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The Impact of Sexual Assault on Mental Health

Categories: Assault Sexual Abuse

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Published: Oct 25, 2021

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Introduction, impact on mental health, how to help, works cited.

Government of Ontario. (2016). Sexual Assault. Retrieved from http://www.ontario.ca/page/sexual-assault
French, B. H., & Neville, H. A. (2017). Gender, race, and sexual coercion: Associations with positive sexual experiences. Journal of Black Psychology, 43(7), 703-725.
Dario, L. M. (2018). Sexual Assault: Mental Health Consequences and Considerations for Therapy. Journal of Aggression, Maltreatment & Trauma, 27(2), 212-230.
Hagene, P. (2015). Posttraumatic stress disorder following sexual assault: Implications for primary care. Primary Care: Clinics in Office Practice, 42(2), 199-214.
Prout, C., & Henderson, J. (2018). I Have the Right To: A High School Survivor's Story of Sexual Assault, Justice, and Hope. Margaret K. McElderry Books.
Hauser, C. (2016). St. Paul’s School Rape Trial: Chessy Prout, Victim, Testifies. The New York Times. Retrieved from https://www.nytimes.com/2016/08/23/us/st-pauls-school-rape-trial-chessy-prout.html
Entertainment Weekly. (2018). Chessy Prout on her powerful new memoir I Have the Right To. Retrieved from https://ew.com/books/2018/03/13/chessy-prout-i-have-the-right-to/
VanCamp, R. (2019). The Medical Model of Counseling and Psychotherapy: Therapist’s Guide to Help Clients Manage Trauma. Journal of Counseling & Development, 97(1), 80-88.
National Sexual Assault Hotline. (n.d.). Retrieved from https://www.rainn.org/
Rape, Abuse & Incest National Network (RAINN). (n.d.). Retrieved from https://www.rainn.org/

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AGNI is publishing this essay as part of The Ferrante Project.

“What would happen,” the poet Muriel Rukeyser asks in her oft-quoted poem “Käthe Kollwitz,” “if one woman told the truth about / her life? / The world would split open.” Over the past few years, I’ve begun to question the truth of that statement, especially as it relates to telling the truth about sexual violence. What is the purpose and function of writing about rape? More to the point, what to me is the purpose and function of writing when writing about my rape?

These questions grew more painful to consider after I published my first book, which examined the long-term effects of violence and survival, and more painful still when I learned this book had ended up on the reading lists of various feminist tastemakers on Twitter, one of whom noted that she was using the book as a writing prompt for her students’ exploration of violence. Thus my personal experience was to become a jumping-off point for others’ creativity, my descriptions of my assault disseminated and refracted through the exercises of strangers so they could understand the effects of such violence themselves. My assault would thus become both symbol and trope, something that could be parsed and imitated until all the rage and humanness drained out of it. I had always known, of course, that this one of the possible outcomes of publishing such a book, especially one that ended up in the maw of social media. But actually reading this student’s response to my essay, in which my assault was reimagined and repeated back to me in her language, made me feel both sickened and small.

Speak truth to power, writers and non-writers alike declaim, and now I’ve seen this phrase trickle through the feeds of people on Facebook and Twitter. The aim is to tell the truth of our lives as we see it, as directly and with as little remorse as possible. Such an outpouring of personal testimony has indeed cracked open the world, in part by reminding participants in social media that the things most American institutions want to forget about our nation—its violence against people of color, its killing of LGBTQ people, its seemingly implacable hatred of women and their bodies—stubbornly persist. There is indeed a power and value to truth-telling. But truth-telling relies on narrative, and narrative telling—even supposedly artless, immediate telling—is in fact crafted. It wants a particular response, and nothing crafts language so effectively as a Web format that requires you to express yourself in 280 characters or less, and sells these truth-telling nuggets in a stream of visual media, making it impossible for the audience to focus on any but the most extreme, compelling, and direct language.

Social media and truth-telling both encourage the reader, primarily, to emote. And having emoted, having felt all the things and thought all the thoughts the writer has asked us to think and feel within that limited format, we can walk away from the engagement satisfied with the blunt, brute fact of our feelings. Social media offers a veneer of authenticity that claims the authority of survivorship and thus makes autobiography and resilience satisfactory political goals.

A memoir about sexual assault guarantees a certain amount of attention, because it is sensational and because writing about violence encourages a kind of voyeurism. But while this may be one possible response, it is not this writer’s desire to make the reader participate in the imagined reconstruction of violence. And reconstructing another person’s trauma is not what we teach other budding writers about the purpose of testimonies of violence, in particular the testimonies of violence that women might produce. If anything, we argue, women’s testimonies should inspire not empathy (or not only empathy) but political outrage, in large part because women’s autobiographical writing has been so effectively suppressed over centuries. Women’s writing about violence serves as a public novelty, one which, if it does not always receive the social stamp of high art, at least promises an authentic expression of rage, of grief, of endurance and survival, and—most powerfully—of hope.

But I’m not actually that interested in resilience. I want jail time for offenders. I want politicians tossed out of office, priests defrocked, federal judges fired and replaced. I want a country that doesn’t treat violence against women as sexual entertainment.

Over the past year, I’ve begun to hate the book I published. The more I read from and talk about it, the more politically and aesthetically suspicious my own writing appears to me. Who had I written it for? Who did I really imagine as its audience? The project started, in part, as a reaction to the 2009 Lilly Ledbetter Fair Pay Act, which got me thinking about the ways in which sex discrimination has shaped my working life, which got me thinking about the sexual assault I experienced as a twenty-year-old woman at a coat factory where I worked one summer as a down stuffer along with several itinerant workers, one of whom attacked me. The book was finally published around the time that our current president, then a presidential candidate, admitted to grabbing women “by the pussy,” which made the #MeToo hashtag started by Tarana Burke in 2006 erupt into a firestorm. Into this storm my book was tossed, and while I was happy at first to add my voice to the movement, over time I began to feel that the book sounded less like me than an automated reply. Using the same language that has characterized the experience of so many other women certainly brings me into community with them, but that shared language also makes the stories of survivors feel depressingly interchangeable and flat.

Perhaps this flattening is created in part by our social expectations about female psychology and women’s writing, in particular our assumption that women’s writing is primarily or only autobiographical, not imaginative, and that it stems from an institutionally disadvantaged position that we equate with pain. This, too, enrages me. It feels as though, because I am female, I was born into this language and psychology; as a woman and a writer, I am a grievance waiting to be heard and endured. At times it feels that the best I can do is pay close attention to that grievance, to give it a slightly different shape and coloration. By writing about my assault, I confirm the most inarguably authentic position of the not-male, and also the not-white: the pained, the wounded, the helpless, the small .

To speak about one’s assault in a way that feels actually authentic is to thread the needle through an incredibly slender eye, made ever more narrow: by the pressure of therapeutic services, which argue that such narratives are not only good, but necessary for psychic healing; political and social institutions, where truth-telling makes for good rallying cries and possible legislation; and by social media, which argues for ever more devastating expressions of the self to be streamed and consumed and disseminated.

Effective writing about violence shares many of the aesthetic traits of political language, which is to say its directness resists excessive or subtle interpretation. It compresses time and context in order to focus on the moment at hand. Writing about violence authenticates itself through the performance of immediacy and vivid feeling. This is what suggests truth—and it is surprisingly, distressingly easy to duplicate.

The social media performances of grief, selfhood, and outrage I daily read feel suspiciously like masquerades. In my feeds, writers try to outshine and outthink the politicians and abusers inspiring our outrage, using language whose nuance rarely rises above theirs. In this way, we are shackled to victimizing doubles. As much as I despise the self-help books, the prayer circles, the thin whine of grief on Twitter and its overuse of the word trauma , the only identity that seems unable to be challenged or shamed is that of the victim. Thus I and others willingly write into and about how we have been diminished or shamed, to stop ourselves from being attacked by those claiming to be more morally progressive online, because the only way to keep yourself safe within that group, it seems, is to become the witting accomplice to your own self-objectification.

Refracting and repeating narratives of violence also risk downplaying or even ignoring matters of race and class in favor of the sensational act itself, even as race and class make violence a more or less likely experience for a person to have. It is not lost on me, for example, that I come from a middle-class family and was attacked by someone skirting the poverty line, that what brought us together was a coat factory that relied on both our labor to exist: me, the mixed-race college student earning money for her next year’s tuition; my attacker, a white man who moved from job to job, city to city, aimless and resentful of the opportunities I would have in a world he imagined pandered to minorities. It is not lost on my either that the stories we repeat most often online are those told by and about middle and upper middle class white women. Our retweeting and sharing of these stories replicates the culture’s co-opting of Tarana Burke’s #MeToo hashtag into the world of (largely) white and (largely) middle-class feminism.

The young student, consciously or unconsciously, performed this co-option when she imitated my writing. She understood that some part of writing about and against violence, especially the violence that women experience, is imitative and coercive. One does not have to be a victim of violence to render that violence believably or powerfully. The actual experience of an assault may be private, it may reveal the world to be artless and cruel, but the sharing of it depends entirely on creative skills, detailed images, and ideas of identities that can be appropriated.

Even as I write this, it strikes me that perhaps I’m wrong to think we’ve become numb to, or jaded about, female narratives of pain. I think back to that look on Arizona senator Jeff Flake’s face in the elevator as he fled the Kavanaugh hearings, the moment when a protester pried apart the elevator doors to demand he hear about the assault she’d survived. I see again the pain twist across his face. Perhaps the reason the #MeToo movement hasn’t achieved more substantial victories for women is not that its language has started to feel formulaic, but that it really is too painful for people to witness. It’s too painful because it asks those who have not suffered to imagine the limits of their physical invulnerability—to realize, if only empathetically, that their sense of self-protection is a fantasy. We turn away from the language of violence not because it has become anodyne, but because we see how easily each of us can be made a victim.

“Perhaps writers like us really can change the world,” one young woman wrote to me recently in a private Twitter message. “Your book inspired me to tell my own story. You can check out my feed.” I thumbed down the screen to read it, the words of this stranger who, like me, was humiliated and hurt, raw and furious, her own terrible story wedged now between video grabs from a Trump rally and a trailer for John Wick 3 . I stopped reading and her story flickered past. I wrote privately to thank her, added a few glib notes of praise, and told her I hoped she’d continue writing. Then I deleted her message.

The Ferrante Project: The freedom of anonymity brings together sixteen women writers of color (alongside sixteen visual artists in a linked project with the Warhol Museum) who anonymously contributed new works in response to, or critique of, the cult of personality, posturing, and preemptive celebrity of writers at the expense—sometimes—of the quality and provocation of the work itself. This is a collaboration between Aster(ix) and CAAPP: Center of African American Poetry and Poetics.

Contributors include Angie Cruz, Sarah Gambito, Dawn Lundy Martin, Khadijah Queen, Ru Freeman, Ayana Mathis, Vi khi nao, Cristina García Cathy Linh Che, Aimee Nezhukumatathil, Deborah Paredez, Emily Raboteau, Paisley Rekdal, Natalie Díaz, Lyrae Van Clief-Stefanon, and Jamey Hatley.

This page collects the works of anonymous writers published by AGNI.

Understanding Violence Against Women (1996)

Chapter: 1 introduction, 1 introduction.

Although men are more likely than women to be victims of violent crimes—61 per 1,000 for men, 42.6 per 1,000 for women (Bastian, 1995)—patterns of victimization differ. Women are far more likely than men to be victimized by an intimate partner (Kilpatrick et al., 1992; Bachman, 1994; Bachman and Saltzman, 1995). In fact, about three-quarters of all lone-offender violence against women in 1993 was perpetrated by someone known to the woman, compared with one-half of lone-offender violence against men (Bachman and Saltzman, 1995). It is important to note that attacks by intimates are more dangerous to women than attacks by strangers: 52 percent of the women victimized by an intimate sustain injuries, compared with 20 percent of those victimized by a stranger (Bachman and Saltzman, 1995). Women are also significantly more likely to be killed by an intimate than are men. In 1993, 29 percent of female homicide victims were killed by their husbands, ex-husbands, or boyfriends; only 3 percent of male homicide victims were killed by their wives, ex-wives, or girlfriends (Federal Bureau of Investigation, 1993). 1

Women are more likely to be victimized by male offenders than by female offenders; about three-quarters of violent crimes against women are committed by males (Bachman, 1994). In one urban emergency room, violence was the most common cause of injury to women between the ages of 15 and 44 and the second most common cause of injury for all women (Grisso et al., 1991). Finally, women are far more likely than men to be sexually assaulted. The National Crime Victimization Survey (NCVS) found women were 10 times more likely to be raped or sexually assaulted than were men (Bastian, 1995). The annual rate of rape is estimated to be 7.1 per 1,000 adult women, and 13 percent of all women will experience forcible rape sometime during their lives (Kilpatrick et al., 1994).

The exact dimensions of violence against women are frequently disputed, yet even conservative estimates indicate that millions of American women experience violent victimization. The fear of violence, in particular the fear of rape, affects many more, if not most, women (Gordon and Riger, 1989). A few researchers have even suggested that learning to cope with the threat of violent victimization is a normative developmental task for females in the United States (Gilfus, 1995).

In spite of the attention that has been paid to violence against women in recent years, the research endeavor is relatively young, and much remains unknown. There really is no one field focused on violence against women per se. For example, studies on rape and sexual assault are distinct from those on intimate partner violence, which is distinct from the nascent study of stalking. And all this research is separate from that on violence in general. Many of the studies in this newly emerging field of research on violence against women are at an early stage of scientific rigor. The methodological weaknesses in the research on battering and rape have been discussed at length in other documents (Rosenbaum, 1988; Gelles, 1990; Koss, 1992, 1993; Rosenfeld, 1992; Smith, 1994). Definitions differ from study to study, making comparisons

difficult. Much of the research on both victims and perpetrators is based on clinical samples, samples of convenience, or other nonrandomized samples, so one cannot draw general conclusions. Sample sizes are often quite small. Only recently have sophisticated statistical analyses been used. Yet in spite of all the shortcomings, a lot has been learned about the extent of violence against women, about perpetrators of violence, and about the effects on victims.

What Is Violence Against Women?

The term violence against women has been used to describe a wide range of acts, including murder, rape and sexual assault, physical assault, emotional abuse, battering, stalking, prostitution, genital mutilation, sexual harassment, and pornography. There is little consensus in the still evolving field on exactly how to define violence against women. The major contention concerns whether to strictly define the word ''violence" or to think of the phrase "violence against women" more broadly as aggressive behaviors that adversely and disproportionately affect women.

Researchers in such fields as sociology and criminology tend to prefer definitions that narrowly define violence, definitions that can be operationalized. For example, Gelles and Straus (1979) defined violence as "any act carried out with the intention of, or perceived intention of, causing physical pain or injury to another person." Similarly, the National Research Council (NRC) report Understanding and Preventing Violence (Reiss and Roth, 1993) limited its definition to "behavior by persons against persons that intentionally threatens, attempts, or actually inflicts physical harm." The 1993 NRC study deliberately excluded behavior that inflicts harm unintentionally, while the Gelles and Straus definition includes behaviors that may be unintentional but are perceived by the victim to be intentional. The 1993 NRC study also specifically excluded from its definition of violence such events as verbal abuse, harassment, or humiliation, in which

psychological trauma is the sole harm to the victim. However, in its consideration of family violence and sexual assault, the report did include the psychological consequences of threatened physical injury.

In contrast to those definitions, researchers in such fields as psychology, mental health, and social work frequently consider "violence" to cover a wider range of behaviors. The Committee on Family Violence of the National Institute of Mental Health (1992) included in its definition of violence "acts that are physically and emotionally harmful or that carry the potential to cause physical harm … [and] may also include sexual coercion or assaults, physical intimidation, threats to kill or to harm, restraint of normal activities or freedom, and denial of access to resources." The Task Force on Male Violence Against Women of the American Psychological Association defined violence as ''physical, visual, verbal, or sexual acts that are experienced by a woman or a girl as a threat, invasion, or assault and that have the effect of hurting her or degrading her and/or taking away her ability to control contact (intimate or otherwise) with another individual" (Koss et al., 1994). Those who argue for these broader definitions suggest they more accurately represent the experiences of victims, who often say they find verbal and psychological abuse more harmful than actual physical abuse (Walker, 1979; Follingstad et al., 1990; Herman, 1995).

In the field of intimate partner violence or battering, the problem of violence against women is frequently characterized as one of coercive control that is maintained by tactics such as physical violence, psychological abuse, sexual violence, and denial of resources. The concern is with the array of behaviors that are used to dominate women. Physical violence need not be used often to be effective: "In fact, abusers may regret resorting to violence, but may perceive themselves as 'driven to it' when their other methods of enforcing subordination are insufficient" (Herman, 1995:2). In the field of rape, fear is a key element; it is an overriding concern for many women (Warr, 1985; Gordon and Riger, 1989; Klod-

awsky and Lundy, 1994). Even though women are less frequently the victims of violent crime than men, women fear crime more (Federal Bureau of Investigation, 1991) and this fear appears to be largely based on their fear of rape (Riger et al., 1981). Many feminist theorists contend that this fear of rape serves to intimidate and control all women (e.g., Griffin, 1971; Brownmiller, 1975; Dworkin, 1991).

Although research would benefit from more unified definitions, the panel understands the difficulty of reaching agreement on definitional issues in light of the many complex behaviors that are involved. The panel held lengthy discussions on defining violence against women, focused on the key issue of whether psychological abuse should be included. The panel concluded that it could not resolve a question that is so open among researchers and that a global definition was not necessary for carrying out the task of reviewing what is known and recommending needed research (see below). Thus, the panel agreed that this study would be primarily a review of the literature on intimate partner violence (battering), rape, and sexual assault. The study does not include violence that occurs in conjunction with other crimes, such as robbery, burglary, or car theft. Nor does it include prostitution, sexual harassment, or issues such as genital mutilation, dowry murders, and trafficking in women that are more relevant internationally than in the United States.

Whether one uses a narrow definition confined to physical and sexual violence or one accepts a broader definition of violence against women, definitional debates also surround each of the individual components. For example, how does one define rape or sexual assault? Should all physical aggression or use of force be considered violent? What constitutes psychological abuse? These questions affect both the research that is done and how much it can be generalized.

Rape and Sexual Assault

Although all definitions of rape, sexual assault, and re-

lated terms include the notion of nonconsensual sexual behavior, the definitions used by researchers have varied along several dimensions. These include the behaviors specified, the criteria for nonconsent, the individuals involved, and who decides whether rape or sexual assault has occurred (Muehlenhard et al., 1992; Koss, 1993).

Many data sources and some researchers rely on legal definitions of rape, but those definitions differ from state to state and change over time. In common law, rape was traditionally defined as "carnal knowledge [penile-vaginal penetration only] of a female forcibly and against her will" (Bienen, 1980:174). The FBI's Uniform Crime Report (1993) still uses this narrow definition of rape even though most states have reformed their rape laws during the past 20 years. There have been three common reforms:

broadening the definition to include sexual penetration of any type, including vaginal, anal, or oral penetration, whether by penis, fingers, or objects;
focusing on the offender's behavior rather than the victim's resistance; and
restricting the use of the victim's prior sexual conduct as evidence.

Many states have also removed the marital exemption from their rape laws. Some states and the U.S. Code (18 U.S.C. § 2241-2245) have replaced the term "rape" with terms such as "sexual assault," "sexual battery," or "sexual abuse'' (Epstein and Langenbahn, 1994). Many laws now have a series of graded offenses defined by the presence or absence of aggravating conditions, making sexual assault laws similar to other assault laws. For example, the U.S. Code uses the categories aggravated sexual abuse when someone "knowingly causes another person to engage in a sexual act by using force against that other person, or by threatening or placing that other person in fear that any person will be subjected to death, serious bodily injury, or kidnapping" or by knowingly causing

another person to become incapable of giving consent by rendering them unconscious or administering intoxicants. Sexual abuse involves lesser threats or engaging in sexual acts with a person who cannot give consent.

The definition of rape or sexual assault used in a research study has an effect on who is counted as a rape victim. The type of screening questions, the use of the word rape versus the use of behavioral descriptions, and other considerations all affect the research results (Koss et al., 1994). Higher rates of rape and sexual assault are found when behavioral descriptions and multiple questions are used than when surveys ask directly about rape or sexual assault. Women may not label experiences that meet the legal definition of rape or sexual assault as such, particularly if the perpetrator was an intimate partner or an acquaintance. The use of behavioral descriptions in studies assures that what is being measured are experiences rather than an individual's conceptions of the words rape or sexual assault.

In this report, rape means forced or coerced penetration—vaginal, anal, or oral; "sexual assault" means other forced or coerced sexual acts not involving penetration; and "sexual violence" includes both rape and sexual assault.

Physical Violence

Although defining physical violence would seem to be more clear-cut, there are disagreements both over definitions and measurement. As noted above, some researchers include only acts that were intended to cause physical harm or injury (Reiss and Roth, 1993); others argue that intentionality may be difficult to ascertain, and therefore physical violence should also include acts that are perceived as having the intention of producing physical harm or injury (Gelles and Straus, 1979). Akin to intentionality is the consideration of the context of the act. For example, should an action taken in self-defense be considered violent? Should an act be considered violent only if an injury occurs, or is the potential for

injury sufficient? Some definitions of physical violence, following legal models of assault, include threats of physical harm; others consider that threats fall under verbal or psychological abuse (Straus, 1990a). There is disagreement about whether behaviors such as slapping a spouse should be equated with more severe acts such as kicking or using a weapon. How violence is defined and measured influences the rate of violence found in a study: all else being equal, the broader the definition, the higher the level of violence reported (Smith, 1994).

Physical violence is most commonly measured by the Conflict Tactic Scales (Straus, 1979, 1990b) or some modification of it. Such scales ask about the occurrence of various representative behaviors. For example, the Conflict Tactic Scales list nine physical violence items:

threw something at you;
pushed, grabbed, or shoved you;
slapped you;
kicked, bit, or hit you with a fist;
hit or tried to hit you with something;
beat you up;
choked you;
threatened you with a knife or gun; and
used a knife or fired a gun.

The last six behaviors in this list are considered to be "severe" physical violence.

In this report, "physical violence" refers to behaviors that threaten, attempt, or actually inflict physical harm. The behaviors listed in the Conflict Tactic Scales, while not all inclusive, typify the type of behaviors meant by physical violence. In this report, "severe" violence refers to the type of behaviors typified by the severe violence items on the scales.

Psychological Abuse

Psychological abuse (also refered to as psychological maltreatment or emotional abuse) has received less research attention than physical or sexual violence, and hence there have been fewer attempts to define it. At a minimum, psychological abuse refers to psychological acts that cause psychological harm (McGee and Wolfe, 1991). It has been argued that separating physical and psychological conditions "overly simplifies the topic and denies reality" (Hart and Brassard, 1991:63): physically violent acts can have psychological consequences and psychological acts can have physical consequences. The difficulty of separating physical violence and psychological abuse is exemplified by the treatment of threats of physical violence, with researchers split over whether to classify such threats as physical violence or psychological abuse. As with physical violence, there is debate about intentionality, that is, must the offender intend harm for an act to be considered abuse? Deciphering the intention of a psychological act may be even more difficult than for a physical act, and so intention is generally not included in defining psychological abuse.

On the basis of descriptions of psychological abuse as reported by battered women, Follingstad et al. (1990) described the following categories of behavior as psychological abuse:

verbal attacks such as ridicule, verbal harassment, and name calling, designed to make the woman believe she is not worthwhile in order to keep her under the control of the abuser;
isolation that separates a woman from her social support networks or denies her access to finances and other resources, thus limiting her independence;
extreme jealousy or possessiveness, such as excessive monitoring of her behavior, repeated accusations of infidelity, and controlling with whom she has contact;
verbal threats of abuse, harm, or torture directed at the woman herself or at her family, children, or friends;
repeated threats of abandonment, divorce, or of initiating an affair if the woman does not comply with the abuser's wishes; and
damage or destruction of the woman's personal property.

Similar to measurements of physical violence, inventories or scales of representative behaviors are used to measure psychological abuse. The Conflict Tactics Scales subscale on verbal aggression (Straus and Gelles, 1990) measures some aspects of psychological abuse: items include "insulted or swore at you," "did or said something to spite you," "threatened to hit or throw something at you," and ''threw or smashed or hit or kicked something." Other measures that have undergone validity testing are the Psychological Maltreatment of Women Inventory, which consists of 58 behavioral items (Tolman, 1988) and the Abusive Behavior Inventory, which includes items on both physical and psychological acts (Shepard and Campbell, 1992).

Interviews with battered women have detailed clear-cut examples of extreme psychological abuse occurring between and in conjunction with physically violent episodes. Psychological abuse frequently occurs with physical violence (Walker, 1979; Browne, 1987; Follingstad et al., 1990; Hart and Brassard, 1991), and research has repeatedly shown a strong association between psychological abuse and physical and sexual violence (e.g., O'Leary and Curley, 1986; Margolin et al., 1988; Sabourin et al., 1993). Some battered women describe psychological abuse—particularly ridicule—as constituting the most paintful abuse they experienced (Martin, 1976; Walker, 1979, 1984; Follingstad et al., 1990). It has been suggested that ridicule may undermine a woman's self-worth, making her less able to cope with both physical violence and psychological abuse (Follingstad et al., 1990). Studies of child abuse have similarly shown that psychological maltreatment is present in most cases of physical abuse, and it predicts detrimental outcomes for children while severity of physical

abuse does not (Claussen and Crittenden, 1991; Hart and Brassard, 1991).

In this report, "psychological abuse" refers to the types of behaviors described by Follingstad et al. (1990) and listed above, with the exception of threats of physical violence, which this report considers under physical violence. There is no separate section of the report devoted to psychological abuse because it has received very little study in and of itself. Rather, it is considered to be part of the pattern of behavior of serious physical violence, psychological abuse, and sometimes sexual violence, between intimate partners that has been well described (e.g., Martin, 1976; Dobash and Dobash, 1979; Walker, 1979; Browne, 1987). This pattern of behavior has been referred to in many terms, including domestic violence, spouse abuse, battering, and wife beating. "Wife beating" and "spouse abuse" imply married couples, although all intimate relationships—cohabiting, dating, and lesbian and gay couples—are frequently meant to be included under these terms. "Domestic violence," although usually referring to violence between intimate partners, is sometimes used to mean all forms of family violence, including child abuse, spouse abuse, sibling abuse, and elder abuse. These conflicting and overlapping terms and their uses are confusing in the study of violence against women.

In this report, "intimate partner violence" and "battering" are used synonymously to refer to the pattern of violent and abusive behaviors by intimate partners, that is, spouses, ex-spouses, boyfriends and girlfriends, and ex-boyfriends and ex-girlfriend. 2 The term batterer is used to mean the perpetrator of intimate partner violence, and battered woman, the victim.

In research studies, dating couples are sometimes considered as intimate partners and sometimes as acquaintances. "Acquaintance" generally refers to someone known to the victim but neither related nor an intimate. Particularly in crime data, it is not always clear what acquaintance means; it may include dating couples. Hence, date rape and dating

violence are sometimes included in crime data as violence by nonintimate acquaintances.

Battered women who have left their batterers have described being stalked by the batterer (e.g., Walker, 1979). This behavior includes following and threatening the woman, repeated harassing phone calls, threatening her family, and breaking into her living quarters. Anecdotal evidence suggests that some batterers go to extraordinary lengths to track down their victims and that women who are stalked by expartners may be at high risk of being killed. Although descriptive information about stalking is available, few data exist.

The acknowledgment of stalking as a crime is a fairly recent phenomenon. California passed the first antistalking law in 1990 (Sohn, 1994); today, 48 states and the District of Columbia have passed antistalking statutes (Boychuk, 1994). Most state statutes define stalking as willful, malicious, and repeated following and harassing of another person. Many statutes include in the definition the intent to place the victim in reasonable fear of sexual battery, bodily injury, or death.

The Panel's Charge And Scope

In the Violence Against Women Act of 1994 (Title IV of P.L. 103-322, the Violent Crime Control and Law Enforcement Act of 1994), Congress directed the National Research Council to develop a research agenda on violence against women (Chapter 9, § 40291):

The Attorney General shall request the National Academy of Sciences, through its National Research Council, to enter into a contract to develop a research agenda to increase the understanding and control of violence against women, including rape and domestic violence. In furtherance of the

Introduction: Sexual Violence

First Online: 29 July 2021

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Lisa Featherstone 4

Part of the book series: World Histories of Crime, Culture and Violence ((WHCCV))

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This chapter introduces and defines rape and sexual assault as they were understood in 1970s Australia, both legally and in Australian culture. Conceptualising Australia within the Western legal tradition, this introduction will establish the parameters of ideas of consent, trauma, gender and violence in the late twentieth century.

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Details of this case are taken from Lazarus v R [2016] NSWCCA 52; R v Lazarus (Unreported, District Court of NSW, Tupman DCJ, 4 May 2017); R v Lazarus [2017] NSWCCA 279.

Crimes Act 1900 (NSW) s 61HA(3) (a)–(c).

Georgina Mitchell, ‘Court of Criminal Appeal Upholds Luke Lazarus Rape Acquittal’, Sydney Morning Herald (SMH) , 27 November 2017, https://www.smh.com.au/national/nsw/court-of-criminal-appeal-upholds-luke-lazarus-rape-acquittal-20171127-gzteon.html .

For discussion on ‘reasonable’ in this case, see Andrew Dyer, ‘Sexual Assault Law Reform in New South Wales: Why the Lazarus Litigation Demonstrates No Need for Section 61HE of the Crimes Act to Be Changed (Except in One Minor Respect)’, Criminal Law Journal 43:2 (2019): 91–3.

Louise Hall, ‘Convicted Rapist Luke Lazarus Jailed for at Least Three Years’, SMH , 27 March 2015.

People of the State of California v. Brock Allen Turner . Turner was originally indicted on five counts, but two were withdrawn before the trial began.

On the issue of swimming, see, amongst others, Michael E. Miller, ‘All American Swimmer Found Guilty of Sexually Assaulting Unconscious Woman on Stanford Campus’, Washington Post , 31 March 2016, downloaded 12 September 2019; Alice Phillips, ‘Freshman Swimmer Brock Turner Faces Five Felony Counts After Alleged Rape’, The Stanford Daily , 27 January 2015, downloaded 12 September 2019.

Elle Hunt, ‘“20 Minutes of Action”: Father Defends Stanford Student Son Convicted of Sexual Assault’, The Guardian , 6 June 2016, downloaded 21 September, 2019.

Elle Hunt, ‘20 minutes of Action’.

Katie J. M. Baker, ‘Here’s the Powerful Letter the Stanford Victim Read to Her Attacker’, Buzzfeed News , 3 June 2016, https://www.buzzfeednews.com/article/katiejmbaker/heres-the-powerful-letter-the-stanford-victim-read-to-her-ra .

Bianca Fileborn and Rachel Loney-Howes, ‘Introduction: Mapping the Emergence of #MeToo’, in #MeToo and the Politics of Social Change , eds. Biance Fileborn and Rachel Loney-Howes (London: Palgrave Macmillan, 2019), 3–4; Sarah Wildman, ‘#MeToo Goes Global’, Foreign Policy , Winter 2019, https://foreignpolicy.com/gt-essay/metoo-goes-global-feminism-activism/ ; ‘#MeToo Movement’s Second Anniversary’, Human Rights Watch , 14 October 2019, https://www.hrw.org/news/2019/10/14/metoo-movements-second-anniversary .

www.now.org.au . See also Destroy The Joint’s social media on #Counting Dead Women and Sherele Moody’s Red Heart Campaign, theredheartcampaign.org . On social media and gender violence, see Ana Stevenson and Bridget Lewis, ‘From Page to Meme: The Print and Digital Revolutions Against Gender Violence’, in Gender Violence in Australia: Historical Perspectives , eds. Alana Piper and Ana Stevenson (Melbourne: Monash University Publishing, 2019), 184–190.

See Bianca Fileborn and Nickie Phillips, ‘From “Me Too” to “Too Far”? Contesting the Boundaries of Sexual Violence in Contemporary Activism’, in #MeToo and the Politics of Social Change , eds. Bianca Fileborn and Rachel Loney-Howes (London: Palgrave Macmillan, 2019), 99–115.

Michael Salter, ‘Want #MeToo to Serve Justice? Use it Responsibly’, The Ethics Centre , 31 January 2019, https://ethics.org.au/want-metoo-to-serve-justice-use-it-responsibly .

Rosalind Gill and Shani Orgad, ‘The Shifting Terrains of Sex and Power’, Sexualities 21:8 (2018): 1320; Michael Salter, ‘Online Justice in the Circuit of Capital: #MeToo, Marketization and the Deformation of Sexual Ethics’, in #MeToo and the Politics of Social Change , eds. Bianca Fileborn and Rachel Loney-Howes (London: Palgrave Macmillan, 2019), 317–334.

Nina Funnell, ‘“Unprofessional, unethical, unsafe”: ABC breaches rape victim’s privacy in new Tracey Spicer documentary’, news.com.au November 13, 2019.

Angela Onwuachi-Willig, ‘What About #UsToo? The Invisibility of Race in the #MeToo Movement’, Yale Law Journal Forum 128 (2018): 105–120.

Fileborn and Loney-Howes, ‘Introduction: Mapping the Emergence of #MeToo’, 5 (italics in original).

Neha Kagal, Leah Cowan, and Huda Jawad, ‘Beyond the Bright Lights: Are Minoritized Women Outside the Spotlight Able to Say #MeToo?’, in #MeToo and the Politics of Social Change , eds. Bianca Fileborn and Rachel Loney-Howes (London: Palgrave Macmillan, 2019): 134.

Kagal, Cowan, and Jawad, ‘Beyond the Bright Lights: Are Minoritized Women Outside the Spotlight Able to Say #MeToo?’, 134; Jess Ison, ‘It’s Not Just Men and Women’: LGBTQIA People and #MeToo’, in #MeToo and the Politics of Social Change , eds. Bianca Fileborn and Rachel Loney-Howes (London: Palgrave Macmillan, 2019): 151–167; Tess Ryan, ‘This Black Body is Not Yours for the Taking’, in #MeToo and the Politics of Social Change , eds. Bianca Fileborn and Rachel Loney-Howes (London: Palgrave Macmillan, 2019): 117–132.

ABC, ‘I Am That Girl’, Four Corner s, 7 May 2018, http://www.abc.net.au/4corners/i-am-that-girl/9736126 , downloaded 2 August, 2019.

Baker, ‘Here’s the Powerful Letter’.

Concepción de León, ‘You Know Emily Doe’s Story. Now Learn Her Name’, New York Times , 4 September 2019, https://www.nytimes.com/2019/09/04/books/chanel-miller-brock-turner-assault-stanford.html , downloaded 5 September 2019.

Tanya Serisier, ‘Speaking Out, and Beginning to be Heard: Feminism, Survivor Narratives and Representations of Rape in the 1980s’, Continuum 32:1 (2018): 52–61.

Loney-Howes, ‘The Politics of the Personal’, 33.

Kaitlynn Mendes and Jessica Ringrose, ‘Digital Feminist Activism: #MeToo and the Everyday Experiences of Challenging Rape Culture’, in #MeToo and the Politics of Social Change , eds. Bianca Fileborn and Rachel Loney-Howes (London: Palgrave Macmillan, 2019), 46.

Mark Speakman and Pru Goward, ‘Sexual Consent Laws to Be Reviewed’, NSW Government Media Release, 8 May 2018, https://www.justice.nsw.gov.au/Documents/Media%20Releases/2018/sexual-assault-consent-laws-to-be-reviewed.pdf .

Under the Queensland Criminal Code 1899, section 24(1) states: ‘A person who does or omits to do an act under an honest and reasonable, but mistaken, belief in the existence of any state of things is not criminally responsible for the act or omission.’ For feminist interpretations of the law, see Kate McKenna, ‘Queensland Consent Laws Confuse Juries and Need Reform, Women’s Advocate Argues’, ABC News , 13 August 2019, downloaded 13 August 2019.

See consentlawqld.com . Bri Lee is the author of Eggshell Skull (Sydney: Allen and Unwin, 2018).

Nina Funnell, ‘#LetHerSpeak’, conference paper Sex and Consent in the Age of #MeToo Workshop, Macquarie University, 6–7 November 2019; Lisa Martin, ‘Tasmania Sex Assault Gag Law to Face Overhaul Early Next Year’, The Guardian , 19 August 2019; Lauren Roberts, “Gag Laws’ Stopping Sexual Assault Survivors in the NT from Speaking Out’, ABC News , 22 October 2019, https://www.abc.net.au/news/2019-10-22/nt-sexual-assault-victims-stopped-from-speaking-out/11622468 . Similar legislation still exists in the Northern Territory at the end of 2019, meaning survivors are denied agency in telling their own stories, and journalists risk jail time in reporting on survivor’s experiences.

For studies historicising responses to sexual assault in the United States, see Tanya Serisier, ‘Speaking Out Against Rape: Feminist (Her)stories and Anti-Rape Politics’, Lilith 16 (2007): 84–95; Maria Bevacqua, Rape on the Public Agenda: Feminism and the Politics of Sexual Assault (Boston: Northeastern University Press, 2000).

Joanna Bourke, Rape: A History from 1860 to the Present Day (London: Virago, 2007), 8–10.

Claire Parker and Paul Sendziuk, ‘It’s Time: The Duncan Case and the Decriminalisation of Homosexual Acts in South Australia, 1972’, in Out Here: Gay and Lesbian Perspectives VI , eds. Yorick Smaal and Graham Willett (Melbourne: Monash University Publishing, 2011), 17–35.

NSW Parliament, Report of the Criminal Law Review Division of the Department of the Attorney-General and of Justice into Rape and Other Sexual Offences (Sydney: Government Printer, 1977), 11.

See Carol Backhouse, ‘A Comparative Study of Canadian and American Rape Law’, Canada-United States Law Journal 7 (1984): 182–3.

NSW Government, Report from the Select Committee on Violence Sex Crimes in New South Wales (Sydney: Government Printer, 1969), viii.

Crimes Act 1900 (NSW) s 62.

Montgomerie H. Hamilton and G. C. Addison, Criminal Law and Procedure, New South Wales: Containing the Crimes Act, 1900, the Criminal Appeal Act of 1912 and Other Statues, vol. 2 , 5th edition, ed. C. E. Weigall (Sydney: Law Book Co., 1947), 80.

For example, NSW Parliament, Report of the Criminal Law Review Division , 12.

Royal Commission on Human Relationships (hereafter RCHR), Final Report vol. 5 (Canberra: Government Printer, 1977), 196.

NSW Parliament, Report of the Criminal Law Review Division , 21.

Lisa Featherstone, ‘“That’s What Being a Woman is For”: Opposition to Marital Rape Law Reform in Late Twentieth-Century Australia’, Gender & History 29:1 (2017): 87–103.

See, for example, Louise A. Jackson, Child Sexual Abuse in Victorian England (London: Routledge, 2000); Stephen Robertson, Crimes Against Children: Sexual Violence and Legal Culture in New York City, 1880–1960 (Chapel Hill: UNC Press, 2005). In Australia, see Judith Allen, Sex and Secrets: Crimes Involving Australian Women Since 1880 (Melbourne: OUP, 1990; Jill Bavin-Mizzi, Ravished: Sexual Violence in Victoria Australia (Sydney: UNSW Press, 1995); Yorick Smaal, ‘“Keeping it in the family”: Prosecuting Incest in Colonial Queensland’, Journal of Australian Studies 37:3 (2013): 316–32; Juliet Peers, ‘The Tribe of Mary Jane Hicks: Imagining Women Through the Mount Rennie Rape Case 1886’, Australian Cultural History 12 (1993): 127–144; Lisa Featherstone and Andy Kaladelfos, Sex Crimes in the Fifties (Carlton: Melbourne University Press, 2016).

Andy Kaladelfos, ‘Crime and Outrage: Sexual Villains and Sexual Violence in New South Wales, 1870–1939’, PhD thesis, University of Sydney, 2010.

Featherstone and Kaladelfos, Sex Crimes in the Fifties , 76–80.

Johanna Sköld and Shurlee Swain, eds., Apologies and the Legacy of Abuse of Children in “Care” (London: Palgrave Macmillan, 2015); Shurlee Swain, History of Australian Inquiries: Reviewing Institutions Providing Care for Children , 2014, https://www.childabuseroyalcommission.gov.au/sites/default/files/file-list/Research%20Report%20-%20History%20of%20Australian%20inquiries%20reviewing%20institutions%20providing%20care%20for%20children%20-%20Institutional%20responses.pdf .

See Conclusion for comments on the Northern Territory Intervention, this volume.

Karen Terry et al., ‘The Causes and Context of Sexual Abuse of Minors by Catholic Priests in the United States, 1950–2010: A Report Presented to the United States Conference of Catholic Bishops by the John Jay College Research Team’, United States Conference of Catholic Bishops, Washington, DC, 2011; The Report of the Archdiocesan Commission of Enquiry into the Sexual Abuse of Children by Members of the Clergy , 3 volumes (Archdiocese of St John’s, Newfoundland, Canada, 1990); Francis D. Murphy, Helen Buckley, and Larain Joyce, The Ferns Report: Presented to the Minister for Health and Children (Dublin: Government Publications, 2005).

www.childabuseroyalcommission.gov.au . See also the Special Issue ‘The Royal Commission into Institutional Responses to Child Sexual Abuse’, Journal of Australian Studies 42:2 (2018), especially Katie Wright and Shurlee Swain, ‘Introduction: Speaking the Unspeakable, Naming the Unnameable: The Royal Commission into Institutional Responses to Child Sexual Abuse’, 139–152.

For other important works, see Human Rights and Equal Opportunity Commission, Bringing Them Home: Report of the National Inquiry into the Separation of Aboriginal and Torres Strait Islander Children from Their Families (Canberra: Government Printer, 1997); E. P. Mullighan, Children on Anangu Pitjantjatjara Yankunytjatjara (APY) Lands Commission of Inquiry: Report into Sexual Abuse (Adelaide: Office of the Commissioner, 2008); Family and Community Development Committee, Victorian Government, Betrayal of Trust—Inquiry into the Handling of Child Abuse by Religious and Other Non-Government Institutions (Victoria: Government Printer, 2013); Victorian Government, Royal Commission into Family Violence Report (Victoria: Government Printer, 2016).

DPP v Pell (sentence) [2019] VCC 260 (13 March 2019), www.austlii.edu.au/cgi-bin/viewdoc/au/cases/vic/VCC/2019/260.html .

At the time of press, full legal analysis of the High Court decision has not yet occurred. A good summary appeared at Ben Mathews and Mark Thomas, ‘How George Pell won in the High Court on a legal technicality’, The Conversation April 7, 2020, https://theconversation.com/how-george-pell-won-in-the-high-court-on-a-legal-technicality-133156 .

On Pell’s relationships with other priests, see Louise Milligan, Cardinal: The Rise and Fall of George Pell (Melbourne: Melbourne University Press, 2017); David Marr, ‘The Prince: Faith, Abuse and George Pell’, Quarterly Essay 51 (2013): 1–98.

Scanned copies cited at theaustralianatnewscorpau.files.wordpress.com/2019/02/statements.pdf , downloaded 7 March 2019.

One of the young men, known as R, died before trial.

ABS, Personal Safety, Australia, 2016, https://www.abs.gov.au/ausstats/[email protected]/mf/4906.0 .

Linda Alcoff, Rape and Resistance (Cambridge: Polity Press, 2018), 52.

Our Watch, Changing the Picture: A National Resource to Support the Prevention of Violence against Aboriginal and Torres Strait Islander Women and Their Children (Melbourne: Our Watch, 2018), Executive Summary, np.

Judy Atkinson, ‘Violence in Aboriginal Australia: Colonisation and Gender’, Aboriginal and Islander Health Worker Journal 14:2 (June 1990): 5–21.

Eugenia Flynn, ‘This Place’, in #MeToo: Stories from the Australian Movement , eds. Miriam Sved, Christie Nieman, Maggie Scott, Natalie Kon-yu (Sydney: Pan Macmillan, 2019), 17.

Larissa Behrendt, ‘Consent in a (Neo)Colonial Society: Aboriginal Women as Sexual and Legal ‘Other’, Australian Feminist Studies 15:33 (2000): 353.

Ryan, ‘This Black Body is Not Yours for the Taking’, 120.

Our Watch, Changing the Picture: A National Resource to Support the Prevention of Violence against Aboriginal and Torres Strait Islander Women and Their Children , Executive Summary, np.

Amy McQuire, ‘The More Things Change: Female Black Lives Don’t Matter. If They Did, Ms Dhu Would Still Be Alive’, New Matilda , 24 November 2015, https://newmatilda.com/2015/11/24/the-more-things-change-female-black-lives-dont-matter-if-they-did-ms-dhu-would-still-be-alive/ .

Flynn, ‘This Place’, 20.

Ryan, ‘This Black Body is Not Yours for the Taking’, 117.

Pat O’Shane, ‘Is There Any Relevance in the Women’s Movement for Aboriginal Women?’, Refractory Girl 12 (1976): 32–34; Melissa Lucashenko, ‘No Other Truth?: Aboriginal Women and Australian Feminism’, Social Alternatives 12:4 (1994): 21–24; Aileen Moreton-Robinson, Talkin’ Up to the White Woman: Aboriginal Women and Feminism (St Lucia, Qld: University of Queensland Press, 2000); Larissa Behrendt, ‘Aborignal Women and the White Lies of the Feminist Movement: Implication for AboriginalWomen in Rights Discourse’, The Australian Feminist Law Journal 1 (1993): 27–44; A. Maguire, ‘All Feminists Are Created Equal, But Some Are More Equal Than Others’, New Matilda , 5 March 2015, https://newmatilda.com/2015/03/05/all-feminists-are-created-equal-some-aremore-equal-others/ , downloaded December 2019.

Edie Carter, Aboriginal Women Speak Out About Rape and Child Sexual Abuse (Adelaide: Adelaide Rape Crisis Centre, 1987). See also Vivian Bligh, ‘A Study of the Needs of Aboriginal Women Who Have Been Raped or Sexually Assaulted’, in We Are Bosses Ourselves: The Status and Role of Aboriginal Women Today , ed. Fay Gale (Canberra: Australian Institute of Aboriginal Studies, 1983).

See Bianca Fileborn, ‘Sexual Violence and Gay, Lesbian, Bisexual, Trans, Intersex, and Queer Communities’, Australian Institute of Family Studies (March 2012): 3–7; Gail Mason and Stephen Tomsen, Homophobic Violence (Sydney: Hawkins Press, 1997); Alan Berman and Shirleene Robinson, Speaking Out: Stopping Homophobic and Transphobic Abuse in Queensland (Brisbane: Australian Academic Press, 2000).

Lucy Cormack, ‘Ugly Part of Our History’: Sydney’s Wave of Gay-Hate Deaths Exposed’, SMH , 26 June 2018.

Steven Angelides, ‘The Homosexualization of Pedophilia: The Case of Alison Thorne and the Australian Pedophile Support Group’, in Homophobias: Lust and Loathing Across Time and Space , ed. David A. B. Murray (Duke University Press, 2009), 64–81; Steven Angelides, ‘The Emergence of the Paedophile in the Late Twentieth Century’, Australian Historical Studies 36:126 (2005): 272–295.

Rebecca Jennings, “It Was Quite a Scary Time’: Lesbians and Violence in Post-War Australia’, in Gender Violence in Australia: Historical Perspectives , eds. Alana Piper and Ana Stevenson (Melbourne: Monash University Publishing, 2019), 153–8.

See Fileborn, ‘Sexual Violence’, 8.

D. Callander, J. Wiggins, S. Rosenberg, V. J. Cornelisse, E. Duck-Chong, M. Holt, M. Pony, E. Vlahakis, J. MacGibbon, and T. Cook, The 2018 Australian Trans and Gender Diverse Sexual Health Survey: Report of Findings (Sydney: The Kirby Institute, UNSW, 2019), 10.

Callander et al., The 2018 Australian Trans and Gender Diverse Sexual Health Survey , 10.

See amongst others Roberta Perkins, The Drag Queen Scene: Transsexuals in Kings Cross (Sydney: George Allen & Unwin, 1983); Roberta Perkins, Working Girls: Prostitutes, Their Life and Social Control (Canberra: Australian Institute of Criminology, 1991).

Meredith Talusan, ‘Trans Women and Femmes Are Shouting #MeToo—But Are You Listening?’, Them , 2 March 2018, https://www.them.us/story/trans-women-me-too . One recent exception is Kaya Wilson, ‘Among Men’, in #MeToo: Stories from the Australian Movement , eds. Miriam Sved, Christie Nieman, Maggie Scott, Natalie Kon-yu (Sydney: Pan Macmillan, 2019), 315–322.

Susan Brownmiller, Against Our Will: Men, Women and Rape (New York: Simon & Schuster, 1975); M. R. Burt, ‘Cultural Myths and Support for Rape’, Journal of Personality and Social Psychology 38 (1980): 217–230; Susan Estrich, Real Rape (Cambridge: Harvard University Press, 1987).

For an excellent summary on rape myths and the literature on them, see Olivia Smith, Rape Trials in England and Wales: Observing Justice and Rethinking Rape Myths (Springer, 2018), 54–57.

See O. Smith and T. Skinner, ‘How Rape Myths Are Used and Challenged in Rape and Sexual Assault Trials’, Social & Legal Studies 26:4 (2017): 4–6. On the impact of rape myths in journalism, see Jane Gilmore, Violence and the Representation of Women in the Media (Melbourne: Penguin, 2019); R. Franiuk, J. L. Seefelt, and J. A. Vandello, ‘Prevalence of Rape Myths in Headlines and Their Effects on Attitudes Toward Rape’, Sex Roles 58 (2008): 790–801.

Anne Edwards and Melanie Heenan, ‘Rape Trials in Victoria: Gender, Socio-cultural Factors and Justice’, Australian and New Zealand Journal of Criminology 27:3 (December 1994): 215.

Constance Backhouse, “Her Protests Were Unavailing’: Australian Legal Understandings of Rape, Consent and Sexuality in the ‘Roaring Twenties”, Journal of Australia Studies 24:64 (2000): 21.

RCHR, Final Report vol. 5 , 163, 164.

Paul Ward, and Greg Woods, Law and Order in Australia (Sydney: Angus and Robertson, 1972), 93.

E. J. Hodgens, I. H. McFadyen, R. J. Failla and F. M. Daly, ‘The Offence of Rape in Victoria’, Australian and New Zealand Journal of Criminology 5:4 (December 1972): 227, 234.

RCHR, Final Report vol. 5 , 161.

Ward and Woods, Law and Order in Australia , 93. See also Menachim Amir, ‘Victim Precipitated Forcible Rape’, Journal of Criminal Law and Criminology 58:4 (1967): 493–502.

Beverley Scholz, ‘Profile of a Gang Rape’, in Delinquency in Australia: A Critical Appraisal , ed. Paul R. Wilson (St. Lucia, Qld: University of Queensland Press, 1977), 119.

Paul Wilson, interview, Royal Commission on Human Relationships: Official transcript of proceedings (Sydney: Commonwealth Reporting Service, 1974–1976), 1667; ‘All Women Have The Right To Say No’, WEL-Informed , October 1979, 17. See also Olivia Plunkett, ‘Innocent Even When Proven Guilty: Sexual Assault of Female Sex Workers in Australia 1966–1996’, BA Honours Thesis, University of Queensland, 2019.

Featherstone and Kaladelfos, Sex Crimes , 14.

See Lisa Featherstone, ‘Trauma and Sexual Violence: Narratives and Cases in Australia in the Late Twentieth Century’, in Paula Michaels and Christina Twomey (eds.) Gender and Trauma since 1900 (London: Bloomsbury Press, 2021).

Cathy Waldby, Breaking the Silence: A Report Based Upon the Findings of the Women Against Incest Phone-in Survey (Sydney: Women Against Incest, 1985), 4; ‘Sexual Abuse of Children’, WEL-Informed , August 1978, 6.

Rebecca Campbell et al., ‘“What Has It Been Like for You to Talk with Me Today?”: The Impact of Participating in Interview Research on Rape Survivors’, Violence Against Women 16:1 (2010): 60–83.

For historical studies of male victimisation, see Andy Kaladelfos and Yorick Smaal, ‘Sexual Violence and Male Prisons: An Australian Queer Genealogy’, Current Issues in Criminal Justice 31:3 (2019), 349–364; Yorick Smaal and Graham Willett, ‘Conduct Unbecoming: Homosex, Discipline and Military Cultures in the Second World War’, in Criminologies of the Military, Militarism, National Security and Justice , eds. Ben Wadham and Andrew Goldsmith (Oxford: Hart Publishing 2018), 169–188; Shurlee Swain, ‘Gender-Based Violence in Out-of-Home Care’, in Gender Violence in Australia: Historical Perspectives , eds. Alana Piper and Ana Stevenson (Melbourne: Monash University Publishing, 2019), 131–145.

ABS, ‘4125.0—Gender Indicators, Australia, Sep 2018’ https://www.abs.gov.au/ausstats/[email protected]/Lookup/by%20Subject/4125.0~Sep%202018~Main%20Features~Safety%20and%20Justice~8 . For some of the problems in identifying female offenders, see David Axlyn McLeod, ‘Female Offenders in Child Sexual Abuse Cases: A National Picture’, Journal of Child Sexual Abuse 24:1(2015): 97–114; Sarah Michal Greathouse et al., ‘Female Sexual Assault Perpetrators,’ in their A Review of the Literature on Sexual Assault Perpetrator Characteristics and Behaviors (Santa Monica: Rand Corporation, 2015), 37–42.

https://www.abs.gov.au/ausstats/[email protected]/mf/4906.0 accessed December 2019 .

Indigenous Deaths in Custody: A Report Prepared by the Office of the Aboriginal and Torres Strait Islander Social Justice Commissioner (Canberra: Government Printer, 1996), Chap. 6 , https://www.humanrights.gov.au/our-work/indigenous-deaths-custody-chapter-6-police-practices ; The Senate, Finance and Public Administration References Committee, Report: Aboriginal and Torres Strait Islander Experience of Law Enforcement and Justice Services (Canberra: Government Printer, 2016), https://www.aph.gov.au/Parliamentary_Business/Committees/Senate/Finance_and_Public_Administration/Legalassistanceservices/Report .

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Kathleen Daly and Brigitte Bouhours, ‘Rape and Attrition in the Legal Process: A Comparative Analysis of Five Countries’, Crime and Justice 39:1 (2010): 606.

Daly and Bouhours, ‘Rape and Attrition in the Legal Process’, 583–4.

Daly and Bouhours, ‘Rape and Attrition in the Legal Process’, 598.

Bourke, Rape , 389.

The cases considered in this book are drawn from a database of sexual offences developed by Andy Kaladelfos and myself, created by research in the Supreme Court and Quarter Sessions records in New South Wales (NSW), Australia’s largest jurisdiction. I examined 610 full and partial court transcripts from 1970, 1975, 1980 and 1985, including trials, sentencing hearings and compensation claims. The verbatim transcripts provide records on sexual offences that span gender and age, and include rape, sodomy, acts of indecency against men, indecent assault of females and child sexual assault in various forms. These transcripts do not represent all court cases of sexual crime in NSW in this time period, but rather represent cases that the court saw fit to record, possibly as they were seen as cases that might be appealed. The 610 court transcripts are imperfect sources, for the transcriptions are regularly incomplete and fragmentary, with only parts of the court proceedings recorded. Often, we do not have an outcome of the trial or a sentence, though sometimes these can be traced in media reports.

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Featherstone, L. (2021). Introduction: Sexual Violence. In: Sexual Violence in Australia, 1970s–1980s. World Histories of Crime, Culture and Violence. Palgrave Macmillan, Cham. https://doi.org/10.1007/978-3-030-73310-0_1

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About Sexual Assault

Sexual violence happens in every community and affects people of all genders and ages. Sexual violence is any type of unwanted sexual contact. This includes words and actions of a sexual nature against a person’s will and without their consent. A person may use force, threats, manipulation, or coercion to commit sexual violence.

Forms of sexual violence include:

Rape or sexual assault
Child sexual assault and incest
Sexual assault by a person’s spouse or partner
Unwanted sexual contact/touching
Sexual harassment
Sexual exploitation and trafficking
Exposing one’s genitals or naked body to other(s) without consent
Masturbating in public
Watching someone engage in private acts without their knowledge or permission
Nonconsensual image sharing

There is a social context that surrounds sexual violence. Social norms that condone violence, use power over others, traditional constructs of masculinity, the subjugation of women, and silence about violence and abuse contribute to the occurrence of sexual violence. Oppression in all of its forms is among the root causes of sexual violence. Sexual violence is preventable through collaborations of community members at multiple levels of society—in our homes, neighborhoods, schools, faith settings, workplaces, and other settings. We all play a role in preventing sexual violence and establishing norms of respect, safety, equality, and helping others.

What is consent?

Consent must be freely given and informed, and a person can change their mind at any time.

Consent is more than a yes or no. It is a dialogue about desires, needs, and level of comfort with different sexual interactions.

Who does sexual violence impact?

Victims of sexual violence include people of all ages, races, genders, and religions — with and without disabilities.

Nearly one in five women in the United States have experienced rape or attempted rape some time in their lives (Black et al., 2011).
In the United States, one in 71 men have experienced rape or attempted rape (Black et al., 2011).
An estimated 32.3% of multiracial women, 27.5% of American Indian/Alaska Native women, 21.2% of non-Hispanic black women, 20.5% of non-Hispanic white women, and 13.6% of Hispanic women were raped during their lifetimes (Black et al., 2011).

Victims often know the person who sexually assaulted them.

People who sexually abuse usually target someone they know.

Nearly three out of four adolescents (74%) who have been sexually assaulted were victimized by someone they knew well (Kilpatrick, Saunders, & Smith, 2003).
One-fifth (21.1%) were committed by a family member (Kilpatrick, Saunders, & Smith, 2003).

Victims are never at fault.

Choosing to violate another person is not about “drinking too much,” “trying to have a good time,” or ”getting carried away,” nor is it about the clothes someone was wearing, how they were acting, or what type of relationship they have with the person who abused them. Violating another person is a choice.

Rape is often not reported or convicted.

A person may choose not to report to law enforcement or tell anyone about a victimization they experienced for many reasons. Some of the most common include:

a fear of not being believed
being afraid of retaliation
shame or fear of being blamed
pressure from others
distrust towards law enforcement
a desire to protect the attacker for other reasons

The Impact of Sexual Violence

The impact of sexual violence extends beyond the individual survivor and reaches all of society.

Impact on survivors

An assault may impact a survivor’s daily life no matter when it happened. Each survivor reacts to sexual violence in their own way. Common emotional reactions include guilt, shame, fear, numbness, shock, and feelings of isolation.

Physical impacts may include personal injuries, concerns about pregnancy, or risk of contracting a sexually transmitted infection. Economic impacts of sexual violence include medical and other expenses in addition to things like time off work. The long-term psychological effects survivors may face if their trauma is left untreated include post-traumatic stress disorder, anxiety, depression, isolation, and others.

Impact on loved ones

Sexual violence can affect parents, friends, partners, children, spouses, and/or coworkers of the survivor. As they try to make sense of what happened, loved ones may experience similar reactions and feelings to those of the survivor such as fear, guilt, self-blame, and anger.

Impact on communities

Schools, workplaces, neighborhoods, campuses, and cultural or religious communities may feel fear, anger, or disbelief when sexual assault happens in their community. Violence of all kinds destroys a sense of safety and trust. There are financial costs to communities including medical services, criminal justice expenses, crisis and mental health service fees, and the lost contributions of individuals affected by sexual violence.

Impact on society

The contributions and achievements that may never come as a result of sexual violence represent a cost to society that cannot be measured. Sexual violence weakens the basic pillars of safety and trust that people long to feel in their communities because it creates an environment of fear and oppression.

A recent study from the Centers for Disease Control and Prevention found that individual victims of sexual violence incur $122,461 over a lifetime in costs associated with lost wages, health, criminal justice, and property damage (Peterson et al., 2017). Additional research shows that sexual violence can derail a person’s education and employment, resulting in a $241,600 income loss over a lifetime (MacMillan, 2000).

Sexual assault and the related trauma response can disrupt survivors’ employment in several ways, including time off, diminished performance, job loss, and inability to work (Loya, 2014).

In 2015, the Equal Employment Opportunity Commission alone recovered $164.5 million for workers alleging harassment (Equal Employment Opportunity Commission, 2016). Indirect costs for employers include decreased productivity, higher turnover, and reputation damage.

Black, M. C., Basile, K. C., Breiding, M. J., Smith, S. G., Walters, M. L., Merrick, M. T., Chen, J., & Stevens, M. R. (2011). National Intimate Partner and Sexual Violence Survey: 2010 summary report . Retrieved from the National Center for Injury Prevention and Control, Centers for Disease Control and Prevention: http://www.cdc.gov/violenceprevention/pdf/nisvs_report2010-a.pdf

Equal Employment Opportunity Commission. (2016). Final Report of the EEOC Select Task Force on the Study of Harassment in the Workplace. Washington. D. C. Retrieved from: https://www.eeoc.gov/eeoc/task_force/harassment/index.cfm

Kilpatrick, D. G., Saunders, B. E., & Smith, D. W. (2003). Youth victimization: Prevalence and implications (NIJ Research Brief NCJ 194972). Retrieved from the National Criminal Justice Reference Service: https://www.ncjrs.gov/pdffiles1/nij/194972.pdf

Loya, R. M. (2014) Rape as an economic crime: The impact of sexual violence on survivor’s employment and economic well-being. Journal of Interpersonal Violence , 30 (16), 2793-2813. doi:10.1177/0886260514554291

MacMillan, R. (2000). Adolescent victimization and income deficits in adulthood: Rethinking the costs of criminal violence from a life-course perspective. Criminology, 38 (2), doi: 10.1111/j.1745-9125.2000.tb00899.x

Peterson, C., DeGue, S., Florence, C., & Lokey, C. N. (2017). Lifetime economic burden of rape among U.S. adults. American Journal of Preventive Medicine . doi:10.1016/j. amepre.2016.11.014

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Cochrane Database Syst Rev

Psychosocial interventions for survivors of rape and sexual assault experienced during adulthood

Sarah j brown.

Coventry University, Faculty of Health and Life Sciences, Priory Street, CoventryUK, CV1 5FB

University of the Sunshine Coast, School of Law and Criminology, 90 Sippy Downs Drive, Sippy DownsAustralia, 4556

Nazanin Khasteganan

Katherine brown, kelsey hegarty.

The University of Melbourne, Department of General Practice, 200 Berkeley StreetParkville, MelbourneAustralia, 3010

The Royal Women's Hospital, VictoriaAustralia,

Grace J Carter

Laura tarzia.

University of Bristol, Centre for Academic Primary Care, Population Health Sciences, Bristol Medical School, Canynge Hall39 Whatley Road, BristolUK, BS8 2PS

Lorna O'Doherty

This is a protocol for a Cochrane Review (Intervention). The objectives are as follows:

To assess the effects of psychosocial interventions on mental health and well‐being for survivors of rape and sexual assault experienced during adulthood.

Description of the condition

Rape and sexual assault are serious crimes, with the two terms being used to differentiate between different types of behaviours (offences). Sexual assault is an act of physical, psychological and emotional violation in the form of a sexual act, inflicted on someone without their consent. It can involve forcing or manipulating someone to witness or participate in sexual acts. An attempt to engage a person in such activities is referred to as attempted sexual assault. Legislation varies both between and within countries in respect of the activities that meet the criteria for sexual assault. For example, in the UK, sexual assault is based on 'touching' without consent, while the Supreme Court of Canada held that the act of sexual assault does not depend solely on contact with any specific part of the human anatomy but rather the act of a sexual nature that violates the sexual integrity of the victim. Rape is a specific form of sexual assault, defined by the World Health Organisation ( WHO 2002 ) as "physically forced or otherwise coerced penetration – even if slight – of the vulva or anus, using a penis, other body parts or an object. The attempt to do so is known as attempted rape." (quote; p 149) There are differences in the types of acts that meet different legislative criteria for rape around the world (e.g. in some countries, rape only applies when a man commits the act against a female), but generally and broadly, the offence involves sexual penetration without consent. When children are raped or sexually assaulted, this is typically referred to as child sexual abuse (CSA), despite the fact that legislation for these offences may include the terms rape and sexual assault (e.g. rape of a minor, sexual assault of a child).

Rape and sexual assault are significantly under‐reported; for example, only 23% of the 323,450 rapes or sexual assaults against individuals aged 12 years or older reported to the USA National Crime Victimization Survey in 2016 had been reported to the police ( Morgan 2017 ), and just 17% of sexual assaults experienced since 16 years of age in the British Crime Survey in 2013/14 ( ONS 2015 ). Thus, it is difficult to understand the full extent of the problem, with estimates varying widely depending on the definitions used and method of data collection. There are more population‐based survey data available to estimate rape and sexual assault perpetrated by intimate partners, compared to non‐partners ( WHO/PAHO 2012 ). The lifetime prevalence of sexual violence perpetrated by an intimate partner reported by women aged 15 to 49 years in the WHO multi‐country study ranged from 6% in Japan to 59% in Ethiopia ( WHO 2005 ). In this study, 0.3 to 12% of women reported having been forced, after the age of 15 years, to have sexual intercourse or to perform a sexual act by someone other than an intimate partner. Estimates of prevalence using reports of perpetrators are rare. A cross‐sectional survey of a randomly selected sample of men in South Africa revealed that 14.3% reported having raped their current or former wife or girlfriend, while one in five reported raping a woman who was not a partner (i.e. a stranger, acquaintance or family member) ( Jewkes 2011 ).

Rape and sexual assault disproportionately affect women ( Walby 2016 ). Research into men's experiences of rape and sexual assault has been characterised by small samples sizes and varying definitions, and thus, the prevalence of rape and sexual assault perpetrated against men is largely unknown. Social and legal marginalisation, exacerbated by gender‐defined services, stigma and discrimination, all mean that the experiences of rape and sexual assault experienced by transgender people are hidden and poorly understood (e.g. see Wirtz 2018 ). In relation to sexual identities, the 2010 National Intimate Partner and Sexual Violence Survey showed that one in five bisexual women were raped by a partner (relative to one in 10 heterosexual women); rates of sexual violence were also higher for gay men and bisexual men, compared to heterosexual men ( Walters 2013 ).

There is growing application of syndemic (concurrent or sequential diseases that additively increase negative health consequences) frameworks to understand the way in which different exposures or conditions (e.g. intimate partner violence (IPV) and substance misuse) co‐occur and exacerbate each other, producing new health problems such as HIV ( Brennan 2012 ; Singer 2003 ). In the context of sexual violence, the approach highlights how structural factors, such as poverty and immigration status, and social aspects, such as different identities, disability, history of exploitation or sex work and lack of support systems, interact to produce health inequities and reinforce the disease burden ( Willen 2017 ). The same factors reduce the capacity of research to bear witness to the experiences of those affected by constellations of social, political and economic factors. The limited evidence we do have on the hidden experiences of men, and other groups both silenced and at high risk, suggest trauma‐related sequelae are similar across all groups ( Coxell 2010 ).

Sexual assault is a serious public health and human rights problem ( WHO 2013a ). It has devastating effects on adult and child victims, their families, and communities. There are extensive immediate and long‐term physical and mental health consequences for survivors. The consequences for adult and child victims include injuries, substance misuse, eating disorders, post‐traumatic stress disorder (PTSD), anxiety, depression, self‐harm and suicidality ( WHO 2013a ). Sexual and reproductive health problems represent the largest and most persistent physical health differences between women with and without exposure to rape or sexual assault, or both. Problems include unwanted pregnancy, sexually transmitted infections ( WHO 2013a ), urinary tract infections, painful sex, chronic pelvic pain and vaginal bleeding ( Campbell 2002 ). For male victims, physical health consequences include genital and rectal injuries and erectile dysfunction ( Tewkesbury 2007 ).

The mental health burden is substantial and similar across male and female victims ( Coxell 2010 ; Tewkesbury 2007 ; Walker 2005 ; WHO 2013a ). Sexual assault was ranked among the top three most traumatic life events in the US National Epidemiologic study (n = 34,653; Pietrzak 2011 ). Participants in that study with a psychiatric diagnosis of PTSD were four times more likely to report exposure to sexual assault than controls, and 13% of women with PTSD had lifetime experience of sexual assault. PTSD is a psychiatric disorder that can follow exposure to psychological trauma and is associated with intrusive memories, nightmares, avoidance, and problems with sleep and concentration ( Lerman 2019 ). These findings are consistent with the World Mental Health Survey ( Liu 2017 ). Guina and colleagues reported no difference in PTSD symptoms and severity among men and women who had experienced sexual trauma ( Guina 2016 ). Other mental health consequences include alcohol use disorders, eating disorders, anxiety, depression, self‐harm and suicidality ( WHO 2013a ). Indirect pathways to poor long‐term health outcomes are also of concern; for example, taking lifetime PTSD as a proxy, PTSD is associated with increased risk of hypertension, cardiovascular disease and gastrointestinal problems ( Pietrzak 2011 ). Thus, the immense medical and psychological impacts of sexual violence exposure can lead to long‐term disability.

The negative effects of rape and sexual assault ripple across generations, having social and economic costs in addition to impacts on physical and mental health by affecting, for example, individuals’ capacities to work and to participate in family and community life. Rape and sexual assault produce a significant social and economic burden, with lost productivity and police and criminal justice costs, in addition to the health and mental health burden. In the UK, each adult rape has been estimated to cost over £73,000 from psychological damage to a person, the physical impacts of associated injuries and illnesses, health service use, and economic losses ( Home Office 2005 ). In the USA, the Centers for Disease Control and Prevention estimated that the lifetime cost of rape was US$122,461 per victim, which amounted to a population economic burden of almost US$3.1 trillion ( Peterson 2017 ). This figure relates to data showing that over 25 million adults had been raped and included medical costs (39%), lost work productivity relating to both victims and perpetrators (52%), criminal justice costs (8%), and other expenses such as victim property loss or damage (1%). There are additional impacts to consider, from lost economic output to increased use of social services, impacts on family, capacity to parent, intergenerational transmission of trauma and violence, and effects for the wider community. Thus, providing accessible, evidence‐based interventions in response to victims is not only a moral imperative, but an essential requirement to limit the consequences of rape and sexual assault across the lifespan and disrupt the costly pathways to poor health.

Description of the intervention

While there is a great deal of consensus that sexual assault and rape are highly detrimental to mental health, the conceptualisation of that harm has been the subject of debate ( Campbell 2009 ). Early sexual assault interventions arose from a crisis theory orientation (e.g. Burgess 1974 ), which informed rape advocacy organisations ( Koss 1987a ). However, there is a lack of evidence for this approach and indications that some women with chronic symptoms needed more intensive treatment ( Kilpatrick 1983 ). Cognitive‐behavioural interventions that built on evidence‐based anxiety treatments were adapted for this population in the 1970s, which included Stress Inoculation Training (SIT; Veronen 1983 ). Later, Prolonged Exposure Therapy (PET; Foa 1986 ) and Cognitive Processing Therapy (CPT; Resnick 1977 ) were developed and evaluated (see Vickerman 2009 for a review). Then, behavioural therapies, such as Eye Movement Desensitisation Reprocessing (EMDR; Shapiro 1995 ), received increased research attention and began to be evaluated in this population (e.g. Rothbaum 1997 ). These approaches sit within a trauma‐response theoretical model ( Goodman 1993 ; Herman 1992 ); however, the clinical diagnosis of PTSD risks pathologising victims ( Berg 2002 ; Gilfus 1999 ), has been identified as re‐traumatising and unhelpful by survivors, and perpetuates ethnocultural biases ( Marsella 1996 ; Wasco 2003 ). Rape and sexual assault do not occur in social and cultural isolation ( Campbell 2009 ). As highlighted recently by the #MeToo movement, victims have to negotiate post‐assault responses and help‐seeking in hostile and doubting environments. This is due to a pervasive culture that propagates messages that victims are to blame, that they caused the assault or rape and deserved it ( Buchwald 1993 ; Burt 1998 ; Lonsway 1994 ; Sandy 1998 ), if they are believed at all. Hence, violence against women scholars have advocated for an ecologically‐informed trauma model of rape recovery ( Koss 1991 ; Neville 1999 ), which takes these issues into account and highlights the different systems within which responses and support are provided, and moreover stresses the importance of social as well as psychological responses. According to Kelly’s ecological theory ( Kelly 1966 ; Kelly 1968 ; Kelly 1971 ), individuals' and community organisations' responses are interdependent, resulting in each person having differential patterns of experiences depending on their ecological circumstances. Koss 1991 and Harvey 1996 adapted these ideas in their ecological model of rape recovery, which Campbell and colleagues used to evaluate legal, medical, and mental health systems' responses to survivors’ needs and the influences on survivors’ psychological, physical, and sexual health outcomes ( Campbell 1998 ; Campbell 1999 ; Campbell 2001 ; Campbell 2004 ). The World Health Organization (WHO; Jewkes 2002 ; Krug 2002 ) and Center for Disease Control and Prevention ( CDC 2004 ) have adapted this approach in the prevention of gender‐based violence. This means that a wide range of interventions has been developed to support or respond (or both) to victims of sexual assault and rape. These include supportive therapies, whereby counsellors and/or specific sexual assault/rape support workers, advocates or advisors give support, information and advice to survivors. They may listen to victims and help them talk over their feelings and problems ( BluePages 2012 ). Counsellors may offer debriefing, which allows emotional processing or ventilation by encouraging recollection, ventilation and reworking of the traumatic event ( Rose 2002 ).

Psychosocial interventions “are interpersonal or informational activities, techniques, or strategies that target biological, behavioral, cognitive, emotional, interpersonal, social, or environmental factors with the aim of improving health functioning and well‐being” ( IOM 2015 , p 5). They vary considerably as interventions target different combinations of these factors. For example, Sikkema and colleagues describe the development of a psychosocial intervention for South African women with sexual trauma histories ( Sikkema 2018 ). The intervention included both individual and group sessions with psycho‐education and focused on the following treatment themes: synergistic stress of sexual trauma and HIV; impact of trauma on health behaviours; safety, intimacy, power, and self‐esteem; stressor identification and appraisal; adaptive versus maladaptive coping; social support; and reduction of shame and stigma. Group education sessions (e.g. Dognin 2017 ) and brief video‐based interventions that provide psycho‐education and modelling of coping strategies to survivors at the time of a sexual assault nurse examination ( Miller 2015 ) have also been developed for this population. Sexual Assault Referral Centres (e.g. NHS 2015 ; Vandenberghe 2018 ) provide a range of initial response and support services, including in the UK, independent sexual violence advisors (ISVAs) who are non‐psychologists trained to look after survivors' needs ( Home Office 2017 ). This role was commissioned by Baroness Stern through the Home Office Violent Crime Unit in 2005. An ISVA is trained to ensure survivors receive care and understanding. Guidance sets out the core principles of an ISVA, which are to: tailor support to the individual's needs; provide accurate and impartial information; provide emotional and practical support to meet the survivor's needs; provide support before, during and after court; act as a single point of contact; ensure the safety of survivors and their dependants; and provide a professional service ( Home Office 2017 ). Discussing the rape or sexual assault prior to court proceedings is seen as prejudicial to a trial ( CPS 2002 ) and most psychological therapies include such discussion. For this reason, psychosocial interventions that are tailored to avoid such discussion can be a vital source of support to rape and sexual assault victims in the pre‐trial period. Although many psychosocial interventions have demonstrated effectiveness, the findings have not been well synthesised, and it can be difficult to know what treatments are effective ( IOM 2015 ).

Women have been the focus of interventions and services for rape and sexual assault; male, transgender and gender non‐conforming/non‐binary populations experience significant barriers in respect of accessing such interventions. This is also reflected in the evaluation literature, with services specifically for non‐female populations receiving little or no evaluation and samples in evaluations of interventions being predominately female. Furthermore, the preponderance of white/Caucasian women attending services and participating across studies of interventions to date, further underscores the importance of undertaking this review; many subgroups remain hidden (e.g. men and boys) or highly vulnerable to abuse (migrant people, minority ethnic people, LGBT (lesbian, gay, bisexual and transgender) people, those involved in sexual exploitation and sex work), or both, and this is reflected in both practice and research contexts. This review has the potential to draw together experiences across studies among individuals typically under‐represented in research, who share certain social, gender, ethnic and economic characteristics, to determine if the approaches under investigation respond differently for subgroups of survivors.

For the purposes of this review, we will include a wide range of psychosocial interventions (for definitions, see the list of psychological therapies on the Cochrane Common Mental Disorders (CCMD) website (cmd.cochrane.org/psychological‐therapies‐topics‐list)). These include: (a) formal Cognitive Behavioural Therapy (CBT) and Trauma‐Focused CBT (TF‐CBT), and CBT‐based techniques; (b) integrative therapies including SIT, PET, CPT; (c) behaviour therapies, such as EMDR and relaxation techniques, many of which are based on cognitive‐behavioural processes ( Freeman 2005 ); (d) third‐wave CBT such as Acceptance and Commitment Therapy and mindfulness; (e) humanistic therapies such as supportive and non‐directive therapy; (f) other psychologically‐orientated interventions such as art therapy; meditation; and narrative therapy; and (g) psychosocial interventions such as support and services delivered by mentors, support workers, advisors, or advocates (for example, independent sexual assault advisors (ISVAs), in the UK), and support groups.

Cognitive‐behavioural processes can also be subclassified into three major classes ( Dobson 2009 ): (1) cognitive re‐structuring, which focuses on internal underlying beliefs and thoughts with the aim of challenging maladaptive thought patterns; (2) coping skills therapy, which targets the identification and alteration of cognitions and behaviours that may increase the impact of negative external events; and (3) problem‐solving therapies, which combine cognitive re‐structuring and coping skills therapy to change internal thought patterns and optimise responses to external negative events. Each of these three classes have a slightly different target for change, demonstrating the wide range of psychological interventions based upon cognitive‐behavioural principles ( Dobson 2009 ).

See Appendix 1 .

Why it is important to do this review

Clinical and policy guidelines inform responses to rape and sexual assault (e.g. NICE 2018 ; WHO 2013b ), but gaps remain in our knowledge of the most effective ways of intervening to improve health outcomes and prevent further victimisation. While there is moderate evidence on the consequences of sexual trauma ( Description of the condition ), it is less clear what happens to people’s health and well‐being over time, including in response to different interventions. Although post‐traumatic stress is strongly associated with rape and sexual assault (e.g. Liu 2017 ), and there are theoretical understandings on the importance of early community response to mitigate it, the effectiveness of interventions in promoting survivor well‐being is unclear. There is good evidence for the effects of psychological treatments in reducing mental health issues in children who have experienced sexual trauma ( Gillies 2016 ), with CBT for sexually abused children with symptoms of post‐traumatic stress showing the best evidence for reduction in mental health conditions ( MacDonald 2012 ; MacMillan 2009 ). However, these conclusions cannot be extrapolated to adults who have experienced sexual trauma, and there has been no recent systematic review or meta‐analysis examining the effects of intervention on this population.

Relative to IPV, sexual violence has received less attention in the research literature, and several prior or ongoing reviews focus on psychological interventions for IPV ( Arroyo 2017 ; Tan 2018 ; Trabold 2018 ). While there is some overlap in the populations of interest, in that many sexual assaults and rapes occur within IPV, rape and sexual assault is not exclusive to IPV and there is a larger group of individuals who experience sexual trauma as adults who require support or interventions. Those reviews that have looked at rape and sexual assault have tended to focus on women ( Parcesepe 2015 ) and children ( Gillies 2016 ; MacDonald 2012 ), indicating that the experiences of men and transgender survivors are less represented in the literature. Similarly, the representation of sexual minorities and ethnic minorities is typically minimal in intervention studies, with studies rarely sufficiently powered to detect benefits and costs for specific user groups or subgroups of survivors. By pooling subgroups from different studies, the current review will have the potential to address some of the gaps on what works for whom, and under what circumstances. Other reviews have focused on diagnosis or outcome (i.e. PTSD) ( Roberts 2015 ), psychological therapies ( Bisson 2013 ) or combined pharmacotherapy and psychological therapies ( Hetrick 2010 ) for PTSD, rather than the population/exposure (rape and sexual assault survivors). For most of the reviews, sexual assault and rape victims or survivors are children or adolescents or are a subset of the population. While these reviews are helpful in understanding appropriate therapies to combat PTSD specifically, not all sexual assault or rape victims experience PTSD, and the impacts of sexual trauma are broader than PTSD. Campbell and colleagues published a review in 2009 ( Campbell 2009 ) and Regehr and colleagues a systematic review in 2013 ( Regehr 2013 ) on interventions to reduce distress in adult victims of sexual assault and rape. These reviews are relevant; however, they are now 10 and six years out of date, respectively, and there have been developments in terms of interventions since their publication. The proposed review will examine the broader range of impacts of sexual trauma for all victims who experience rape and sexual assault as adults. Each of the previous two reviews included six studies and we identified 10 eligible studies in our scoping review. Hence, this review is feasible and addresses an important gap in the current literature.

Criteria for considering studies for this review

Types of studies.

Any study that allocated individuals or clusters of individuals by a random or quasi‐random method (whereby the method of allocation was not truly random such as alternate allocation, allocation by birth date, day shift etc.) to a psychosocial intervention for adult victims of rape or sexual assault compared with no intervention, usual care, waiting list, or minimal or active comparison (see 'Comparator intervention' under Types of interventions ).

Studies will be eligible for inclusion in the review if they used random assignment to treatment and comparison groups or employed one of the following designs: quasi‐randomised controlled trial (RCT) (non‐randomised experimental design trials); cluster‐RCT (instead of individual randomised trials, groups will be randomised) or cross‐over trial (longitudinal studies where the participant receives a sequence of different treatments).

Types of participants

All adults aged 18 years and older, of any gender, who have experienced rape or sexual assault as an adult (i.e. aged 18 years and older), irrespective of a mental health diagnosis. Types of sexual assault will include rape, attempted rape, forced oral sex, anal sex, penetration with objects, touching of intimate parts and any sexual contact where consent was not given, as well as forcing or manipulating someone to witness sexual acts. We will include studies of participants who screened positive for exposure to sexual violence, even if they do not report what those behaviours were. We will include studies involving subsets of eligible participants provided that the subset includes at least 50% of those randomised and can be analysed separately. We will include studies of participants recruited in any setting (e.g. community, forensic, criminal justice, and health).

We will exclude samples made up entirely of individuals (adult or child) who were victims of rape, sexual assault, or sexual abuse during their childhood (aged 17 years and under), as well as samples of children (i.e. those younger than 18 years of age).

Types of interventions

Experimental intervention.

The experimental intervention consists of any type of psychosocial and psychological intervention that targets recovery from sexual assault or rape, including the following.

Formal CBT, TF‐CBT and CBT‐based techniques.
Integrative therapies, including Stress Inoculation Training (SIT; Veronen 1983 ), Prolonged Exposure Therapy (PET; Foa 1986 ) and Cognitive Processing Therapy (CPT).
Behaviour therapies such as EMDR and relaxation techniques.
Third wave CBT (e.g. Acceptance and Commitment Therapy, mindfulness).
Humanistic therapies (e.g. supportive and non‐directive therapy).
Other psychologically‐orientated interventions (e.g. art therapy, meditation, trauma‐informed body‐based practices (e.g. embodied relational therapy, yoga and Tai Chi), narrative therapy).
Other psychosocial interventions, including support services delivered by mentors, support workers, advisors or advocates such as ISVAs in the UK, support groups, and coping interventions.

We will include interventions of any duration or frequency of treatment so long as the treatment meets the criteria stated above.

For all interventions, mode of intervention delivery will include one or more of the following: face‐to‐face; telephone; or computer‐based delivery. We will include both individual and group delivery of the intervention.

Comparator intervention

Comparator interventions will consist of inactive controls, such as usual care, no treatment, delayed provision of psychological interventions (or waiting‐list conditions), or pharmacological treatment only, and minimal interventions such as information provision. However, we will not exclude studies on the grounds that an active control group has been used (e.g. where an intervention from one category (CBT) is compared to an intervention from another category (psychosocial intervention), or different intensities or dosages of an intervention are compared). We recognise that there will be instances where researchers employ an active comparison condition for pragmatic or ethical reasons (e.g. the importance of offering some care or treatment to a survivor and that research studies may replicate this when designing or delivering an evaluation). In our analyses, we will strive to pool studies that conduct similar types of comparisons (i.e. active versus inactive or active versus active).

Types of outcome measures

We will not select studies based on the nature of the outcomes assessed. The review is designed to measure the effects of psychological therapies and psychosocial interventions for survivors of rape and sexual assault experienced during adulthood, based on a wide range of indicators of a person's health and well‐being, particularly mental health and well‐being. We are also mindful about evaluating harm and adverse consequences from therapies and other interventions.

Primary outcomes

Treatment efficacy, PTSD symptoms: response to treatment, determined by differences in scores for PTSD symptoms, assessed by independent observer or self‐report. Validated observer‐rated instruments include the Clinician‐Administered PTSD Symptom Scale ( Kulka 1988 ), Clinician‐Administered PTSD Scale (CAPS; Blake 1990 ; Blake 1995 ), and the PTSD Symptom Scale ‐ Interview (PSS‐I; Foa 1993 ). Validated self‐report measures include the PTSD Symptom Scale ‐ Self‐Report (PSS‐SR; Foa 1993 ; Rothbaum 1990 ), Impact of Event Scale (IES; Horowitz 1979 ), Impact of Event Scale ‐ Revised (IES‐R; Weiss 1997 ), and PCL‐5 ( Bovin 2016 ), which is the self‐reported PTSD Checklist for the Fifth Edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM–5; APA 2013 ).
Treatment efficacy, depressive symptoms: response to treatment, determined by differences in scores for depressive symptoms, assessed by independent observer or self‐report measures, including the Hospital Anxiety and Depression Scale (HADS; Zigmond 1983 ), Beck Depression Inventory (BDI; Beck 1961 ), Center for Epidemiologic Studies Depression Scale (CES‐D; Radloff 1977 ), Patient Health Questionnaire (PHQ; Spitzer 1999 ), and Hamilton Depression Rating Scale (HAM‐D; Hamilton 1960 ).
Treatment acceptability: the number of participants who dropped out of the intervention (as distinct from attrition), including in studies of two intervention types and other assessments of acceptability (e.g. measures of patient/client satisfaction).
Adverse effects, such as counts of mortality, completed suicides, and attempted suicides, or worsening of symptoms (specifically, group differences on PTSD, depression, self‐harm and suicidality ‐ see below for tools), including those summarised in narrative form, or using a tool such as the Negative Effects Questionnaire ( Rozental 2018 ). We will record whether or not studies made reference to this outcome.

Secondary outcomes

Anxiety symptoms, assessed with self‐report scales such as the Beck Anxiety Inventory (BAI; Beck 1988 ), State‐Trait Anxiety Inventory (STAI; Spielberger 1970 ), or Generalised Anxiety Disorder ‐ Seven‐item Scale (GAD‐7; Kertz 2013 ; Spitzer 2006 ).
Dissociation symptoms, measured using instruments such as the Dissociative Experiences Scale (DES; Bernstein 1986 ), or the Dissociative Experiences Scale‐II (DES‐II; Bernstein 1986 ; Carlson 1993 ).
Global mental health functioning/distress, which is frequently measured by either the Global Severity Index (GSI), Positive Symptom Distress Index (PSDI) and Positive Symptom Total (PST) of the SCL‐90‐R ( Derogatis 1983 ), or by the Behavior And Symptom Identification Scale (BASIS‐32; Eisen 1999 ).
Feelings of guilt or self‐blame (or both) experienced by survivors, measured by self‐report tools such as the Trauma‐Related Guilt Inventory (TRGI; Kubany 1996 ), Rape Attribution Questionnaire (RAQ; Frazier 2003 ), South African Stigma Scale ( Singh 2011 ), Social Support Appraisal (SSA) scale ( Vaux 1986 ), Rape Aftermath Symptom Test (RAST; Kilpatrick 1988 ), or Inventory of Interpersonal Problems (IPP; Horowitz 1988 ).
substance use, measured by a number of established scales, including the Michigan Alcoholism Screening Test (MAST; Selzer 1971 ), Drug Abuse Screening Test (DAST; Skinner 1982 ), Addiction Severity Index (ASI; McLellan 1980 : McLellan 1992 ), Alcohol Use Inventory (AUI; Chang 2001 ), Drug Use Disorders Identification Test (DUDIT; Berman 2005 ), or the Alcohol Use Disorders Identification Test (AUDIT; Pradhan 2012 ).
Quality of life, which is commonly measured by self‐report measures such as the WHO Quality of Life scale ‐ Abbreviated Version (WHOQOL‐BREF; Skevington 2004 ) and EuroQol‐5 Dimensions (EQ‐5D; Brooks 1996 ).
Self‐harming or suicidality often measured by the Deliberate Self‐Harm Inventory (DSHI; Gratz 2001 ), Self‐Harm Behaviour Questionnaire (SHBQ; Guttierez 2001 ), or the Self‐Injury Questionnaire (SIQ; Santa Mina 2006 ).
Sexual violence assessment, measured by instruments such as the Sexual Experiences Survey (SES; Koss 1987b ) and the Abuse Assessment Screen (AAS) ( Basile 2007 ; NSVRC 2011 ). These tools differ in terms of their method of delivery; their appropriateness for screening for females, males, or both; the setting in which screening is to occur; the total number of questions they contain; and the number of questions that are specific to sexual violence ( Basile 2007 ; NSVRC 2011 ).

We will include all time points; however, the primary time point for treatment efficacy will be three months post‐treatment. We will classify short‐term time points as zero to six months, medium‐term as six to 12 months, and long‐term as 12 months or longer.

Search methods for identification of studies

Electronic searches.

We will search the databases and trials registers listed below for published and unpublished studies. We will adapt the MEDLINE strategy in Appendix 2 for the other sources using appropriate indexing terms and syntax. We will not apply any limitations on publication date, place or language of any research; we will not exclude any potentially relevant studies and we will include research from different backgrounds and disciplines. The Information Specialist for Cochrane Developmental Psychosocial and Learning Problems will search all of the databases listed below, with the exception of the Common Mental Disorders Controlled Trials Register, which will be searched by the Information Specialist for Cochrane Common Mental Disorders.

Cochrane Central Register of Controlled Trials (CENTRAL; current issue) in the Cochrane Library, which includes the Developmental, Psychosocial and Learning Problems Specialised Register.
Cochrane Common Mental Disorders Controlled Trials Register (CCMDCTR; current to June 2016). See Appendix 3 for one of the core strategies (MEDLINE) used to populate CCMDCTR. Full details are available at cmd.cochrane.org/specialised‐register.
MEDLINE Ovid (1946 onwards).
MEDLINE In‐Process & Non‐Indexed Citations Ovid (current issue).
MEDLINE Epub Ahead of Print Ovid (current issue).
Embase Ovid (1974 onwards).
CINAHL Plus EBSCOhost (Cumulative Index to Nursing and Allied Health Literature; 1937 onwards).
PsycINFO Ovid (1806 onwards).
ERIC EBSCOhost (Education Resources Information Center; 1966 onwards).
Social Policy and Practice Ovid (1890s onwards).
PTSDpubs Proquest (previously known as PILOTS; 1871 to present).
Cochrane Database of Systematic Reviews (current issue), a part of the Cochrane Library.
Web of Science Core Collection: Citation Indexes Clarivate Analytics (1970 onwards, Science Citation Index, Social Sciences Citation Index, Conference Proceedings Citation Index ‐ Science and Conference Proceedings Citation Index ‐ Social Science & Humanities).
Epistemonikos (www.epistemonikos.org).
ClinicalTrials.gov (www.ClinicalTrials.gov).
WHO International Clinical Trials Registry Platform (ICTRP; apps.who.int/trialsearch).
Be Part of Research (replaced UK Clinical Trials Gateway; www.bepartofresearch.nihr.ac.uk/).

Searching other resources

Personal communication.

We will contact trialists and experts in the field regarding unpublished and ongoing research and to ask for further trial data. Those whom we will consider to be experts will be those who have conducted or authored studies and literature that are connected to the research (including Ronald Acierno, Ann Burgess, Enrique Echeburua, Edna Foa, Dean Kilpatrick, Patricia Resick, Heidi Resnick, and Barbara Rothbaum).

Reference lists

We will examine the reference lists of all included studies and relevant systematic reviews to identify additional studies from the electronic searches (for example, unpublished or in‐press citations).

Supplementary searches

We will conduct a forward citation search of included studies using Web of Science.

Data collection and analysis

Selection of studies.

Two review authors (NK and SB) will independently assess the titles and abstracts of all records identified through the searches against the inclusion criteria ( Criteria for considering studies for this review ), coding them as 'yes' (eligible), 'no' (not eligible) or maybe (potentially eligible or unclear). In the event of disagreements about inclusion, both review authors will assess and discuss the full article for relevance. If agreement cannot be reached by discussion, they will consult a third review author (LOD) as a mediator. Final decisions will be made by consensus.

We will retrieve full‐text reports for selected abstracts and two pairs of review authors (NK and SB, LOD and LT) will independently assess each report against the inclusion criteria ( Criteria for considering studies for this review ). Studies will be identified for either inclusion or exclusion. We will contact study authors, as required, to decide whether the inclusion criteria have been met. We will record reasons for excluding ineligible studies. In the event of disagreements, we will consult a third review author (KB) as a mediator. Final decisions will be made by consensus.

We will identify and exclude duplicate records and will collate multiple reports that relate to the same study, so that each study, rather than each report, is the unit of interest in the review. We will record the selection process in sufficient detail to complete a four‐phase (identification, screening, eligibility and included) PRISMA flow diagram for study collection ( Moher 2009 ) and the 'Characteristics of excluded studies' tables.

Data extraction and management

We will use Covidence ( Covidence 2018 ) as a platform to upload the included studies and extract data,and export data into Review Manager 5 (RevMan 5) ( Review Manager 2014 ). We will generate a PRISMA diagram report. Review Manager will allow us to analyse the data and build the text, tables and figures for presenting the review.

We will pilot and refine the data collection form using the first five studies included in the review. Two pairs of review authors (NK paired with KB, LOD and GC) will independently extract data on key characteristics, methods and outcomes from each included study, and compare their results to identify differences. Where differences are identified, we will resolve them by consensus or by referral to another member of the review team (SB). When further clarification or missing data are needed from study authors, we will make all reasonable attempts to contact the study authors and obtain the relevant information.

Specifically, we will extract data on the following characteristics from each included study.

Methods: brief description of study design and randomisation method; dates or total duration of study; location of study.
Participants: baseline characteristics, including gender, age, ethnicity, sexual identity, markers of opportunity and deprivation; study setting; inclusion and exclusion criteria; number of eligible people recruited and assigned; number of dropouts; numbers analysed.
Interventions: number of intervention groups; type of psychosocial intervention; mode of delivery; frequency and duration of delivery; level of training of person delivering the intervention; relevant comparator intervention characteristics.
Outcomes: primary and secondary outcomes; outcome measures used; timing of outcome measurement.
Notes: funding for trial; notable conflicts of interest of trial authors.

One review author (NK) will transfer data into RevMan 5 ( Review Manager 2014 ). Another review author (SB) will independently check the data extraction forms for accuracy and completeness.

Assessment of risk of bias in included studies

Randomized parallel‐group trials.

We will undertake our 'Risk of bias' assessment using Review Manager Web (RevMan Web) ( Review Manager Web 2019 ) and according to Cochrane's revised 'Risk of bias' tool for randomised trials (RoB 2) ( Sterne 2019 ). The study aims to assess the effect of assignment to intervention ‐ the 'intention‐to‐treat' effect. We will assess the risk of bias for each result arising from studies that report our primary outcomes (i.e. treatment efficacy based on depression and PTSD). Depending on the availability of data for short‐, medium‐ and long‐term time points, we may apply RoB 2 to any result involving our primary outcome. Where there is indication of adverse effects in the form of worsening symptoms (self‐harm and suicidality in addition to depression and PTSD), we will also apply RoB 2 to these results. Two pairs of review authors (NK and SB, LOD and GC) will independently undertake assessments. In the event of disagreements that cannot be resolved by discussion, we will consult another review author (GF or KB) as a mediator.

For a single trial result, we will respond to a series of 'signalling' questions covering five domains.

Risk of bias arising from the randomisation process.
Risk of bias due to deviations from the intended interventions (effect of assignment to intervention).
Risk of bias due to missing outcome data.
Risk of bias in measurement of the outcome.
Risk of bias in the selection of the reported result..

We will select one of the five response options to each question (‘yes’, ‘probably yes’, ‘probably no’, ‘no’ and ‘no information’). We will use these responses to reach a judgement of low, high or some concerns. The final step will be to combine these responses for the five domains to reach an overall rating of low risk of bias, some or high risk of bias for the result. When considering treatment effects, we will take into account the risks of bias of the results contributing to that effect.

Cluster‐randomised parallel‐group trials

We will assess the risk of bias of cluster‐randomised trials in line with Section 16.3.2 of the Cochrane Handbook for Systematic Reviews of Interventions ( Higgins 2011a ), assessing each study for risk of bias across the five domains listed below.

Bias arising from the randomisation process.
Bias due to deviation arising from intended interventions.
Bias due to missing outcome data.
Bias in the measurement of outcome.
Bias in the selection of the reported outcome.

We will also examine bias arising from identification or recruitment of individual participants within clusters.

Randomised cross‐over trials

We do not expect to find cross‐over trials; however, should we identify any, we will apply the same approach as recommended in Section 16.4.3 ( Higgins 2011a ), which essentially involves assessing the five domains above.

Quasi‐experimental

In assessing the risk of bias in quasi‐randomised studies, we will apply the same methods as those recommended for randomised trials, in line with Cochrane guidance ( Higgins 2011b ) and new guidance from Sterne and colleagues ( Sterne 2019 ). Generally, we will judge such studies to be at high risk of bias arising from the randomisation process.

Measures of treatment effect

We will import the data for each study and outcome entered into Covidence ( Covidence 2018 ) into RevMan 5 ( Review Manager 2014 ), to perform meta‐analyses and present results in graph form.

Dichotomous data

While the primary and secondary outcomes will usually be assessed with continuous measures, we expect that some investigators will present dichotomous data on these outcomes. We will require counts and percentages by trial arm for each study that reports dichotomous outcomes. Using the summary data, we will calculate the pooled risk ratio (RR) and 95% confidence intervals (CI) across the trials for each outcome. Where the data required to calculate the RR are neither available nor obtainable from the study authors, we will provide the findings as reported in the published paper.

Continuous data

We will require means and standard deviations by trial arm for studies that report continuous outcomes. When studies have used the same continuous outcome measure, we will calculate mean differences (MD) with 95% CI. When studies have used different outcome measures to assess the same construct, we will calculate standardised mean differences (SMD) and 95% CI as the measure of effect ( Schünemann 2011 ). We expect that outcomes will have been measured with a range of tools (see Types of outcome measures ) across studies, and that we will largely be calculating SMD. We will use Cohen's general rule of thumb to interpret effect sizes computed using the SMD, where 0.2 represents a small effect, 0.5 represents a medium effect, and 0.8 or larger represents a large effect ( Cohen 1988 ). We will present conceptually distinct outcomes in separate forest plots. Where means and standard deviations are not available or obtainable from the study authors, we will provide the findings as reported in the published paper. We will use a narrative approach to describe continuous outcome data that do not have a normal distribution or are reported as medians and interquartile ranges, or both, given that meta‐analysis assumes normality.

If it is necessary to combine dichotomous data and continuous data in a meta‐analysis, we will need estimates of the standard error. Standard errors can be computed for all studies by entering the data into RevMan 5 as dichotomous and continuous outcome type data, as appropriate, and converting the CI for the resulting log odds ratios and SMD into standard errors ( Higgins 2011c ). Once SMD (or log odds ratios) and their standard errors have been computed for all studies in the meta‐analysis, we will combine them using the generic inverse‐variance method in RevMan 5 ( Review Manager 2014 ). Relating to outcomes where different scales can be used in reporting results, such as quality of life, we will use SMD to compile data.

Unit of analysis issues

Cluster‐randomised trials.

We do not anticipate any unit of analysis issues in this review. However, should we identify any cluster‐randomised trials, we will adjust the standard errors or sample sizes using the method described in the Cochrane Handbook for Systematic Reviews of Interventions ( Higgins 2017 ). The adjustment method requires the intra‐class correlation coefficient (ICC). If the ICC is not available, we will use ICCs from analogous cluster‐randomised trials. If analogous studies are not available, we will use a series of plausible values in a sensitivity analysis (see Sensitivity analysis ).

Studies with multiple treatment groups

If studies compare multiple eligible experimental interventions with a single control group, we will split the control group to enable pairwise comparisons. If studies use multiple control groups, we will combine the control groups to compare them to the experimental intervention group.

Dealing with missing data

Where data are missing, we will follow the recommendations outlined in the Cochrane Handbook for Systematic Reviews of Interventions ( Higgins 2011a ). We will classify data as either 'missing at random’ or ’not missing at random’. Where we consider data to be missing at random, we will analyse the available data. For data that we consider not missing at random, we will make every effort to contact study authors to gather the missing information. We will ask questions in an open‐ended manner to prevent the skewing of responses ( Higgins 2011a ). We will document all correspondence with study authors. It will not be possible to use analytical methods to handle missing data as we will only collect summary data from the studies; we will not source individual level data from the study authors ( Egger 2001 ). We will highlight any suppositions that we make during our analysis when data are unavailable. We will estimate the log rank statistics where these are not published in an article, and we will use previously reported methods, where applicable ( Parmar 1998 ; Tierney 2007 ). We will address the potential impact of missing outcome data in the 'Risk of bias' assessment. If appropriate, we will perform a sensitivity analysis to assess the impact of the missing information on our results (see Sensitivity analysis ), using the methods described in the Cochrane Handbook for Systematic Reviews of Interventions ( Higgins 2011a ): section 16.2.2 for dichotomous outcomes and section 16.2.3 for continuous outcomes.

Assessment of heterogeneity

Variability in the participants, interventions and outcomes studied may be described as clinical heterogeneity; variability in study design and risk of bias may be described as methodological heterogeneity. Variability in the intervention effects being evaluated in the different studies is known as statistical heterogeneity. It is a consequence of clinical or methodological heterogeneity, or both, among the studies and manifests in the observed intervention effects being more different from each other than one would expect due to random error (chance) alone.

We will identify sources of clinical heterogeneity by constructing tables to summarise studies in terms of participants, setting, type of intervention, intervention delivery (e.g. group or individual, number of sessions) and outcomes examined. Where studies are similar, we will conduct further analyses, initially by reviewing the consistency of the results across studies using graphical representations ( Egger 1997 ). To initially identify the heterogeneity/inconsistency of the whole network, we will use the Q statistic, separating the studies based on whether they share the same design or not. We will assess statistical heterogeneity with the Chi 2 test, which will provide us with evidence of variation in effects, disregarding the effect of chance. The Chi 2 test is ineffective for analysing heterogeneity in studies with only a small number of participants or trials, so we will set our P value at 0.10 ( Deeks 2017 ), and assess heterogeneity using the I 2 statistic, which will find the percentage of variability due to heterogeneity outside of the effect of chance (Higgins 2003).

We assume that some statistical heterogeneity is inevitable, and hence, will evaluate heterogeneity using the I 2 statistic ( Deeks 2017 ). We will interpret the observed value of I 2 using the guide given in Section 9.5.2 of the Cochrane Handbook for Systematic Reviews of Interventions ( Deeks 2017 ), where 0% to 40% might not be important, 30% to 60% may represent moderate heterogeneity, 50% to 90% may represent substantial heterogeneity, and 75% to 100% shows considerable heterogeneity. We will take into consideration the size and direction of effects and the strength of evidence for heterogeneity using the Chi 2 test and the 95% CI for I 2 .

Where there is evidence for statistical heterogeneity, we will use the strategies outlined in Section 9.5.3 of the Cochrane Handbook for Systematic Reviews of Interventions ( Deeks 2017 ), to identify potential sources of heterogeneity among the results of the studies. In particular, we will explore differences in the characteristics of the studies or other factors as possible explanations for heterogeneity in the results. We will summarise any differences identified in the narrative summary. The significance of the I 2 statistics observed will rely upon the effects of treatment and the quality of evidence suggesting heterogeneity.

We will use RevMan 5 ( Review Manager 2014 ) to produce forest plots and calculate tau 2 , the between‐trial variance in a random‐effects meta‐analysis (Deeks 2017; Review Manager 2014). To understand the intervention effects, we will use tau 2 to identify a range for the primary outcome. We will use the Cochrane Handbook for Systematic Reviews of Interventions as a guideline throughout this process (Deeks 2017).

Assessment of reporting biases

We will attempt to locate the protocols or study records (or both) in trial registries of the RCTs included in the review. Where the protocol is available, we will compare its outcomes against the published report; and where the protocol cannot be found, we will compare the outcomes included in the methods section of the trial report to the reported results. We will identify outcome reporting bias where outcomes are included in the methods but not reported ( Pocock 1987 ; Tannock 1996 ).

If there are 10 or more studies, we will construct funnel plots to investigate associations between effect size and study precision (which is closely related to sample size) ( Egger 1997 ). We will also apply Egger's regression asymmetry test to funnel plots to test for funnel plot asymmetry ( Egger 1997 ). Such an association could be due to publication or related biases, or due to systematic differences between small and large studies. If we identify an association, we will examine the clinical diversity of the studies as a possible explanation. If appropriate, we will also conduct a sensitivity analysis to determine whether assumptions about the effect of the bias impact the estimated treatment effect and the conclusions of the review (see Sensitivity analysis ).

Data synthesis

We will perform a meta‐analysis if there are sufficient data and it is meaningful to pool the data across studies; for instance, the treatments, participants and the underlying clinical measures are similar enough for pooling to make sense. Our decision to perform a meta‐analysis will be determined by the comparability of populations, denominators and interventions (clinical heterogeneity); the comparability of the duration of follow‐up (methodological heterogeneity); and the comparability of outcomes. We will use a random‐effects model to analyse the data across the studies. The Mantel‐Haenszel method, a default program in RevMan 5 ( Review Manager 2014 ), can take account of few events or small study sizes, and can be used with random‐effects models.

We will stratify results for the main comparison (psychosocial interventions versus inactive controls, such as usual care, no treatment, delayed provision of psychological interventions (or waiting‐list conditions) or pharmacological treatment only, and minimal interventions such as information provision) by type of therapy (categories 1 to 7 listed under Types of interventions ), where there are sufficient numbers of studies of the same intervention type, comparison arm and reporting the same outcome. For other comparisons, comparing two experimental interventions (i.e. an intervention from one category against an intervention from another category), we will again require two or more studies comparing similar experimental interventions using similar outcomes.

If it is inappropriate to combine the data in a meta‐analysis (on account of insufficient studies or data), we will report the effect sizes with 95% CI or standard errors of individual studies, and provide a narrative, rather than quantitative, summary of the findings that addresses the following aspects.

What is the direction of effect?
What is the size of effect?
Is the effect consistent across studies?

Subgroup analysis and investigation of heterogeneity

We are keen to investigate intervention effects according to subsets of participants and for subsets of studies, and we will perform the subgroup analyses set out below. However, we are aware that subgroup analyses of subsets of participants are challenged because sufficient details to extract data about separate participant types are seldom published in reports.

Category of intervention (e.g. CBT, behavioural therapies, head‐to‐head comparisons)
Participant characteristics (e.g. gender, ethnicity, time to treatment, symptom load, and types of trauma exposure)
Intensity of intervention (e.g. up to four sessions, five or more sessions)
Mode of intervention delivery (e.g. individual versus group)
Setting of recruitment or intervention delivery (healthcare, community, police‐led, charity‐led)

Participant characteristics have been identified as integral to subgroup analyses, as there may be differences in the efficacy of treatments for different groups of individuals. Recruitment setting has also been identified as important, as there may be differences between survivors recruited via healthcare as opposed to police‐led and criminal justice or charity environments. Intensity of interventions are also of interest; we might, for example, compare outcomes from intense psychological therapies versus interventions oriented towards provision of psychosocial support. Finally, it will be important to stratify analyses by type of intervention given their distinct mechanisms and theoretical underpinnings. The characteristics related to participants, settings and interventions will have important practical implications for our review findings and recommendations.

We will use a simple approach, described in Chapter 9.6.3 of the Cochrane Handbook for Systematic Reviews of Interventions ( Deeks 2017 ), to investigate whether there is a difference in the intervention effect between the subgroups. As described in Chapter 9.6.4 of the Cochrane Handbook for Systematic Reviews of Interventions ( Deeks 2017 ), meta‐regression is an extension to subgroup analyses that allows the effect of continuous as well as categorical characteristics to be investigated, and, in principle, allows the effects of multiple factors to be investigated simultaneously. Generally, meta‐regression should not be considered when there are fewer than 10 studies in a meta‐analysis. If there are more than 10 studies available, we will use meta‐regression techniques recommended for STATA ( Harbord 2004 ; Stata 2017 ).

If we identify a considerable degree of heterogeneity (75% to 100%), we will first check the data for errors. If the data are correct, we will conduct a sensitivity analysis by excluding certain studies from the existing meta‐analysis, to assess the influence of the studies on the degree of heterogeneity (see Sensitivity analysis ).

Sensitivity analysis

We will base our primary analyses on available data from all included studies relevant to the comparison of interest. However, in order to examine any effects of methodological decisions on the overall outcome, we will perform sensitivity analyses provided there are sufficient numbers of studies. These sensitivity analyses may include the following.

Re‐analysis of the data excluding studies with results at high risk of bias.
Re‐analysis of the data excluding studies with missing outcome data.
Re‐analysis of the data excluding other identified studies of low methodological quality.

Additional sensitivity analyses may be required if particular issues related to the studies under review arise.

'Summary of findings' table

We will create our 'Summary of findings' table(s) using GRADEpro GDT ( GRADEpro GDT 2015 ) and following standard methods described in the Cochrane Handbook for Systematic Reviews of Interventions ( Schünemann 2017 ). The table(s) will provide key information concerning the quality of evidence, the magnitude of effect of the interventions examined, and the sum of available data on primary outcomes. The table(s) will include details relating to the participants, interventions, comparisons, outcomes (PICO), settings, length of the follow‐up, and outcome measurement.

The key comparison for the 'Summary of findings' table(s) will be impact of psychosocial interventions versus inactive controls on treatment efficacy. For each outcome, we will present standardised effect size estimates and 95% CI. The primary outcomes for the review are: treatment efficacy measured by group differences on PTSD symptoms and on depressive symptoms. The table will present treatment acceptability based on worsening of the primary treatment outcomes and self‐harm and suicidality, and intervention dropout rates. It will also present adverse outcomes.

It is recognised that the main comparison combines all intervention types in one and that it may be more useful to stakeholders to understand effects by type. Thus, depending on availability of data, we will stratify results using primary outcomes for CBT versus inactive controls and behavioural therapies versus inactive controls, presenting these in additional tables.

We will assess the certainty of the evidence using the GRADE approach and will include the results of this assessment in the 'Summary of findings' table(s). The level of certainty will be defined by five factors: risk of bias; indirectness of factors (such as evidence, population, control, intervention and outcomes); inconsistency of results; imprecision of results (and large CI); and a high likelihood of publication bias. We will downgrade all evidence by one level for a single factor up to a maximum of three levels for all factors. The final grade will be determined by how likely the effect can be predicted. We will assess the certainty of the evidence on a four‐point scale, ranging from high (the real effect is close to what will be predicted) to very low (what actually happens is significantly varied from the predicted effect) ( Schünemann 2017 ).

We will create the 'Summary of findings' table(s) after we have entered the data into RevMan 5 ( Review Manager 2014 ), written up our results and conducted the risk of bias assessment, but before writing our abstract, discussion and conclusions, to allow the opportunity to consider the impact of risk of bias in the studies contributing to each outcome on the mean treatment effect and our confidence in these findings.

Acknowledgements

This Cochrane Review is part of a larger study about healthcare for sexual violence: Multidisciplinary Evaluation of Sexual Assault Referral Centres for better Health (MESARCH). The research is funded by an institutional (Coventry University) research grant (project number 16/117/04) from the National Institute for Health Research (NIHR) Health Service and Delivery Research Programme.

We would like to thank members of the MESARCH Study Steering Committee, in particular Gillian Finch of our Lived Experiences Group, for input into the development of this protocol.

We would also like to thank members of the Cochrane Developmental, Psychosocial and Learning Problems review group for their guidance in developing this protocol and the following reviewers for their contributions in refining it: Dee Shneiderman; Lisa Fedina PhD, University of Michigan, School of Social Work; Anao Zhang, University of Michigan School of Social Work; Dr Ben Carter, Senior Lecturer in Biostatistics and KCTU Mental Health Statistics Group Lead, King's College London; and Lindsay DG Thomson, Professor of Forensic Psychiatry, University of Edinburgh, Medical Director, The State Hospitals Board for Scotland, and Director of Forensic Network and School of Forensic Mental Health.

Finally, we would like to thank the Cochrane Editorial and Methods Department for the opportunity to participate in a pilot of the new risk of bias tool (RoB 2), and their support in preparing this Protocol.

Disclaimer: The views expressed herein are those of the review authors and not necessarily those of the NHS, the NIHR or the Department of Health and Social Care.

Appendix 1. How the intervention might work

Cognitive‐behavioural interventions are based on the proposition that behaviours are cognitively mediated ( Butler 2006 ). Mental health and social problems may be influenced by cognitions and resulting behaviours. Because cognitive activity may be monitored and altered, behaviours may be changed through cognitive changes ( Dobson 2009 ). Therefore, addressing certain thinking patterns and beliefs may result in positive changes in symptoms, problems and behaviours, which may reduce some of the negative consequences of rape or sexual assault ( Butler 2006 ). In the case of trauma, theorists believe that the appraisal of fear involves the activation of trauma‐induced schema that lead the survivor to pay attention to information that is consistent with the schema and to ignore evidence that is inconsistent ( Resick 1992 ). This means that benign or ambiguous events can trigger a fear appraisal in trauma survivors ( Beck 1985 ). Hence, cognitive theory, as applied to the process of PTSD ( Veronen 1983 ), focusses on two processes: (1) changing a person’s cognitive appraisal of the traumatic event, or changing the process by which an individual attaches meaning to an event; and (2) changing a person’s attribution of the event. Coping skill treatments are designed to equip victims with an array of skills to manage their trauma. Some interventions are designed to be delivered within a short period of time following the assault or rape (e.g. less than three months), whereas others are used for survivors over the longer term. The former attempt to provide prophylactic treatment to prevent chronic problems, while others intend to facilitate faster recovery ( Vickerman 2009 ).

Interventions for sexual assault and rape survivors typically employ a combination of approaches; for example, in the case of SIT, PET, and CPT, as outlined below.

SIT was adapted by Veronen and Kilpatrick ( Veronen 1983 ) from anxiety management procedures ( Meichenbaum 1977 ). It incorporates three elements: (1) behaviourally‐based psycho‐education so that victims can understand and normalise fear and avoidance behaviours; (2) guided hierarchical in vivo assignments to target rape‐related phobias (e.g. darkness); and (3) training in six behavioural and cognitive‐behavioural coping strategies, which are thought‐stopping, guided self‐dialogue, muscle relaxation, controlled breathing, covert modelling, and role playing. The goal of SIT is to increase the survivor’s awareness of conditioned stimuli to improve early detection of anxiety‐provoking cues, which facilitates the use of coping skills early in the stress response to reduce anxiety ( Sherman 1998 ).

PET was developed from earlier treatments using flooding exposure techniques and emotion processing theory with anxiety disordered patients ( Foa 1986 ). These techniques were extended by Foa and colleagues ( Foa 1986 ; Foa 1994 ), who argued that it is the encoding of memories under extreme distress that leads to disjointed and disorganised memories, which impede natural recovery and lead to PTSD. The aim of PET is to decrease the anxiety associated with rape memories. PET begins with psycho‐education, breathing training, and the development of a fear and avoidance hierarchy for in vivo exposures. In therapy, victims are asked to relive the rape scene and describe it aloud as they are imagining it, using present tense and vivid detail, which may be done several times in one therapy session. The victim’s narrative is recorded and daily homework requires the victim to listen to their recorded account for further exposure ( Foa 1991 ).

CPT was developed from emotional processing theory to identify a rape victim’s 'stuck points', which are the parts of the traumatic narratives that cause them the greatest conflict ( Resick 1992 ; Resick 1993 ). These are manifestations of unsuccessful attempts to accommodate information in relation to the trauma into pre‐existing memory and belief structures. The goal of CPT is to help victims to integrate their trauma into pre‐existing schemas, to decrease avoidance and intrusions of unintegrated aspects of the trauma. Unlike PET, CPT seeks to directly correct participants’ misconceptions or misinformation about their trauma (for example, 'I’m not safe anywhere' or 'I can't trust anyone'). CPT also includes psycho‐education, exposure and cognitive methods. Exposure is achieved via the victim writing accounts of the rape and its meaning, which the victim rereads between sessions and writes about the impact of the trauma multiple times, in order to incorporate new understandings and evaluation. Therapy then addresses one of five themes (safety, trust, power/control, esteem or intimacy) in each of the last five sessions, via the use of cognitive‐restructuring worksheets, Socratic questioning and discussion.

Behavioural therapies are based on the premise that all behaviours are learned and, therefore, that unhealthy behaviours can be changed. Techniques such as systematic desensitisation and flooding are often used with this population, which emphasise the importance of extinguishing anxiety and reducing avoidant behaviours. For example, Foa and colleagues believe that exposure to the trauma allows mistaken evaluations and faulty stimulus‐response associations to be corrected ( Foa 1986 ; Foa 1994 ). Victims are taught to replace a fear response with relaxation responses. This can be done gradually, with systematic desensitisation, or more quickly via flooding.

EMDR was developed by Shapiro 1995 for the treatment of PTSD. It involves exposure elements and cognitive techniques. In EMDR, a scene is used to represent the entire rape trauma. The survivor imagines the scene and recites words related to the scene, while the therapist moves his or her fingers back and forth in front of the survivor, so that the survivor performs rhythmic, multi‐saccadic eye movements (quick, simultaneous movements of both eyes between two or more phases of fixation in the same direction) by watching the therapist’s fingers. This movement is argued to facilitate the processing of trauma memory through the dual attention required to focus on attending to the therapist’s finger movement (external stimulus) and the trauma scene (internal stimulus). When the survivor’s anxiety to the scene has decreased, a new adaptive belief is rehearsed until this new belief feels true ( Rothbaum 1997 ). EMDR is similar to the behavioural techniques of flooding and systematic desensitisation ( Boudewyns 1996a ), and studies comparing EMDR with and without eye movements show that EMDR without eye movements leads to equivalent outcomes as EDMR with eye movements ( Boudewyns 1996b ; Pitman 1996 ). EMDR is thought to work for patients who have been traumatised by the fact that eye movements can reduce the intensity of disturbing thoughts under certain conditions ( Bisson 2013 ).

Third wave CBTs (e.g. acceptance and commitment therapy and mindfulness) act on changing the function of psychological events and the individuals relationship to them through acceptance, being present, and committed action ( Hayes 2006 ).

Counselling encompasses a range of interventions that may be employed by, for example, rape crisis centres ( Cryer 1980 ; Foa 1991 ; Resick 1988 ). Counselling can be premised on a number of approaches (e.g. humanist, psychodynamic) and may be delivered as an intervention in itself or in combination with other approaches. Counselling is likely to be very individually focused in order to discuss issues raised by the survivor, and the necessary variation makes it difficult to understand exactly what is included in each session.

Humanistic and supportive therapies include an eclectic mix of therapeutic techniques. Supportive therapy is almost always non‐directive, that is, the survivor is empowered to guide the content and the therapist avoids offering direct advice ( Cohen 2005 ; Deblinger 2001 ). The focus is on developing a supportive, emotionally‐involved relationship between the therapist and participant ( Cohen 2005 ). Supportive therapy can be conducted in either an individual or group format.

Other psychologically‐orientated interventions include a diverse range of therapies that aim to help survivors cope with, express and work through trauma via, for example, expressive writing ( Harte 2013 ) or mindfulness ( Brotto 2012 ). For instance, equine‐assisted therapy for anxiety and post‐traumatic stress symptoms has been shown to reduce symptoms of post‐traumatic stress, severe emotional responses to trauma, generalised anxiety, symptoms of depression and alcohol use, as well as increasing the use of mindfulness strategies ( Earles 2015 ).

Psychosocial interventions include a wide range of interventions that target interpersonal, social and environmental factors that relate to recovery from the trauma of rape and sexual assault in addition to, or instead of, the individual factors that are the focus of psychological therapies. The way in which the interventions might work will be dependent on the factors that are targeted. Psycho‐education elements aim to provide information, modelling and training, for example, to explain maladaptive and adaptive coping strategies and to encourage the use of the latter (e.g. see Sikkema 2018 ). Group programmes and the provision of advisors or mentors provide social support, which can be important given the stigma and shame associated with rape and sexual assault that can lead to social isolation. These can increase self‐esteem ( Sikkema 2018 ), and provide practical assistance and emotional support ( Home Office 2017 ).

Appendix 2. MEDLINE search strategy

1 sex offenses/ 2 Incest/ 3 intimate partner violence/ 4 human trafficking/ 5 rape/ 6 spouse abuse/ 7 (sex$ adj5 (abuse$ or assaul$ or attack$ or aggress$ or coer$ or exploit$ or force$ or molest$ or offen$ or traffick$ or trauma$ or unlawful$ or unwanted or violen$)).tw,kf. 8 (intercourse adj5 (coer$ or force$ or unwanted)).tw,kf. 9 intimate partner violence.tw,kf. 10 (rape or raped or incest$).tw,kf. 11 (sex$ adj3 (victim$ or revictim$ or re‐victim$ or survivor$)).tw,kf. 12 or/1‐11 13 Anxiety/th 14 Anxiety Disorders/th 15 Adaptation, Psychological/ 16 exp Behavior Therapy/ 17 Combined Modality Therapy/ 18 community networks/ 19 exp Complementary therapies/ 20 exp Counseling/ 21 Depression/th 22 Depressive Disorder/th 23 Depressive Disorder, Major/th 24 Exercise/ 25 Exercise therapy/ 26 Health Education/ 27 Health Knowledge, Attitudes, Practice/ 28 Interview, Psychological/ 29 exp mind body therapies/ 30 Psychological adjustment/ 31 Psychological Trauma/pc, rh, th 32 psychosocial support systems/ 33 exp psychotherapy/ 34 "Referral and Consultation"/ 35 Self‐Help Groups/ (8831) 36 Social Support/ 37 Stress Disorders, Post‐Traumatic/pc, rh, th 38 video recording/ or videotape recording/ 39 Writing/ 40 ((abreaction or desensitization or exposure or implosive) adj3 therap$).tw,kf. 41 "acceptance and commitment therapy".tw,kf. 42 (advisor$ or advocate$ or advocacy).tw,kf. 43 ((animal$ or art or colo?r or creative$ or dance or dancing or drama or equine or experiential or music or narrative or play$ or sensory or singing) adj3 (program$ or intervention$ or therap$)).tw,kf. 44 (autogenic or autosuggestion$ or auto‐suggestion$ or breathing exercise$ or hypnosis or hypno‐therapy or hypnotherapy).tw,kf. 45 behavio$ activation.tw,kf. 46 (behavio?r$ adj3 (intervention$ or program$ or therap$ or training or treatment$)).tw,kf. 47 ((biofeedback or feedback or imagery) adj3 (intervention$ or therap$ or train$ or treatment$)).tw,kf. 48 ((brief or combination or compass$ focus$ or integrated or integrative or time‐limited) adj3 (intervention$ or therap$ or treatment$)).tw,kf. 49 ((client focus$ or non‐direct$ or nondirect$ or solution focus$ or trauma$ or talking) adj3 therap$).tw,kf. 50 (cognitiv$ or cognition).tw,kf. 51 CBT.tw,kf. 52 ((cope or coping) adj1 (intervention$ or mechanism$ or skill$ or technique$)).tw,kf. 53 counsel?ing.tw,kf. 54 ((couple$ or family or group or systemic$ or multimodal$ or multi‐modal$) adj3 (program$ or intervention$ or therap$ or treat$)).tw,kf. 55 dialectical behavio?r$ therap$.tw,kf. 56 (exercise$ or physical training).tw,kf. 57 ((existential or gestalt or humanistic or interpersonal or milieu or person‐centred or residential or socioenvironmental or socio‐environmental) adj1 therap$).tw.kf. 58 expressive writing.tw,kf. 59 ("Eye Movement Desensitization and Reprocessing" or EMDR).tw,kf. (439) 60 (meditat$ or mental training or mindfulness$ or mind training or brain training or yoga).tw,kf. 61 motivational interview$.tw,kf. 62 (reality therap$ or problem solving).tw,kf. 63 (psycho$ therap$ or psychotherap$).tw,kf. 64 (psychoanalytic$ or psycho‐analytic$ or psychodynamic$ or psycho‐dynamic$).tw,kf. 65 (psychodrama or psycho‐drama or acting out or role play).tw,kf. 66 (psychosocial or psycho‐social or psychoeducation$ or psycho‐education$).tw,kf. 67 rational emotive.tw,kf. 68 (Relax$ adj3 (training$ or treatment$ or therap$)).tw,kf. 69 (Service$ adj3 (refer$ or use$)).tw,kf. 70 (stress inoculation training or SIT or prolonged exposure therapy or PET or cognitive processing therapy or CPT).tw,kf. 71 ((support or advice or advis$1) adj1 (centre$1 or center$1 or community or group$ or network$ or social or staff$)).tw,kf. 72 (therapeutic allianc$ or therapeutic relationship$ or therapeutic communit$).tw,kf. 73 Third wave.tw,kf. 74 or/13‐73 75 12 and 74 76 (rape adj3 (centre$ or center$ or service$ or support)).tw,kf. 77 ((sex$ assault adj3 centre) or (sex$ assault adj3 center) or (sex$ assault adj3 service) or (sex$ assault adj3 support)).tw,kf. 78 ((sex$ abuse$ adj3 centre) or (sex$ abuse$ adj3 center) or (sex$ abuse$ adj3 service) or (sex$ abuse$ adj3 support)).tw,kf. 79 or/76‐78 80 75 or 79 81 randomized controlled trial.pt. 82 controlled clinical trial.pt. 83 randomi#ed.ab. 84 placebo$.ab. 85 drug therapy.fs. 86 randomly.ab. 87 trial.ab. 88 groups.ab. 89 or/81‐88 90 exp animals/ not humans.sh. 91 89 not 90 92 80 and 91 ***************************

Appendix 3. Cochrane Common Mental Disorders Controlled Trials Register

Core medline search.

The search strategy below is the weekly OVID Medline search, which was used to inform the Group’s specialised register. It is based on a list of terms for all conditions within the scope of the Cochrane Common Mental Disorders Group plus a sensitive RCT filter.

1. [MeSH Headings]:

eating disorders/ or anorexia nervosa/ or binge‐eating disorder/ or bulimia nervosa/ or female athlete triad syndrome/ or pica/ or hyperphagia/ or bulimia/ or self‐injurious behavior/ or self mutilation/ or suicide/ or suicidal ideation/ or suicide, attempted/ or mood disorders/ or affective disorders, psychotic/ or bipolar disorder/ or cyclothymic disorder/ or depressive disorder/ or depression, postpartum/ or depressive disorder, major/ or depressive disorder, treatment‐resistant/ or dysthymic disorder/ or seasonal affective disorder/ or neurotic disorders/ or depression/ or adjustment disorders/ or exp antidepressive agents/ or anxiety disorders/ or agoraphobia/ or neurocirculatory asthenia/ or obsessive‐compulsive disorder/ or obsessive hoarding/ or panic disorder/ or phobic disorders/ or stress disorders, traumatic/ or combat disorders/ or stress disorders, post‐traumatic/ or stress disorders, traumatic, acute/ or anxiety/ or anxiety, castration/ or koro/ or anxiety, separation/ or panic/ or exp anti‐anxiety agents/ or somatoform disorders/ or body dysmorphic disorders/ or conversion disorder/ or hypochondriasis/ or neurasthenia/ or hysteria/ or munchausen syndrome by proxy/ or munchausen syndrome/ or fatigue syndrome, chronic/ or obsessive behavior/ or compulsive behavior/ or behavior, addictive/ or impulse control disorders/ or firesetting behavior/ or gambling/ or trichotillomania/ or stress, psychological/ or burnout, professional/ or sexual dysfunctions, psychological/ or vaginismus/ or Anhedonia/ or Affective Symptoms/ or *Mental Disorders/

2. [Title/ Author Keywords]:

(eating disorder* or anorexia nervosa or bulimi* or binge eat* or (self adj (injur* or mutilat*)) or suicide* or suicidal or parasuicid* or mood disorder* or affective disorder* or bipolar i or bipolar ii or (bipolar and (affective or disorder*)) or mania or manic or cyclothymic* or depression or depressive or dysthymi* or neurotic or neurosis or adjustment disorder* or antidepress* or anxiety disorder* or agoraphobia or obsess* or compulsi* or panic or phobi* or ptsd or posttrauma* or post trauma* or combat or somatoform or somati#ation or medical* unexplained or body dysmorphi* or conversion disorder or hypochondria* or neurastheni* or hysteria or munchausen or chronic fatigue* or gambling or trichotillomania or vaginismus or anhedoni* or affective symptoms or mental disorder* or mental health).ti,kf.

3. [RCT filter]:

(controlled clinical trial.pt. or randomised controlled trial.pt. or (randomi#ed or randomi#ation).ab,ti. or randomly.ab. or (random* adj3 (administ* or allocat* or assign* or class* or control* or determine* or divide* or distribut* or expose* or fashion or number* or place* or recruit* or subsitut* or treat*)).ab. or placebo*.ab,ti. or drug therapy.fs. or trial.ab,ti. or groups.ab. or (control* adj3 (trial* or study or studies)).ab,ti. or ((singl* or doubl* or tripl* or trebl*) adj3 (blind* or mask* or dummy*)).mp. or clinical trial, phase ii/ or clinical trial, phase iii/ or clinical trial, phase iv/ or randomised controlled trial/ or pragmatic clinical trial/ or (quasi adj (experimental or random*)).ti,ab. or ((waitlist* or wait* list* or treatment as usual or TAU) adj3 (control or group)).ab.)

4. (1 and 2 and 3)

Records were screened for reports of RCTs within the scope of the Cochrane Common Mental Disorders Group. Secondary reports of RCTs were tagged to the appropriate study record. The CCMD‐CTR is current to June 2016 only.

Contributions of authors

Sarah Brown and Nazanin Khasteganan drafted the protocol, with regular discussion and input from Lorna O'Doherty. Katherine Brown, Kelsey Hegarty, Grace Carter, Laura Tarzia and Gene Feder reviewed the drafts.

SB is the guarantor for the review.

Sources of support

Internal sources.

Funds 20% of the MESARCH (Multidisciplinary Evaluation of Sexual Assault Referral Centres for better Health) project

External sources

Funds 80% of the MESARCH project

Declarations of interest

With the exception of Kelsey Hegarty and Laura Tarzia, all review authors are funded for their work on this review by the Multidisciplinary Evaluation of Sexual Assault Referral Centres for better Health (MESARCH) project; a project (number 16/117/04) funded by an institutional research grant from the National Institute for Health Research (NIHR) Health Service and Delivery Research Programme to Coventry University.

Sarah Brown (SB) ‐ none known.

Nazanin Khasteganan (NK) ‐ none known.

Katherine Brown (KB), in the interest of transparency, declares that she led a local evaluation of the Blue Sky Centre, a sexual assault referral centre in Warwickshire, between 2013 and 2015.

Kelsey Hegarty (KH) declares institutional research funding from the National Health and Medical Research Council for a trial of screening and intervention in primary care. KH also declares monies paid to her from the World Health Organization to attend a guideline group on intimate partner violence, and funds from General Practice Victoria to deliver a training program on intimate partner violence for general practitioners.

Grace Carter (GC) ‐ none known.

Laura Tarzia (LT) declares funding from the Australian Research Council to develop an online intervention for women experiencing intimate partner sexual violence, and funding from the University of Melbourne to develop a smartphone application for early intervention for students affected by sexual violence or dating violence.

Gene Feder (GF) declares that he is Chief Investigator or Co‐investigator on a range of NIHR and MRC (Medical Research Council) grants.

Lorna O'Doherty (LOD) declares that she is Chief Investigator on the MESARCH project.

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Ex-South Dakota mayor Jay Ostrem charged in triple homicide after alleged sexual assault of family member

T he former mayor of a South Dakota town is accused of murdering three people after becoming enraged over a neighbor allegedly sexually assaulting a family member.

Jay Edward Ostrem, 64, was arrested on Monday and is currently being held in Minnehaha County Jail on $1 million cash-only bond, according to the South Dakota Attorney General’s Office.

Ostrem was the mayor and city councilor of Centerville in 2010, KELO reported, citing previously filed lawsuits against the suspect.

The incident took place around 9:44 p.m. Monday night, when a “frantic” man called 911 and said that his relative had been fatally shot, court papers obtained by KELO said.

The caller claimed that the shooter was a man from across the street, and said the man had gone back into his home.

The man then said that he had also been shot, and stopped communicating with the dispatcher a short time later.

When police arrived at the scene, they witnessed Ostrem leaving his home, the papers explained.

The former mayor ignored the cops’ asking him to stop and continued walking away until a Game, Fish, and Parks officer who responded to the scene met up with him and demanded he get on the ground.

Ostrem complied, and told the officer he had a gun in his pocket, the court write-up noted.

When officers approached, they noticed that Ostrem had an AR-style rifle on the ground near him. He was also bleeding from his left hand and smelled of alcohol.

Officers then found a .380 handgun in Ostrem’s pocket, as well as spent shotgun shell casings and at least one spent rifle casing.

When the police entered the home where the 911 call was made from, they found three people dead from apparent gunshot wounds.

The investigators moved on to Ostrem’s house, where one of his adult family members told them that a neighbor had been at their home on Thursday night, while Ostrem was sleeping.

The family member claimed that she and the neighbor were drinking, and then he forcibly kissed her, exposed himself to her, and pressed himself against her, the court papers said.

The woman explained that she told Ostrem about the assault on Monday, and then “got up and went raging out of the house.”

Ostrem did not say anything as he left, and she did not know where he was going, the woman claimed.

She also said that she did not see Ostrem again until law enforcement arrived at the scene.

Ostrem was former law enforcement, and had weapons in the home and possibly in his car, the woman added.

The incident is now under investigation by the South Dakota’s Division of Criminal Investigation.

The three victims have not been publicly identified pending family notification, the Attorney General’s Office said.

“Jay Ostrem has been arrested and charged with three counts of First Degree Murder, and law enforcement has secured the scene,” said Attorney General Jackley. “There is no further threat to the public.”

Ex-South Dakota mayor Jay Ostrem charged in triple homicide after alleged sexual assault of family member

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Sexual assault against adolescents and adults is a global public health problem. Sexual assault encompasses a broad spectrum of behaviors and is generally defined as any attempted or completed sexual act, ranging from unwanted sexual touch to rape, that is committed against someone without a person's freely given consent (Basile et al., 2014; World Health Organization, 2017).
Sexual assault victimization and psychopathology: A review and meta
Sexual assault (SA) is a common form of trauma: 17-25% of women and 1-3% of men will be sexually assaulted in their lifetime (Black et al., 2011; Fisher, Cullen, & Turner, 2000; Koss, Gidycz, & Wisniewski, 1987; Tjaden & Thoennes, 2000, 2006).The high prevalence of SA is particularly concerning in light of its significant psychological consequences for survivors (e.g., Campbell, Dworkin ...
PDF Writing about Sexual Harassment: A Guide to the Literature
The Civil Rights Act of 1991 clearly contemplates actions for sexual harassment and permits plaintiffs to recover compensatory and punitive damages up to a maxi-mum of between $50,000 and $300,000, depending on the size of the employer. 42. U.S.C. § 1981a(a)(1), (b) (Supp. III 1991). Jury trials are now available under Title VII for plaintiffs ...
Recent Thinking about Sexual Harassment: A Review Essay
the variety of sexual harassment claims. Twenty-five years ago, Catharine MacKinnon made her pathbreaking argument that sexual harassment constitutes sex discrimination under Title VII of the 1964 Civil Rights Act. 1 Her work entrenched a paradigm of sexual harassment as sexual conduct that men impose on women because they are women. Since then, a variety of plaintiffs whose complaints do not ...
Sexual Violence against Women
types of women were the victims of sexual assault (for example, not "nice" women, not white women, not middle-class women). Similar This essay reviews the following books: Diana E. H. Russell, Rape in Mawia,ge, ex-panded and revised edition with a new introduction (Bloomington: Indiana University
1 Introduction
1 Introduction. The crimes of rape and sexual assault are among the most injurious that perpetrators can inflict on other individuals. These crimes are devastating, extending beyond the initial victimization to such consequences as unwanted pregnancy, sexually transmitted infections, post-traumatic stress disorder, depression, flashbacks, sleep disorders, eating disorders, post-incident ...
Mental Health Consequences of Sexual Assault
Sexual violence has been linked to many negative health outcomes. The most recent systematic review examining the association between sexual abuse and lifetime diagnosis of psychiatric disorders was conducted by Chen et al. in 2010.This review included only longitudinal studies (n = 37; 3,162,318 participants), which compared survivors of sexual abuse, which may have occurred at any age, with ...
PDF THE INVESTIGATION AND PROSECUTION OF SEXUAL VIOLENCE
8. systematic manner (if charged as a crime against humanity) or during an armed conflict (if charged as a war crime).28. (2) The nature of criminal responsibility: The defendant in a case concerning a domestic crime of sexual violence is usually the physical perpetrator of the sexual act.
Notes on Writing about Sexual Violence
A memoir about sexual assault guarantees a certain amount of attention, because it is sensational and because writing about violence encourages a kind of voyeurism. But while this may be one possible response, it is not this writer's desire to make the reader participate in the imagined reconstruction of violence.
Persistent Suffering: The Serious Consequences of Sexual Violence
1. Introduction. In this paper, knowledge from research on the consequences of sexual violence against girls and women and their search for internal healing is synthesized using the method of theory synthesis. The significance of the #MeToo movement in women's search for internal healing after sexual violence is also explored and discussed.
Sexual Assault Essays: Examples, Topics, & Outlines
Sexual Assault on Universities and College Campuses Introduction to Sexual Assault Sexual assault refers to an involuntary sexual act where an individual is forced to engage in against his or her will (Hoffman, 1998). As the world evolves and becomes more politically correct and more culturally sensitive, certain injustices that might have been swept under the rug in the past are now no longer ...
Overview of Rape and Sexual Violence
The term "sexual violence" refers to a specific constellation of crimes including sexual harassment, sexual assault, and rape. The person who commits this crime may be a stranger, acquaintance, friend, family member, or intimate partner. Researchers, practitioners, and policymakers agree that all forms of sexual violence harm the individual, the family unit, and society and that much work ...
1 Introduction
Some states and the U.S. Code (18 U.S.C. § 2241-2245) have replaced the term "rape" with terms such as "sexual assault," "sexual battery," or "sexual abuse'' (Epstein and Langenbahn, 1994). Many laws now have a series of graded offenses defined by the presence or absence of aggravating conditions, making sexual assault laws similar to other ...
Module 4: Rape and Sexual Assault
Date rape usually occurs in the context of a relationship between two people in a social setting before the assault, with subsequent betrayal of trust. The date rapist tends to be sexually promiscuous, to have a hostile attitude toward women, and to use verbal coercion and alcohol to facilitate the sexual assault.
Sexual Assault (Chapter 29)
Summary. Sexual assault, including unwanted sexual contact, coercion, and rape, is a social phenomenon that has been approached in a variety of ways in different global contexts. Attempts to address risk and protective factors for perpetrators and victims are limited by the difficulty of collecting empirical data on experiences that can be ...
Introduction: Sexual Violence
Abstract. This chapter introduces and defines rape and sexual assault as they were understood in 1970s Australia, both legally and in Australian culture. Conceptualising Australia within the Western legal tradition, this introduction will establish the parameters of ideas of consent, trauma, gender and violence in the late twentieth century.
Mental and sexual health outcomes following sexual assault in
Introduction. Interpersonal violence and child sexual abuse are leading risk factors for disability-adjusted life-years and mortality among adolescents globally. ... 2013, and April 20, 2015, 583 young people aged 13-17 years presented to the Havens following a sexual assault. 92 (16%) were ineligible or excluded: one aged 12 years, two ...
About Sexual Assault
Sexual violence is any type of unwanted sexual contact. This includes words and actions of a sexual nature against a person's will and without their consent. A person may use force, threats, manipulation, or coercion to commit sexual violence. Forms of sexual violence include: Rape or sexual assault. Child sexual assault and incest.
Sexual assault and harassment
Sexual assault and harassment. Sexual assault involves unwanted sexual activity, with perpetrators often using force, making threats, or taking advantage of victims not being able to give consent. Immediate reactions to sexual assault may include shock, fear, or disbelief. Long-term symptoms may include anxiety, fear, or posttraumatic stress ...
Songwriter-producer for Beyoncé sued for alleged sex assault in L.A.
Eight-time Grammy Award winner Terius "The- Dream" Gesteelde-Diamant, the producer behind hits for Beyoncé, Rihanna and Ye, was sued Tuesday in Los Angeles by a former protégé for alleged ...
Psychosocial interventions for survivors of rape and sexual assault
Why it is important to do this review. Clinical and policy guidelines inform responses to rape and sexual assault (e.g. NICE 2018; WHO 2013b), but gaps remain in our knowledge of the most effective ways of intervening to improve health outcomes and prevent further victimisation.While there is moderate evidence on the consequences of sexual trauma (Description of the condition), it is less ...
Trans rights are 'greatest assault of my lifetime' on women's rights
Trans rights are 'greatest assault of my lifetime' on women's rights, says JK Rowling Harry Potter author explains her beliefs in an essay for The Women Who Wouldn't Wheesht, a new book on ...
Ex-South Dakota mayor Jay Ostrem charged in triple homicide after ...
The former mayor of a South Dakota town is accused of murdering three people after becoming enraged over a neighbor allegedly sexually assaulting a family member. Jay Edward Ostrem, 64, was ...