to lesbian, gay, bisexual and transgender survivors of sexual violence. Retrieved from http://new.vawnet.org/ Assoc_Files_VAWnet/AR_LGBTSexualViolence.pdf Gibbs, L. E. (1983). Validity and reliability of the Michigan Alcoholism Screening Test: A review. Drug and Alcohol Dependence, 12, 279–285. Girshick, L. B. (2002). No sugar, no spice: Reflections on research on woman-to-woman sexual violence. Violence Against Women, 8, 1500–1520. Hughes, T. L., Johnson, T., & Wilsnack, S. C. (2001). Sexual assault and alcohol abuse: A comparison of lesbians and heterosexual women. Journal of Substance Abuse, 13(4), 515–532. Hughes, T., McCabe, S. E., Wilsnack, S. C., West, B. T., & Boyd, C. J. (2010). Victimization and substance use disorders in a national sample of heterosexual and sexual minority women and men. Addiction, 105(12), 2130–2140. 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 students in higher education. Journal of Consulting and Clinical Psychology, 55, 162–170. Long, S. M., Ullman, S. E., Long, L. M., Mason, G. E., & Starzynski, L. L. (2007). Women’s experiences of male-perpetrated sexual assault by sexual orientation. Violence and Victims, 22(6), 684–701. McCabe, S., Boyd, C., Cranford, J., Morales, M., & Slayden, J. (2006). A modified version of the Drug Abuse Screening Test among undergraduate students. Journal of Drug Treatment, 31, 297–303.

648

Sigurvinsdottir and Ullman

Mirowsky, J., & Ross, C. E. (1990). Control or defense? Depression and the sense of control over food and bad outcomes. Journal of Health and Social Behavior, 31, 71–86. Moore, J. F., & Waterman, C. K. (1999). Predicting self-protection against sexual assault in dating relationships among heterosexual men and women, gay men, lesbians, and bisexuals. Journal of College Student Development, 40, 132–140. Morris, J. F., & Balsam, K. F. (2003). Lesbian and bisexual women’s experiences of victimization: Mental health, revictimization, and sexual identity development. Journal of Lesbian Studies, 7(4), 67–85. National Center for Injury Prevention and Control. (2013). The National Intimate Partner and Sexual Violence Survey (NIPSVS): 2010 Findings on victimization by sexual orientation. Atlanta, GA: Center for Disease Control and Prevention. National Coalition of Anti-Violence Programs. (2010). Hate violence against the lesbian, gay, bisexual, transgender and queer communities in the United States in 2009. Retrieved from http://www.avp.org/documents/NCAVP2009HateViolenceReportforWeb.pdf Reed, S. J., & Valenti, M. T. (2012). “It ain’t all as bad as it may seem”: Young Black lesbians’ responses to sexual prejudice. Journal of Homosexuality, 59(5), 703–720. Roberts, A. L., Austin, S. B., Corliss, H. L., Vandermorris, A. K., & Koenen, K. C. (2010). Pervasive trauma exposure among U.S. sexual orientation minority adults and risk of post traumatic stress disorder. American Journal of Public Health, 100, 2433–2441. Rothman, E. F., Exner, D., & Baughman, A. L. (2011). The prevalence of sexual assault against people who identify as gay, lesbian or bisexual in the United States: A systematic review. Trauma, Violence, and Abuse, 12(2), 55–66. Selzer, M. L. (1971). The Michigan Alcoholism Screening Test: The quest for a new diagnostic instrument. The American Journal of Psychiatry, 127(12), 1653–1658. Skinner, H. A. (1982). The Drug Abuse Screening Test. Addictive Behaviors, 7, 363–371. Testa, M., VanZile-Tamsen, C., Livingston, J. A., & Koss, M. P. (2004). Assessing women’s experiences of sexual aggression using the Sexual Experiences Survey: Evidence for validity and implications for research. Psychology of Women Quarterly, 28, 256–265. Tjaden, P., & Thoennes, N. (2000). Full report of the prevalence, incidence, and consequences of intimate partner violence against women: Findings from the National Violence Against Women Survey (Report No. 93-IJ-CX-0012). Washington, DC: National Institute of Justice. Ullman, S. E. (1996). Social reactions, coping strategies, and self-blame attributions in adjustment to sexual assault. Psychology of Women Quarterly, 20(4), 505–526. Ullman, S. E. (2000). Psychometric characteristics of the Social Reactions Questionnaire: A measure of reactions to sexual assault victims. Psychology of Women Quarterly, 24, 257–271. Ullman, S. E., & Siegel, J. M. (1995). Sexual assault, social reactions, and physical health. Women’s Health, 1(4), 289–308. Ullman, S. E., Starzynski, L. L., Long, S., Mason, G., & Long, L. M. (2008). Sexual assault disclosure, social reactions, and problem drinking in women. Journal of Interpersonal Violence, 23, 1235–1257. Ullman, S. E., Townsend, S. M., Starzynski, L. L., & Long, L. M. (2006). Correlates of Polysubstance use and comorbid PTSD in sexual assault victims. Violence and Victims, 21, 727–746. Acknowledgments. The research was supported by the National Institute on Alcohol Abuse and Alcoholism grant R01 #17429 to Sarah E. Ullman. The authors would like to acknowledge Mark Relyea, Cynthia Najdowski, Liana Peter-Hagene, Amanda Vasquez, Meghna Bhat, Rene Bayley, Gabriela Lopez, Farnaz Mohammad-Ali, Saloni Shah, Susan Zimmerman, Diana Acosta, Shana Dubinsky, Brittany Tolar, Hira Rehman, Joanie Noble, Sabina Skupien, Nava Lalehzari, Justyna Ciechonska, and Edith Zarco for assistance with data collection. Correspondence regarding this article should be should be directed to Rannveig Sigurvinsdottir, MA, University of Illinois at Chicago, Department of Psychology, 1007 W. Harrison, M/C 285, Chicago, IL 60607. E-mail: [email protected]