Problems with sexuality after sexual assault

Problems with sexuality after sexual assault

van Berlo, Willy

In this article, we review a number of studies on sexual functioning after sexual assault. Among the studies discussed, three different approaches can be distinguished: the descriptive analyses of sexual functioning and sexual problems, the exploration of factors which predict sexual problems, and the study of relationships between sexual problems and other psychological problems. Although the studies vary considerably in methodology, they point to the conclusion that frequency of sexual contact decreases after sexual assault. Satisfaction and pleasure in sexual activities seem to diminish for a considerable group of victims for at least 1 year postassault. In several studies it was revealed that victims develop sexual problems that can persist for years after the assault. These include response inhibiting problems, such as fear and arousal and desire dysfunctions. Most researchers have found that factors such as a young age, a known offender, and penetration during the assault are related to sexual problems. With respect to physical violence used during the assault, the results are inconclusive. Furthermore, emotions felt during and immediately after the assault, such as anger towards self, shame, and guilt, may predict sexual problems. Avoidance of sexual contact also appears to be related to sexual problems. A loving and understanding partner seems to be a protective factor. Finally it can be concluded that sexual problems are related to other psychological problems, including posttraumatic stress symptoms and depression.

Key Words: rape, sexual assault, sexual functioning, sexual problems.

Since the introduction of Post Traumatic Stress Disorder (PTSD) in the Diagnostic Statistical Manual of Mental Disorders III (DSM III) (American Psychiatric Association, 1980), symptoms experienced by victims after a sexual assault have often been defined in terms of this disorder. PTSD consists of three clusters of symptoms: intrusions, avoidance, and arousal. These symptoms and other psychological problems, such as depression and fear, have been the subject of many investigations over the past 20 years. In several retrospective and prospective studies, it has been found that sexual assault victims suffer from PTSD and that the symptoms may persist for at least a year after the assault (Atkeson, Calhoun, Resick, & Ellis, 1982; Dahl, 1993; Dancu, Riggs, Hearst-Ikeda, Shoyer, & Foa, 1996; Ensink & Van Berlo, 1999; Ensink, Van Berlo, & Everaerd, 2000; Foa & Riggs, 1993; Kilpatrick, Resick, & Veronen, 1981; Kilpatrick, Saunders, Veronen, Best, & Von, 1987; Rothbaum & Foa cited in Foa & Rothbaum, 1998; Rothbaum, Foa, Riggs, Murdock, & Walsh, 1992, Ullman & Siegel, 1993).

In addition to PTSD, increased attention has been devoted to sexual functioning after sexual assault. Important questions are whether changes in sexual behavior and subjective experience occur, which sexual problems victims of sexual assault experience, and how long these problems last. It is also important to investigate which specific factors predict long-term sexual problems. In this article, we review the literature on this subject. We searched all Anglo-Saxon literature concerning sexual dysfunction after sexual assault on adults.1 Sexual assault was defined as rape and attempted rape. A number of researchers have compared the sexual problems of rape victims with those of incest victims. These comparative results will also be noted, but in this review we focus primarily on adult sexual assault victims. In virtually all cases, the focus is on women victims. In exceptional cases, data pertaining to men were reported also, and these will be mentioned separately. Sexual dysfunction has been defined differently by different researchers. We will cover these differences, study by study.

The studies included in this review vary with regard to focus and methodology. We have chosen to cover these studies more or less chronologically, with a distinction between retrospective and prospective studies.

Early Studies

The initial studies on sexual functioning after sexual assault were focused primarily on sexual behavior and satisfaction. Feldman-Summers, Gordon, and Meagher (1979) were the first to systematically and empirically investigate sexual satisfaction and behavior after a rape trauma. Fifteen adult rape victims, who had reported their victimization to a rape counseling centre, were compared to a nonraped sample with regard to satisfaction with sex-related activities before and at different periods of time after the rape, and current sexual behavior. The victimized sample was asked to complete two questionnaires, one concerning satisfaction with various sex-related activities 1 week before the rape, 1 week after the rape, and 2 months after the rape (the time elapsed between participation in the study and the rape ranged from 2 months to 7 years). The second assessed the frequency with which the respondent engaged in various sexual behaviors and current satisfaction with sexual relations. The nonvictimized sample also completed both questionnaires but only rated their current satisfaction with sexual activities; that is, no reference was made to a past episode, as was the case for the victimized sample. Compared to prerape, sexual satisfaction with several sexrelated activities substantially decreased following rape. Autoerotic and affectional experiences (e.g., hugging, holding hands), however, appeared to be unaffected by the rape. The victimized and nonvictimized groups did not differ significantly in frequency of oral sex, sexual intercourse, anal intercourse, masturbation, or orgasms. The victimized group, however, reported less satisfaction with current sexual relations than the nonvictimized group. The authors argued that sexual activities associated with the rape (intercourse, touching of genitals) become less satisfying, whereas autoerotic and affectional activities remain unaffected. Sample size in this study was very small, and the time of the assault varied significantly among the group of victims.

The negative-association hypothesis, as put forward by Feldman-Summers et al. (1979), is that sexual activities occurring during a sexual assault become associated with sexual assault and, therefore, become more problematic in later sexual interactions than sexual activities not occurring during the assault. This hypothesis was not confirmed by Orlando and Koss (1983), who compared a representative university sample of 99 victims with 21 nonvictimized women. The victimized women retrospectively rated their satisfaction with sex-related activities for the month before victimization, the month after, and 3 months after the assault, as well as currently. Because the elapsed time since victimization averaged 18 months, the nonvictimized women rated their satisfaction with the same activities over a 30-day period 19 months, 18 months, and 15 months earlier, and within the last month. Sexual activities were divided in behaviors likely to occur during a rape, such as intercourse and oral-genital stimulation, and unlikely to occur during a rape, such as hugging and stroking. Across time periods and categories of behavior, the sexually victimized women were less satisfied than the nonvictimized women. All women were less satisfied with sexual activities likely to occur during a rape than with activities unlikely to occur. Both victimized and nonvictimized women reported a significant decrease in sexual satisfaction during the 1-month postvictimization measure; 3 months after the rape, the level of satisfaction returned to the original level. Thus, although their level of satisfaction 3 months after the rape was on the same level as before the rape, the victims were less sexually satisfied than the nonvictimized women across all time periods. The authors argued that, because there is no theoretical reason to assume that victimized women differ from nonvictimized women in sexual satisfaction prior to the assault, their lower sexual satisfaction ratings across time periods suggest that victimization results in a generalized lowering of retrospective sexual-satisfaction ratings. And because even nonvictimized women gave lower sexual-satisfaction ratings for the 1-month postvictimization measure, there might be an influence of demand characteristics and an impact of repeated measurement. The authors concluded, however, that because sexual satisfaction of the victims was significantly lower, the impact of sexual assault beyond the level induced by experimental procedures, was demonstrated.

Norris and Feldman-Summers (1981) found that satisfaction was decreased until years after the assault. In a sample of 179 rape victims, between 22% and 33% reported a decrease in overall sexual satisfaction and a decrease in frequency of intercourse, oral sex, and orgasms since the rape. Mean number of years that had elapsed between the time of the rape and participation in the study was 3.4 years, with 88% of the rapes having occurred in the past 5 years.

Koss, Dinero, Seibel, and Cox (1988) located 489 rape victims among a national sample of 3,187 female college students. Of these, 11% were raped by a total stranger, and 85% by acquaintances (i.e., nonromantic acquaintances, casual dates, steady dates, and family members). Four symptoms were assessed: depression, anxiety, relationship satisfaction, and sexual satisfaction. To measure sexual satisfaction, women were asked to indicate, on a 5-point scale, their satisfaction with kissing and hugging, petting and stroking, and sexual intercourse. Victims of stranger rape and acquaintance rape, and the subgroups within the acquaintance rape sample, did not differ on sexual satisfaction. No control group was used.

Kilpatrick, Best, Saunders, and Veronen (1988) compared 43 rape victims with 96 nonvictims with respect to mental health problems, including sexual dysfunctions. On average it had been 15 years since the sexual assault had occurred. Respondents were interviewed by means of the Diagnostic Interview Schedule, a structured interview designed to determine whether a respondent meets the DSM-criteria for diagnosing current and lifetime prevalence of mental health disorders, including sexual dysfunction. Victims were 2 1/2 times more likely to experience sexual dysfunction than were nonvictims. No differences were found between women who were raped by husbands or dates, and strangers.

Becker, Skinner, Abel, Howell, and Bruce (1982) compared 20 rape and 20 attempted rape victims who attended a rape crisis center a year after the sexual assault with respect to several psychological problems, including sexual problems. No differentiation was made between different types of sexual problems. Compared to attempted rape victims, twice as many completed rape victims reported sexual problems a year after the sexual assault (50% vs. 25%).

More than half of a sample of 41 victims in a study by Nadelson, Notman, Zackson, and Gornick (1982) reported sexual difficulties 1 to 2 years postassault, including 25% who described avoidance of any sexual relationship since the rape. In this study sexual problems were not specified either.

The incidence and types of sexual dysfunctions were more systematically investigated by Becker, Skinner, Abel, and Treacy (1982) in a sample of 83 rape and incest victims. The participants were recruited through newspaper articles, social service agencies, rape crisis centers, schools, and hospitals. They were interviewed and completed the Sexual Arousal Inventory (Hoon, Hoon, & Wincze, 1976) to determine the incidence and type of sexual dysfunction. The time since the assault was longer than 1 year for more than 85% of the women. Two series of comparisons were made. Firstly, sexual dysfunctional versus nondysfunctional individuals were compared, and secondly, dysfunctional rape victims versus dysfunctional incest victims. Of all the respondents, 43% reported having no,sexual problems; 57% had at least one sexual dysfunction. There was no statistical difference between dysfunctional rape and incest victims in the number of sexual problems experienced. Over 70% of the dysfunctional women reported that their sexual problems had been precipitated by their sexual assault. No specific information is given about the incest victims and whether the incest was their first sexual experience. Thus, results may be questionable in this respect. The vast majority of sexual dysfunctions were fear of sex, arousal dysfunction, and desire dysfunction. This was especially true for rape victims. Incest victims suffered significantly more than rape victims from secondary anorgasmia, but orgasmic disorder was less common in general. Vaginismus did not occur. The authors stated, therefore, that women’s physiological responding is less interfered with as a consequence of rape and incest, but victims perceive sexual stimuli as anxiety provoking or relabel their sexual feelings as either reduced or inhibited. With regard to assault characteristics, victims who did not develop sexual problems were more likely to have been assaulted with minimal verbal coercion and more physical coercion used by the rapist. The authors suggested that when the attack was clearly a physical assault, the victim may feel less guilt. For those victims who developed sexual symptoms, penetration of the body was much more frequent.

In another study by Becker and colleagues, a control sample was included (Becker, Skinner, Abel, & Cichon, 1986). In this study, 372 sexual assault victims (including rape, attempted rape, incest, and child molestation) were interviewed regarding sexual history and sexual assault history, and compared with 99 nonassaulted women. The victimized participants were recruited via a victim treatment clinic. The time elapsed since the most recent assault ranged from 2 months to 40 years. Fifty-nine percent of the victims reported having at least one sexual problem, whereas only 17% of the nonassaulted women reported any sexual problems. With regard to the women with sexual problems, 66% of the dysfunctional victims were experiencing multiple sexual problems, whereas 23% of the nonassaulted dysfunctional women reported multiple dysfunctions. Compared to the nonassaulted women, the victims in this study reported more early response cycle problems, especially fear of sex and arousal dysfunction. In another publication on the same sample, sexual dysfunctions were related to assault characteristics (Becker, Skinner, Abel, Axelrod, & Cichon, 1984). Compared to rape– only survivors who reported no sexual problems, sexually dysfunctional victims were more likely to have experienced a repeated or ongoing assault, were more likely to have known their assailants, and were significantly younger at the time of their first assault than were the victims who reported no sexual problems. In the incest subgroups, these differences were not found. Penetration, degree of aggression used, the use of a weapon by the assailant, the number of assailants, the location of the assault, and whether the assault was reported to the police were unrelated to the development of an assault-related sexual problem. However, sexually dysfunctional survivors were significantly more likely to hold themselves at least partially responsible for their assaults than were the functional survivors.

Predictors of reactions to sexual assault were also investigated by Siegel, Golding, Stein, Burnam, and Sorenson (1990). This study was part of the Los Angeles Epidemiologic Catchment Area (ECA) study, one of five sites of the NIMH-initiated collaborative ECA program. In this program, prevalence of specific psychiatric disorders were estimated. Respondents in the Los Angeles site were also asked a series of questions regarding lifetime sexual assault. In this retrospective study, both demographic factors and assault characteristics were examined as predictors of reactions to sexual assault. In a random community sample of 3,132 adult men and women, 447 appeared to have experienced sexual assault at least once in their lifetime (34% of these victims were men). Sexual assault was described as sexual contact under pressure or force, with sexual contact meaning touching victim’s sexual parts, touching the perpetrator’s sexual parts, or sexual intercourse. The mean time elapsed between assault and investigation was not mentioned. The victims of sexual assault were asked 15 questions about their emotional and behavioral responses to any sexual assault they had experienced, including three questions about sexual problems (becoming fearful of having sexual relations, having less sexual interest, and having less pleasurable sexual relations). Being fearful of sex, having less sexual interest, and less pleasurable sexual relations was reported by respectively 22%, 33%, and 27% of the female victims, and by 8%, 7%, and 8% of the male victims. Persistence of reactions was measured by looking at the percentage experiencing a reaction in the past year among those whose assault had occurred more than I year ago. Fewer than 15% reported sexual problems. Factor analysis over the 15 items revealed three factors accounting for 52% of the variability: Sexual Distress (decreased sexual interest and sexual pleasure and fear of sex; 35% of variance), Fear/Anxiety (9% of variance) and Depression (9% of variance). Sexual distress was predicted by younger age at assault, greater physical threat during assault, and greater probability of intercourse.

In another study from the same ECA program, associations of sexual assault with reproductive and sexual health symptoms were evaluated (Golding, 1996). In a sample of 3,419 women from Los Angeles and North Carolina, 362 women reported a history of sexual assault. Sexual assault was measured using a single item referring to pressured or forced sexual contact, before and after age 16. Most women were victims of adult sexual assault (88% of Latina’s, 79% of European-American women, 79% of African-American women, and 100% of other women). Questions about the characteristics of the assaults) were also asked. Sexual symptoms were pain during intercourse, lack of sexual pleasure, sexual indifference, and burning sensations in the sexual organs or mouth. Thirteen percent of the assaulted women reported genital burning (both medically explained and unexplained); 32%, sexual indifference; 19%, pain during intercourse (explained and unexplained); and 16%, lack of sexual pleasure. Time between assault and investigation was not mentioned. Sexually assaulted women were more likely to report pain during intercourse (whether or not medically explained) and lack of sexual pleasure than nonassaulted women. With regard to assault characteristics, women who were assaulted more than once were more likely to report medically explained dyspareunia. Women assaulted by their husbands were at higher risk for sexual indifference and lack of sexual pleasure, but women assaulted by acquaintances were at less risk for sexual indifference. Women who had been coerced through persuasion were more likely to report medically explained genital burning, whereas physical threat was negatively related to explained genital burning. Women coerced using love withdrawal were at less risk for unexplained genital burning and dyspareunia. Finally, women who were penetrated were at higher risk than women who were not penetrated for lack of sexual pleasure. Reproductive and sexual health problems were also associated with ethnic and demographic variables. Assault was associated with sexual indifference only among Latinas. According to the authors, previous research suggests that Latinas may report victim-blaming attitudes to a greater extent than European American and African-American women. This factor, combined with Latino cultural values that place great importance on women’s virginity, might make Latinas especially vulnerable to sexual problems following sexual assault. An association with demographic variables was not found with regard to sexual symptoms.

Recent Studies

Shapiro and Schwarz (1997) assessed trauma symptoms and sexual self-esteem after date rape in a population of 199 female college undergraduates. The participants completed several questionnaires, including the Dating and Sexual Activity Questionnaire (Zeanah, 1993), the Sexual Self-Esteem Inventory (Zeanah & Schwarz, 1996), the Trauma Symptom Inventory (TSI) (Briere, 1995) and the Unwanted Sexual Experiences Questionnaire, constructed by the investigators. The Dating and Sexual Activity Questionnaire includes questions about frequency of sexual intercourse and number of lifetime male sexual partners. Women who had zero to three sexual partners and had sexual intercourse less than once per month were considered “sexually inexperienced”; women who had zero to three sexual partners and had sexual intercourse at least once per month were grouped into the “committed sexually active” category; women who had four or more sexual partners and had sexual intercourse at least once per month were categorized as “uncommitted sexually active.” The TSI includes the subscales Dysfunctional Sexual Behavior and Sexual Concerns. Date rape was defined as follows: an incident involving unwanted vaginal intercourse, oral sex, and/or anal sex, and the assailant used physical force or threat of physical force or administered alcohol or drugs. The assailant was a casual or steady date with whom the victim was romantically or sexually interested, and the victim was at least 12 years old at the time of the incident. Twenty-one percent of the participants reported having experienced a date rape; 7% reported attempted date rape, and 5% “other” rapes (e.g., stranger rape). Women in the date rape group indicated more frequent sexual intercourse and more sexual partners than the women who had not been raped. Women who had been date raped were more likely to have reported the uncommitted, sexually active pattern of relationships than the no rape group. The authors stated that if a sexual lifestyle of frequent sexual intercourse and several sexual partners also predated the date rape, it may be a risk factor for these types of rape incidents. It is also possible, according to the authors, that the experience of date rape causes some women to become more promiscuous. Women who had been date raped indicated more trauma symptoms, including dysfunctional sexual behavior and sexual concerns, and lower sexual self-esteem than did women who had never been raped. Lowered sexual self-esteem meant, in this study, that women who had been date raped were less comfortable with what they were doing sexually and were less satisfied with their ability to control their sexual relationships than women who did not have such an experience. These results held even across different sexual lifestyle patterns (i.e., being committed in a sexual relationship or not, and being sexually experienced or not).

Bartoi and Kinder (1998) compared child sexual abuse victims, adult sexual abuse victims, and a control group with regard to current sexual satisfaction, overall quality of relationships with sexual partners, sexual functioning, interpersonal communication with sexual partners, and number of unwanted pregnancies. Child sexual abuse was defined by the following sexual experiences under the age of 16: oral, vaginal, or anal intercourse, or genital manipulation with someone who was at least 5 years older; being touched in a way that made her feel violated; or being coerced into unwanted sexual activity. Adult sexual abuse survivors were participants who were forced into a sexual act after age 16 by either coercion or lack of ability to give consent as a result of alcohol or drug use. In their university sample of 175 sexually active women, 40% were abused in childhood, 20% were abused in adulthood only, and 45% had never been sexually abused. The time between abuse and investigation was not mentioned. Besides questions about relationships with men, sexual activities, and unwanted pregnancies, the participants were administered the Golombok Rust Inventory of Sexual Satisfaction (GRISS). The GRISS measures sexual adjustment and sexual functioning. Sexual dysfunction refers to infrequency of different sexual activities, noncommunication, dissatisfaction with current sexual relationship, avoidance of sexual activity, nonsensuality, vaginismus and anorgasmia. Women who were abused in adulthood were significantly more sexually dissatisfied and less sensual (i.e., a lack of caressing in the sexual relationship) than the women in the comparison group. The first group did not differ from the women who were sexually abused in childhood, who in turn did not differ from the women in the comparison group. No differences were found between the groups with regard to anorgasmia, sexual avoidance, sexual noncommunication, and vaginismus. No difference was found between child abuse and adult abuse groups with regard to quality of interpersonal communication with a sexual partner, number of unplanned pregnancies, or number of unsafe sexual encounters. Because the adult abuse group differed from the comparison group on two variables (sexual dissatisfaction and sensuality), but did not differ from them on the physiological variables, such as vaginismus and anorgasmia, the authors concluded that as a consequence of sexual abuse the psychological aspects of sexuality are disturbed, whereas the physiological aspects remain unaffected. Bartoi and Kinder suggested that sexual abuse causes women to lose insight into their own sexuality. They can no longer recognize what is satisfying or unsatisfying. Because they feel that they have lost control over their sexuality as a result of the trauma, they may be cautious rather than sensual with their partners.

Letourneau, Resnick, Kilpatrick, Saunders, and Best (1996) assumed that trauma victims who develop PTSD are those individuals at risk for long-term sexual problems. The authors suggested that PTSD acts as a moderating variable between trauma and sexual problems: The ability to feel emotions is often impaired in individuals with PTSD, and these emotions may also include feelings associated with intimacy and sexuality. They therefore hypothesized that crime victims with PTSD, regardless of gender or type of trauma, would be at greater risk for sexual problems than crime victims who did not have PTSD, and secondly, that crime victims with severe sexual victimization would be at even greater risk for sexual problems than victims of other types of crime. These hypotheses were tested using a representative community sample of 391 female crime victims, interviewed by means of the Incident Report Interview (Kilpatrick, Saunders, Veronen, Best, & Von, 1987) and a modified version of the Diagnostic Interview Schedule (DIS; Robins, Helzer, Croughan, & Ratcliffe, 1981). Time elapsed between the investigation and the most recent crime was about 10 years. PTSD was assessed with items that were based on the DSM-III criteria for PTSD. Sexual problems were assessed in the DIS by six questions concerning lack of interest in sex, fear of sex, inability to become sexually excited or aroused, inability to stay sexually excited or aroused, inability to have an orgasm, and painful vaginal intercourse. Fifty-eight percent of the participants responded affirmatively to at least one of these questions. Nearly 30% of the participants with sexual problems had experienced a completed rape, as compared to 15% of the participants who experienced completed rape but did not have any sexual problems. Participants with sexual problems were also more likely to have experienced depression or PTSD at some time in their lives. Other variables significantly related to sexual problems were having experienced some form of criminal victimization and physical injury during the crime. Logistic regression revealed that PTSD contributed a significant amount of the variance after accounting for variance contributed by the other variables. This means that women who have experienced PTSD at some point in their lives are at significantly greater risk for having sexual problems than women who never had PTSD. The authors stated that the results of the study are consistent with a learning model of sexual problems: Women who experience a sexual crime are conditioned to respond with negative feelings (e.g., fear, anger). PTSD may sustain these negative feelings, whereas positive feelings are suppressed and avoidance of cues is maintained. Moreover, victims with PTSD would be less likely to engage in sexual activities during which extinction would be possible. Even when they do engage in sexual activities, sexual problems may exist, due to the effects of emotional numbing. Limitations of this study are, according to the authors, the fact that it was based on retrospective information and that the items used to gather information about sexual problems were underdeveloped. They further stated that researchers and clinicians working with trauma victims should use standard assessment measures of sexual dysfunction, and they have to determine whether sexual symptoms are related to the trauma. Future researchers should focus on determining whether individuals with PTSD-related sexual problems have different needs from other clients with sexual problems.

Prospective Studies

In most of the studies described earlier, current sexual behavior and/or current sexual problems after sexual assault were investigated. This means that victims were asked to indicate whether they experienced sexual problems at the time of investigation. The victims were then compared to a group who did not experience rape or attempted rape, and the differences were usually attributed to the assault. The time elapsed between the assault and the moment of inquiry varies among the reviewed studies, but this is not always indicated. If a college sample was used, one can assume that, at most, a few years had passed since the assault. In some community studies, however, the assaults happened many years previously, sometimes as many as 40 years. In those cases it becomes very difficult to attribute sexual problems solely to the assault. Some of the studies reviewed were retrospective in nature, meaning that participants were asked to report on their sexual functioning just before and after the assault. In these studies participants have to rely on their memory, which can seriously affect the results of the study. If victims can be interviewed immediately after the assault and followed over a defined period of time, results will be less likely to be obscured by memory processes. This is the case in prospective research. Another important aspect of prospective research is that it is possible to explore how long complaints persist and which factors are predictive of persisting complaints. A negative aspect of this type of research, however, is that women who will not talk about their rape experiences are excluded from this type of study.

In one of the early prospective studies, by Burgess and Holmstrom (1979), 81 rape victims were interviewed at the time they were admitted to the hospital, weekly in the first 3 months after the rape and then at 6-month, 9-month, and 1-year intervals, and finally 4-6 years after the rape. Independent variables were sex life prior to rape, changes in frequency of sexual relations, symptoms (flashbacks, discomfort with sex, aversion and inorgasmic response), and partner’s reaction. The dependent variable was described as the time required for the victims to feel recovered in the area of sexuality. The majority of victims (74%) judged themselves recovered 4-6 years after the rape. Half of these recovered within months, the other half within years. Twenty-one victims did not feel recovered 4-6 years after the rape. An association between prior sexual activity and length of recovery was not found. Following the rape, 38% of 63 previously sexually active victims gave up sexual activity for at least 6 months, and one third reported a delay in resuming sexual activity and a decrease in usual frequency. Half of the sexually active victims reported having flashbacks to the rape in a variety of situations, and the majority experienced the flashback during sexual activities. Sixteen of the 63 sexually active victims reported pain or discomfort when resuming sexual relations. Forty-one percent reported having difficulty either experiencing any sexual feelings or being orgasmic during sex. In general, the more sexual symptoms that developed, the longer the recovery period for the victim.

In a prospective study by Ellis, Calhoun and Atkeson (1980), 116 rape victims who attended a rape crisis center were interviewed 2 weeks, 4 weeks, 16 weeks, and 48 weeks postassault. Each time they were asked four questions: “How often have you been having sex lately?” “How much of the time have you enjoyed sex lately?” How much of the time have you been orgasmic during sex with a partner (by whatever means)?” and a question about sexually induce flashbacks. “Sex” was not further defined. In the first interview, they were also asked about the assault itself and about their sexual functioning in the year before the assault. Of the women who were sexually active in the year before the assault, 29% had stopped having sex with their partner, and 32% had been having sex less often. Thirty-nine percent said their sexual frequency had not changed. Four weeks postassault, 43% had not been sexually active and many of those who were, had sex less often. Forty-eight weeks after the rape the percentage of women having sex frequently (i.e., two times a week or more) or somewhat frequently (2-4 times a month) had returned to prerape levels. About 10% who indicated having sex rarely or episodically (when they happened to have a partner) before the rape chose not to be sexually active at all. Four weeks postassault, 30% enjoyed sex most of the time (compared to 57% prior to the rape); by 48 weeks, 45% enjoyed sex most of the time, and 12% still reported flashbacks after 48 weeks. Forty percent of the women said they were orgasmic most of the time in the year before the assault. Four weeks postassault, this percentage had dropped to 29%, and this level increased to 33% after 16 weeks, and did not change after this point. The authors concluded that most vicims’ sexual activity had returned after 48 weeks, but between 10% and 20% developed sexual difficulties, persisting over a long period of time.

In a more recent prospective study, the Norwegian researcher Dahl (1993) investigated the development of psychological and sexual problems after sexual assault. Participants were 53 women who had contacted an emergency ward in Oslo. They were interviewed 2 weeks, 3 months, and 1 year after the sexual assault. Posttraumatic stress was assessed with the Comprehensive Psychopathological Rating Scale– Posttraumatic Stress Disorder (Malt, 1988). Sexual problems were measured a year after the assault and were assessed by means of the Structural Clinical Interview for DSM-III. Thirty percent (14 women) were found to have developed sexual problems; 6 had developed a phobia of intercourse and avoided sexual contact, and 10 women had sexual arousal problems including the inhibition of physiological arousal. They met the diagnostic criteria for female sexual arousal disorder. Five of them also reported hypoactive sexual desire and three of them reported dyspareunia. A year after the rape, 30% had developed PTSD, and moderate posttraumatic stress-symptoms were seen in an additional 28%. Six of the 14 women who reported sexual problems also met the criteria of a PTSD diagnosis. Another six had sexual problems as their main symptom, four of these belonging to the moderate PTSD group. An additional two from the sexual problem group also had a major depressive disorder which was sometimes also complicated by posttraumatic reexperiencing during intercourse. The author concluded that sexual disorders, which in her study were as frequent as PTSD, can be looked upon as part of a trauma-avoidance symptomatology when they appear within the PTSD group. Sexual problems alone might present a less complicated reaction to rape or they might represent a PTSD sequela.

Dahl (1993) also investigated which factors predicted sexual problems. No one who was not penetrated during the sexual assault developed a sexual disorder. Satisfaction with life before the rape was significantly related to sexual problems (the more satisfied, the more likely to develop problems). A high depression score, a depersonalization score, and a feeling of being damaged in the acute phase after the rape were significantly related to sexual problems. Statistical tendencies indicated that women who liked the offender before the sexual assault, women who had not consumed alcohol, where the offender applied confidence-inducing strategies in the situation before and the prelude phase, where the offender used considerable physical violence or verbal threats, or where the rape lasted more than an hour, were most susceptible to develop a sexual disorder. Women who were young and healthy tended to be more likely to develop sexual problems. A high degree of social support and high satisfaction with the partner relationship before the rape tended to serve as protective factors.

Neglected in the research on sexual functioning after sexual assault is the role of emotions felt during and immediately after the assault. Emotions, especially the intensity of emotional reactions, play an important role in trauma theory when it comes to pathology. Fear (see Foa & Rothbaum, 1998; Horowitz, 1986; Kilpatrick et al., 1981) and other emotions, such as anger towards the perpetrator and the self, guilt, and shame, may also play a role in the development of psychological problems (see Ensink et al., 2000; Herman, 1992; Janoff-Bulman, 1997; Montada, 1992; Resick & Schnicke, 1993), although surprisingly little attention has been devoted to feelings of shame. In a prospective study by Ensink and Van Berlo (1999) (see also Van Berlo & Ensink, 2000), it was assumed that the intensity of emotions that are self-directed, such as guilt and shame, play an important part in the development of long-term sexual dysfunctions. In this study, 39 victims of rape and attempted rape who had reported the assault to the police were interviewed a month, 3 months and a year after the assault. The goal of the study was to investigate the development of psychological problems as a consequence of a sexual assault experience and to identify factors that predict long-term psychological problems. Sexual behavior and sexual problems were– aside from the development of PTSD, fear, and depression-some of the problems investigated. Research questions in this respect concerned, firstly, at what moment after the assault victims resumed their sexual activities, how they experienced their sex lives after the assault, whether they suffered from sexual dysfunctions (and the nature of these dysfunctions if they were experienced). Secondly, factors that might predict sexual dysfunctions were investigated. These factors were focused on assault characteristics, emotions felt during and immediately after the assault, and avoidance of sexual contact. The third research question was whether sexual problems were isolated or part of other psychological problems. Questions about sexual behavior, sexual experience, and sexual dysfunctions were asked by means of a semi-structured questionnaire constructed for this investigation. Posttraumatic stress symptoms and depressive symptoms were assessed, respectively, with the Posttraumatic Stress Diagnostic Scale (PDS; Foa, 1995) and the Beck Depression Inventory (BDI; Beck, Ward, Mendelson, Mock, & Erbaugh, 1961) (only assessed a year after the assault). The intensity of the emotions felt in the period immediately after the sexual assault were rated on 7-point scales. This was done for the emotions fear, anger at self, anger at perpetrator, shame, disgust, and guilt feelings.

Of the victims, 49% were sexually active again within a month after the sexual assault, although 41% of the sexually active victims indicated that sexual contact was less frequent than before the sexual assault. Being sexually active was highly correlated with having a partner. Being sexually active did not correlate with assault characteristics (i.e., perpetrator known to the victim or not, penetration, and degree of physical violence used during the assault). A year after the assault, 71% of the victims were sexually active again; for 44% of the sexually active, the frequency of sexual contact was still decreased as compared to before the sexual assault. Between 14% to 34% of the victims found sensual or sexual contact unpleasurable.

A month after the assault, 51% of the victims had one or more sexual problems. These included fear of sex, sexual aversion, desire and arousal problems, and anorgasmia. For most participants, these problems did not exist before the assault. A year after the assault, these percentages were hardly diminished. For 71% of the victims with one or more sexual problems, these problems were persistent during the year after the assault. Also, a year after the assault at least 59% felt moderately to severely distressed with regard to these dysfunctions. With regard to assault characteristics, sexual penetration during the assault predicted fear of sex a year after the assault. A known perpetrator predicted aversion of sex and lack of desire. The degree of violence used during the assault did not predict long-term sexual dysfunctions. With regard to emotions felt during and immediately after the assault, anger towards self, shame, and guilt predicted fear of sex, lack of desire and aversion. Women who had a partner and were sexually active had fewer sexual problems than women who did not have a partner and were not sexually active.

A month after the assault, 69% of the participants met the criteria of PTSD. After 3 months, 62% met the criteria for a PTSD diagnosis, and a year after the assault 47% still were experiencing PTSD. Sixteen percent were depressed, and they scored high to very high on the BDI a year after the assault. It was found that a year after the assault sexual dysfunctions were highly correlated with a diagnosis of PTSD, the severity of PTSD, and depression. Women who were not sexually active more often had a diagnosis of PTSD and more often suffered from severe PTSD symptoms, especially intrusions, than women who were sexually active. The authors asserted that the intrusions may sustain fear of sex and a lack of desire and arousal. When there is not a loving and understanding partner, the intrusions may lead to the avoidance of sexuality. Because sexual contact is avoided, the intrusions will not diminish. When there is not the opportunity to have positive sexual contact, sexuality will be associated with the sexual assault experience, and sexual problems, especially response inhibiting problems, will persist.

The power of the last two studies described lies in the connection made between sexual problems and factors that predict sexual problems, and the attention to the relationship between psychological and sexual problems. Disadvantages in both studies are the small sample size and the lack of a control group. Thus, the results with respect to the number of women with sexual problems should be regarded with some caution.

Discussion

In the studies described, three approaches can be distinguished, (a) description of sexual functioning, focussing on the question whether sexual assault or rape has an impact on sexual functioning, what type of sexual problems can be specified, and how long these problems last; (b) which factors predict sexual problems; and (c) whether sexual problems are related to other psychological problems.

Description of Sexual Functioning

Researchers whose focus has been on the impact of rape have directed their attention to different types of sexual problems or have not specified sexual problems. This makes a general conclusion difficult. In general, however, attention is devoted to frequency of sexual contact, sexual satisfaction, and specific sexual problems.

Most authors conclude that rape has an impact either on the frequency of, or satisfaction with, sexual contact (Bartoi & Kinder, 1998; Burgess & Holmstrom, 1979; Ellis et al., 1980; Ensink & Van Berlo, 1999; Nadelson et al., 1982; Norris & Feldman-Summers, 1988). Feldman-Summers, Gordon, and Meagher (1979), however, who used a control group, did not find a difference in current frequency of several sexual activities between the victimized sample and the control group. Sample size in this study, however, was very small (15 victims), and the time of the assault varied significantly among the group of victims. Bartoi and Kinder (1998) found no difference between adult sexual abuse victims and a control group as to sexual avoidance, although it is unclear in this study how long ago the assault happened. In the study of Shapiro and Schwartz (1997), women who were date raped even had more frequent sexual intercourse and more sexual partners than the women who had not been raped. The authors indicated that there may be two explanations: The sexual activity pattern may have predated the date rape and was, therefore, a risk factor, or, on the other hand it is possible that the date rape causes some women to become more promiscuous. A few participants in the study of Van Berlo and Ensink (2000) also indicated that they engaged in more sexual activity after the assault than before it. Although the sample is too small to provide a general explanation, there is some indication that increased frequency for some victims has to do with regaining control of their sex lives again and ridding themselves of the images of the sexual assault.

According to the retrospective studies of Feldman-Summers et al. (1979) and Orlando and Koss (1983), satisfaction with several sexrelated activities immediately after the sexual assault decreases, but after a few months returns to prerape levels, although Orlando and Koss also found that rape victims were overall less satisfied than nonvictimized women. Both studies, however, suffer from methodological problems, the first on account of the small sample size, and the second because their participants had to recall their state of satisfaction from 18 months earlier. Norris and Feldman-Summers (1981) found a decrease in sexual satisfaction in a substantial number of the victims until a few years after the assault. Bartoi and Kinder (1998) found greater current dissatisfaction among victims as compared to controls, although these authors did not mention the time elapsed between assault and investigation. Ellis et al. (1980) mentioned in their prospective study that almost a year after the rape, only 45% enjoyed sexual activity most of the time. In the study of Ensink and Van Berlo (1999), 14% to 34% of the victims found sensual or sexual contact unpleasurable until a year after the assault. Thus, although the results are not conclusive, satisfaction and pleasure in sexual activities seem to diminish for a considerable group of victims for at least 1 year postassault and probably longer.

Several studies reveal that victims develop specific sexual problems, some of which persist for years after the assault (Becker et al., 1986; Becker, Skinner, Abel, Howell & Bruce, 1982; Becker, Skinner, Abel, & Treacy, 1982; Burgess & Holmstrom, 1979; Dahl, 1993; Ellis et al., 1980; Ensink & Van Berlo, 1999; Shapiro & Schwarz, 1997; Van Berlo & Ensink, 2000). Percentages vary between 25% and 59%. Siegel et al. (1990) reported in their representative study that 22% of the female victims developed fear of sex, 33% lost sexual interest, and 27% had less pleasurable sexual relationships. For male victims, the percentages were respectively 8%, 7%, and 8%. In the representative study of Golding (1996), 13% of sexually assaulted women reported genital burning, 32% reported sexual indifference, 19% reported pain during intercourse, and 16% reported lack of sexual pleasure.

In general, it has been found that sexual problems have less to do with pain during intercourse or with orgasm dysfunction but more to do with response inhibiting problems, such as fear, arousal dysfunction, or desire dysfunction (Becker et al., 1986; Dahl, 1993, Ensink & Van Berlo, 1999), although Golding (1996) found that assaulted women more often than nonassaulted women reported both lack of desire and pain during intercourse. The response inhibitory nature of sexual problems makes clear that sexual stimuli are perceived as anxiety provoking and are subsequently relabeled as reduced or absent altogether. Becker et al. (1984) therefore indicated that a primary treatment for sexually dysfunctional assault victims must be directed at the cognitive aspects of the negative perception of sexual stimuli.

Factors Predicting Sexual Problems

Several factors which might predict long-term impact have been studied, such as characteristics of the sexual assault, the immediate emotional reaction, and the social support. With regard to the relation between assault characteristics and sexual problems, the results vary. Young age and a known offender seem to be related to sexual problems (Becker et al., 1984; Dahl, 1993; Ensink & Van Berlo, 1999; Siegel, Golding et al., 1990). Golding (1996) found that women assaulted by their husbands were at higher risk for sexual indifference and lack of sexual pleasure, but women assaulted by an acquaintance were at less risk for sexual indifference. Neither Koss et al. (1988) nor Kilpatrick et al. (1988) found a difference between victims of stranger rape and victims of acquaintance rape with respect to sexual satisfaction. With respect to penetration during the assault, some researchers have not found a relation with sexual dysfunctioning (Becker et al., 1984), whereas others have found that penetration predicts long-term sexual problems (Becker, Skinner, Abel, Howell & Bruce, 1982; Becker, Skinner, Abel & Treacy, 1982; Siegel et al., 1990; Dahl, 1993; Golding, 1996; Ensink & Van Berlo, 1999). Becker et al. (1984) and Ensink and Van Berlo (2000) did not find that the degree of physical violence during sexual assault predicts longterm sexual problems, whereas Siegel et al. (1990) and Dahl (1993) found that physical violence and sexual problems were positively correlated. Becker, Skinner, Abel, and Treacy (1982), on the contrary, found a trend that the more physical violence was used by the assailant, the less sexual problems a victim experienced. The authors argued that victims feel less guilty if the rape resulted from physical overpowerment. Golding (1996) also found that physical threat was negatively related with complaints. So the research results are quite inconclusive with respect to the question whether physical violence used during the assault evokes long-term sexual problems.

Another question is whether the immediate emotional reaction predicts sexual dysfunction. Van Berlo and Ensink (2000) and Dahl (1993) found that the immediate reaction predicts long-term sexual problems. Dahl (1993) found that a feeling of being damaged in the acute phase after the rape were significantly related to sexual problems. Van Berlo and Ensink found that emotions felt during and immediately after the assault are strong predictors of persistent sexual dysfunction. A year after the assault, emotions which are focused on the self (anger towards self, shame, and guilt) play a significant role, especially with regard to response inhibiting dysfunctions. The authors stated that guilt and shame inhibit sexual feelings. At the same time these are emotions that are connected with sexuality in general for most women. When a woman is sexually assaulted, and especially when she feels responsible, she does not allow herself to have sexual feelings for a long time after the assault.

Some factors are thought to form a buffer against the development of sexual problems. An understanding partner is a protective factor in developing sexual (and other) problems (Dahl, 1993; Van Berlo & Ensink, 2000). Van Berlo and Ensink also found that women who were sexually active after the assault, were less troubled by sexual problems, such as fear of sex, lack of desire, and aversion, and the intrusions of traumatic memories. Most women who were sexually active indicated that they had a loving and understanding partner. This result means that sexually active women with a loving partner either experience less fear, aversion, intrusions of traumatic memories, and lack of desire and, therefore, are ready for sexual contact, or that sexual contact with their partner reduces these aversive feelings. The authors concluded that when there is not a loving and understanding partner around, intrusions may lead to the avoidance of sexuality. Because sexual contact is avoided, the intrusions will not diminish. Intrusions will diminish when sexual assault images are replaced by positive sexual images. When there is not the opportunity to have positive sexual contact, sexuality will be associated with the sexual assault experience, and sexual problems, especially response inhibiting problems, will persist. More studies are needed in order to allow a more grounded conclusion.

Relation Between Sexual Problems and Other Psychological Problems

Recent research reveals that sexual problems may not stand alone but are related to other psychological problems, such as posttraumatic stress symptoms and depression (Dahl, 1993; Letourneau et al., 1996; Van Berlo & Ensink, 2000). Letourneau et al. (1996) concluded that PTSD may act as a moderating variable on the development of sexual problems in women with sexual and nonsexual trauma histories. A consequence of PTSD is the numbing of feelings. Because positive feelings are suppressed and cues that are associated with the crime are avoided, victims with PTSD may be less likely to engage in sexual activities, during which extinction would be possible. This suggestion was confirmed in the study of Van Berlo and Ensink (2000), who found that women who are not sexually active a year after the assault more often have sexual problems than women who do have sexual contact, and that they more often have a PTSD diagnosis and more severe PTSD symptoms as well. These victims specifically suffer from persistent intrusions (although contrary to the expectation, they do not have more avoidance symptoms).

More research is necessary to explore the relation between PTSD and sexual problems, and emotional reactions and sexual problems. More specifically, representative prospective studies, in which standardized measures of sexual dysfunction are used and a control group is included, are needed.

Conclusions

Although the reviewed studies vary considerably in methodology, it is clear that sexual dysfunction can be a major problem after sexual assault, and that these problems may persist for a long time. The response inhibiting nature of the sexual problems prevent victims from having sexual contact again because sexual stimuli are perceived as anxiety provoking and evoke intrusive memories. To engage in consensual sexual activities, which are pleasurable to the woman, however, seems to help women to overcome aversive feelings with respect to sexuality. As Becker et al. (1984) pointed out, treatment for sexually dysfunctional women should be directed at the cognitive aspects of the negative perception of sexual stimuli. Furthermore it is important to prevent sexual problems by paying attention to the emotional reactions, such as anger, shame, and guilt feelings. Cognitive intervention may help to overcome these feelings and may minimize the risk of chronic problems.

‘We did a search in PsychLit covering the literature since 1983, using as key words rape, sexual assault, sexual dysfunction, sexual functioning, and sexual problems. Additional references were found in the NISSO library and in the reference lists of the articles obtained from the primary search method.

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Willy van Berlo Netherlands Institute of

Social Sexological Research

Bernardine Ensink Free University

Willy van Berlo works at the Netherlands Institute of Social Sexological Research, Utrecht, The Netherlands. Bernardine Ensink is a member of the Department of Psychology at Free University, Amsterdam, The Netherlands.

Correspondence concerning this article should be addressed to Willy van Berlo, Nederlands Instituut voor Sociaal Sexuologisch Onderzoek (NISSO), Postbox 9022, 3506 GA Utrecht, The Netherlands. (wvberlo@xs4all.nl)

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