Most victims of childhood sexual abuse experience some degree of PTSD. Multiple victimizations are a major contributing factor to PTSD in childhood sexual abuse (Jasinski et al., 2000 and Polusny and Follette, 1995). PTSD is intensified when it is combined with increasing exposure to trauma, including adult sexual assault.

It is well documented that the cycle of violence generally begins in the home. Parents suffering from childhood victimization often victimize their children directly or indirectly (fail to provide a safe environment) (Hall, Sachs, & Rayens, 1998). One prospective study showed that 12% of male children sexually abused as children became pedophiles as adults. Adult abusers versus those who did not go on to abuse were more likely to have been abused by females (38% versus 17%), to witness physical abuse (81% versus 58%), to have lacked age-appropriate supervision (67% versus 40%), and to have demonstrated cruelty to animals (29% versus 5%) (Salter, McMillian, Richards, et al., 2003). Another study of men with increased risky behavior revealed that 25% had unwanted sexual activity before age 13 (Dilorio, Hartwell, & Hansen, 2002).

Previous childhood sexual trauma may interrupt the development of self-representation, contribute to the loss of self or fragmentation of self, increase concerns regarding control issues, disrupt identity issues, disrupt body-image evolution, and lower self-esteem (Hanna, 1996 and Putnam, 1989). Sexual trauma is compounded if the individual is a member of a stigmatized group and is further subjected to acts of discrimination or oppression. “Stigma trauma,” coined by Fullilove (1992), is often experienced by women of color in the form of gender oppression and ethnicity. Similarly, gay males may experience stigma trauma in the form of sexual orientation prejudices and bias hate crimes.

Burgess and Holmstrom (1974) coined the expression rape trauma syndrome (RTS) when describing the acute and long-term problems related to sexual attacks in a group of 146 victims studied four to six years later. RTS is considered a specific type of PTSD pertaining solely to consequences of trauma related to sexual assault or childhood sexual abuse and is not gender specific. RTS is broken into the acute phase or disorganization phase, which is characterized by expressive or guarded interviews following the sexual assault. Problems experienced by victims are categorized into physical, emotional, social, or sexual reactions impacting both the acute and long-term process of reorganization.

The term “rape trauma syndrome” is a nursing diagnosis for implementing recovery strategies and is not used as a diagnostic category. RTS, however, more appropriately addresses the sequel related to sexual assault, especially as experienced by women. It separates PTSD trauma experienced as a result of war or natural disaster that often happens to groups or communities and rarely involves nonconsensual invasion of the body by another individual. A wealth of research related to PTSD in nonsexual violence populations exists, but a paucity of material exists on RTS.

Recovery from sexual violence and RTS varies from person to person. One 1992 study found 94% of victims during the first week following the sexual assault had PTSD. A 1993 study found 50% of women met the criteria for PTSD one year following sexual assault (Ledray, 1994). The 1992 National Victim Center report Rape in America: A Report to the Nation estimated that 1.3 million women are experiencing PTSD two years after the sexual assault and that more than twice that number of women experienced PTSD at some time following the sexual assault.

Not all individuals will suffer long-term RTS. Support systems and the social environment are key factors in recovery. How the sexual assault is perceived by the individual’s support system is also critical. If the sexual assault is viewed as an act of violence rather than a sexual act, recovery appears to be predictable with fewer long-term effects, provided that the individual possesses adequate coping mechanisms. Individuals who are exposed to stigma or ongoing environmental trauma appear to have increased long-term effects represented by RTS. Draucker and Madsen (1999) found that sexually abused children experienced not only the sexual assault but may have been further traumatized by feelings of being “banished, alienated, or exiled.” Sexually abused children also experienced deep-seated shame and the fear of feeling emotions producing guilt and anxiety (Zupancic & Kreidler, 1998). Individual coping mechanisms are dependent on the resolution of developmental issues and stages. Children who are victims of sexual abuse (either incest or molestation) appear to have more compromised coping mechanisms than adults of sexual abuse.

Women have twice the rate of PTSD as compared to men, especially if they were sexually abused as children (Brunnello et al., 2001, Katon, 2001 and Wise et al., 2001). A direct correlation between the severities of violence, the multiplicity of sexual abuse, and RTS also seems to exist (Jasinski, et al., 2000; Koss, Koss, & Woodruff, 1991; Ledray, 1990). Individuals with PTSD are 26 to 37 times more likely to develop affective illness, generalized anxiety disorder, or panic disorder (Katon, 2001).

Fear penetrates each of the categories in the acute phase and closely parallels the attack. Disturbances in sleep and eating patterns are two common occurrences caused by fear. The emotional reactions are seated in fear and phobic reactions and affect the ability to work, leave home, and relate to friends, family, and partners. Gratitude over surviving the attack is often clouded by the fear of being attacked again and possibly killed or mutilated (Hazelwood & Burgess, 1995; Koss et al., 1991). Similar to physical symptoms, emotional scars often go undetected because of poor history taking or the healthcare provider’s inability or inexperience in managing or responding to acts of violence.

RTS is expressed in a complex, entangled lifestyle when an individual lacks adequate coping skills or social or medical support, or is subject to ongoing trauma in his or her environment. As time goes on, the physical, emotional, social, and sexual categories impacted by the sexual attack become less segregated and more intertwined, making the exact nature of a particular problem less obvious. Comorbidities of RTS include chemical dependence (including injecting drug use and alcoholism) in 75% of veterans with PTSD (Kulka et al., 1990), in 43% of individuals with a diagnosis of PTSD (Breslau, Davis, Andreski, et al., 1991), and in increased levels among Hispanic women (Kaukinen & Demaris, 2005). Substance abuse, especially with alcohol, cigarettes, and cocaine, is common when victims desire to numb or cope with the pain of sexual trauma. Among various drug treatment programs, 46.4% of patients had a history of sexual assault as adults and 38.2% in childhood (El-Bassel et al., 2004 and North, 1996). In addition, 30.7% of women in a methadone maintenance treatment program (MMTP) had been sexually abused by a partner in the previous six months, and cocaine use increased this violence (El-Bassel et al., 2004). Another study found that 59% of substance abusers had symptoms consistent with PTSD, yet they were undiagnosed and at the time they were admitted for detoxification had not received any treatment (Fullilove et al., 1993). In this same study, 97% of women with PTSD reported one or more violent traumas compared to 73% of women without PTSD.

Women share a common history stating they were often revictimized in subsequent rapes or domestic violence scenarios (Coid et al., 2001, El-Bassel et al., 2004, Fullilove et al., 1992, Johnson et al., 2003, Schafer et al., 2004, Teets, 1997 and Wise et al., 2001). Women with a history of childhood sexual abuse may use substance abuse as one of the maladaptive coping mechanisms (Blume, 1998). Subsequent substance abuse following sexual assault or incest is more common in women than in men.

Heightened risk-taking behavior is well documented among substance-abusing populations, placing women at an increased risk for HIV infection and other STIs. Other STIs that are commonly transmitted include hepatitis, human papillomavirus (HPV), chlamydia infection, gonorrhea, and herpes. In one study, 15% of sexually abused women had one or more STIs, and 20% had a rape-related pregnancy (McFarlane et al., 2005). Another study of African-American women showed that having a history of a STI, including HIV, placed them at an increased risk for drug use, depression, and interpersonal violence (Johnson, et al., 2003). Bitterness toward past life experiences often pushes individuals with a history of sexual abuse toward risk-taking scenarios, including multiple partners, exchanging sex for money, unsafe sexual practices, unwanted pregnancies, and revictimization by intimates (Champion et al., 2001, Coid et al., 2001, El-Bassel et al., 2004, Fergusen et al., 1997, Gonzales et al., 1999, Johnson et al., 2003, Manfrin-Ledet and Porche, 2003, Pitzner et al., 2000, Resnick et al., 1997, Sowell et al., 2002, Springs and Friedrich, 1992, Wise et al., 2001 and Zierler et al., 1991).

Risky sexual behavior places individuals at increased risk for acquiring HIV infection. Although risk-taking behavior is composed of many variables, the one common thread through numerous studies was a history of childhood sexual abuse in both men and women. In populations infected with HIV, between 30% and 87% of individuals had a history of childhood sexual abuse as compared to similar populations not infected with HIV (Bedimo et al., 1997, Brady et al., 2002, Dilorio et al., 2002, El-Bassel et al., 2001, Fullilove et al., 1993, Gruskin et al., 2002, Johnson et al., 2003, Miller, 1999, Mullings et al, 2007, NIMH multisite HIV prevention trial, 2001, O’Leary et al., 2003, Stevens et al., 1995, Thompson et al., 1997, Wingood and DiClemente, 1997, Wyatt et al., 2002 and Zierler et al., 1991). One contributing factor may be the increased rates of substance abuse, placing women at risk for continued poverty, incarceration, poor employment skills, and marginalization. This constellation often leaves men and women to depend on exchanging sex for money, to submit to continued partner abuse, and to neglect using condoms.

One study examining predictors of partner violence compared both male-to-female and female-to-male scenarios among African American, Hispanic, and white couples. While there were cultural differences in all groups, physical abuse in childhood by parents, impulsivity, and alcohol abuse remained the most constant predictors for intimate partner violence (Schafer, et al., 2004).

Men and women with a history of sexual violence have a higher incidence of substance abuse compared to populations that do not share that history (Morrill et al., 2001 and Wingood and DiClemente, 1997). In a study of injecting drug users, 68% of the women and 19% of the men reported histories of sexual violence (Braitstein, Li, Tyndall, et al., 2003). Women were 4.25 times more likely to abuse substances if they had a history of sexual abuse compared with women who did not have a history of sexual abuse (Cohen, Deamont, Barkan, et al., 2000). Chaotic and marginalized minority communities may serve as persistent external oppression, providing risky sexual behavior symbolic value. Wallace et al. (1996) suggested harm-reduction community models that can build community networks and reduce sexual and substance abuse. (Wallace, Fullilove, & Flisher, 1996).

Leenerts (1999) described how abusive relationships influence self-care practices in low-income white women infected with HIV. Sexual abuse confuses self-images, damages a woman’s self-image, and breaks the spirit. In this study of the abused women, 58% used drugs. Disconnecting from self-care or health-promoting behavior was the emerging theme among women with a history of sexual abuse. Other studies have also found an association between poor self-esteem and competence among women who experienced violence including verbal abuse (Hebert and Bergeron, 2007 and Sowell et al., 1999). Using the model that evolved from Leenerts’s study (2003), forensic nurse examiners can build partnerships with victims to encourage self-care practices and build connections to self-care.

History of sexual abuse is even higher among incarcerated women, ranging from 55% to 73% (Browne et al., 1999, Dole, 1998, Harris et al., 2003, Leenerts, 2003 and Stevens et al., 1995). In these samples, childhood sexual abuse was reported in 30% to 59% of inmate cases. This rate reflects a significant difference from community-based studies of childhood sexual abuse reported at 18% (Finkelhor, 1994). Ethnicity and lower socioeconomic status may reflect some of the differences between incarcerated and community populations. An increased rate of suicide has been reported among women with PTSD (Lewis, 2006). Browne and colleagues (1999) reported that childhood physical or sexual victimization before age 18 appeared to predispose women to significantly more physical violence by intimates in adulthood. In this same sample, women who were molested before age 18 were twice as likely to report sexual assaults by nonintimates in their adult lives. From this study, the impact of interpersonal violence over time and generations is understood, as 82% of the women in this study had experienced “severe parental violence and/or childhood sexual abuse before reaching adulthood” (Browne et al., 1999). Browne postulated that the long-term effects of violence are the primary reasons contributing to incarceration with associations to other risk-taking behaviors, such as substance abuse and being in precarious situations.

The adoption of mandatory drug sentencing in 1987 by the U.S. Sentencing Commission was strengthened in 1996 and has resulted in increased rates of incarceration for women from 4% to 6%. Incarceration is a common consequence of substance abuse, accounting for 66% of women in federal penitentiaries and 33% of women in state prisons according to the Bureau of Justice Statistics in January 1998. These statistics have remained fairly consistent as of 2002 reports by the Department of Justice. This situation is further discussed in Chapter 38. In 2002 68% of persons jailed had used illegal drugs prior to arrest and 63% had participated in substance abuse or other programs. There have been increases in the number of persons incarcerated for arrests while using amphetamines and approximately 24% of incarcerated persons had alcohol-related crimes (DOJ, 2007). In 2005, the DOJ reported that 1,846,400 arrests were for substance abuse–related crimes.

The majority of women feel betrayed, often sparking rage, as the majority are sexually violated by someone known to them. This anger can be turned inward as well as outward. Many women on death row are there because they murdered their assailant in partner violence cases (Bureau of Justice, 2001; Greenfield et al., 1998 and Justice Works, 2003). Tom Mason and Dave Mercer described two repeating themes of female psychopaths: lifetime of abuse beginning in early childhood and revictimization by various institutions. PTSD with substantial Axis I and Axis II comorbidities has been documented in other works described in this chapter (Fischbach and Herbert, 1997, Heim et al., 2000, Katon, 2001 and Wise et al., 2001). Conversely, many more women return to abusive partners in the hope that their partner will change (Goss & DeJoseph, 1997).

Increased rates of depression and anxiety are frequently associated with sexual abuse. One study reported that 78% of women who had been physically or sexually abused had a mental illness (Leenerts, 2003). This illness can be expressed in substance abuse, as previously discussed, and in suicide and physical cutting. Childhood abuse (including sexual abuse) and household dysfunction have been highly correlated with suicide (Dube, Anda, Felitti, et al., 2001). In another study of triethnic adolescents, histories of sexual abuse, physical abuse, and environmental stresses were among five of the strong risk factors for suicide (Rew, Thomas, Horner, et al., 2001). Self-mutilation and self-injury are often cries for help from persons who have been sexually abused (Steighner, 2003).

Women sexually violated by strangers describe the devastating shifts in their relationships. Partners often feel helpless and at a loss to know what to do to support their partners. Two exceptional ABC broadcasts (“Partners of Rape,” Nightline, March 27, 2000; “Domestic Violence,” The Oprah Winfrey Show, September 25, 2002) presented couples searching for answers regarding sexual assault, trying to comprehend the process of violence and begin healing. Few of these marriages could survive the ordeal, and the majority of the couples interviewed were divorced.