PTSD: National Center for PTSD

Sexual Assault Experienced as an Adult

Jessica Keith, PhD and Chris Skidmore, PhD

Please be advised that this article includes language about sexual assault and violence.

People of all sexual orientations, ages, racial and ethnic backgrounds, and physical sizes, appearances and abilities have experienced sexual assault. This article summarizes information about sexual assault experienced by adults in the United States. Although survivors of sexual assault are remarkably resilient, research suggests that survivors are at increased risk of developing mental and physical health difficulties after the assault, including posttraumatic stress disorder (PTSD; 1,2).

While people of different sexes respond to the experience of sexual assault in many similar ways (3), stereotypical ideas related to femininity and masculinity often impact survivors' experiences (3-5). Transgender individuals often experience additional unique challenges (6,7).

In addition to describing sexual assault and discussing the cultural context that may impact the experience of survivors, this article reviews the epidemiology of sexual assault and its relationship to PTSD. Tips to support mental health providers with assessment of sexual assault and treatment of related mental health concerns are also reviewed.

What is sexual assault?

Sexual assault is any type of sexual activity that occurs without the explicit consent of a person involved. The sexual activity can include acts such as unwanted touching, grabbing, oral sex, anal sex, sexual penetration with an object, being made to perform sexual acts and/or sexual intercourse. Rape is a more specific term defined by the Centers for Disease Control (CDC) as a type of sexual assault that involves, "any completed or attempted unwanted vaginal (for women), oral, or anal penetration" (8, p17).

There are many ways that those who perpetrate sexual assault involve others in sexual activity against their will or without their consent. Perpetrators may use physical force, psychological force, manipulation, intimidation, threats of retaliation, emotional coercion, or drugs or alcohol to facilitate assaults. Ways that someone can be forced or coerced into sexual activity include:

• Being pressured by someone who has authority or power—for example, a boss, doctor, religious leader, teacher, or military superior.
• Being bribed or manipulated.
• Being unable to give consent—for example, sexual activity when one is asleep, drugged, unconscious or under the influence of substances.
• Being threatened with harm to self, family members, children, friends or pets.
• Being physically forced.

Sexual assault can occur in many different circumstances, including within marriages and other romantic relationships, during hazing practices, in schools and workplaces, within families, in jails and prisons, and in the military. Military sexual trauma, or MST, is the term used by the Department of Veterans Affairs (VA) to refer to experiences of sexual assault or threatening sexual harassment experienced during military service.

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Who commits sexual assaults?

Most sexual assaults are committed by someone known to the person assaulted. The National Intimate Partner and Sexual Violence Survey (NISVS), a nationally representative study conducted by CDC, found that most sexual assaults are perpetrated by a current or former spouse or partner, significant other or acquaintance, with less than 1 in 6 rapes or attempted rapes perpetrated by a stranger (8). Although most perpetrators of sexual violence against women are men, for men who experience sexual assault, the sex of the perpetrator varies based on the type of sexual violence. While the majority of rapes of men are committed by other men, for other types of sexual violence such as sexual coercion, being forced to penetrate and unwanted sexual contact, over half of men report having women perpetrators (8). Men who have been assaulted may be more likely than women who have been assaulted to have multiple perpetrators (4).

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How common is sexual assault in the U.S.?

Estimating how often sexual assault occurs is a difficult task. Rates vary based on who is studied, how they are asked and how sexual assault experiences are defined. In addition, many individuals choose not to report being sexual assaulted to police or to interviewers collecting statistics for understandable reasons. Survivors may not want to share something personal, may want to avoid thinking about the experience, may feel shame or may blame themselves for a perpetrator's behavior. They may fear that they will not be believed or that they will be judged or blamed by others. They may fear retaliation for reporting, especially if the perpetrator has authority over them, or they may have mixed feelings about reporting a crime committed by someone with whom they have a relationship (9). Men may be even less likely to report sexual assault than women due to sex-specific stigma and stereotypes about masculinity and sexuality (4,10-12).

Despite these challenges, there are some statistics available. Estimates from the 2015 NISVS reported that:

• Nearly 44% of women in the U.S. had experienced sexual violence during their lifetime, including childhood, with 21% experiencing rape or attempted rape and nearly 5% experiencing sexual violence within the past 12 months (13).
• Nearly 25% of men had experienced sexual violence during their lifetime, with 3.5% reporting such violence in the past 12 months (13).

Some research suggests that when sexual assault is not defined in a sex-specific manner, such as involving penetration of a victim by a perpetrator, women and men report similar rates of nonconsensual sexual contact (10).

LGBTQ+ community

Rates of experiencing sexual assault may be higher among lesbian, bisexual, gay and transgender individuals (7, 14). A Department of Justice Report of violent victimization by sexual orientation over the 4 years from 2017-2020 found that lesbian/gay and bisexual individuals experience rape/sexual assault at a higher rate than heterosexual individuals—respectively, 3.1 and 27.6 compared to 1.5 of every 1000 persons aged 16 and over (15). The 2016/17 NISVS found that bisexual women had significantly higher rates of experiencing lifetime sexual violence compared to heterosexual and lesbian women, and that gay and bisexual men had significantly higher rates of experiencing lifetime sexual violence compared to heterosexual men (16). The nationwide 2015 U.S. Transgender Survey found that almost 50% of the trans people who responded reported being sexually assaulted at some point in their lives, with 10% experiencing sexual assault within the past year (7).

People of Color

Some research suggests that rates of experiencing sexual assault may be higher among Black and Indigenous women compared to other groups (17), though such assaults may be under-recognized due to the United States' historical legacy of racist laws that did not recognize Black and Indigenous women as legitimate victims of assault (18). Vulnerabilities for experiencing sexual assault likely intersect, leading to increased risks for certain groups. For example, trans people of color who have been homeless or who have or had a disability are more likely to have experienced sexual assault (7). Black women who live in poverty also may experience higher rates of sexual assault (18).

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What are some facts that debunk common myths about sexual assault?

Myths about sexual assault continue to persist in society and contribute to a culture of victim blaming, silencing and under-reporting (19,20). These myths can also implicitly or explicitly impact the beliefs of medical, law enforcement and mental health professionals, leading to poor treatment of sexual assault survivors (11,20). This section presents facts about sexual assault that refute some commonly encountered myths.

Table 1. Facts About Sexual Assault to Support Mental Health Care Best Practices

Sex-specific myths about men and sexual assault are often related to sex-based stereotypes and social norms regarding masculinity and male sexuality. Men who experience sexual assault may be more likely than women to be judged more harshly or have their experiences dismissed or minimized by others due to such myths (10,11,25).

Table 2. Sex-specific Facts About Sexual Assault to Support Culturally-sensitive Care

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What are some ways that individuals are impacted by sexual assault?

Sexual assault is an experience, not a diagnosis or a mental health condition, and there is no one typical pattern of response to the experience. Many survivors are quite resilient and function well. Some people feel severe distress immediately, and others have delayed reactions, even many years later. Some suffer for a long time after an assault, and others appear to recover naturally. Aspects of an individual's identity and background, such as age and prior trauma exposure, can impact response. In addition, aspects of the assault, including the setting, amount of physical pain and injury experienced, characteristics of the perpetrator(s), the relationship of the survivor to the perpetrator and the level of physical violence play a role in response (3,29).

Support and reactions of others also impact a person's response to sexual assault. Negative reactions, such as judging or blaming the survivor or not offering assistance and resources, are associated with higher rates of depression, PTSD, substance use and other negative health outcomes (30,31). In contrast, positive reactions such as listening, validating, providing resources and telling the survivor that the assault was not their fault are associated with better coping and the development of fewer PTSD symptoms (32).

Initially after a sexual assault, many survivors feel shock, confusion, anxiety, anger and/or numbness. Survivors may not fully acknowledge what has happened, or they may downplay the experience to get through the intense emotional impact of it. Self-blame, shame and self-doubt are also common initial reactions (33). In the days and weeks following an assault, many survivors experience strong or unpredictable emotions. They may have nightmares or repeated, intense memories of the event that are difficult to ignore. They may have difficulty concentrating and sleeping and may feel jumpy or on edge. While these reactions are expected, some survivors experience more impairing symptoms during the first month after a sexual assault. When these symptoms disrupt functioning, such as at work or school, and prevent survivors from coping well or accessing support, it may be a sign of acute stress disorder (34).

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What is the relationship between sexual assault and PTSD?

While many survivors recover naturally on their own after a sexual assault, some go on to have longer-term problems. The most widely studied long-term psychological consequence of experiencing sexual assault is PTSD. Data from a large-scale study comparing the effects of different types of traumatic events suggest that the experience of sexual assault may be more likely to lead to PTSD (assessed with DSM-IV criteria) than other types of traumatic events. In this study, 45% of women and 65% of men who reported having experienced rape met criteria for PTSD (54).

Survivors of sexual assault who have PTSD may struggle with avoidance of people who resemble the perpetrator, may avoid relationships and sexual intimacy, may struggle to trust others and feel safe in the world and may blame themselves for actions taken or not taken at the time of the assault. These symptoms may improve over time or may last and continue to cause problems.

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What are some other difficulties that may occur after experiencing sexual assault?

Research suggests that survivors are at increased risk of developing mental and physical health difficulties after sexual assault (1,2).

Depression and major depressive disorder (MDD)

Depression is a common reaction following sexual assault. When depression continues for several weeks or more and causes distress or impairment, it may be a sign of major depressive disorder (MDD). Symptoms of MDD can include depressed mood, an inability to enjoy things (anhedonia), changes in sleeping or eating patterns, problems with concentration and decision making, feelings of guilt or worthlessness, and suicidal thoughts or behavior (36).

Suicidal thoughts and behavior

Research suggests that compared to the general population and to survivors of other traumas, survivors of sexual assault are at higher risk for suicidal ideation, suicide attempts and completed suicide (37). Risk for suicide may be heightened for survivors of multiple lifetime traumatic events and those who also have symptoms of depression, PTSD or substance use disorders (38).

Shame and guilt

Emotions like shame and guilt may follow sexual assault and some survivors blame themselves for being assaulted. This self-blame may relate in part to stereotyped sex-specific expectations; for example, women may blame themselves for not taking more caution, for drinking around others or for dressing in a certain manner, whereas men may feel guilty for physical and behavioral responses during the assault (10,39). Survivors who blame themselves may have more difficulty recovering following sexual assault, and unfortunately, survivors are sometimes blamed intentionally or unintentionally by others, which can intensify shame and guilt and further interfere with recovery (30,32).

Anger

Many survivors report struggling with anger after a sexual assault. They may experience anger when thinking about the assault, but they may also experience anger when they feel vulnerable, unheard or taken advantage of. Men who experience sexual assault may be particularly likely to struggle with anger (40). Although anger is a natural and understandable reaction to being hurt, prolonged intense anger or anger that is acted out with aggression can interfere with the recovery process and further disrupt survivors' lives.

Sexual functioning concerns

Sexual functioning concerns are experienced by many survivors of sexual assault and can cause anxiety, shame and relationship distress. Some survivors may avoid sexual activity and intimacy as an attempt to cope with the fear, anxiety or traumatic memories such activity elicits. Women survivors may experience a decrease in sexual interest and desire and an increase in physical pain and discomfort during consensual sexual activity with a partner (41,42). Some women increase sexual activity following sexual assault, possibly related to attempts to numb distressing feelings related to the assault (43). Men may question their sexual orientation or their sense of self as a man following sexual assault. They may struggle with sexual functioning or avoid sexual intimacy, or conversely, may engage in compulsive sexual behaviors as a way to cope or reaffirm their sense of "manhood" (3,25,44).

Social difficulties

Survivors may also experience difficulties in romantic relationships, friendships and social interactions (3). This may be due to shame, anxiety or depression, which can result in avoidance of social activities. It can also be related to understandable difficulties with trusting others following the interpersonal violation of assault. Performance at work and school can also be affected. Disruptions in relationships can worsen other problems such as depression and negatively impact recovery.

Use of alcohol and other substances

Survivors may use alcohol and other substances to try to cope with, numb or escape symptoms and memories related to sexual assault (3). For some, this may lead to the development of substance use disorders, characterized by dependence or impairment in health and functioning due to substance use (36). Although alcohol and other substances can provide temporary relief, they often cause long-term problems for survivors' functioning and well-being (45).

Physical health difficulties

Finally, the experience of sexual assault appears to be associated with various physical health difficulties. Survivors may experience physical injuries during an assault, and some are exposed to sexually transmitted infections at the time (3). When compared to individuals who have not experienced sexual assault, survivors appear to have poorer perceptions of their own health. They may also be at greater risk for physical symptoms that can be related to chronic stress and pain as well as chronic health conditions like diabetes, heart disease, hypertension, pulmonary disease, and liver disease (2,8,46,47). Women who experience sexual assault are at higher risk for gynecologic and reproductive problems, as well as difficulties with eating and weight. Men may be at higher risk for HIV, possibly related to risk taking behaviors following assault (2,46). Survivors' difficulties may first come to the attention of their medical providers, which highlights the importance of screening and trauma-sensitive treatment practices in medical settings.

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What can professionals do to help?

Unfortunately, sexual assault is prevalent in our society today. However, survivors of sexual assault do not have to suffer alone or in silence. There are things that all professionals who assist or interact with survivors of sexual assault can do to help.

Provider self-awareness and sensitivity

Professionals can be sensitive to the impact of sex-based stereotypes on sexual assault survivors and to myths related to sexual assault. They can strive to be self-aware of any biases related to these and mindful not to inadvertently apply them to the survivors they are assisting. It is crucial that providers respond to disclosures of sexual assault by all individuals in a supportive manner, which includes:

• Listening to the survivor.
• Validating their experience and emotional response.
• Providing appropriate resources and referrals.
• Reinforcing for the survivor that sexual assault was not their fault.

Reactions such as blaming or questioning the survivor about their actions, treating the survivor differently (for example, as if they are damaged in some way), attempting to control the survivor's actions (for example, forcing them to report the assault) or focusing on one's own feelings or experiences rather than the survivor's feelings and needs should be carefully avoided, as such negative responses can push a survivor away from needed care and further impede recovery (32).

Assessment considerations

Health care providers are encouraged to ask all of their patients, in a sensitive manner, if they have experienced a trauma such as sexual assault. For example, providers might ask, "I ask all my patients, have you ever experienced sexual contact against your will or when you were unable to say no (for example, after being forced or threatened or to avoid other consequences)?" If a patient responds, "yes," a provider is encouraged to offer empathy and ask about how the patient's experience might impact their treatment needs and preferences for care.

Trauma-informed care

Since patient trauma histories are often unknown, best practices for providers are to apply principles of trauma-informed care with all patients. Such an approach includes:

• Decreasing power differentials between provider and patient.
• Providing choices to the survivor whenever possible - for example, what name to be called, where to sit in the room, when to meet, and what interventions to use.
• Being open in providing information to the patient about the exam, recommendations and resources; explaining any procedures or exams before initiating them.
• Phrasing requests in a way that is asking rather than ordering.
• Prioritizing the survivor's privacy and confidentiality.
• Incorporating the survivors' strengths into care - for example, asking a survivor what helps them cope in the moment if they are distressed, recognizing positive gains in health-related behaviors and recognizing the patient's resilience to survive a trauma such as sexual assault.

Treatment considerations

Evidence-based treatments for PTSD can give sexual assault survivors diagnosed with PTSD the best chance of recovery. Trained professionals can provide these treatments effectively and in a sensitive manner to all survivors. There are evidence-based treatments for specific conditions that may be associated with sexual assault. For example, first-line psychotherapies for PTSD have been proven to reduce PTSD symptoms in individuals who experienced sexual assault.

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