Molly Brady, PsyD; Ava Drennen, PhD; Dawn Jewell, PsyD; Daniel Bruns, PsyD
On October 15, 2017, the hashtag #MeToo first emerged on Twitter. Within 24 hours, #MeToo had appeared in over half a million tweets, and in 12 million Facebook posts by 4.7 million people.1 In the weeks and months that followed, a remarkable number of anguished stories were told. This emphasized that sexual trauma and harassment occurs all too frequently in our personal and professional lives, is intricately tied with social justice issues, has long-term health consequences for survivors of trauma, and should be recognized as a public health concern.2 This movement sparked change in a wide array of professions, populations, and policy. Most importantly, perhaps, the movement inspired conversation.
Now approaching two years since the foundation of #MeToo, what do we know? In this article, we summarize what has been established about the scope of the problem, delineate the multifaceted effects that can result from sexual trauma, and explore some of the unique contributions that we as health psychologists can make in addressing these issues.
Prevalence of sexual trauma
Sexual assault and sexual harassment are long-standing problems, occurring more often than reporting rates would suggest. Unfortunately, establishing accurate prevalence rates of sexual assault is difficult for several reasons including pervasive patterns of underreporting. To wit, in a study of college-aged women who had been assaulted, only 11.5% of all rapes were reported to police.3 Studies suggest that sexual harassment and sexual trauma are grossly underreported for myriad of reasons including shame and fear of blame or reprisal. Such fears appear to be validated in the research: one or more incidents of retaliation were endorsed by 58% or female and 60% of male US military service members who had reported to military officers that they had been sexual assaulted.4
According to a briefing paper from the International Society for Traumatic Stress Studies, a national study of US women found that over one-third experienced some form of sexual assault, with even higher rates in marginalized groups, such as individuals diagnosed with disabilities, gender and sexual identity minorities, individuals who are sexually trafficked or engaging in sex work, individuals who are homeless, and aboriginal or indigenous groups.5 Research on childhood sexual assault in North America suggests prevalence rates ranging from 11.2 to 26.6% for girls and between 5.1 and 17.3% for boys.5 Sexual trauma is clearly not a problem reserved only for vulnerable populations such as children: despite growing awareness of the problem in mainstream culture in recent years, sexual trauma continues to be a concern even for adults in professional settings. For example, military rates of sexual assault have increased nearly 38% over those reported in 2016.6
We recognize that the data above may be impacted by increased reporting and other factors. Nevertheless, we would argue that this is a critical time for our field to take meaningful action in addressing the ripple effects of sexual trauma given the spotlight that #MeToo has provided.
Possible effects of sexual trauma
The health effects of sexual trauma are both multifaceted and enduring. Unwanted sexual experiences appear to be particularly detrimental to behavioral health functioning: these experiences were associated with 2 to 7.5 times greater risk of developing Posttraumatic Stress Disorder (PTSD) and other significant clinical issues, the highest odds of all trauma types evaluated in the study.7 Recent studies on both civilian and military populations have repeatedly identified associations between sexual assault/harassment and the development of not only PTSD, but also depression and anxiety disorders.5,8-11 Among those traumatized by rape, approximately 46% of women and 65% of men develop PTSD.12
Beyond the deleterious effects of depression, anxiety, and PTSD, studies have shown that traumatized individuals can suffer from chronic hyperarousal and may present in medical settings with stress-related symptoms. The literature discusses this chronic hyperarousal in the context of an adaptive response to extreme threat that is complicated by genetic or epigenetic modifications to DNA functioning that “dial-up” the “fight or flight response.”13-15 Childhood sexual abuse has been associated with greater risk for the development of a variety of physical health conditions, including gastrointestinal disorders, cardiopulmonary dysfunction, chronic pelvic pain, reproductive health issues, headaches, and obesity.5,16-19
Furthermore, evidence suggests that the negative effects of trauma, such as sexual assault, can have an intergenerational effect. Lifetime trauma experienced by women (independent of maternal stress during pregnancy) has been associated with negative infant affectivity, perhaps modified by prenatal cortisol exposure.20 Toddlers whose mothers experienced interpersonal violence-related PTSD have been found to demonstrate altered patterns of cortisol reactivity to stress, possibly increasing their risk of developing psychological disorders later in life.20,21
Clinical implications of #MeToo for health psychologists
In an interdisciplinary setting, the process of inquiring about traumatic events is often extremely sensitive, and documenting these incidents presents a challenge for health psychologists: On one hand, recording the information in a vague manner, or to omit sensitive details may negatively impact treatment and may inhibit a psychologist’s ability to recall the trauma, and anticipate and address events that may be re-traumatizing for the patient. On the other hand, recording detailed information about a sexual trauma in an Electronic Health Record (EHR) where many providers have access may be perceived by the patient as a breach of confidentiality. This dilemma may be particularly relevant for health psychologists given that many operate within a larger health systems, hospitals, or integrated care clinics. While access to EHRs in these environments are often advantageous for patient care, sensitive information about trauma and related symptoms needs careful consideration and patients should be aware of limits to confidentiality. Given that sexual trauma, by its very nature, robs individuals of their power and autonomy, a critical element in discussing these experiences is to ensure the patient’s wishes (for instance with regard to disclosure) are honored and their agency in the process is explicitly recognized.22 Additionally, when starting a conversation about sexual trauma in a clinical setting, awareness of cultural context and barriers to disclosure (e.g. feelings of shame, fears of consequences and privacy concerns) are also important to keep in mind.23
Health psychologists have the advantage of being prepared to discuss trauma symptoms from a biopsychosocial perspective, including recognizing the neurobiological impact of emotional trauma.24-26 This approach can help to de-stigmatize trauma symptoms for patients. Relatedly, health psychologists are uniquely positioned to recognize and treat somatic distress secondary to sexual trauma.
Trauma symptom management, even if not the explicit focus of treatment, should be considered and integrated across a health psychologist’s practice. Successful treatment may require management of pre-existing symptoms related to historical trauma while the patient is navigating the medical system. For instance, basic components of medical care such as a physician’s examination may trigger fear, anger, avoidance, and/or an exacerbation of trauma-related symptoms.27 A goal of behavioral health treatment in these cases may be to limit re-traumatization by the very medical system attempting to provide care.
Evidence-based treatments for posttraumatic stress reactions should be considered when trauma is the established focus of treatment. The American Psychological Association Clinical Practice Guideline for the Treatment of PTSD strongly recommended Cognitive Processing Therapy and Cognitive Therapy, for adult patients.28 This guideline also encourages psychologists to address common comorbid concerns, such as depression or problematic substance use.
The #MeToo movement highlighted the pervasive nature of sexual assault, including the power dynamics and lasting impacts of sexual traumas in the workplace. The American College of Occupational and Environmental Medicine (ACOEM) has developed treatment guidelines to address PTSD stemming from traumatic experiences at work, including sexual assault in the workplace.29 These included: exercise (aerobic exercise and resistance training)30,31, yoga32-34, Cognitive Behavioral Therapy35,36, and Prolonged Exposure. Additional treatments include meditation, guided imagery, and mindfulness.37
It is now recognized that as sexual trauma is an extremely private condition, traumatized individuals may first seek care for somatic aspects of their condition.23-26 The health psychologist is thus in a unique position that allows treating the presenting physical symptoms, while also seeking to understand and alleviate the unexpressed aspects of the patient’s pain. Studies have shown that with appropriate therapeutic support, those who have suffered a trauma can experience posttraumatic growth.38,39
Psychoeducational resources may be helpful for providers and patients. The following are a few websites containing research, links to support groups, and opportunities for further involvement: Rape, Abuse & Incest National Network (RAINN.org), National Sexual Violence Resource Center (nsvrc.org), and The Joyful Heart Foundation (joyfulheartfoundation.org).
- CNN, Santiago C, Criss D. An activist, a little girl and the heartbreaking origin of ‘Me too’ CNN. https://www.cnn.com/2017/10/17/us/me-too-tarana-burke-origin-trnd/index.html. Accessed June 6, 2019.
- National Sexual Violence Resource Center. Sexual assault statistics. National Sexual Violence Resource Center,. https://www.nsvrc.org/node/4737. Published 2018. Accessed June 9, 2019.
- Kilpatrick D, Resnick H, Ruggiero K, Conoscenti L, McCauley J. Drug-facilitated, Incapacitated, and Forcible Rape: A National Study. In: Justice USDo, ed. Charleston, SC: National Crime Victims Research & Treatment Center; 2007.
- Department of Defense Office of People Analytics. 2016 Workplace and Gender Relations Survey of Active Duty Members Overview Report. Department of Defense. https://apps.dtic.mil/dtic/tr/fulltext/u2/1032638.pdf. Published 2017. Accessed June 6, 2019.
- ISTSS Sexual Violence Briefing Paper Work Group. Sexual assault, sexual abuse, and harassment: Understanding the mental health impact and providing care for survivors. International Society for Traumatic Stress Studies. www.istss.org/sexual-assault Published 2018. Accessed June 6, , 2019.
- Sexual Assault Prevention and Response Office. Annual report on sexual assault in the military fiscal year 2018. https://int.nyt.com/data/documenthelper/800-dod-annual-report-on-sexual-as/d659d6d0126ad2b19c18/optimized/full.pdf#page=1. Published 2019. Accessed.
- Roberge EM, Haddock LA, Oakey-Frost DN, Hinkson KD, Bryan AO, Bryan CJ. Unwanted sexual experiences and retraumatization: Predictors of mental health concerns in veterans. Psychol Trauma. 2019.
- Boudreaux E, Kilpatrick DG, Resnick HS, Best CL, Saunders BE. Criminal victimization, posttraumatic stress disorder, and comorbid psychopathology among a community sample of women. J Trauma Stress. 1998;11(4):665-678.
- Ullman SE, Brecklin LR. Sexual assault history and health-related outcomes in a national sample of women. Psychology of Women Quarterly. 2003;27(1):46-57.
- World Health Organization. Global and regional estimates of violence against women: Prevalence and health effects of intimate partner violence and nonpartner sexual violence. World Health Organization. https://www.who.int/reproductivehealth/publications/violence/9789241564625/en/. Published 2013. Accessed June 9, 2019.
- Zinzow HM, Resnick HS, McCauley JL, Amstadter AB, Ruggiero KJ, Kilpatrick DG. Prevalence and risk of psychiatric disorders as a function of variant rape histories: results from a national survey of women. Soc Psychiatry Psychiatr Epidemiol. 2012;47(6):893-902.
- Kessler RC, Sonnega A, Bromet E, Hughes M, Nelson CB. Posttraumatic stress disorder in the National Comorbidity Survey. Arch Gen Psychiatry. 1995;52(12):1048-1060.
- Ross DA, Arbuckle MR, Travis MJ, Dwyer JB, van Schalkwyk GI, Ressler KJ. An Integrated Neuroscience Perspective on Formulation and Treatment Planning for Posttraumatic Stress Disorder: An Educational Review. JAMA Psychiatry. 2017;74(4):407-415.
- Brand SR, Engel SM, Canfield RL, Yehuda R. The effect of maternal PTSD following in utero trauma exposure on behavior and temperament in the 9-month-old infant. Ann N Y Acad Sci. 2006;1071:454-458.
- Bracha HS. Human brain evolution and the “Neuroevolutionary Time-depth Principle:” Implications for the Reclassification of fear-circuitry-related traits in DSM-V and for studying resilience to warzone-related posttraumatic stress disorder. Prog Neuropsychopharmacol Biol Psychiatry. 2006;30(5):827-853.
- Hemmingsson E, Johansson K, Reynisdottir S. Effects of childhood abuse on adult obesity: a systematic review and meta-analysis. Obes Rev. 2014;15(11):882-893.
- Irish L, Kobayashi I, Delahanty DL. Long-term physical health consequences of childhood sexual abuse: a meta-analytic review. J Pediatr Psychol. 2010;35(5):450-461.
- Maniglio R. The impact of child sexual abuse on health: a systematic review of reviews. Clin Psychol Rev. 2009;29(7):647-657.
- McCarthy-Jones S, McCarthy-Jones R. Body mass index and anxiety/depression as mediators of the effects of child sexual and physical abuse on physical health disorders in women. Child Abuse Negl. 2014;38(12):2007-2020.
- Enlow MB, Devick KL, Brunst KJ, Lipton LR, Coull BA, Wright RJ. Maternal Lifetime Trauma Exposure, Prenatal Cortisol, and Infant Negative Affectivity. Infancy. 2017;22(4):492-513.
- Cordero MI, Moser DA, Manini A, et al. Effects of interpersonal violence-related post-traumatic stress disorder (PTSD) on mother and child diurnal cortisol rhythm and cortisol reactivity to a laboratory stressor involving separation. Horm Behav. 2017;90:15-24.
- Herman JL. Trauma and recovery. Rev. ed. New York: BasicBooks; 1997.
- Carson KW, Babad S, Brown EJ, Brumbaugh CC, Castillo BK, Nikulina V. Why Women Are Not Talking About It: Reasons for Nondisclosure of Sexual Victimization and Associated Symptoms of Posttraumatic Stress Disorder and Depression. Violence Against Women. 2019:1077801219832913.
- Bae SM, Kang JM, Chang HY, Han W, Lee SH. PTSD correlates with somatization in sexually abused children: Type of abuse moderates the effect of PTSD on somatization. PLoS One. 2018;13(6):e0199138.
- Ben-Ezra M, Palgi Y, Shrira A, Hamama-Raz Y. Somatization and psychiatric symptoms among hospital nurses exposed to war stressors. Isr J Psychiatry Relat Sci. 2013;50(3):182-186.
- Spitzer C, Barnow S, Wingenfeld K, Rose M, Lowe B, Grabe HJ. Complex post-traumatic stress disorder in patients with somatization disorder. Aust N Z J Psychiatry. 2009;43(1):80-86.
- Roberts SJ. The sequelae of childhood sexual abuse: a primary care focus for adult female survivors. Nurse Pract. 1996;21(12 Pt 1):42, 45, 49-52.
- American Psychological Association. Clinical Practice Guideline for the Treatment of Posttraumatic Stress Disorder (PTSD). American Psychological Association. https://www.apa.org/ptsd-guideline/. Published 2017. Accessed June 20, 2019.
- Hegmann KT, Bruns D, Warren P, et al. Post-traumatic stress disorder guidelines. In: Hegmann K, ed. MDGuidelines®. Occupational medicine practice guidelines: Evaluation and Management of Common Health Problems and Functional Recovery in Workers. Vol 2017. 3rd ed. Westminster, CO.: Reed Group; 2018.
- Rosenbaum S, Tiedemann A, Sherrington C, Curtis J, Ward PB. Physical activity interventions for people with mental illness: a systematic review and meta-analysis. J Clin Psychiatry. 2014;75(9):964-974.
- LeBouthillier DM, Asmundson GJG. The efficacy of aerobic exercise and resistance training as transdiagnostic interventions for anxiety-related disorders and constructs: A randomized controlled trial. J Anxiety Disord. 2017;52:43-52.
- van der Kolk BA, Stone L, West J, et al. Yoga as an adjunctive treatment for posttraumatic stress disorder: a randomized controlled trial. J Clin Psychiatry. 2014;75(6):e559-565.
- Rhodes A, Spinazzola J, van der Kolk B. Yoga for Adult Women with Chronic PTSD: A Long-Term Follow-Up Study. J Altern Complement Med. 2016;22(3):189-196.
- Mitchell KS, Dick AM, DiMartino DM, et al. A pilot study of a randomized controlled trial of yoga as an intervention for PTSD symptoms in women. J Trauma Stress. 2014;27(2):121-128.
- McGovern MP, Lambert-Harris C, Xie H, Meier A, McLeman B, Saunders E. A randomized controlled trial of treatments for co-occurring substance use disorders and post-traumatic stress disorder. Addiction. 2015;110(7):1194-1204.
- Monson CM, Macdonald A, Vorstenbosch V, et al. Changes in social adjustment with cognitive processing therapy: effects of treatment and association with PTSD symptom change. J Trauma Stress. 2012;25(5):519-526.
- Kelly A, Garland EL. Trauma-Informed Mindfulness-Based Stress Reduction for Female Survivors of Interpersonal Violence: Results From a Stage I RCT. J Clin Psychol. 2016;72(4):311-328.
- Tedeschi RG, Calhoun LG. The Posttraumatic Growth Inventory: measuring the positive legacy of trauma. J Trauma Stress. 1996;9(3):455-471.
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