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1 Gender and Time Differences in the Associations Between Sexual Violence Victimization, Health Outcomes, and Risk Behaviors American Journal of Men s Health Volume 2 Number 3 September Sage Publications / hosted at Ekta Choudhary, MS, MPH, Jeffrey H. Coben, MD, and Robert M. Bossarte, PhD An estimated 1 out of 6 women and 1 out of 33 men has been a victim of sexual assault at some point in their lifetime. The objective of this study was to quantify the associations between sexual assault and negative health outcomes among males and females who reported being sexually assaulted in the past 12 months or at some point before the past 12 months. Data were obtained from the 2005 Behavioral Risk Factor Surveillance System core and sexual violence modules. A series of logistic regression models, including all respondents and stratified by gender, was used to identify differences associated with victimization. Among women, victimization before the past 12 months was significantly associated with poor health status, poor mental health, lower life satisfaction, activity limitations, smoking, and binge drinking. Women who reported victimization in the past 12 months were also significantly more likely to report poor mental health, lower life satisfaction, activity limitations, and binge drinking. Among males, significant associations were found with smoking (past 12 months), poor life satisfaction (before the past 12 months) and activity limitations (before the past 12 months). Results of this study suggest that poor mental and physical health associated with victimization are more prevalent in women and that these relationships persist over time. The broad range of outcomes associated with victimization suggests that further research is needed to better understand the consequences associated with sexual violence across the lifespan. Keywords: sexual assault; sexual violence; gender differences; health outcomes An estimated 18% of women and 3% of men have been victims of forced sexual intercourse at some point in their lifetime (Tjaden & Thoennes, 2006). A comprehensive review of previous studies on sexual assault reported that an estimated 15% to 25% of females in the general population have experienced some form of sexual abuse (Leserman, 2005). Comparatively few studies have provided extensive information on male sexual From the Department of Community Medicine, West Virginia University (EC, JHC, RMB); the Department of Emergency Medicine, West Virginia University (JHC); and the Injury Control Research Center, West Virginia University (JHC, RMB). Address correspondence to: Robert M. Bossarte, PhD, PO Box 9151, Injury Control Research Center, West Virginia University, Morgantown, WV 26506; rbossarte@hsc.wvu.edu. victimization among the general population; however, some studies have suggested that sexual assault against males may be more prevalent than previously thought (Rentoul & Appleboom, 1997). It is believed that sexual assault is seriously underreported among adult males (King & Woollett, 1997). Underreporting by men is believed to be the result of socially constructed and reinforced beliefs about masculinity and sexual orientation (Davis, 2002; Ellis, 2002; Rentoul & Appleboom, 1997). The normative patterns and assumptions associated with the social construction of gender result in a paradigm of masculinity that may be challenged by male sexual victimization (Davis, 2002). Therefore, the study of gender differences in outcomes associated with sexual violence victimization is crucial to understanding the intersections of gender and health (Davis, 2002; Ellis, 254

2 Sexual Violence Victimization, Health Outcomes, and Risk Behaviors / Choudhary et al ; Faravelli et al., 2004; King & Woollett, 1997; Leserman, 2005; Rentoul & Appleboom, 1997). Although studied less often, the prevalence and consequences of male sexual violence victimization may differ significantly when compared to similar health outcomes and risk behaviors among women (Leserman, 2005; Rentoul & Appleboom, 1997). Existing comparisons of the consequences of sexual assault have reported that males are more likely to report externalizing behaviors (e.g., substance use) and females are more likely to report internalizing behaviors (e.g., depression) following victimization (Faravelli et al., 2004; Koss, 1993). Sexual violence victimization has been associated with a broad range of health and risk behaviors, which may improve over time, including posttraumatic stress disorder, depression, eating disorders, substance use, smoking, and poor self-rated health (Coker et al., 2002; Faravelli et al., 2004; Koss, 1993; Koss, Koss, & Woodruff, 1991; Leserman, 2005). The high prevalence of sexual violence against both women and men suggests that there is a need to better understand the relationships between sexual violence and sequelae of psychological and physical conditions associated with victimization. The objective of this study was to compare the associations between sexual assault victimization, negative physical and mental health outcomes, and risk behaviors among male and female victims of sexual violence using data from a recently added sexual violence Behavioral Risk Factor Surveillance System module. Data and Methods Data for this project were obtained from the 2005 Behavioral Risk Factor Surveillance System (BRFSS) survey, an on-going data collection program conducted by state health departments, designed to measure risk factors in the U.S. adult population. Detailed information about the questionnaire and data collection process can be obtained from the BRFSS web site ( The questionnaire has three parts including a core component used by all states, topic-specific optional modules, and state-added questions. This study uses data from the core questionnaire and optional sexual violence modules collected as part of the annual BRFSS survey. In 2005, the sexual violence optional module was implemented by 20 states including Puerto Rico and the U.S. Virgin Islands. The overall response rate among participating states ranged from 29.6 % to 67.6% (Centers for Disease Control and Prevention, 2006). Two mutually exclusive outcomes were constructed. These included being forced to have sexual intercourse at any point in the respondent s lifetime or in the 12 months prior to data collection. Recent victimization was identified using the question, In the past 12 months, has anyone had sex with you after you said or showed that you didn t want to or without your consent? Victimization before the past 12 months was identified using the question, Has anyone ever had sex with you after you said or showed that you didn t want them to or without your consent? This question was not asked of respondents reporting victimization in the past 12 months. Measures included as covariates in the stratified models were self-reported health status (poor or fair); number of days of poor mental health in the past 30 days (including stress, depression, and problems with emotions); overall life satisfaction (dissatisfied or very dissatisfied); activity limitations due to physical, mental, or emotional health problems; current everyday smoking; and heavy episodic drinking (5 or more drinks at one occasion) in the past 30 days. All models controlled for potential confounding variables, which included age, gender, marital status, race/ethnicity, income, and education. Age was divided into six categories (18-24, 25-34, 35-44, 45-54, 55-64, and 65+). All participants were divided into four main race/ethnicity categories including White, African American, Hispanic, and Other. Marital status was controlled for using married, unmarried, and divorced or separated categories. Educational attainment was dichotomized into attended high school or less and more than high school education. Annual household income groups were divided into less than $25,000, $25,000- $50,000, and above $50,000 categories. Stratified multivariate logistic regression models were conducted to test the associations between victimization independent of other health and risk behaviors. Logistic regression analyses provide odds ratios, which compare the victimization groups to the nonvictimized reference groups. The Chi-Square Test of Homogeneity was used to identify significant differences between frequencies. All regression models were conducted using SAS (Ver. 9.1) and SUDAAN (Ver. 9.01).

3 256 American Journal of Men s Health / Vol. 2, No. 3, September 2008 Results In 2005, a total of 92,357 respondents participated in the sexual violence module. The majority of the participants were White (73.08%), between the ages of 35 and 44 years (19.98%), married (64.39%), and had an education level greater than high school (59.95%). Lifetime sexual violence victimization (victimization in the past 12 months and before the past 12 months) was significantly higher (χ 2 = , p <.0001) among females (n = 6,235, 10.69%) than males (n = 664, 1.81%). Among those who reported sexual violence victimization, 378 reported that the victimization was in the past 12 months, including 87 males (26.10%) and 291 females (73.90%). An additional 6,521 participants reported victimization before the past 12 months, including 577 males (13.03%) and 5,944 (86.97%) females. The associations between sexual violence victimization and negative physical and mental health and risk behaviors among males and females are shown in Table 1. The reference groups for these associations were male or female participants who reported no victimization. Participants who reported victimization within the past year of data collection reported significant associations between poor mental health, poor life satisfaction, smoking, and episodic drinking and victimization. All four health outcomes and two risk behavior variables were significantly associated with victimization before the past 12 months. When compared to women who reported no victimization, women who reported victimization within the past 12 months or before the past year were significantly more likely to report poor mental health, lower life satisfaction, activity limitations, smoking (before past 12 months only), and episodic drinking. Among males, only smoking (past 12 months), poor life satisfaction (before past 12 months), and activity limitations (before past 12 months) were significantly associated with victimization. The prevalence (weighted percentages) of adverse health outcomes and risk behaviors among sexual violence victims by gender and time of victimization was also examined (see Table 2). The weighted frequencies were compared within and across the time periods of victimization (past 12 months vs. before past 12 months) and also by gender (males vs. females). When compared, the prevalence of health outcomes and risk behaviors across two categories of victimization (past 12 months vs. before past 12 months) among all victimized respondents (total), significant differences were observed in poor mental health (χ 2 = 10.62), poor life satisfaction (χ 2 = 7.40), smoking (χ 2 = 16.50), and episodic drinking (χ 2 = 13.94) variables. Comparing those who were victimized within the past 12 months to those who were victimized at some point prior to the past year, there were significant differences in the percentage of female respondents reporting poor mental health ( a week - χ 2 = 19.52), poor life satisfaction (χ 2 = 6.53), smoking (χ 2 = 8.95), and binge drinking (χ 2 = 9.82). There were also significant differences in the percentage of males reporting everyday smoking (χ 2 = 7.99). Discussion The prevalence of sexual violence among males (1.81%) and females (10.69%) reported in this study is lower than previous estimates of sexual violence victimization (Leserman, 2005; Tjaden & Thoennes, 2006). The reason for this lack of consistency is unclear but may result from differences in question wording (Leserman, 2005). Nevertheless, our findings illustrate the pervasiveness of this public health problem. The results of this study also suggest that victimization is associated with a broad range of health outcomes and risk behaviors, and identify important gender and time differences in health outcomes and risk behaviors. Sexual victimization was associated with a variety of adverse health consequences and high-risk behaviors. Those who were victimized were more likely to abuse tobacco and alcohol and to report poor overall health, poor mental health, and subsequent activity limitations resulting from poor health status. These findings lend additional support to the notion that adverse life experiences, including sexual assault, may substantially contribute to long-term health outcomes (Felitti et al., 1998). Consistent with results from previous studies, our project identified important gender differences in the associations between health outcomes and sexual violence victimization (King & Woollett, 1997; Walker, Archer, & Davies, 2005). Among all respondents reporting victimization, victimization in the past 12 months was significantly associated with five health outcomes and risk behaviors, whereas less recent victimization (before past 12 months) was

4 Sexual Violence Victimization, Health Outcomes, and Risk Behaviors / Choudhary et al. 257 Table 1. Associations Between Sexual Violence Victimization, Health Outcomes, and Risk Behaviors Past 12 Months OR Adj (95% CI) Before Past 12 Months OR Adj (95% CI) Variables Total Male Female Total Male Female General health status Poor/Fair *** *** (0.86, 4.89) (0.43, 11.06) (0.86, 5.55) (1.77, 2.65) (0.95, 4.53) (1.80, 2.68) Good Number of days with < a week *** *** poor mental health (0.79, 2.78) (0.44, 3.38) (0.76, 3.64) (1.47, 1.92) (0.62, 1.71) (1.62, 2.10) a week 3.92*** *** 2.49*** *** (2.12, 7.25) (0.37, 4.47) (2.85, 11.85) (2.18, 2.84) (0.96, 2.44) (2.35, 3.05) None Poor life satisfaction Yes No 3.46*** *** 2.60*** 2.59 *** 2.61 * ** (2.07, 5.78) (0.77, 6.84) (2.37, 6.99) (2.20, 3.07) (1.65, 4.09) (2.18, 3.11) Activity limitations due Yes 2.06* * 2.73** 1.82 ** 2.91 *** to physical, mental, or (1.18, 3.61) (0.34, 2.20) (1.40, 4.89) (2.43, 3.03) (1.29, 2.57) (2.58, 3.28) emotional problems No Everyday smoking Yes 2.39* 4.31* * * (1.32, 4.33) (1.41, 13.19) (0.93, 3.62) (1.00, 1.34) (0.62, 1.50) (1.03, 1.39) No Episodic drinking Yes 3.00*** *** 1.26* ** ( 5 drinks at (1.78, 5.07) (0.75, 3.81) (2.01, 6.16) (1.04, 1.52) (0.55, 1.40) (1.16, 1.69) one occasion) No Note: OR Adj = adjusted odds ratio; that is, adjusted for gender, age, race/ethnicity, marital status, education, and income level; CI = confidence interval. *Statistically significant at p value.05. **Statistically significant at p value.001. ***Statistically significant at p value significantly associated with all six. Only two health outcomes and risk behaviors were significantly associated with victimization among males. Importantly, the only statistically significant multivariate association between substance use and sexual violence victimization among males in our study was an increased likelihood of smoking among those who had been victims of sexual violence in the past 12 months. In contrast, the associations between sexual violence victimization experienced in the past 12 months and before the past 12 months and two risk behaviors (heavy episodic drinking and smoking) were statistically significant among females. However, the relatively smaller sample sizes of males and those victimized in the past 12 months precludes any definitive conclusions. The identified gender differences support findings from previous research that have reported an increased likelihood of externalizing behaviors (i.e., heavy episodic drinking and smoking) among men and internalizing behaviors (i.e., depression, low self-esteem) among women who have been victims of sexual assault (Faravelli et al., 2004; Koss, 1993). However, unlike past research, we also observed strong associations between measures of externalizing behaviors (smoking and heavy episodic drinking) and sexual victimization among females. The study is subject to several limitations. All analyses are based on self-reports and therefore may underestimate the prevalence of victimization. The use of mutually exclusive categories prohibits consideration of repeat victimization, which may be associated with more severe consequences (Messman- Moore, Brown, & Koelsch, 2005; Santiago, McCall- Perez, Gorcey, & Beigel, 1985). Also, differences in question wording may affect the validity of direct comparisons with results from previous studies.

5 258 American Journal of Men s Health / Vol. 2, No. 3, September 2008 Table 2. Prevalence of Health Outcomes, Risk Behaviors by Time of Victimization, and Gender Past 12 Months Wtd % (95% CI) Before Past 12 Months Wtd % (95% CI) Variables Total Male Female Total Male Female General health status Poor/Fair (4.11, 14.23) (2.55, 34.91) (3.55, 12.89) (7.39, 9.76) ( ) ( ) Number of days with < a week poor mental health a,b,c (12.84, 27.30) (9.26, 35.02) (11.85, 29.20) (24.10, 28.13) ( ) ( ) a week (41.27, 61.28) (11.14, 43.75) (49.54, 71.32) (29.76, 34.06) ( ) ( ) Life satisfaction c No (17.89, 33.68) (10.25, 42.52) (17.87, 35.80) (12.37, 15.48) ( ) ( ) Activity limitations due Yes to physical, mental, or (22.68, 40.08) (8.04, 33.75) (25.71, 46.48) (33.60, 37.94) ( ) ( ) emotional problems a,b Everyday smoking a,b,c,d Yes (70.13, 89.36) (73.50, 96.62) (63.22, 87.85) (54.03, 59.84) ( ) ( ) Episodic drinking Yes ( 5 drinks at (42.83, 66.12) (36.38, 74.91) (39.47, 67.83) (21.39, 28.04) ( ) ( ) one occasion) b,c Note: Wtd% = weighted percentage; CI = confidence interval. a. Differences between males and females are statistically significant in Past 12 Months: p value = < 0.05 b. Differences between males and females are statistically significant in Before Past 12 Months: p value = < 0.05 c. Differences between two time periods of victimization are statistically significant among total and females: p values <.001. d. Differences between two time periods of victimization are statistically significant among males: p values <.001. Finally, analyses are based on cross-sectional data and cannot determine causality. Despite these limitations, this study provides important information about the associations between adverse health outcomes and risk behaviors among male and female victims of sexual violence. Based on the pattern of negative physical and mental health outcomes among males and females across two time periods of victimization, prevention specialists and those working with victims and their families should consider the possibility that negative consequences associated with victimization may differ according to individual characteristics such as gender and time of victimization (Koss, 1993). Future analyses should include a broader range of behaviors, such as involvement in interpersonal violence and longitudinal studies of health outcomes, to identify important correlates of victimization (Rentoul & Appleboom, 1997). Acknowledgments This research is supported by 5 R49 CE from the National Center for Injury Prevention and Control, Centers for Disease Control and Prevention. The findings and conclusions in this report are those of the authors and do not necessarily represent the views of the Centers for Disease Control and Prevention. References Centers for Disease Control and Prevention. (2006). BRFSS data quality and technical report. Retrieved Sept. 19, 2007 from: quality.htm Coker, A. L., Davis, K. E., Arias, I., Desai, S., Sanderson, M., Brandt, H. M., et al. (2002). Physical and mental health effects of intimate partner violence for men and women. American Journal of Preventive Medicine, 23(4), Davis, M. (2002). Male sexual assault victims: A selective review of the literature and implications for support services. Aggressive and Violent Behavior, 7, Ellis, C. D. (2002). Male rape The silent victims. Collegian, 9(4), Faravelli, C., Giugni, A., Salvatori, S., & Ricca, V. (2004). Psychopathology after rape. American Journal of Psychiatry, 161(8), Felitti, V. J., Anda, R. F., Nordenberg, D., Williamson, D. F., Spitz, A. M., Edwards, V., et al. (1998). Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults. The Adverse Childhood

6 Sexual Violence Victimization, Health Outcomes, and Risk Behaviors / Choudhary et al. 259 Experiences (ACE) Study. American Journal of Preventive Medicine, 14(4), King, M., & Woollett, E. (1997). Sexually assaulted males: 115 men consulting a counseling service. Archives of Sexual Behavior, 26(6), Koss, M. P. (1993). Rape. Scope, impact, interventions, and public policy responses. American Psychologist, 48(10), Koss, M. P., Koss, P. G., & Woodruff, W. J. (1991). Deleterious effects of criminal victimization on women s health and medical utilization. Archives of Internal Medicine, 151(2), Leserman, J. (2005). Sexual abuse history: Prevalence, health effects, mediators, and psychological treatment. Psychosomatic Medicine, 67(6), Messman-Moore, T. L., Brown, A. L., & Koelsch, L. E. (2005). Posttraumatic symptoms and self-dysfunction as consequences and predictors of sexual revictimization. Journal of Traumatic Stress, 18(3), Rentoul, L., & Appleboom, N. (1997). Understanding the psychological impact of rape and serious sexual assault of men: A literature review. Journal of Psychiatric and Mental Health Nursing, 4(4), Santiago, J. M., McCall-Perez, F., Gorcey, M., & Beigel, A. (1985). Long-term psychological effects of rape in 35 rape victims. American Journal of Psychiatry, 142(11), Tjaden, P., & Thoennes, N. (2006). Extent, nature, and consequences of rape victimization: Findings from the National Violence Against Women Survey (No. NCJ ). Washington, DC: U.S. Department of Justice, National Institute of Justice. Walker, J., Archer, J., & Davies, M. (2005). Effects of rape on men: A descriptive analysis. Archives of Sexual Behavior, 34(1),

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