Physical activity to address multimorbidity among survivors of sexual violence: A comprehensive narrative review

Abstract

Background:

Sexual Violence (SV) is highly prevalent and experienced by women and men throughout the United States and world. Survivors of SV often experience poor mental and physical health, and poor health-related quality of life. Studies have explored the associations between SV survivorship and maladaptive health behaviors, but few have examined SV and health promoting activities such as exercise.

Purpose:

The aim of this narrative review is to describe available peer-reviewed literature regarding SV and physical activity and provide recommendations for future research. Specifically, this review aimed to identify information relevant for promoting and designing exercise interventions that can integrate into clinical treatments for adult survivors of SV.

Methods:

A search of electronic databases identified 18 articles on SV and exercise behavior.

Results:

Four of these studies were exercise interventions, 10 were observational studies, and 4 were qualitative interviews. Results broadly indicate that levels of physical activity among survivors of SV is unclear. Findings from trials indicate exercise may have a positive impact on mental health in survivors of SV. Qualitative interviews found survivors often enjoyed exercising and identified several health benefits, suggesting exercise interventions may be feasible and acceptable in this population. Interviews also identified valuable information about survivors’ experiences with exercise.

Conclusions:

Research in this area would benefit from: representative samples of adults among populations at high risk for victimization, more consistent and in-depth reporting of SV history and exercise levels, consistent and trauma-informed outcome measurements, and more diverse study designs and interventions. Increased exploration of exercise in this population is warranted given the well-established evidence base indicating the health promoting qualities of exercise for mental and physical health among trauma affected populations.

1. Introduction

Sexual Violence (SV) is a concerning and pervasive public health issue in the United States. An estimated 18.3% of women and 1.4% of men have experienced sexual assault, one type of SV (Barth et al., 2016). Another 44.6% of women and 22.5% of men have experienced SV victimization other than rape, including being made to penetrate, sexual coercion, unwanted sexual contact, or non-contact unwanted sexual experiences (Black, Basile, & Breiding, 2010). SV has been shown to have widespread negative physical and mental health impacts that are similar to but distinct from other trauma-affected populations. There is substantial evidence linking SV with cardiometabolic risk factors such as cardiovascular and inflammatory disease (i.e. rheumatoid arthritis, fibromyalgia, diabetes, high blood pressure) (D’Aoust et al., 2017; Lee et al., 2016; Lutwak & Dill, 2013), chronic pain (Barth et al., 2016; Dillon, Hussain, Loxton, & Rahman, 2013; Rough & Armor, 2017; Santaularia et al., 2014; Vancampfort, Stubbs, et al., 2017), functional impairment (Martin et al., 2008), and overweight/obesity (Masodkar, Johnson, & Peterson, 2016; van den Berk-Clark et al., 2018). Survivors also frequently experience comorbid mental health conditions including anxiety, depression, poor body image, emotion dysregulation, and disordered eating (Brewerton, 2007; D’Aoust et al., 2017; Hall, Hoerster, & Yancy, 2015; Jina & Thomas, 2013; Weaver, Griffin, & Mitchell, 2014; Wong & Chang, 2016). Given that SV leads to drastically higher rates of post-traumatic stress disorder (PTSD) than other traumatic events, along with the high prevalence of SV victimization and the resulting SV-specific health concerns, investigation of treatment interventions aimed specifically at survivors of SV is important (Black et al., 2010; Chivers-Wilson, 2006).

Participation in physical activity can help prevent the development of cardiometabolic disorders (American Heart Association Nutrition Committee et al., 2006; Haskell, 2003) and has also been shown to be widely beneficial for mental health (Penedo & Dahn, 2005). There is substantial and growing evidence that exercise improves mental and physical health among individuals diagnosed with PTSD, and that exercise is feasible and acceptable as a health promotion strategy among trauma-exposed populations (Rosenbaum et al., 2015). Yet, this work primarily explores exercise for male-dominated populations which experience frequent combat-related traumas (i.e. military veterans, police) without prioritizing the unique experiences and needs of SV survivors (Pebole, Gobin, & Hall, 2020; Pebole & Hall, 2019a, 2019b). SV represents a trauma with a unique sense of loss of bodily autonomy. Exercise represents a treatment approach which allows the individual to have positive body experiences that contradict these feelings of loss of control (Van der Kolk, 2015). Evidence generally indicates that exercise has positive impacts on many of the health concerns survivors experience, with benefits including reducing symptoms of depression (Kvam, Kleppe, Nordhus, & Hovland, 2016), anxiety (Anderson & Shivakumar, 2013), and PTSD (Rosenbaum et al., 2015), improving body image (Hausenblas & Fallon, 2006), promoting a sense of mental well-being (Mandolesi et al., 2018), reducing cardiovascular risk, and improving physical function (Hall et al., 2019; Rosenbaum, Tiedemann, Sherrington, Curtis, & Ward, 2014; Vancampfort, Rosenbaum, et al., 2017). But research on health behavior in this population is focused primarily on maladaptive behaviors (i.e. disordered eating, substance use), and often ignores health promoting activities such as exercise. As a result, little is known about exercise and associated outcomes among survivors of SV.

Exploration of the relationship between SV and exercise is needed, in light of the significant health-promoting effects of exercise and the potential for physical activity to prevent and attenuate many of the physical and mental health concerns frequently experienced by this population. The aim of this paper is to review existing published literature regarding exercise and SV survivors. Specifically, this review aimed to identify information relevant for promoting and designing exercise interventions that can integrate into clinical treatments for adult survivors of SV. Findings from this review can be used by behavioral researchers as a guide for future work in this area. Gaps in the existing literature and areas for future research are discussed.

2. Methods

2.1. Definitions

The term SV is often used interchangeably with related terms such as sexual assault, partner violence, sexual harassment, rape, and sexual abuse. There remains a lack of consensus regarding the definition of SV and how it should be measured to understand the problem. Operationalization of these concepts vary across research, countries, and legislations, making this an over-arching challenge in conducting primary research and reviews in this area. For this review we adopted the uniform definition of SV set forth by the Centers of Disease Control and Prevention (CDC): “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.” This definition includes forced sexual acts or sexual acts facilitated by the use of alcohol/drugs, non-physical pressure, intentional sexual touching, and non-contact acts of a sexual nature. SV can also occur when a perpetrator forces or coerces a victim to engage in sexual acts with a third party (Black et al., 2010; Breiding, Chen, & Black, 2014; Breiding et al., 2015). For this definition of SV, sexual acts include nonconsensual penetration, forced penetration, unwanted sexual contact, and non-contact unwanted sexual experiences. Perpetrators can include individuals both known and unknown to the survivor (Black et al., 2010).

Terminology used for those who have experienced SV is often ambiguous, with public health and advocacy organizations often using the terms “victim” and “survivor” interchangeably. Both terms are applicable. Researchers have used the term ‘survivor’ here to indicate individuals who have experienced SV. We use this term to emphasize the strength and resilience of these individuals regardless of where they are in recovery. However, we recognize that this is a contested term, that some survivors prefer the term victim, and using either term has limitations (Young & Maguire, 2003).

Exercise and physical activity are related, but unique terms. Physical activity refers to any bodily movement produced by the skeletal muscles that results in energy expenditure above resting levels. It can occur in many contexts, including transport, occupation, and leisure-time (Caspersen, Powell, & Christenson, 1985). Exercise is physical activity that is usually performed repeatedly over an extended period of time for the purpose of increasing aerobic or muscular physical fitness, improving health, and/or improving sport performance (Caspersen et al., 1985). For this review, we have included studies which incorporate measurements of leisure-time physical activity levels and exercise.

2.2. Overview

This represents the first formal review of this research area. Exercise among survivors of SV is understudied, with relatively few published studies. As such, upon examining the evidence-base we found that study design, methodologies, and outcomes varied greatly across studies, making a meta-analysis approach not feasible for this review. As a result, a narrative review was conducted to provide an overview of the evidence available in this field, with acknowledgement of the potential for bias. Narrative reviews are an appropriate method to account for a diverse research base and literature using different methodologies; they can provide a broad overview of a topic (Baethge, Goldbeck-Wood, & Mertens, 2019; Green, Johnson, & Adams, 2006). Meta-analyses of this field will not be possible until more work is done with consistent study designs, outcome measurements, and definitions of SV.

2.3. Research question

Promotion and design of clinical exercise programs for this population necessitates understanding how SV impacts decisions about, and perceptions of, exercise. It also necessitates understanding how exercise can improve health in this population. As such, we reviewed studies which included the relationships between SV and exercise behaviors and perceptions, and how exercise can improve the health of survivors. Specific questions addressed in this narrative review include: (1) Does a history of SV impact activity levels among survivors compared to those who have not experienced SV? (2) What are the perceptions of and experiences with exercise among SV survivors? and (3) What is the level of evidence surrounding activity interventions and health outcomes in survivors of SV?

2.4. Search strategy

The published literature on this topic is small, so we purposefully opted to use inclusion criteria that were broad to capture many relevant studies. Included studies were published in peer-reviewed journals and conducted among exclusively adult samples. Researchers conducted a search of published literature (including PubMed, PsychInfo, Scopus, and SportDiscus databases) for original articles published from 1980 until July 1, 2020. An applied health sciences librarian was consulted while refining the search criteria to confirm researchers obtained a comprehensive list of articles which reflected the subject of interest. To capture a wide variety of studies, researchers used a search with medical subject headings (MeSH) terms sexual violence, sexual assault, sexual abuse, or sexual trauma; and exercise, physical activity, aerobic walking, yoga, weight training, cycling, sedentary, inactive. Activity level did not need to be the primary outcome but did need to be measured, included in the analysis, and reported. Reference sections of relevant articles were also searched for additional sources. SV prevalence and perpetration in youth, organized, and professional sport is a new and important area of investigation that has grown in the last few years (McCray, 2015; Ohlert, Rau, Rulofs, & Allroggen, 2020). However, due to the stated focus of this review on clinical exercise interventions, we have excluded studies focusing on experiences of SV in professional/formally organized sport.

3. Results

3.1. Search results

Fig. 1 shows the article selection process for this literature review. Eighteen studies of exercise and SV were identified and included in this review, most of which were conducted in the United States (n = 16; 89%). Studies were frequently conducted among samples of exclusively women (n = 11; 61%). Of the studies that reported race (n = 15, 83%), all reported primarily White samples. None of the included studies measured or reported information on gender and sexual minorities. Types of SV that were found and reported on for this review range from experiences of sexual assault, sexual harassment, childhood sexual abuse, and psychosexual abuse. SV contexts included events in civilian, military, partner, and non-partner settings. Several included studies did not specify which type of SV survivors had experienced (i.e. Smith, 2014; Stevens & McLeod, 2018).

Fig. 1.

Scheme for sexual violence and physical activity selection process.

This search produced 18 studies which were classified into three types: 1) observational studies examining exercise behavior among survivor of SV, 2) exercise interventions for this population, and 3) qualitative work on survivor’s experiences with exercise. Most of the study designs were observational (n = 10; 56%), followed by qualitative interviews (n = 4; 22%) and exercise interventions (n = 4; 22%). Identified studies were categorized by study design, details are summarized in Tables 1 and 2.

Table 1.

Quantitative Studies Examining Sexual Violence and Exercise Behavior.

First Author, Year	N	Age*	Sex/Race	Population	Study Design	Ex Intervention/variable	Outcome Measure	Results
Intervention Studies
Smith, 2014	14	Mean: 45.5 Range: 30–62	100% female 100% White	Receiving outpatient treatment at RCC for rape or childhood sexual abuse	Non-randomized intervention CBT vs CBT + Ex	40-min Aerobic circuit training, 10 min stretching moderate intensity (60–80% MHR), 4 days a week, 8 weeks	Primary: dropout rate, satisfaction survey Secondary: PTSD symptoms; CAPSa, PCL-Sb	1 exercise dropout all participants in CBT + Ex satisfied with ex + therapy sessions; all participants with CBT satisfied both groups had significant improvements in CAPS, PCL-S scores; no between group differences found
Shors, 2018	32 women had a history of SV (105 total women)	Mean: 20 Range: 18 – 32	100% female race not reported	Adult women	randomized trial meditation + aerobic ex vs meditation alone vs aerobic exercise alone vs control	aerobic ex = walking or elliptical, 60–80% MHR, 30 min, 2x a week, 6 weeks	Post-traumatic cognitions; PTCIc Rumination; RRSd Self-worth; Best Self Scalee Strength of stressful memories; AMQf	Ex + meditation significantly reduced PTCI and RRS in women with history of SV above ex or meditation alone Ex + meditation also enhanced self-worth above ex or med alone
Nicotera, 2020	37	Mean: 29 SD: 8 Range: 18–56	100% female 67.6% White	Adult women survivors of sexual assault participating in community-based yoga	One sample trial, community-based yoga	Trauma informed yoga, (9 weeks, 1/week, 1 h of yoga and mindfulness)	Emotional awareness; FFMQg Emotion Regulation; DERSh	Statistically significant improvements in participants’ emotion regulation and skilled awareness
Clark, 2014	17	Mean: 42.6 SD: 9.0	100% female 70.6% White	Women seeking services for domestic abuse	Non-randomized; trauma sensitive yoga + group therapy vs only group therapy	trauma sensitive yoga (12 weeks, 1/week for 30–40 min)	Dropout rate acceptance & safety	25% dropout rate from yoga group high acceptance and safety
Observational Studies
Lang, 2003	221	Mean: 44.6 SD: 14.6 Range: 20–86	100% female 71% White	Women veterans seen at the primary clinic at the VA San Diego Healthcare System (1998 questionnaire)	Cross-sectional	Self-reported regular exercise engagement	Body mass Index (BMI) weekly (1/week moderate or vigorous exercise) measurement of PA unclear	Assaulted women less likely to exercise vigorously on a regular basis No evidence of association of SV on weight or moderate exercise
Thomas, 2019	34,645	51.5% born between 1960 and 1979	21.6% female 76% White	Service Members enrolled in Millennium Cohort Study (2007–2013)	Longitudinal cohort study	Self-reported minutes of ex	low (<150 min/week) medium (150 to <300 min/week), medium-high (300 to <450 min/week) high (450+ mins) levels of PA	Sexual Assault significantly associated with medium-high and high physical activity levels Negative associations between sexual harassment and medium-high physical activity levels
Dichter, 2011	21,162	62.1% Under the age of 45	100% female 72.6% White	Women responding to the 2006 BRFSS survey	Cross sectional survey	Self-reported sedentary behavior	no regular exercise in the last 30 days	Victimization was not associated with lack of exercise
Vandemark, 2008	780	Mean: 40.1 SD: 0.07	85% female 78.3% White	2005 South Carolina BRFSS respondents who experienced SV	Cross sectional survey	met exercise standards of ≥ 90 min of moderate or vigorous exercise per week	Met or did not meet PA standard	Exercise reduced the odds of poor mental health among survivors by half
Cole, 2017	149	Most (39%) between 22 and 29	100% female 83.9% White	Women Enrolled in Boxing class for SV survivors compared to traditional fitness classes (survey year not reported)	Cross sectional survey	Women’s boxing group exercise class	Empowerment; EESi Self-Efficacy; SEEj	Victimized women in boxing class were more empowered than victims and nonvictims in traditional fitness classes
Hesdon, 2003	384	Mean: 30.4	50% Female 97.4% White	Community gymnastics and running clubs vs community control (survey year not reported)	Cross sectional survey	regular weight trainers (>1 h/week) regular runners (>1 h week) no PA (<1 h week)	SV history; yes/no Body satisfaction; BSSk Motivation for exercise; Sport Motivation Scalel	Adult abuse was most frequently reported by weight trainers Among women, childhood abuse survivors feared failure in exercise
Frayne, 2003	3,632	Mean: 48 SD: 16.9	100% female 76.5% White	Women veterans (1995 survey)	Cross sectional survey	Sedentary lifestyle	Self-report Moderate PA < 3/week	Women with a military sexual assault history were more to be sedentary likely than those reporting no such history
Hollander, 2010	292	Mean: 21.5	100% female 89.1% White	Women enrolled in feminist self-defense class at a major state University in the Pacific Northwest (survey year nor reported)	Cross sectional survey + interview (as a part of another longitudinal study)	Enrollment in self-defense class Vs Non self-defense students	Reported SV history (yes/no); SESm Motivation for enrolling in self-defense class	No significant differences in history of SV between self-defense and non self-defense students Women who reported having been raped were likely to say being attacked was one reason they enrolled in the self-defense class
Huddleston, 1991	230	All participants 18–21	100% female race not reported	College aged women on campus (survey year not reported)	Cross sectional survey	Self-defense vs other activity types	Assault type self report (physical vs sexual; yes/no). Enrollment in self-defense vs other physical education classes	Women in the self-defense group were significantly more likely to have been the victim of an attempted rape or sexual assault No differences in the incidence of other victimization experiences (including physical abuse, completed rape, and child sexual assault)
Brecklin, 2004	3,187	Mean: 21.7 SD: 5.34	100% female 86% White	Women respondents to the “National Survey of Inter-Gender Relationships” sent to college students across the USA (1987)	Cross sectional survey	“have you ever studied self-defense or taken assertiveness training” yes/no	Self-report childhood sexual abuse; yes/no Adult sexual victimization; SESm	Women with multiple forms of childhood victimization (e.g., both child sexual and physical abuse) were almost twice as likely to participate in self-defense/assertiveness training

Abbreviations: SD, standard deviation; RCC, Rape Crisis Center; MHR, Max heart rate; Ex, exercise; PA, physical activity; BMI, body mass index; SV, sexual violence; CBT, Cognitive behavioral therapy; CAPS, Clinician Administered Post-Traumatic Stress Disorder Scale; PCL-S, Post-traumatic Stress Disorder Checklist, Specific Version; PTCI, Post-Traumatic Cognitions Inventory; RSS, Ruminative Responses Scale; AMQ, Autobiographical Memory Questionnaire; FFMQ, Five Facet Mindfulness Questionnaire; DERS, Difficulties in Emotion Regulation Scale; EES, Empowerment in Exercises Scale; SEE, Self-Efficacy for Exercise Scale; BSS, Body Satisfaction Scale; SES, Sexual Experiences Survey;

^*Inconsistencies in age reporting due to article reporting inconsistencies;

^a(Weathers et al., 1999)

^b(Blevins et al., 2015)

^c(Foa, Ehlers, Clark, Tolin, & Orsillo, 1999)

^d(Treynor, Gonzales, & Nolen-Hoaksema, 2003)

^e(Ogilvie & Clark, 1992)

^f(Rubin, Schrauf, & Greenberg, 2003)

^g(Baer et al., 2008)

^h(Gratz & Roemer, 2004)

ⁱ(Moore & Fry, 2014)

^j(Resnick & Jenkins, 2000)

^k(Slade, Dewey, Newton, Brodie, & Kiemle, 1990)

^l(Pelletier et al., 1995)

^m(Koss & Gidycz, 1985).

Table 2.

Qualitative studies examining sexual violence and exercise behavior.

First Author, Year	N	Age*	Sex/Race	Population/Dx Criteria	Methods	Analysis	Primary Themes	Secondary themes
Smith-Marek, 2018	8	Mean: 44.62 Range: 31–63 SD: 11.65	100% female 87.5% White	Women self-identified survivors of SV who were enrolled in a yoga group at the RCC Participants recruited from yoga group, but not required part of program	Structured focus group discussion with all 8 participants 6 of 8 also participated in individual interviews	Phenomenological approach: The Listening Guidea	Exercising (and not exercising) fosters safety Exercising is risky Past trauma restricts exercise choices Exercising is beneficial	Participants desired exercise Not exercising protected women from unwanted attention; trauma restricts ex location and groups; survivors preferred to exercise on own or with other survivors Exercise helped self-esteem, body image Competence, relatedness, and autonomy as basic needs influencing exercise among survivors
Guthrie, 1997	30	Mean: 38 Range: 26–62	100% female 86.6% White	Non-Competitive Martial Artists 19 of whom reported a past of psychosexual abuse	Structured individual interviews Stand alone study	Inductive Content Analysisb	Martial Arts resulted in enhanced self-esteem associated with healing from abuse	Enhanced mental and physical health improved ability to set physical and mental boundaries and use their own voice decreased generalized fear/anxiety, helplessness, panic attacks, chronic pain, dissociative episodes
Stevens, 2018	5	All participants between ages 21 and 55	100% female Ethnicity reported, not race	Women who accessed support as adults from experiences of childhood sexual abuse, or SV experienced as an adult all enrolled in 10-week yoga program; but not required part of program	Semi-structured individual interviews Plus follow up e-mail to enable participants to share any further reflections	Interpretive Phenomenological Analysisc	Dealing with major themes of life Importance of being in a group Yoga facilitated personal learning and caused positive changes Yoga and RCC as a resource	Dealing with isolation and fear Being accepted by a group Overcoming challenges Improved physical and mental health
Concepcion, 2005	7	Mean: 34 Range: 18–54 SD: 14	100% female 85% White	Women who had been in abusive relationships and who had exercised for 3 months	Guided individual interviews	Graduate students transcribed and coded themes; triangular consensus used	Exercise provided a sense of accomplishment and improved their mental and emotional status Hope and healing and a sense of being “normal” and having freedom, and working toward a future self	Important aspects of exercise environment: Safety, women exercise instructors, confidentiality, professional context of exercise environment, being listened to by exercise professionals

Abbreviations: SV, sexual violence; PA, physical activity; RCC, Rape Crisis Center; SD, standard deviation

^*Inconsistencies in age reporting due to article reporting inconsistencies;

^a(Gilligan, Spencer, Weinberg, & Bertsch, 2003)

^b(Lincoln & Guba, 1985)

^c(Smith, Flowers, & Larkin, 2009).

3.2. Observational studies: sexual violence and physical activity

There were 10 published observational studies that examined the associations between SV and physical activity. None of these observational studies measured additional characteristics of SV outside of indication of violence (yes/no) on administered surveys. Additionally, none of these studies utilized objective assessments of activity such as pedometers or accelerometers, and only one study examined change in physical activity over time (Thomas et al., 2019). Few studies used data from the last 10 years. Date of questionnaire administration ranged from 1987 (Brecklin, 2004) to 2013 (Thomas et al., 2019). All observational studies that reported race of participants included primarily White respondents (average: 81.2% White; range: 71%–97.4% White). Additionally, seven of these observational studies included only women participants (Brecklin, 2004; Cole & Ullrich-French, 2017; Dichter, Cerulli, & Bossarte, 2011; Frayne, Skinner, Sullivan, & Freund, 2003; Hollander, 2010; Huddleston, 1991; Lang et al., 2003), and all but two studies (Hesdon & Salmon, 2003; Thomas et al., 2019) reported primarily female respondents. Most of the primary outcomes utilized in these studies included health behaviors associated with increased cardiovascular risk (i.e. smoking, binge drinking, sedentary behavior) (Cole & Ullrich-French, 2017; Dichter et al., 2011; Frayne et al., 2003; Lang et al., 2003; Vandemark & Mueller, 2008). Primary outcomes of two studies were physical activity (Hesdon & Salmon, 2003; Thomas et al., 2019), and three studies examined motivation for and responses to self-defense training (Brecklin, 2004; Hollander, 2010; Huddleston, 1991).

3.2.1. Activity levels

Eight of these studies included analysis of activity levels (Brecklin, 2004; Cole & Ullrich-French, 2017; Hesdon & Salmon, 2003; Hollander, 2010; Huddleston, 1991; Lang et al., 2003; Thomas et al., 2019; Vandemark & Mueller, 2008) and two examined sedentary behavior (Dichter et al., 2011; Frayne et al., 2003). Measurement of activity levels and sedentary behavior were inconsistent. Among the studies that examined activity levels, one study found the odds of medium-high (300–449 min/week) and high activity levels (≥450 min/week) were significantly increased among those with a history of sexual assault compared to those without a history of assault (Thomas et al., 2019). This study also found negative associations between sexual harassment and medium-high physical activity levels. Another study found assaulted women were less likely to exercise vigorously at least once a week (self-report intensity/frequency) than those without history of SV (Lang et al., 2003). The results examining the association between SV and inactivity were also mixed, with one study reporting no association between partner violence and sedentary behavior (self-report no regular exercise in the past 30 days) (Dichter et al., 2011), and one study reporting an association between military sexual assault and sedentary behavior (moderate physical activities < three times per week) among women veterans (Frayne et al., 2003).

3.2.2. Physical activity perceptions/experiences

The remaining observational studies describe the survivor’s experience with exercise. A cross sectional study of respondents who had experienced SV in South Carolina found regular exercise (≥90 min moderate to vigorous exercise/week) reduced the odds of self-reported poor mental health (defined as five or more poor mental health days in the past 30 days) (Vandemark & Mueller, 2008). Several observational studies suggest that women survivors of assault may be more likely to participate in group self-defense classes (Brecklin, 2004; Cole & Ullrich-French, 2017; Hollander, 2010; Huddleston, 1991) compared to those without history of assault. Related research found that survivors of SV enrolled in a women’s only boxing class were more empowered than both survivors and non-survivors enrolled in traditional fitness classes (Cole & Ullrich-French, 2017). One study comparing those who regularly weight trained, ran, or who did not engage in regular exercise in the general population found that women who strength train were more likely to report sexual abuse than individuals who participated in gymnastics, running, and non-active controls. This study also found women with a history of childhood abuse were concerned about avoiding failure at exercise (Hesdon & Salmon, 2003).

3.3. Exercise interventions for survivors of sexual violence

Four intervention studies among survivors of SV examined exercise as a treatment for SV related symptoms (Clark et al., 2014; Nicotera & Connolly, 2020; Shors, Chang, & Millon, 2018; Smith, 2014). These studies were done more recently than the observational studies, with the oldest study being published in 2014 (Clark et al., 2014). Survivors were recruited mainly via outpatient services (Clark et al., 2014; Nicotera & Connolly, 2020; Smith, 2014). One study recruited participants via campus flyers and online postings (Shors et al., 2018). All study participants in intervention studies were female, and all study samples were primarily White (average: 79.4% White; range: 67.6%–100% White). Two of the intervention studies measured feasibility and acceptability as primary outcomes via participant retention, adherence, self-rated satisfaction, and perceived safety throughout the intervention (Clark et al., 2014; Smith, 2014). The rest of the intervention studies measured a range of trauma-related mental health symptoms including PTSD symptomology, emotion regulation, post-traumatic cognitions, rumination, memory, mindfulness, empowerment, self-efficacy, and body satisfaction (Nicotera & Connolly, 2020; Shors et al., 2018). None of these interventions offered a multicomponent exercise intervention that included aerobic endurance and strengthening activities as recommended by public health guidelines (King, Powell, & Kraus, 2019; US Department of Health and Human Services, 2018). Three of these studies included exercise in combination with other interventions (i.e. cognitive behavioral therapy, meditation, group therapy) (Clark et al., 2014; Shors et al., 2018; Smith, 2014), while the fourth recruited women connected to care through a community non-profit organization without indicating if participants were also receiving concurrent mental health treatment (Nicotera & Connolly, 2020).

3.3.1. Feasibility Outcomes

The first study (n = 17) examined a 12-week trauma-sensitive yoga intervention designed for survivors of partner SV who were enrolled in outpatient group therapy; the control group attended regular group therapy sessions without yoga (Clark et al., 2014). The yoga intervention (n = 8) was a once weekly, 30–40 min, supervised trauma-sensitive yoga session at the end of the weekly group therapy session. Two people dropped out of the trauma sensitive yoga group, and all participants in trauma-sensitive yoga found it to be meaningful and enjoyable on program evaluations made by the research team. The second feasibility study (n = 14) was non-randomized, and compared cognitive behavioral therapy to a group engaging in both cognitive behavioral therapy and supervised aerobic circuit training (Smith, 2014). All participants included in this study were receiving outpatient treatment at a Rape Crisis Center. One participant in the exercise group (n = 7) dropped out, all participants in the exercise and behavioral therapy group were satisfied with both the exercise and therapy sessions as measured by program evaluations.

3.3.2. Mental health outcomes

The previous feasibility study found in its secondary aims that both control and exercise groups experienced improvements in PTSD symptoms as measured by the Clinician-Administered PTSD Scale (CAPS; Weathers, Ruscio, & Keane, 1999) and PTSD Checklist – Specific form (PCL-S; Blevins, Weathers, Davis, Witte, & Domino, 2015), but no significant between-group differences were reported (Smith, 2014). The remaining studies also examined mental health outcomes. One randomized trial compared a group participating in meditation plus aerobic walking to exercise alone, meditation alone, and a control group with no training (Shors et al., 2018). Participants were adult women (aged 18–32 years) recruited via research flyers who were not engaged in a regular exercise or meditation (<20 min three days/week of exercise in the last month; < 30 min meditation per week). Survivors of SV were only a small sub-group of this study’s sample (32 out of 105 participants); analyses were done separately on this group. The exercise and meditation intervention groups were supervised and performed twice weekly for six weeks for about 30 min. In the group of SV survivors, exercise and meditation significantly reduced trauma related cognitions, rumination, and improved self-worth. Lastly, a single arm study (n = 28) explored a nine-week community-based trauma informed yoga intervention for survivors of sexual assault which was implemented by mental health providers and supervised by registered yoga teachers. Yoga sessions were held once weekly. This program resulted in improvements in emotion regulation and skilled awareness among its female participants (Nicotera & Connolly, 2020).

3.3.3. Physical health outcomes

None of the interventions examined physical health outcomes.

3.4. Qualitative interview themes

There were four published qualitative studies examining exercise among women survivors, detailed in Table 2 (Concepcion & Ebbeck, 2005; Guthrie, 1997; Smith-Marek, Baptist, Lasley, & Cless, 2018; Stevens & McLeod, 2018). Study samples included survivors of SV with a history of receiving support from local mental health programs (Concepcion & Ebbeck, 2005; Smith-Marek, Baptist, Lasley, & Cless, 2018; Stevens & McLeod, 2018), and women engaged in non-competitive martial arts training (Guthrie, 1997). All qualitative studies interviewed only female participants, and all studies reporting race were done with primarily White study samples (average: 86.4% White; range: 85%–87.5% White). Overarching aims of the studies included understanding the lived experiences of exercise among women survivors of SV (Smith-Marek, Baptist, Lasley, & Cless, 2018; Stevens & McLeod, 2018), understanding physical activity’s relationship with self-view and emotional status (Concepcion & Ebbeck, 2005), and identifying self-esteem changes associated with martial arts (Guthrie, 1997). Research participants in these studies all reported exercising regularly.

3.4.1. Benefits of physical activity

Main facilitators to exercise behavior found throughout these studies were comfort with the exercise environment, connectedness to other survivors, and perceived benefits of exercise (Concepcion & Ebbeck, 2005; Guthrie, 1997; Smith-Marek, Baptist, Lasley, & Cless, 2018; Stevens & McLeod, 2018). Participants identified the positive aspects of being physically active: improving physical and mental health, enhancing self-esteem, healing from trauma, feeling connected to other survivors, and a greater sense of autonomy. Survivors identified specific mental health improvements with exercise including improved body image (Guthrie, 1997; Smith-Marek, Baptist, Lasley, & Cless, 2018), improved ability to set physical and mental boundaries (Smith-Marek, Baptist, Lasley, & Cless, 2018), decreased overall fear and anxiety (Concepcion & Ebbeck, 2005; Smith-Marek, Baptist, Lasley, & Cless, 2018; Stevens & McLeod, 2018), decreased sense of helplessness, and less panic attacks and dissociative episodes (Guthrie, 1997; Smith-Marek, Baptist, Lasley, & Cless, 2018; Stevens & McLeod, 2018).

3.4.2. Challenges to physical activity

Barriers to engaging in exercise which emerged from these studies included poor health status, fear of judgement, competing responsibilities, access to exercise location and transportation, and safety concerns (Concepcion & Ebbeck, 2005; Guthrie, 1997; Smith-Marek, Baptist, Lasley, & Cless, 2018). Research suggested sexual trauma restricts exercise location and exercise partners, indicating survivors prefer to avoid unwanted attention and prefer exercise locations where they feel safe, comfortable, and connected to others (Concepcion & Ebbeck, 2005; Guthrie, 1997). One study suggested survivors were disinterested in vigorous exercise (Guthrie, 1997). Outside of indicating enjoyment of martial arts and yoga, these studies gave no additional guidance on preferred exercise modes.

4. Discussion

This review is the first to report on exercise among survivors of SV and represents a needed expansion of the research in trauma-exposed populations to include survivors of SV. Included studies provide initial guidance for using exercise as a treatment for SV related health concerns. Findings can be integrated into the implementation of clinical exercise programs in partnership with organizations which serve survivors of various forms of SV.

Observational studies in this review broadly indicate that the impact of SV on physical activity is unclear. Perceptions and experiences with exercise among survivors of SV from qualitative interviews included here revealed positive reflections of exercise on mental health from survivors. Interviews also highlight several areas of importance for structing patient centered exercise in this population such as emphasizing safety in the exercise environment and avoiding unwelcome attention. Interventions reported low dropout rates and high participant endorsement, suggesting exercise interventions may be feasible and acceptable for this population. Interventions also provided preliminary findings indicating the positive impact of exercise on the mental health of survivors of SV, although more studies are needed to assess its direct affects.

The overall positive impact of exercise on mental health and positive reflections on exercise from survivors included here indicate the time is ripe to start increasing exercise offerings to this population and evaluating how these programs improve physical and mental health. Limitations and discussion of this research base are discussed here, as well as considerations for future research.

4.1. Sample characteristics

Reviewed studies included samples of survivors of SV from across different demographics and treatment seeking behaviors. Although this gives us a look at physical activity among different populations of survivors, the small number of studies make it hard to generalize to each of these sub-populations. None of these studies discussed in detail populations at high risk of SV outside of female sex. These high-risk populations include people from traditionally marginalized groups such as Black, Indigenous people of color, individuals with disabilities, people from the lesbian, gay, bisexual, transgender/transexual, queer/questioning, intersex, and allied/asexual/aromantic/agender (LGBTQIA) community, and incarcerated persons (Coulter et al., 2017; Homma, Wang, Saewyc, & Kishor, 2012; Melzer-Lange, 1998; Stemple & Meyer, 2014; Wolff, Blitz, & Shi, 2007; Wolff and Jing, 2009). Along with experiencing disproportionately high rates of SV, these populations face additional barriers to accessing quality healthcare and engaging in health promoting activities due to wider societal issues such as stigma, racism, and homophobia (Fredriksen-Goldsen et al., 2014; Paradies, 2006; Prather, Fuller, Marshall, & Jeffries, 2016; Valanis et al., 2000). Expansion of this line of research should thus include targeted outreach to these communities to help inform the development of health promotion programs that are inclusive of these at-risk and underserved groups. Additionally, although men experience lower risk of experiencing SV, male survivors of SV still suffer significant negative health outcomes and may experience gender-specific exercise concerns (Stemple & Meyer, 2014; Vearnals & Campbell, 2001). For example, male survivors of SV often have intense feelings of emasculation and shame about not being able to protect themselves (Weiss, 2010). It is plausible that these feelings could result in exercise preferences for activities which conform to more traditionally male ideologies in attempts to regain a sense of power and protection.

4.2. Measurement of sexual violence

This group of studies experienced large heterogeneity in measuring/assessing SV. The studies included in this review represent survivors from a range of SV experiences (necessitated by the small literature available), making it impossible to make conclusions about how each type of violence impacts exercise outcomes. Although we can make broad statements about how sexual maltreatment impacts behavior from these studies, we cannot make conclusions about how each specific type of SV affects exercise based on the small amount of research done on each sub-set. Indeed, characteristics of SV such as nature of the SV event, age of victim, and perpetrator relationship with the survivor all influence the psychological impact of SV (Gobin & Freyd, 2009, 2014), and may impact exercise behavior and/or preferences. Furthermore, SV is never stand-alone. Individuals who experience SV also experience psychological violence and may be subjected to physical violence. As a result, it is hard to understand which outcomes are a result of SV versus those that result from other forms of violence experienced when SV takes place. More research that includes precise definitions and characteristics of SV would greatly strengthen this literature base.

Additionally, some studies done in highly traumatized samples who may have experienced SV were excluded because they did not directly measure/analyze SV (i.e. homeless women; Shors, Olson, Bates, Selby, & Alderman, 2014; young adults with many adverse childhood events; Neumark-Sztainer et al., 2020). Despite these limitations, this presented research does provide initial guidance for behavioral researchers in designing and implementing exercise programs for this population. These considerations are useful for interventionists partnering with organizations that serve survivors with diverse experiences of SV (i.e. Rape Crisis Centers, local community advocacy centers, mental health facilities), and as such would experience enrollment in exercise programs from survivors with different experiences of SV.

4.3. Measurement of activity

Included studies also varied widely in their approach to assessing activity levels. Observational studies on exercise mode indicate that survivors frequently participate in self-defense and weightlifting. It is unclear from these studies how/why SV impacts exercise mode preferences, although qualitative studies indicate self-defense improved mental health (Guthrie, 1997). It is also unclear if survivors would be similarly overrepresented in other types of exercise classes. Regarding physical activity levels, observational studies largely relied on self-report tools to measure activity levels. These self-report tools often experience inaccurate reporting and can be impacted by external factors such as age and complexity of the questionnaire (Shephard, 2003; Sylvia, Bernstein, Hubbard, Keating, & Anderson, 2014; Westerterp, 2009). Characterization of activity levels among studies are often inconsistent with guidelines set forth by public health organizations, with few of the observational studies classifying exercise behavior by guidelines set forth by the CDC and World Health Organization (US Department of Health and Human Services, 2018; World Health Organization, 2003). Activity not meeting guidelines may not be sufficient to improve health (King et al., 2019), and thus knowledge of activity levels that do not meet these standards may not be meaningful from a public health perspective. Future studies should utilize these national guidelines and include objective activity measurements. As it stands currently, the relationship between SV and physical activity levels remains unclear. More work is needed to identify if/how experiences of SV impact decisions on being active and identify risk factors for physical inactivity in this population.

4.4. Exercise trial outcome measurements

Mental health outcome measurements among intervention studies were not consistent, with outcomes ranging from PTSD symptoms to self-worth and emotion regulation, among others. This indicates an overall beneficial effect of exercise on some aspects of mental health in this population. Yet the small group of studies with small sample sizes, combined with the heterogeneity among used measures makes their validity and reproducibility unclear. There is also preliminary evidence indicating that involvement in exercise may strengthen communities of survivors and promote resilience through social-psychological mechanisms such as increased self-confidence and social connection (Fasting, Brackenridge, Miller, & Sabo, 2008). Yet, variables related to these concepts remain understudied. Moreover, none of the included studies included physical health outcomes despite the well-known deleterious effect SV has on physical health. Future work should identify all relevant psychosomatic symptoms (physical and mental) survivors experience and include them as outcomes. Increased studies among survivors of SV may identify several mechanisms through which exercise may improve trauma-specific health concerns and uncover new opportunities for exercise to operate as an effective adjuvant treatment.

4.5. Study design

Observational studies have been limited largely to one-time, cross sectional surveys among this population. Improvements in sample diversity and measurements (classification and outcome) are discussed above. Larger and more longitudinal studies are needed to examine the impact of survivorship on exercise behaviors across the lifespan and identify additional aspects of survivorship that may impact physical activity levels and exercise behavior.

Increased feasibility studies of exercise interventions among survivors of SV are needed. Themes from qualitative studies should be incorporated into interventions to make them patient-centered and trauma-informed. It is unclear from the included research which implementation efforts have been made to effectively engage survivors of SV, if any. This is especially relevant considering several studies included here which emphasized the importance of participant safety and avoiding unwanted attention (Concepcion & Ebbeck, 2005; Smith-Marek, Baptist, Lasley, & Cless, 2018). Exercise is a mirror of society, and so SV and other forms of harmful violence may even be perpetuated in exercise environments. Survivors are vulnerable to re-victimization and may go on to experience SV in exercise settings, which often experience little regulation (Fasting & Brackenridge, 2009; Fasting, Brackenridge, & Knorre, 2010; Kirby, Greaves, & Hankivsky, 2000). This underlines the importance of increased work identifying exercise-specific principles to enhance participants’ safety within this context (Pebole et al., 2020).

Intervention studies in this population would benefit from several improvements. Randomization and blinding in exercise trails are needed, as well as multicomponent interventions that include strength, aerobic, flexibility, and balance activities. Exercise modes in the above interventions included only aerobic training (walking, elliptical, or circuit training) and yoga. The included modes indicate a lack of focus on exercise interventions structured to meet public health guidelines which specify 150 min a week of moderate intensity or 75 min a week of vigorous intensity and 2 days a week of strength training to improve physical and mental health (Centers for Disease Control and Prevention, 2018). These limited exercise modalities also signify a lack of tailored and person-centered approaches for this population. This is especially concerning given the existing evidence which included an over-representation of survivors in self-defense classes and supported the acceptability of self-defense programs among survivors. Yet, self-defense was not offered as an exercise mode in included interventions (Cole & Ullrich-French, 2017; Guthrie, 1997; Hollander, 2010; Huddleston, 1991). Future research should examine exercise preferences in this population and expand offered exercise modes.

5. Conclusion

SV has substantial, wide reaching negative health impacts for survivors that can persist over a lifetime. This review provides preliminary evidence suggesting that exercise may be widely beneficial for mental health in survivors of SV. We also present qualitative data relative to exercise preferences and implementation in this population. The paucity of research examining exercise among survivors of SV emphasizes the need for significantly more work to accurately understand the relationships between exercise and SV, including: (1) understanding if/how SV impacts decisions about being physically active, (2) the impact exercise can have on the mental and physical health of survivors, and (3) important trauma-informed considerations for designing future exercise interventions. Research in this area would benefit from: representative samples among populations at high risk for victimization, more consistent and in-depth recording of SV history and exercise levels, consistent and trauma-informed outcome measurements, and more diverse study designs and intervention components including a wider range of exercise modes. Assessment of physical health and functioning outcomes in exercise trials should also be included, as well as clinical health outcomes, healthcare utilization, social support, and other health promoting behaviors.