Sexual assault victimization and suicidal behavior in women: a review of the literature
Introduction
Suicidal behavior is an increasing problem in contemporary American society. Although women do not commit suicide as frequently as men, it is well established that women engage in higher rates of nonfatal suicidal behavior (e.g., suicide attempts) than men (see Brockington, 2001, Canetto & Lester, 1995 for reviews). For example, in 1999, females made three suicide attempts for each attempt made by males (American Association of Suicidology, 2001). In the National Comorbidity Survey (NCS) conducted in 1990–1992, 4.6% of U.S. adults made a lifetime suicide attempt, two thirds of which were made by women (Borges, Walters, & Kessler, 2000). A recent national telephone survey of U.S. adults showed that 5.6% of females reported suicidal ideation in the past year and 2.5% reported a specific plan to attempt suicide, with no sex difference in past-year suicide attempts (Crosby, Cheltenham, & Sacks, 1999). Recent data on adolescent women show similar patterns. National data show that 1 in 10 adolescent girls are estimated to attempt suicide in their lifetime as compared with 1 in 25 adolescent boys (Lewinsohn, Rohde, & Seeley, 1996). In addition, the 1995 National College Health Risk Behavior Survey showed that college women were much more likely to attempt suicide in the past year than college men, but there were no gender differences in past-year suicide ideation (Brener, Hassan, & Barrios, 1999).
Sexual victimization is common in all stages of women's lives, with 20–30% of women having histories of sexual abuse or assault in childhood and/or adulthood McCloskey, 1997, Russell & Bolen, 2000. Sexual revictimization is also common with one third of child sexual abuse (CSA) victims reporting repeated victimization (Arata, 2002). Many women with a history of sexual assault have significant psychological and physical health sequelae, including PTSD, depression, sexual problems, physical health problems, and increased healthcare utilization (see Golding, 1999, Resick, 1993 for reviews). Several studies have shown that sexual assault history consistently differentiates those women engaging in suicidal behavior from those who do not. Most research using representative samples has not examined correlates of suicidal behavior in women separately or within sexually victimized women specifically. Research is needed on how different types of sexual assault histories (e.g., childhood, adulthood, multiple assaults) and various psychosocial factors relate to risk of suicidal behavior within sexually victimized women identified from the general population.
To better understand the role of sexual assault in women's suicidal behavior, the literature is reviewed in this area, gaps are identified in our knowledge base, and suggestions are offered for a future agenda of research and intervention targeting sexual assault as one potent risk factor that may be key in explaining this outcome. Finally, an explicitly “gendered” approach is needed given the gender paradox (Canetto and Sakinofsky, 1998) in suicidal behavior (e.g., more completed suicide in men and more attempted suicide in women) and the different cultural meanings of suicidal behavior in males and females Canetto, 1995, Canetto, 1997. This is particularly important in light of shifting gender-role norms, which may now be less protective of females than in the past. Specifically, gender differences in rates of suicide and lethality of methods used (e.g., males have higher rates and use more lethal methods) may be shifting. In general, the traditionally greater acceptance and encouragement of violence and aggression in males compared with females may be changing as men's and women's roles in the United States have become more similar in recent years. Young women appear to be engaging in more violent behavior now than in the past (Lamb, 2002), which may lead to more violence towards others and towards themselves in the form of more serious suicide attempts. This may lead to an increase in completed suicides by females and a decrease in the gender gap in suicides, especially for teens, for whom suicide is the third leading cause of death (American Association of Suicidology, 2001).
In a recent review on suicide and women worldwide, Brockington (2001) reported that various studies have shown a link of rape, sexual abuse, and domestic violence to suicide attempts, yet evidence on completed suicide was lacking. Fondacaro and Butler (1995) reviewed research studies on the link of CSA and suicidal behavior (e.g., suicide attempts) in adult women and found mixed results, with most studies showing more suicidal ideation in adult CSA survivors in both nonclinical samples (Sedney & Brooks, 1984) and clinical samples Briere & Runtz, 1986, Briere & Zaidi, 1989 than in nonvictimized women. However, some studies showed more suicidal behavior in adult CSA survivors compared with nonvictims Briere & Runtz, 1986, Briere & Runtz, 1988, Briere & Zaidi, 1989, whereas other studies did not show this difference Briere & Zaidi, 1989, Herman, 1981, Sedney & Brooks, 1984. The authors concluded that the relationship of CSA with suicidal behavior is unclear, but that other possibly important third variables, such as comorbid child physical abuse, family dysfunction, depression, and effects of CSA disclosure have often not been controlled. They also asserted that certain types of CSA, such as intrafamilial CSA, appear to be related to suicidal behavior Edwall et al., 1989, Wozencraft et al., 1991. Santa Mina and Gallop (1998) also reviewed clinical studies of child abuse and suicidal behavior from 1988 to 1998 and found evidence that adults reporting sexual or physical abuse in childhood report more self-harm, suicidal ideation, and suicidal behavior than those without a childhood victimization history. Adult rape was not included in their review, nor were studies of adolescents under age 16. They also concluded that the link of childhood trauma and adult self-harm or suicide is strongest when abuse was of long duration, by known perpetrators, and involved force and penetration.
Section snippets
Present review
This article reviews studies of general population samples and nonprobability samples (e.g., college students, clinical/hospital patients) to evaluate whether findings are consistent across sample types and to determine what differences may exist in associations of sexual assault and suicidal behavior in different segments of the female adolescent and adult population. Studies were identified from PsychInfo and Medline databases through June 2002 using key words “sexual assault” and “sexual
Adult samples
A number of research studies show that a history of sexual assault is associated with both suicidal ideation and suicide attempts in the adult general population Burnam et al., 1988, Davidson et al., 1996, Kilpatrick et al., 1985. Specifically, two general population studies reported an association of adult sexual assault victimization with both suicidal ideation and attempts Burnam et al., 1988, Kilpatrick et al., 1985. These studies used single-item measures of sexual assault and both
Nonprobability sample studies
Recently, several nonprobability sample studies have also linked sexual victimization to risk of suicidal behavior in women. Sexual victimization has been shown to relate to suicidal behavior in women recruited from hospitals, treatment program participants, female college students, as well as psychiatric outpatients, inpatients, homeless/runaway youth, alcoholics, psychiatric/drug abuse patients, and juvenile delinquents. First, I review samples of medical patients and psychiatric/drug abuse
Pathways from sexual assault to suicidal behavior: mediators and moderators
Most studies have not yet examined multiple risk factors or pathways through which sexual victimization affects the development of suicidal behavior in women specifically. Few have been longitudinal in nature or theoretically based, which are important limitations to much of the available research in this area. Such studies are crucial, however, for evaluating the ways in which early victimization relates to development of suicidal behavior in women. For instance, there is a strong association
Implications and directions for future research
Both childhood and adulthood histories of sexual victimization are clear risk factors for suicide attempts especially among women (Davidson et al., 1996), and therefore should be targets of intervention and treatment for suicide prevention programs. Psychopathology measures including alcohol-dependence symptoms, PTSD, and depression were also significantly associated with suicidal behavior in our research (Ullman & Brecklin, 2002) as in past research Grant & Hasin, 1999, Thompson et al., 2000
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2019, Personality and Individual DifferencesCitation Excerpt :Thus, it is not surprising that researchers have been interested in trying to identify factors that predict self-destructive behaviors in women. One distinct factor that has been found to be consistently involved in accounting for self-destructive behavior has been the presence of sexual assault history (e.g., Chang, Batra, Premkumar, Chang, & Hirsch, in press; Tomasula, Anderson, Littleton, & Riley-Tillman, 2012; Ullman, 2004; Ullman & Najdowski, 2009). For example, in a recent study, adolescent girls who reported a history of sexual assault, compared to those who reported no history of sexual assault, were found to be more likely to report engaging in NSSI behaviors (Tatnell, Hasking, Newman, Taffe, & Martin, 2017).
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