William T. O’Donohue, Lorraine T. Benuto and Lauren Woodward Tolle (eds.)Handbook of Adolescent Health Psychology201310.1007/978-1-4614-6633-8_13© Springer Science+Business Media New York 2013
Adolescent Sexual Assault: Prevalence, Risk Associates, Outcomes, and Intervention
(1)
Clinical Neuroscience Division, Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, 67 President Street, Charleston, SC 29425, USA
(2)
Family Services Research Center, Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, 326 Calhoun Street, Charleston, SC 29425, USA
Abstract
Adolescence and young adulthood is a notable period of risk for sexual assault, with more than half of all rape victims experience their first rape before the age of 18. Whereas many who experience this form of violence exhibit marked resilience, adolescent sexual assault is notably associated with negative mental and physical health outcomes that may include but are not limited to depression, post-traumatic stress, sexually transmitted infections, and substance misuse. This chapter is intended to provide a brief overview of the literature regarding adolescent sexual assault, including an introduction to terminology commonly used in legal, clinical, and scientific discourse, as well as discussion of the scope of the problem of sexual assault among adolescents, a review of factors potentiating risk for sexual assault, associated physical and mental health outcomes, and a brief introduction to evidence-supported intervention and treatment relevant to sexual assault.
Introduction
Sexual assault is an unfortunate and all too common experience for adolescents in the USA. Although the majority of youth who experience sexual assault are resilient, these experiences can have both acute and chronic effects on adolescent development and adjustment in a substantial number of cases. The preponderance of the literature regarding sexual assault focuses on either the experiences of children (i.e., child sexual abuse) or adults, specifically adult women; however, attention to sexual assault experiences during adolescence is warranted, given that it is a particularly high-risk developmental period with respect to sexual assault. This chapter provides a brief introduction to the literature regarding adolescent sexual assault. Specifically, it discusses the scope of the problem among adolescents, factors potentiating risk for sexual assault, physical and mental health outcomes, as well as intervention and treatment relevant to sexual assault.
Terminology
Several terms are frequently used in the adolescent sexual assault literature. Gaining familiarity with these terms and their applications can be helpful in understanding the implications and limitations of the research discussed throughout this chapter.
Sexual abuse is a term broadly defined by Webster’s New World Law Dictionary as meaning “unlawful sexual activity or contact with a person without his/her consent.” Specific nonconsensual sexual acts constituting sexual abuse include (a) oral, anal, or genital penetration; (b) anal or genital digital or other penetration; (c) genital contact with no intrusion; (d) fondling of breasts or buttocks; (e) indecent exposure; (f) inadequate or inappropriate supervision of a child’s voluntary sexual activities; and (g) use of a child in prostitution, pornography, Internet crimes, or other sexually exploitative activities (Goldman, Salus, Wolcott, & Kennedy, 2003). However, sexual abuse is most frequently used to address childhood sexual violence that is chronic or ongoing in nature. In this context, child sexual abuse may include acts such as incest (sexual contact among family members) or sexual contact between a child and an older child or adult. An important consideration in the determination of child sexual abuse is the age of legal consent—that is, the age at which a person can legally consent to sexual activity. The age of legal consent and specific definitions concerning child sexual abuse/assault are largely dictated by state legislation that vary from state to state; however, the Federal Child Abuse Prevention and Treatment Act (CAPTA; 42 U.S.C.A. §5,106 g) broadly addresses child sexual abuse. CAPTA defines the minimum standards of child abuse and neglect as “any recent act or failure to act on the part of the parent or caretaker, which results in the death, serious physical or emotional harm, sexual abuse or exploitation, or an act or failure to act which presents an imminent risk of serious harm.”
As children enter adolescence, the risk of experiencing sexual violence is heightened. Terminology (and research) on peer-perpetrated and/or acute sexual violence often refers to these acts as sexual assault. Sexual assault victimization encompasses any form of unwanted sexual contact obtained through violent or nonviolent means (United States Department of Justice, 2008). Sexual assault victimization most often refers to acute victimization, rather than the more protracted or chronic victimization often referenced by the term sexual abuse. Sexual assault victimization includes the more distinctly defined acts of rape and attempted rape, as well as unwanted touching and/or fondling of breasts or genitalia. Rape is a form of sexual assault that involves some type of unwanted penetration of the victim’s vagina, mouth, or anus. Rape may be perpetrated through several non-mutually exclusive tactics: (a) forcible rape, or the use of force or threat of other harm to the victim; (b) drug- or alcohol-facilitated rape, deliberately giving the victim alcohol or drugs with the intent of incapacitating the victim to the point at which they can no longer control their behavior, protect themselves, or consent; and (c) incapacitated rape, or when a perpetrator takes advantage of a victim who is passed out or too drunk or high from voluntary alcohol or drug use to consent or control their behaviors. Attempted rape is a type of sexual assault that involves attempted, but non-completed unwanted sexual penetration as defined above. Statutory rape occurs when a perpetrator has sexual penetration with someone who is defined by law as too young to be capable of giving consent. Again, age of consent varies from state to state, with most states setting the age between 16 and 18 years of age.
As discussed with child sexual abuse, there is also existing Federal legislation addressing the acts of rape and attempted rape. Although the Federal Criminal Code of 1986 (Title 18, Chapter 109A, Sections 2241–2233) does not explicitly use the term “rape,” aggravated sexual abuse is referenced, including aggravated sexual abuse by force or threat of force and aggravated sexual abuse by other means. Aggravated sexual abuse by force or threat of force is defined within the code as follows: when a person knowingly causes another person to engage in a sexual act, or attempts to do so, by using force against that person, or by threatening or placing that person in fear of death, serious bodily injury, or kidnapping. Aggravated sexual abuse by other means is defined as follows: when a person knowingly renders another person unconscious and thereby engages in a sexual act with that other person or administers to another person by force or threat of force without the knowledge or permission of that person a drug, intoxicant, or similar substance and thereby, (a) substantially impairs the ability of that person to appraise or control conduct and (b) engages in a sexual act with that person. This definition has several important implications for what should be included in the assessment of rape. First, this definition includes more than just unwanted penile penetration of the vagina, and references other forms of penetration, such as oral and/or anal penetration. Second, the definition recognizes that not all perpetrators are male, and not all victims are female. Third, the definition acknowledges that unwanted sexual penetration should be recognized in both the instance of being obtained by force/threat of force and the instance of drug-alcohol facilitation/incapacitation. Fourth, the definition highlights that statutory rape (i.e., any type of non-forcible sexual penetration with a child) is a serious federal offense and should be measured in national surveys in order to capture the full scope of the problem of rape.
This basic review of terminology provides a foundation for the most common types of experiences being assessed in adolescent sexual assault research. Next, we will discuss several of the most prominent methodological issues implicit in the measurement and assessment of adolescent sexual assault.
Issues Related to the Estimation of Adolescent Sexual Assault Prevalence
Our best national estimates of the prevalence and scope of adolescent sexual assault are likely underestimates of the problem at hand. Several issues contribute to this likely underestimation. These include but are not limited to unacknowledged victims, low rates of disclosure and reporting, and methodological shortcomings of national prevalence surveys.
Acknowledgement and Disclosure
There is evidence that many victims of experiences meeting the legal definitions of rape or sexual assault do not perceive or acknowledge their experience as a rape or sexual assault (Kilpatrick, Resnick, Ruggiero, Conoscenti, & McCauley, 2007). These victims are often referred to as “unacknowledged victims” and are unlikely to report their cases to police, seek services from rape crisis centers or other service agencies, or participate in research projects that are recruiting for “sexual assault or rape victims,” because they do not necessarily consider their experience to be rape and do not see themselves as “rape victims.” Further, even if an adolescent acknowledges that what has happened to them is rape, the vast majority of rape victims do not report (or disclose) the assault to police or other authorities, especially if drugs or alcohol are involved. As an example of this phenomenon, a recent study recruiting a national sample of 2,000 women enrolled in US colleges and universities found that 11.5 % of women reported a lifetime history of forcible, incapacitated, or drug- and alcohol-facilitated rape (Kilpatrick et al., 2007). However, only about one out of six (16 %) of the women endorsing a history of forcible rape reported the incident to police or other authorities. An even smaller percentage (7 %; or about one out of fourteen) of those that experienced a drug- or alcohol-facilitated or incapacitated rape reported the incident to the authorities. These data indicate that most rape victims do not report their experiences to police or other authorities. More specific to adolescents, only about one–half to one–third of adolescent victims tell anyone about their assault, and even fewer—one out of sixteen (6 %)—report the incident to authorities (Broman-Fulks et al., 2007; Koss & Gidycz, 1985). Although it cannot be definitively stated that rates of sexual assault among adolescents are sixteen times those reported by annually released national sources like the National Crime Victimization Survey, it is clear that national prevalence estimates based solely on sexual assaults reported to authorities result in a gross underestimation of the scope of sexual assault among US adolescents.
Assessment Methodology
Getting an accurate picture of the scope of sexual assault is also made difficult by several notable measurement issues. The accuracy of the measurement is largely dependent on the sensitivity of assessment and methodology. Stronger, more comprehensive assessments utilize behaviorally specific questions, as opposed to relying on labels such as “sexual assault,” and include the range of experiences described by state and federal definitions of sexual assault. An example of one such behaviorally specific question appears on the Sexual Experiences Survey (a standard assessment in sexual assault research; Koss & Gidycz, 1985): Have you had sexual intercourse when you didn’t want to because a man gave you alcohol or drugs to prevent you from resisting? Comprehensive assessments also include specific language describing experiences where the victim was too intoxicated or high to provide consent, as well as statutory rape experiences, in addition to the more commonly assessed forcible and coerced assaults.
Method of assessment is also an important consideration in reviewing sexual assault research. Most nationally representative victimization surveys discussed in this chapter employed random-digit-dial methods to select their sample and interviewed their participants via telephone. Random-digit-dial methods generate telephone numbers at random giving it the advantage of sampling from residences with both listed and unlisted telephone numbers. Whereas this form of telephone assessment is relatively cost-effective, it also limits the data available to those who are contactable by phone (e.g., not institutionalized, residing in a home, having a home phone line) and willing to participate in a research survey, thus limiting the generalizability of findings. Additionally, all self-report methods are subject to recall bias and participants’ willingness to disclose personal information. The assessment of experiences within the time frame of “lifetime” may be more susceptible to recall bias, particularly when adults are asked to recall sexual assault experiences that may have occurred many years prior to the conduct of the survey. Therefore, studies that survey adolescents directly and ask about shorter time frames (like the past year) tend to reduce the length of time that respondents are asked to recall and may increase accuracy in reporting.
Unfortunately, the perfect study on adolescent sexual assault does not exist. Each study aims to maximize the reliability, representativeness, validity, and accuracy of its findings within its given constraints (both time and cost). The subsequent sections of this chapter will review research findings from studies that employ rigorous methodology, utilize behaviorally specific assessment measures, and draw conclusions within the framework of the study’s limitations. When this caliber of research is not available, we will briefly address the limitations of the literature in that area.
Prevalence of Adolescent Sexual Assault
Adolescence is a notable period of risk for sexual assault experience. More than half of all rape victims experience their first rape before the age of 18 (Kilpatrick, Edmunds, & Seymour, 1992; Tjaden & Thoennes, 2000). Moreover, national data indicate that adolescents and young adults experience the highest rates of rape and other sexual assault of all age groups, with approximately one-third of all lifetime forcible rapes occurring between the ages of 11 and 17 years (Kilpatrick et al., 1992; Rennison, 2002). Although there are numerous studies that produce prevalence estimates among nonrepresentative adolescent samples (e.g., clinical, regional, school-specific samples), we will focus only on national estimates, as they maintain the broadest degree of generalizability.
Two main general statistics are provided by national data on sexual assault: prevalence and incidence. Prevalence is the proportion or percent of the population that has been sexually assaulted at least once in a specific period of time, such as “lifetime” or “past-year.” The Centers for Disease Control and Prevention monitors a compendium of health-risk behaviors among male and female youth enrolled in grades 9 through 12 and annually compiles their data in a report entitled Youth Risk Behavior Surveillance System (YRBSS; Centers for Disease Control and Prevention, 2007). Although the YRBSS uses a crude assessment of rape (asking only, “Have you ever been physically forced to have sexual intercourse when you didn’t want to?”), the 2007 YRBSS report estimated the prevalence of rape among adolescents to be 7.8 % (11.3 % of females and 4.5 % of males). A more thorough, although less recent, assessment of the prevalence of sexual assault experiences among US adolescents was provided by the National Survey of Adolescents (NSA; Hanson et al., 2003; Kilpatrick et al., 2003a). Conducted in 1995, the NSA included a nationally representative sample of 4,023 adolescents (ages 12–17) and used validated epidemiological methods of assessment. According to the NSA, 3.4 % of male and 13 % of female adolescents endorsed a lifetime history of forced sexual assault.
Nationally representative studies have also produced recent estimates of the prevalence of adolescents’ experience of dating violence and drug-facilitated/incapacitated assault. Wolitzky-Taylor et al. (2009) estimated the overall prevalence of adolescent dating violence, defined as peer-to-peer sexual assault, physical assault, and drug-alcohol-facilitated sexual assault. Among teens ages 12–17, 1.6 % reported experiencing dating violence, equating to a population estimate of 400,000 US adolescents. Prevalence of dating violence increases by age, with estimates of 14 % and 22 % among 16- and 17-year-olds, respectively. Drug-facilitated and incapacitated sexual assaults appear to be even more prevalent among adolescents, with 2.1 % of adolescent girls reporting at least one such experience in their lifetime (McCauley et al., 2009). Similar to dating violence, incapacitated and drug- or alcohol-facilitated sexual assaults were notably more prevalent among older adolescents. This elevated risk for peer-to-peer or acquaintance-perpetrated assault continues into young-adulthood, with this time frame being second only to adolescence with respect to risk for sexual assault. Several large, nationally representative studies have focused exclusively on the impact of sexual assault among college women. These studies, the National College Women’s Sexual Victimization Survey (NCWSV; Fisher, Cullen, & Turner, 2000) and the National Women’s Study—Replication (NWS-R; Kilpatrick et al., 2007), estimated a 3 % annual prevalence rate for completed forcible rape, 2.1 % for incapacitated rape, and 1.5 % for drug-alcohol-facilitated rape. In total, over 300,000 college women in the USA (5.2 %) reported a rape experience in the year prior to this 2006 study.
Incidence refers to the number of new cases of sexual assault that occur in a specified period of time. Incidence is most often expressed as a victimization rate, or number of incidents per given number of people. Because incidence rates are case-based statistics, it is also important to note that there is a distinction between sexual assault cases and sexual assault victims, such that a single victim may have experienced more than one sexual assault case. The US Department of Justice National Crime Victimization Survey (2009) reports the recent annual incidence rates (per 1,000 persons) of sexual assault reported to authorities to be 0.9 for adolescents aged 12–15 years and 0.6 for adolescents aged 16–19 years. Note that these rates reflect cases of sexual assault or rape that were reported to authorities and, as previously discussed, are likely significant underestimates of the actual annual incidence.
Taken together, prevalence data indicate that adolescence is a very high-risk time period for sexual assault. When extrapolated into population estimates, the cost to society posed by adolescent sexual assault becomes glaring. It is not surprising that identification of individual, ecological, and sociocultural risk and protective factors has high public health relevance. Next, we will discuss and summarize what is known with regard to risk and protective factors for adolescent sexual assault, as well as provide an overview of the health and mental health outcomes associated with adolescent sexual assault experiences.
Risk Factors
While a well-established literature has identified that sexual assault can affect adolescents of a variety of ages, socioeconomic backgrounds, ethnic/racial groups, and familial backgrounds, several specific risk factors for sexual assault have been identified among this group, including demographic, individual characteristics, and behavioral factors (Finkelhor, Ormrod, Turner, & Hamby, 2005; Franklin, 2010; Kilpatrick, Saunders, & Smith, 2003b; Putnam, 2003). These categories of risk factors are addressed below.
Demographic factors conferring risk for adolescent sexual assault include gender, age, and family characteristics. When examining prevalence rates of sexual assault across gender, researchers have consistently found that a disproportionate number of adolescent girls report exposure to sexual assault (Bailey & McCloskey, 2005; Finkelhor, Turner, Ormrod, Hamby, & Kracke, 2009; Foster, Kuperminc, & Price, 2004; Hamburger, Leeb, & Swahn, 2008; Kilpatrick et al., 2003b; Tjaden & Thoennes, 2000). For example, results from a nationally representative sample of 12–17-year-olds indicated that 13.2 % of girls reported a lifetime prevalence of sexual assault, compared to 3.5 % of boys (Hanson et al., 2008). Similarly, a separate nationally representative study indicated that sexual assault prevalence among adolescent girls was 7.9 % over the past year and 18.7 % over the lifetime (Finkelhor et al., 2009). Again, these prevalence estimates likely underestimate actual prevalence among adolescents, and this may be especially true among adolescent boys; however, significant gender differences in prevalence are a consistent finding among nationally representative studies and indicate that female gender serves as an important risk factor for sexual assault in adolescence.
Adolescence represents the highest risk-period for sexual assault (U.S. Department of Health and Human Services [U.S. DHHS], 1998). Specifically, research indicates that, of people under age 18 reporting sexual assault, approximately 10 % were 0–3-year-olds, 28.4 % were between ages 4 and 7, 25.5 % were between ages 8 and 10, and 35.9 % were ages 12–17 (U.S. DHHS, 1998). Further, researchers have noted an interaction between age and gender, as age is a more significant risk factor for girls than boys (Bailey & McCloskey, 2005). Statistics from the Bureau of Justice indicated that women between age 16 and 24 have the highest risk of sexual assault (Hart, 2003), with reports of sexual assault from women in this age group consistently being four times higher than the overall sexual assault prevalence for women (Humphrey & Kahn, 2000). Socioeconomic status and ethnic/racial background are identified as risk factors for other forms of child and adolescent mistreatment (i.e., physical abuse, neglect); however, these factors have not been identified as risk factors for sexual assault.
In addition to demographic characteristics, personal and familial characteristics can confer increased risk for sexual assault. Presence of a disability, such as blindness, deafness, and mental retardation, increases the likelihood of sexual assault throughout development (Westcott & Jones, 1999). Findings have indicated that boys with disabilities display higher risk for sexual assault than either girls with disabilities or boys without disabilities (Sobsey, Randall, & Parrila, 1997). Further, a multitude of family characteristics increase the incidence of sexual abuse among adolescents (Putnam, 2003). Specifically, these familial factors include parental physical or mental disability, parental substance use and neglect, marital conflict or domestic violence, social isolation, and coercive or physically abusive parenting (Fergusson, Lynskey, & Horwood, 1996; Nelson et al., 2002). Finally, many studies have documented that prior incidences of sexual assault significantly increase risk for revictimization during adolescence (Krebs, Lindquist, Warner, Fisher, & Martin, 2009; Miller, Markman, & Handley, 2007; Stevens, Ruggiero, Kilpatrick, Resnick, & Saunders, 2005).
Commonly identified sexual assault risk factors also encompass the domain of high-risk behaviors, such as substance abuse. A study examining the trajectories of sexual assault and substance use demonstrated that early initiation of substance use leads to increased risk for sexual assault, presumably due to poor decision-making during intoxication (Kingston & Raghavan, 2009). In fact, it is estimated that alcohol is involved in approximately 50 % of sexual assaults perpetrated by a date or acquaintance during adolescence (Abbey, McAuslan, & Ross, 1998). Thus, early initiation of substance use may increase the risk for sexual assault exposure through several mechanisms, including impaired decision-making skills, impaired judgment while intoxicated, increased engagement in risk-taking behaviors, association with delinquent peers, greater exposure to potentially dangerous situations, and decreased ability to physically defend oneself in threatening situations (Danielson et al., 2006; Davis, George, & Norris, 2004; Kingston & Raghavan, 2009; Klaczynski, 2001; Koenen et al., 2005). In addition to substance use, other risk-taking behaviors have been associated with sexual assault among adolescents, including risky dating and sexual practices, such as unprotected sex and indiscriminate sexual contact (Combs-Lane & Smith, 2002). Other potential risk factors include decreased danger cue recognition and prior victimization. Specifically, frequent misperception of danger cues among adolescents may increase the likelihood of sexual assault, due to increased vulnerability and inability to accurately assess threat of personal danger, thus resulting in a slower response rate during potentially dangerous situations (Franklin, 2010).
Physical Health and Mental Health Consequences of Sexual Assault
The consequences of sexual assault experiences can be diverse and long-lasting. Researchers have identified a range of physical and mental health consequences faced by adolescents who have experienced a sexual assault. Some are evident immediately after the abuse and require acute care, whereas others represent risk for longer term health consequences that may not be apparent until later adolescence or adulthood.
The healthcare needs of adolescents immediately following a sexual assault vary depending on the characteristics of the sexual assault and length of time between assault and disclosure, but can include both treatment of physical needs and collection of evidence for forensic and legal purposes. In terms of medical needs, the most common problems faced by adolescent sexual assault victims are physical injuries and sexually transmitted infections (STIs). Though the estimates vary depending on the definition of injury, one study found that 64 % of female adolescents presenting for an acute sexual assault examination had some degree of genital or anal injury (Adams, Girardin, & Faugno, 2001). In a larger study of women ages 15 and older using a more stringent definition of injury, only 20 % of the sample presented with genital-anal trauma; however, adolescent victims were twice as likely as older women to present with these types of injuries, and an additional 52 % of the overall sample showed signs of general bodily injuries (Sugar, Fine, & Eckert, 2004). It should be noted that the majority of genital injuries, unless severe in nature, tend to heal quickly without intervention, such that victims presenting for treatment even within days or weeks after an assault may show no physical signs (McCann, Miyamoto, Boyle, & Rogers, 2007).
Another potential risk to adolescent sexual assault victims is the contraction of STIs. Studies show rates of STIs are low but significant in this population. Reports vary depending on referral source and data collection methods, but generally indicate higher rates for female adolescents (compared to male) and for adolescents who were sexually active prior to the assault (compared to sexually abstinent). For example, one study reported an overall rate for STIs (gonorrhea, chlamydia, syphilis, trichomonas, or HIV) of 14.6 % in pubertal girls during examinations for suspected sexual assault (Siegel, Schubert, Myers, & Shapiro, 1995), whereas a more recent study reported a rate of 24 % for girls who were not sexually active prior to the assault and 39 % for those who reported pre-assault sexual activity (Kawsar, Anfield, Walters, McCabe, & Forster, 2004). It should be noted that these are likely to be overestimates of prevalence rates due to research procedures restricting STI testing to a subsample of adolescents at the highest risk for testing positive (e.g., those who reported attempted or completed penetration, those with suspected symptoms of STIs). In studies where a majority of the adolescents were tested for STIs, rates are much lower (e.g., 5.6 % of victims testing positive for an STI; Kelly & Koh, 2006).
Medical assessments during adolescence are unlikely to detect the overall physical health problems that have been linked to sexual assault. However, sexual assault during childhood or adolescence is a risk factor for longer term health problems that manifest during later adolescence or adulthood. Generally, adult victims of adolescent sexual assault have higher rates of health care utilization and report significantly more health complaints compared to adults without such a history (Arnow, 2004; Golding, Cooper, & George, 1997; Thompson, Arias, Basile, & Desai, 2002). This finding is consistent for both self-reported doctor’s visits and objective examination of medical records (Newman et al., 2000). Data from the National Comorbidity Survey, a large nationwide epidemiological study, indicate that adults with a history of sexual assault are more likely to have a serious medical problem including arthritis, asthma, diabetes, cancer, heart problems, stroke, hernia, hypertension, and multiple other problems compared to adults without such a history (Sachs-Ericsson, Blazer, Plant, & Arnow, 2005). This result is especially compelling because the association remained significant even when taking into account other adverse childhood events including physical abuse, family conflict, poverty, and separation from parents.
In addition to these global health concerns, studies have focused on more specific health problems among adults with a history of sexual assault. Researchers are unable to test whether the assault plays a causal role in these disorders, but rather examine prevalence rates of sexual assault history among groups of patients presenting with such health concerns. In studies of this type, prevalence rates of sexual assault history have been found to be elevated among patients who have chronic pelvic pain with or without a known medical cause, fibromyalgia, severe premenstrual syndrome, chronic headaches, irritable bowel syndrome, obesity, non-epileptic seizures, and a wide range of reproductive and sexual health complaints, including excessive bleeding, amenorrhea, pain during intercourse, lack of sexual pleasure, and menstrual irregularity (Ehlert, Heim, & Hellhammer, 1999; Fuemmeler, Dedert, McClernon, & Beckham, 2009; Golding, 1996; Golding, Taylor, Menard, & King, 2000; Peterlin, Ward, Lidicker, & Levin, 2007; Rohde et al., 2008; Ross, 2005; Sharpe & Faye, 2006; Walker et al., 1997). Though many of these health problems are potentially psychosomatic in nature, they represent a burden both to the sexual assault victim and the healthcare system.
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