This article will explore a range of psychological research investigating the factors that can contribute to one’s vulnerability and resilience to post-traumatic stress disorder (PTSD) after experiencing sexual trauma.
Trigger warning: Sexual trauma can be a distressing and uncomfortable topic; please consider this before reading.
Definition and Consequences of Sexual Trauma
Sexual trauma is defined as “one or multiple sexual violations that invoke significant distress”, and any lasting emotional, psychological or physical symptoms that result from this. This can result from rape, incest, molestation, physical assault or any kind of force or pressure into sexual activity.
The consequences of sexual trauma can manifest in a multitude of ways, and many are ‘normal’ reactions. One reason why some experience PTSD after sexual trauma while others do not is that they go on to experience a wide range of other mental health problems other than PTSD, such as depression or substance abuse; however, they can and often do occur co-morbidly. Further consequences might include difficulty trusting others and establishing intimate relationships. Because of the diverse nature of PTSD, it is important to use an integrative, person by situation interactional model when analysing vulnerability and resilience to the disorder.
The current criteria as provided in the Diagnostic and Statistical Manual of Mental Disorders (DSM V) for PTSD (adapted for the context of sexual trauma) are as follows:
A: Exposure to sexual trauma e.g. rape, sexual assault, incest, molestation…
B: Intrusion Symptoms e.g. repeated thoughts / memories of the assault, nightmares, flashbacks…
C: Persistent avoidance of thoughts, feelings and situations associated with the sexual trauma
D: Negative alterations in cognitions and mood that are associated with the traumatic event
E: Alterations in arousal and reactivity associated with the trauma e.g. difficulty sleeping or concentrating, jumpiness, irritability…
F: Persistence of symptoms for more than one month
G: Significant symptom-related distress or functional impairment that is not due to any other factor than the trauma itself
H: Symptoms not due to medication, substance misuse or illness
Prevalence of PTSD After Sexual Trauma
It can be difficult to determine the exact prevalence of PTSD after sexual trauma as many incidences go unreported. However, there is still a considerable amount of research suggesting that sexual trauma is the most likely to induce PTSD. Women are more likely to experience PTSD after sexual trauma than men, and this is not accounted for by differences in perceived threat to life or injury. However, many more women than men are subject to sexual violence – a figure that is likely influenced again by lesser disclosure on mens’ behalf. Reported rates of PTSD in rape victims vary from 30 to 65% depending on how and when symptoms are assessed.
History of Sexual Abuse
There is significant evidence that a history of childhood sexual abuse can be a contributing factor increasing an individual’s vulnerability to PTSD after a sexual traumatic event when they are adults. Sexual abuse in childhood can cause chronic genital pain, which can make sexual assault or contact in future more physically traumatic and is linked with PTSD symptoms. Those who are sexually abused in childhood are twice as likely to be assaulted as adults, so any consequences of childhood abuse such as feelings of guilt, lack of perceived control and low self-esteem that are very common in these cases can carry on into adulthood and predispose someone to experience PTSD after future sexual traumatic experiences. Therefore, those who are more resilient to PTSD are less likely to have experienced such events in childhood.
In a representative sample, 58% of women who had experienced PTSD named sexual assault to be the worst traumatic event they had experienced, suggesting that there is something specific to sexual trauma that makes people particularly susceptible to experiencing the disorder.
It might be that the personally intrusive nature of sexual trauma both during and after the assault could be a factor making one more vulnerable to experiencing PTSD. For instance, rape victims with PTSD are more likely to have been attacked by a stranger, where they experienced a threat to their physical and personal integrity, or were injured or subjected to substantial verbal and physical force. Further, aspects of the medical environment such as the use of invasive medical instruments can bring about or exacerbate distressing symptoms. However, even when event characteristics are controlled for, sexual trauma alone predicts unique variance in the risk of one developing PTSD, suggesting there are other factors at play.
Neurobiology of Trauma: HPA Axis Dysregulation
The hypothalamic-pituitary-adrenal (HPA) axis is involved in the control of stress responses, and its dysregulation is strongly implicated in the development of PTSD. This has been observed in survivors of sexual trauma. Cortisol (stress hormone) is a major facet in the HPA axis, released when stimulated by corticotropin releasing hormone (CRH) and inhibited via negative feedback acting at the hypothalamic and pituitary levels. Its dysregulation leads to inappropriate fear responses. Intense psychological trauma such as sexual abuse can disrupt this HPA axis by increasing levels of CRH. The following diagram illustrates this process in patients with and without PTSD:
Increased CRH = thick black line
Decreased adrenal release of cortisol = thin black line
Increased negative feedback inhibition of HPA axis by cortisol = thick red lines (diagram from Yehuda, Hoge, MacFarlane, Vermetten, Lanius, Nievergelt, Hobfoll, Koenen, Neylan & Hyman, 2015)
Depending on a particular variation of the FKBP5 gene involved in the HPA axis, one can either be genetically predisposed, or provided with more resilience to PTSD.
Based on twin and adoption studies, the heritability estimate for PTSD is 30 to 40%. This is linked with heritable neurobiological endophenotypes, such as lower hippocampal and prefrontal cortical volume and increased amygdala (fight-or-flight) activity, because dysregulation of the HPA axis can interact with other impairments of neurological functioning, such as in the hippocampus, which plays a critical role in emotional memories. This might explain PTSD intrusion symptoms like flashbacks and nightmares.
To turn to an earlier point on history of sexual abuse, women who were abused in childhood tend to have lower hippocampal volume, which when coupled with a dysregulated HPA axis, can result in poorer cognitive functioning, resulting in less effective coping strategies and thus a higher risk of PTSD symptoms.
Higher prefrontal cortex volume (associated with strategic thinking, will to live) is found in those who experience trauma but not PTSD. This is linked with high IQ, which is found to be the greatest factor for resilience to PTSD as it is associated with more effective coping mechanisms. On the other hand, maladaptive beliefs and attributional styles that a victim of sexual trauma might have when interpreting the assault can exacerbate feelings of powerlessness that can contribute to the manifestation of PTSD.
Attributing blame in a way that focuses on the past and believing that one is powerless in their recovery is also associated with poorer outcomes in PTSD. For instance, believing that the world is “completely dangerous”, that one is “entirely incompetent”, or that some entity had vicarious control over the event can lead to a sense of mental defeat. It is this state of mind that can lead to one becoming highly vulnerable to PTSD.
Social influences are critical in shaping outcomes resulting from sexual trauma. Lack of social support is highlighted as the most important risk factor in PTSD. If a victim of sexual trauma does not have a supportive network with whom they can disclose the abuse and make sense of what has happened to them in a secure and trusting relationship, they are much more likely to go on to experience PTSD.
After sexual trauma, many people can experience secondary victimisation, where negative or stigmatising reactions from others can lead to an increased risk of PTSD, as they might also blame themselves for what happened to them, or believe that the incident has permanently transformed them or their reputation. Some of these reactions are perpetuated by rape myths, such as the idea that people often lie about being raped or that men cannot be raped. This is why it is important for victims to turn to professionals or helplines specialising in sexual trauma.
Racial, Ethnic and Cultural Influences
Symptoms of PTSD are found across races, ethnicities and cultural groups. However, the ways in which trauma and PTSD symptoms, such as dissociative or somatic symptoms, are interpreted are culturally constructed and can have a profound influence over the extent to which an individual discloses their sexual traumatic experience. This in turn impacts the extent to which they are at risk of experiencing PTSD.
Sexual assault victims of ethnic minorities tend to report more negative social reactions from others. In a triethnic study, Hispanic rape victims were shown to be the most psychologically distressed by their traumatic experience, followed by Black and finally White victims. This might be in part due to the fact that Hispanic female victims tend to engage in more avoidance behaviours and feel more shame regarding sexual trauma. This latter point will be discussed further with regard to religion*.
Resilience to PTSD After Sexual Trauma
“[Resilience is] efficacious adaptation regardless of significant traumatic threats to personal and physical integrity” (Agaibi & Wilson, 2005)
Resilience and recovery can be defined in many ways; I took this definition from Agaibi and Wilson. However, resilience is multifaceted and includes many processes that evolve over time. In the event of sexual trauma, resilience is comprised of elements of the individual and their environment that can serve as protective factors. Post-traumatic growth is a term that refers to positive psychological changes that one can experience after a trauma. This is more effective for people with certain temperamental characteristics, such as extroversion and openness to experience.
All considered, it is important to remember that resilience is complex, and having these protective factors will not necessarily generate positive or adaptive responses to sexual traumatic experiences. What may be considered resilient in one context or in one individual may not be so in another.
Some important factors to recovery as reported by survivors of sexual trauma include:
– Disclosing the abuse
– Positive self-perception
– Religion or spirituality
– Community cohesiveness
– Self-efficacy (Read more)
– Having a creative outlet
– Developing prevention strategies
*Religion can be a double-edged sword in this case, because as much as it can be a source of comfort for some people, it can also be a source of guilt; for example in Catholicism, which might explain the aforementioned fact that Hispanic women feel a lot more shame and guilt following sexual abuse. In terms of prevention strategies, recent research highlights the benefit of empowerment self-defence – an intervention proven to reduce attempted assault by 50% within a year, influence community and social norms, facilitate social support, increase autonomy and promote active coping mechanisms.
There are a range of biological, psychological and social factors that interact and can cause an individual to be more vulnerable or resilient to PTSD after a sexual trauma. Knowledge of these influences can serve as a vital framework for improving post-sexual-traumatic outcomes. Successful recovery is subjective, but can be measured by whether the survivor regains control of his or her life and experiences overall better functioning.
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