Chronic sexual concerns may include fear of intimate relationships, lack of sexual enjoyment, difficulty with desire and arousal, and anorgasmia. Compared with women who were not sexually assaulted, they are more likely to experience depression, suicide attempts, chronic anxiety, anger, substance abuse problems, dissociative personality disorder, borderline personality disorder, fatigue, low self-esteem, feelings of guilt and self-blame, and sleep disturbance (127,129–131). They often experience social isolation, phobias, feelings of vulnerability, fear, humiliation, grief, and loss of control (132,133). Survivors of sexual assault represent a disproportionate number of patients with chronic headaches, fibromyalgia, and chronic pelvic pain (they have a lower pain threshold) and are more likely to have somatic symptoms that do not respond to routine medical treatment (130,134). Women with common gynecologic symptoms, such as dysmenorrhea, menorrhagia, and sexual dysfunction, are much more likely to have a history of sexual assault (135). If they were forced to perform oral sex, they may have a dental phobia and avoid preventive dental care.
Survivors may develop posttraumatic stress disorder (PTSD), in which characteristic symptoms are exhibited following a psychologically traumatic event outside of normal human experience. Symptoms of PTSD include blunting of affect, denial of symptoms, intrusive reexperiencing of the incident, avoidance of stimuli associated with the assault, and intense psychological distress and agitation in response to reminders of the event (112,124). Women affected by PTSD are more likely to commit suicide. The cognitive sequelae include ﬂashbacks, nightmares, disturbances in perception, memory loss, and dissociative experiences (136). These women may not be able to tolerate pelvic examinations and may avoid seeking routine gynecologic care because these examinations may remind them of the sexual abuse they experienced as children. They are more likely to use the medical care system for nongynecologic concerns (137). Women with PTSD are at greater risk for being overweight and having gastrointestinal disturbances (121).
Rape Although the legal definition of sexual assault may vary from state to state, most definitions of rape include the following elements: 1.
The use of physical force, deception, intimidation, or the threat of bodily harm 2.
Lack of consent or inability to give consent because the survivor is very young or very old, impaired by alcohol or drug use, unconsciousness, or mentally or physically impaired 3.
Oral, vaginal, or rectal penetration with a penis, finger, or object
The National Women’s Study provides the best statistics available about the incidence of forcible rape in the United States (132). This study revealed that 13%, or one of eight adult women, are survivors of at least one completed rape during their lifetime. Of the women they surveyed, 0.7% were raped during the past year, equaling an estimated 683,000 adult women who were raped during a 12-month period. Of the women surveyed, 39% were raped more than once. Most rapes occurred during childhood and adolescence; 29% of all forcible rapes occurred when the survivor was younger than 11 years of age, and 32% occurred between the ages of 11 and 17 years. “Rape in America is a tragedy of youth” (132). Twenty-two percent of rapes occurred between the ages of 18 and 24 years, 7% between the ages of 25 and 29 years, and only 6% occurred when the survivor was older than 30 years of age. Although women of all ages and cultures are vulnerable to sexual assault, prisoners, adolescents, drug users, the elderly, those who experienced sexual assault as children, women in abusive relationships, and women with emotional and physical disabilities are at most risk (138–140).