Keywords

Introduction

Experiences of psychological trauma are unfortunately common. Most people will experience at least one potentially traumatic event during the course of their life [1,2,3]. While traumatic events like combat exposure, motor vehicle accidents, and natural disasters can have significant impacts on those who experience them [2], experiences of sexual and gender-based traumatic events (e.g., sexual assault, childhood sexual abuse, intimate partner violence) represent the greatest source of post-trauma psychopathology [1, 2, 4, 5]. Traumatic events can alter people’s fundamental beliefs about themselves, others, and the outside world, changing the way they take in information and behave in their day-to-day lives [6,7,8,9,10]. Furthermore, trauma can contribute to short- or long-term mental and physical health concerns. For any medical provider, a basic understanding of psychological trauma and its effects is essential to providing quality, trauma-informed care. This chapter reviews psychological trauma with a special focus on sexual and gender-based violence.

What Is Psychological Trauma?

As defined by the “Diagnostic and Statistical Manual of Mental Disorders – Fifth Edition,” a traumatic event is “exposure to actual or threatened death, serious injury or sexual violation” [11]. This exposure may be one in which the individual (1) directly experiences the traumatic event, (2) learns that the traumatic event occurred to a close family member or close friend, or (3) experiences first-hand repeated or extreme exposure to aversive details of the traumatic event (e.g., having to collect human remains as a first responder or hearing detailed accounts of sexual assault as part of a job). Although many people label stressful experiences that do not meet the above criteria (e.g., divorce, job loss, ailing family member) as “traumatic,” mental health practitioners and researchers generally differentiate these types of stressful events from traumatic events. It can be helpful to think of all of these experiences existing on a continuum that ranges from a stressor (divorce, job loss, ailing family member) to a trauma as defined by the DSM-5 (combat exposure, life-threatening motor vehicle accident, physical or sexual assault) [12]. Events from the entire stress/trauma continuum can contribute to or exacerbate mental health symptoms such as depression or anxiety, affect overall physical health, and impair daily functioning. However, events that meet the DSM definition of trauma are often associated with specific psychological sequelae, like posttraumatic stress disorder (PTSD), and more strongly associated with other mental health concerns, including depression and anxiety. Therefore, the differentiation between stressor and trauma is important when considering the psychological effects of the experience of trauma and how best to work with trauma survivors.

Sexual and Gender-Based Violence

Broadly defined, sexual violence is “a sexual act that is committed or attempted by another person without freely given consent of the victim or against someone who is unable to consent or refuse” [13]. Gender-based violence refers to acts of violence that disproportionately impact one gender, typically women, and arise from normative gender role expectations and unequal distributions of power [14]. Sexual and gender-based traumas include sexual assault, childhood sexual abuse (CSA), sexual harassment, stalking, and intimate partner violence (IPV). By nature, sexual and gender-based violence is personal and intrusive and generally falls under the DSM definition of a traumatic event. A wealth of research has established significant associations between sexual and gender-based violence and mental and physical health concerns [15,16,17,18,19].

Sexual violence is relatively common. According to the CDC’s National Intimate Partner and Sexual Violence Survey, 44% of women and 25% of men in the United States experience some form of sexual violence in their lifetime [20]. Sexual violence includes a broad range of unwanted sexual behaviors including rape (forced sexual penetration), being forced to penetrate, sexual assault (e.g., a broad term for a range of unwanted physical sexual contact), sexual coercion (unwanted sexual contact due to pressure or threats), and noncontact sexual assault (e.g., flashing or masturbating in front of the victim). Victims of sexual violence often know the perpetrator, who may have been a former or current intimate partner, friend, or acquaintance [16]. For female victims, the vast majority of perpetrators are male (97% for rape, 92% for noncontact sexual assault, and 93–96% for other types of sexual violence including being made to penetrate, sexual coercion, and unwanted sexual contact). Male victims of rape and noncontact sexual assault also report that the majority of perpetrators are male (87% for rape and 48% for noncontact sexual assault). However, male victims of other types of sexual violence (e.g., being made to penetrate, sexual coercion, and unwanted sexual contact) report the majority of perpetrators are female (53–82% depending on type of violence) [16].

Characteristics of Sexual and Gender-Based Violence

Experiences of sexual and gender-based violence can differ based on a variety of characteristics such as duration of the event (single event vs. ongoing series of events), age at the time of the trauma, the environmental context in which the trauma occurred [21, 22], and other contextual factors (e.g., relationship between victim and perpetrator, use of alcohol by any party, type of coercion used, level of physical injury, experiences with help-seeking following the assault). These characteristics can affect how survivors respond to trauma as well as how they make sense of this experience in the context of their lives.

Generally, survivors who have experienced a traumatic event as a single isolated event have a better prognosis than those who experience ongoing or chronic trauma [23]. While a single trauma can be thought of as an anomaly, survivors of chronic or ongoing trauma may develop dysfunctional beliefs that are confirmed over and over again by a pattern of traumatization. Sexual and gender-based violence that occurs in childhood or adolescence can have strong implications for victims’ emotional development and well-being. This childhood trauma can disrupt a child’s sense of self before it is fully developed. It may isolate a child from people and environments the child once considered to be safe and is often associated with difficulties regulating emotions during future stressful events [23]. Consistent with this, survivors of childhood sexual abuse often experience significant mental health symptoms and are more vulnerable to experiencing further traumatic stressors throughout their lives [24].

Environmental and contextual factors of sexual and gender-based trauma also affect the experience, prognosis, and response of survivors. For example, assaults that occur within occupational or educational settings can result in strong feelings of distrust of authority and betrayal by the specific people involved and the larger institution [21]. Assaults that involve weapons or result in physical injuries are associated with greater mental health symptomatology [25]. Assaults that were facilitated by alcohol or drugs, as compared to those facilitated by physical force, are associated with lower rates of treatment and help-seeking by survivors [26]. Furthermore, the negative psychological effects of sexual violence are not fully determined by the effects of the violence itself, but also impacted by survivors’ positive or negative experiences interacting with medical and legal helping systems [27].

Reactions to Sexual and Gender-Based Violence

Mental Health Reactions to Trauma

Experiencing sexual and gender-based trauma can profoundly impact a person’s life affecting both their mental and physical health [13,14,15,16,17]. However, it is important to recognize that traumatic experiences do not always lead to long-term impairment in functioning or chronic mental health symptoms. In fact, resilience and recovery are the most common reactions to trauma [28,29,30,31,32]. People who demonstrate a resilient reaction may experience mild-to-moderate mental health symptoms (e.g., slight decrease in mood or a bit more anxious) following a sexual assault, but these symptoms do not significantly impact their day-to-day functioning. Multiple factors such as the intensity of sexual violence, the context of the assault, and the level of support following a trauma contribute to resiliency.

A recovery reaction involves greater symptomatology and functional impairment than a resilient reaction. However, a person who has a recovery reaction finds that their symptoms decrease over a few months post trauma [31,32,33]. Rothbaum and colleagues illustrated the recovery reaction in a study with female rape survivors [32]. In this study, most survivors (94%) met symptom criteria for PTSD within the first 2 weeks following their experience of being raped. After 5 weeks, the percentage of survivors who met symptom criteria for PTSD had dropped to 65%, and by the end of three and a half months, only 47% of the survivors reported significant enough symptoms to warrant a PTSD diagnosis (although note that a substantial percentage remained symptomatic) [32]. Studies suggest that, for many, a process of natural recovery can take place following the experience of trauma.

In contrast, there are others who develop long-term, chronic, trauma-related symptoms that impair their general functioning. PTSD is the mental health diagnosis most commonly associated with the experience of trauma [1, 2, 23]. PTSD includes symptoms from four symptom clusters: intrusive symptoms (intrusive trauma-related thoughts, unpleasant dreams, flashbacks, and emotional distress and physical reactions in response to reminders), avoidance (avoiding thoughts and feelings related to the event or avoiding people, places, and things associated with the trauma), altered mood and cognitions (inability to recall important parts of the trauma, negative thoughts about oneself and the world, exaggerated blame, negative affect, decreased interest in activities, feeling isolated, and emotional numbing), and hyperarousal (sleep problems, irritability, risky behavior, difficulty concentrating, hypervigilance, increased startle) [11].

Other mental health disorders that have strong associations with the experience of sexual or gender-based traumas include depression, anxiety disorders (such as panic disorder or generalized anxiety disorder), substance use disorders, and borderline personality disorder [17, 23]. Many times, these disorders co-occur with PTSD, leading to complex mental health presentations [2]. Furthermore, experiences of sexual and gender-based violence can exacerbate a preexisting mental health condition and increase symptomatology. Effective treatments, both psychotherapies and medication, exist for the treatment of mental health disorders secondary to the experience of trauma [34, 35].

Cognitive Reactions to Trauma

One reason that traumatic experiences can have such a profound reaction on mental health is that these experiences can uproot victims’ foundational beliefs of themselves, others, and the world they live in. Traumatic life events can challenge basic assumptions or beliefs about the self and the world, including the belief in personal invulnerability, the view of oneself (and others) in a positive light, and the belief in a meaningful, orderly world [8]. These basic assumptions are innately relevant to sexual and gender-based violence because traumatic experiences have the power to shatter existing beliefs and replace them with belief systems characterized by deception, betrayal, a loss of safety, helplessness, vulnerability, a restriction of freedom, diminished esteem, and isolation from others [6, 7].

When preexisting belief systems are challenged by a traumatic event, the survivor faces the struggle of reconciling pre-trauma and post-trauma beliefs. Survivors often make sense of traumatic belief systems through the process of assimilation or altering beliefs about the trauma to fit their preexisting beliefs about themselves and the world. For example, survivors may hold a preexisting belief in a “just world” (i.e., that bad things don’t happen to good people). In an effort to uphold that belief, following objectively terrible traumatic experiences, survivors may begin to believe that they must be bad people [34, 36]. Alternatively, survivors may reconcile pre- and post-trauma belief systems by overaccommodating preexisting beliefs to make sense of what happened to them. For example, survivors who were victimized by trusted friends or acquaintances may adopt beliefs that no one can be trusted [37, 38]. The process of accommodation, or addressing apparent contradictions between pre- and post-trauma belief systems in a way that avoids broad generalizations and “all or nothing thinking,” is a critical aspect of recovery from traumatic experiences. Trauma-focused therapies such as cognitive processing therapy often aim to increase accommodation, or make sense of discrepant pre- and post-trauma beliefs, while decreasing assimilation and overaccommodation [38].

Social Reactions to Trauma

Sadly, survivors of sexual and gender-based violence often report significant feelings of shame and guilt, blaming themselves for their victimization and experiences, and questioning their self-worth. Frequently, these reactions are reinforced by widespread cultural beliefs around sexual and gender-based violence such as rape myths (e.g., women who dress certain ways are “asking for it;” people frequently lie about being raped; it was not rape if either person had been drinking; men cannot be raped) and other negative societal messages (e.g., dismissing inappropriate sexual behavior as “boys will be boys” or “locker room talk”). These views are often reflected in media and popular culture with inaccurate representations of sexual violence (e.g., suggesting that rape is most commonly perpetrated by a stranger, implicating women’s sexual history as a factor in victimization, romanticizing men aggressively pursuing “hard to get” women). If survivors decide to disclose their experiences of sexual and gender-based violence, they can face strong negative reactions that stem from these rape myths and negative societal messages. These negative social reactions to survivors’ disclosures can significantly increase psychological distress, intensifying symptoms of PTSD, depression, and alcohol abuse [39,40,41,42].

Even survivors who choose to never disclose their experiences are not excluded from feeling the effects of negative social reactions—these negative messages can be internalized, increasing survivors’ fear of judgment and feelings of guilt and shame [43]. In contrast, positive social reactions to disclosures, such as connecting survivors to helpful resources or offering emotional support, can aid survivors’ ability to effectively cope with traumatic experiences [44]. Given the high risk of negative reactions and emotional distress following disclosure of sexual or gender-based violence, it is not surprising that many survivors disclose their experiences only to a small number of trusted others or choose not to disclose these experiences at all. Unfortunately, a decision not to disclose traumatic experiences comes with potential costs. Without disclosure, survivors may not have access to social support and tangible mental health and medical resources that could play a critical role in their recovery. Of course, decisions to disclose also come with high potential costs beyond the distress associated with negative social reactions. In some situations, including experiences of intimate partner violence or child abuse, disclosure may have direct implications for victims’ safety. Disclosure of traumatic victimizations that occur in occupation settings can result in threats to a victim’s employment status and financial security.

The magnification of survivors’ feelings of deep shame, guilt, and powerlessness, as a result of negative experiences during help-seeking, has been referred to as a “secondary victimization” following the assault [45]. For many survivors, invalidating reactions from others following a traumatic experience can be more distressing than the traumatic experience itself. However, positive experiences of disclosure and help-seeking can be critical steps toward long-term healing. When survivors are believed, treated with empathy and respect, and connected with the necessary services as a result of disclosure, this support from their social structures can benefit them in their recovery [45, 46]. For this reason, it is critical that victims who choose to disclose to informal systems of support (e.g., family members, friends) or formal systems of support (e.g., medical or mental health providers, legal systems) receive compassionate, validating responses.

Physical Health Reactions to Trauma

In addition to the significant mental health consequences associated with experiences of sexual and gender-based violence, survivors of these experiences often experience a wide range of negative physical health consequences. Compared to those without an abuse history, people with a history of childhood sexual and physical abuse are more likely to report health problems such as difficulties with sleep, gastrointestinal problems, headaches, chest pain, and back or joint pain [47]. Survivors of intimate partner violence have been found to be at risk for chronic pain, digestive problems, headaches and migraines, back pain, sexually transmitted diseases, vaginal bleeding, vaginal infections, and abdominal pain [19, 48]. Additionally, women who have experienced any sexual violence are more likely than women without a history of violence to have asthma, irritable bowel syndrome, frequent headaches, chronic pain, and difficulty sleeping [16]. The same results were also found in men who had a history of any sexual violence compared to men with no history of violence [16]. Furthermore, sexual and gender-based violence is associated with poor overall physical health [16, 18] and a greater number of total health problems [19]. There also appears to be a dose-response effect. People who experience a greater number of traumatic events have a greater likelihood of experiencing poor physical health [47], and those who experience more frequent or severe violence have more physical health symptoms [48]. Research on the associations between traumatic experiences, mental health, and physical health is mixed. Some research suggests that the relationship between traumatic experiences and physical health symptoms can be explained by mental health symptoms, like PTSD [18]. Other research suggests that the number of traumatic events in a patient’s history is related to poor physical health regardless of the level of mental health symptoms like PTSD symptomatology [49].

The Trauma Survivor as a Patient

Given the frequency of sexual and gender-based violence, all medical providers care for people who have experienced sexual or gender-based violence, even if they are unaware that the patient is a survivor. Therefore, providing medical care that is informed by an understanding of the impact of sexual and gender-based violence on an individual is essential [50]. Medical providers and the systems in which they work can make modifications to create an environment that helps a survivor feel safe, respected, and empowered. Although not every patient who has experienced a sexual or gender-based trauma will disclose this experience to medical providers, having knowledge of patients’ trauma histories can inform medical practices to help keep patients engaged in care. Trauma histories may help explain frustrating or confusing patient behaviors (e.g., not following treatment recommendations). Having knowledge of patients’ histories may inform adaptations to clinician’s exam techniques. Additionally, given that trauma survivors typically present to physical healthcare settings first, a trusted medical provider can potentially assess the need for and help bridge survivors to mental healthcare, assisting the patient in receiving the treatment that would be most beneficial for them.

Screening for current or past sexual and gender-based violence is important in routine medical care to potentially improve the health and well-being of patients [51]. It is wrong to assume that patients will volunteer information regarding their experiences of violence. While some may, many will not opt to disclose. Therefore, screening measures offer a routine way to assess for current and past experiences of violence in a way that maximizes disclosure from patients. Research suggests that patients are in support of routine screening for experiences of violence, although it is important that they are provided with options of how much and how to disclose [52, 53].

Some medical providers may feel uncomfortable discussing patients’ experiences of violence. Providers may think these experiences are too personal or too difficult for patients to talk about. Well-meaning providers may worry about upsetting or retraumatizing their patients or may feel unsure of how to respond if patients disclose experiences of sexual or gender-based trauma. Raising these issues can also feel like opening “Pandora’s box”—given the time constraints of many physicians, there may be concerns that one does not have enough time to thoroughly assess for history of or ongoing traumatic experiences. These concerns are generally alleviated with more practice discussing sexual and gender-based violence with patients. The most important response is relatively simple: maintaining a nonjudgmental approach and expressing empathy for the survivor. Patients may not be ready to disclose all of the details of their experience, or they may not be ready to leave an abusive situation. Allowing the patient to make decisions on how much they disclose or whether they would like a referral to other services communicates confidence that you, as a provider, believe that the patient is capable of making their own decisions. This increased sense of efficacy can provide the patient with a sense of control and help them engage more fully in their healthcare.

Conclusion

Psychological trauma is defined by the DSM-5 [11] as “exposure to actual or threatened death, serious injury or sexual violation.” Sexual and gender-based violence constitutes a type of psychological trauma with strong risks of mental and physical health problems [13,14,15,16,17]. Given the frequency of sexual and gender-based violence—44% of women and 25% of men in the United States are estimated to experience some form of sexual violence in their lifetime [20]—all medical providers will provide care for survivors of these experiences. Understanding how individuals are impacted by sexual and gender-based violence is a critical piece in providing trauma-informed care for survivors of these experiences.

Sexual and gender-based trauma can profoundly impact a person’s life. It can challenge people’s foundational beliefs about themselves, others, and the world [7], making it difficult to make sense of the traumatic experience and deeply altering the way survivors view their lives. Feelings of shame and guilt that are common in survivors of sexual and gender-based violence contribute to personal distress and, at times, a reluctance to disclose their experience of trauma. Additionally, many survivors avoid reminders of sexual and gender-based traumas leading to a restrictive day-to-day life. Seeking treatment through psychotherapy or medication can ameliorate trauma-related distress and mental health symptomatology.

Sexual and gender-based violence also may lead to poor physical health. Physicians and healthcare systems that provide care, informed by an understanding of the impact of traumatic experiences, can more effectively engage survivors in care. Routine screenings can assist physicians in identifying victims and survivors of sexual and gender-based violence in order to provide these patients with resources or referrals, adjust exam methods to account for the patients’ experiences, and provide patients with general support. In this way, physicians play a critical role in systems of care for trauma survivors, representing a critical link in the chain that helps survivors to recover some of what has been taken from them.