A Meta-Summary of Qualitative Findings about Professional Services for Survivors of Sexual Violence

Abstract

Sexual violence occurs at alarming rates in children and adults. Survivors experience myriad negative health outcomes and legal problems, which place them in need of professional services. A meta-summary was conducted of 31 published qualitative studies on adults’ responses to sexual violence, with a focus on survivors’ use of professional services. Combined samples included 46 men, 984 women, and six couples who had experienced sexual violence at any point in their lives. Findings indicated that qualities of professional service providers and outcomes of professional services were perceived either positively or negatively (rather than neutrally) by survivors, regardless of the provider’s professional discipline. Professionals who work with sexual violence survivors can use these findings to improve their practices.

Introduction

Sexual violence is reported to occur at alarming rates in both children under age 18 and in adults. In retrospective studies of adults in the United States, approximately 25% to 30% of women and 13% to 16% of men report having experienced sexual abuse before the age of 18 (Bolen & Scannapieco, 1999; Dube, Anda, Whitfield, Brown, Felitti, Dong, et al., 2005). Furthermore, the National Violence Against Women Survey results indicate that 3% of men and 17.6% of women report that they have experienced forced sexual encounters in their lifetime (Tjaden & Thoennes, 2006).

Survivors of sexual violence are known to experience myriad short-term and long-term negative physical and mental health outcomes. Physical injury during the immediate post-trauma period, along with long-term genitourinary, gastrointestinal, and chronic pain problems, place survivors in need of the professional services of nurses, physicians, and other health care professionals (Campbell, Lichty, Sturza, & Raja, 2006; Centers for Disease Control & Prevention, 2007; Stein, Lang, Laffaye, Satz, Lenox, & Dresselhaus, 2004). Mental health concerns including anxiety, depression, and post-traumatic stress disorder (PTSD) occasion the need for encounters with therapists and counselors (Bonomi, Anderson, Rivara, & Thompson, 2007; Dube et al., 2005; Kendler, Bulik, Silberg, Hettema, Myers, & Prescott, 2000; Suris, Lind, Kashner, & Borman, 2007). Sexual assault frequently requires legal intervention with police, lawyers, and the court system (Hazelwood & Burgess, 2001). This article will synthesize the findings about professional services for survivors of sexual violence in 31 qualitative study reports. These reports published between 1992 and 2005 document women’s and men’s responses to sexual violence.

Literature Review

Numerous variables related to professional services for survivors of sexual violence have been examined using quantitative methods. Most of the literature on professional services used by survivors focuses on one professional discipline or several closely-related disciplines. Studies abound on the attitudes and actions of professionals dealing with survivors of sexual violence and on the outcomes of these encounters. These professionals include legal/criminal justice personnel, physicians, nurses, mental health counselors/therapists, and educators.

Rates and practices of reporting sexual violence, both by victims and professionals, have been widely examined. Some studies indicate that reporting, prosecuting, and conviction rates are based on factors such as gender, race, age of victim, poverty, and level of urbanicity (Felson & Pare, 2007; Howerton, 2006; MacMillan, Jamieson, & Walsh, 2003; Menard & Ruback, 2003; Sedlak, Doueck, Lyons, Wells, Schultz, & Gragg, 2005). Other studies have examined patient and provider opinions and actions related to mandatory reporting (Strozier, Brown, Fennell, Hardee, & Vogel, 2005; Sullivan & Hagen, 2005).

Numerous studies have examined myths and stereotypes about sexual violence and the extent to which various professionals hold these views (DuMont, Miller, & Myhr, 2003). While some myths and stereotypes have been shown to be less common in recent years in some professional groups (Page, 2008), stereotypes about the degree of physical force and injury, sexual experience of the victim, and intimate relationships between victim and perpetrator still exist (DuMont et al.; Page).

A large number of studies have focused on knowledge or training of professionals including educators, police, medical residents, and emergency room personnel (Dubow, Giardino, Christian, & Johnson, 2005; Jones, Garrett, & Worthington, 2004; McLaughlin, Monahan, Doezema, & Crandall, 2007; Plichta, Vandecar-Burdin, Odor, Reams, & Zhang, 2006). A perceived lack of specialized training by professionals has been linked to less comfort in interviewing/questioning possible victims (Kinney, Bruns, Bradley, Dantzler & Weist, 2007) and to low levels of reporting and appropriately dealing with existing and potential sexual violence sequelae (Martin, Young, Billings, & Bross, 2007). Studies that test treatment outcomes are widely reported. Various types of psycho-therapy have been shown to effectively reduce anxiety, depression, and PTSD symptoms, and to increase wellbeing of sexual violence survivors (Kessler, White, & Nelson, 2003; Martsolf & Draucker, 2005). The effectiveness of Sexual Assault Nurse Examiner programs and specialized rape crisis services has also been evaluated (Campbell, Patterson, & Lichty, 2005; Plichta, Clements, & Houseman, 2007; Wasco, Campbell, Howard, Mason, Staggs, Schewe, & Riger, 2004). Other studies have explored whether and to what extent professionals who work with sexual assault victims experience vicarious trauma (Trippany, Wilcoxon, & Satcher, 2003; Way, VanDeusen, & Cottrell, 2007).

Process outcomes related to the enactment of professional services have also been examined. Some studies have investigated patient comfort with sexual abuse prevention or screening activities (Littleton, Berenson, & Breitkopf, 2007; Thomas, Flaherty, & Binns, 2004), and with various aspects of the sexual assault examination (Mears, Heflin, Finkel, Deblinger, & Steer, 2003).

An emerging area of research on rape is attention to the interactions between victims and the system (particularly police and medical professionals; Campbell, 2005). In an earlier study, Campbell and colleagues (Campbell, Wasco, Ahrens, Sefl, & Barnes, 2001) determined that rape victims’ encounters with legal and medical services were often less than satisfactory; expected services were not provided and poor treatment (often called the “second rape”) occurred in at least one-half of the cases. However, Campbell et al. (2001) also found that about 47% of study participants considered their interactions with medical professionals to be healing.

A much smaller body of knowledge about professional services provided to survivors of sexual violence has been generated using qualitative research techniques. Several studies have examined the experiences of rape crisis workers (Clemans, 2004; Rath, 2008; Ullman & Townsend, 2007). At least eight qualitative studies investigated some aspect of professional services use by survivors (Draucker, 1999b; Draucker & Petrovic, 1997; Edmond, Sloan, & McCarty, 2004; Ericksen, Dudley, McIntosh, Ritch, Shumay, & Simpson, 2002; Gallop, McCay, Guha, & Khan, 1999; Konradi, 1996; Logan, Evans, Stevenson, & Jordan, 2005; Mills & Daniluk, 2002). These studies examined: (a) barriers to and outcomes from specific types of therapy or of mental health services in general (Draucker, 1999b; Draucker & Petrovic; Edmond et al.; Logan et al.; Mills & Daniluk); (b) effectiveness of specialized rape crisis services (Ericksen et al.); (c.) use of restraints during inpatient hospitalizations (Gallop et al.); and (d.) the experience of using legal services (Konradi).

The current study uses the findings from 31 qualitative studies examining all aspects of women’s and men’s responses to sexual violence (including, but not limited to, professional services) to extract findings and conduct a meta-summary of those findings related to survivors’ use of professional services. A thorough discussion of the sampling process appears in the method section which follows. A meta-summary of qualitative findings will add to the existing body of knowledge by aggregating survivors’ perspectives of their professional services experiences across a wide variety of disciplines as depicted in findings of qualitative studies.

Method

A research team comprised of four faculty members and two doctoral students at Kent State University College of Nursing conducted a research synthesis as a part of a larger synthesis project of qualitative studies on a wide variety of aspects of men’s and women’s responses to sexual violence. The first and second authors have conducted numerous studies on various types of interpersonal violence including sexual violence, intimate partner violence, childhood maltreatment, and adolescent dating violence (Draucker & Martsolf, 2006; Draucker & Stern, 2000; Martsolf, 2004; Martsolf, Draucker, & Chapman, 2004). The fifth author completed her dissertation work on the topic of helping behaviors used by survivors of sexual violence and the third and fourth authors are experienced nurses in the areas of mental health and women’s health respectively. The last author joined the research team as part of her doctoral work.

This meta-summary was part of a larger project titled “Women’s and Men’s Responses to Sexual Violence.” The purpose of the larger project was to develop a mid-range theory to describe, explain, and predict adults’ responses to sexual violence experienced at any time during the lifespan. One research question in the larger project was: “What is the role of social structural forces (cultural, social, economic, and institutional), including those of the healthcare system, on the participants’ responses to sexual violence? While the purpose of the larger study was to look at numerous factors related to how women and men respond to sexual violence, the purpose of this qualitative meta-summary is to focus on how services provided by professionals from a variety of disciplines influence responses of survivors of sexual violence.

Sandelowski and Barroso (2007) differentiate between two qualitative research synthesis processes: meta-summary and meta-synthesis. “Qualitative metasummary is a quantitatively oriented aggregation of qualitative research findings that are themselves topical or thematic summaries or surveys of data” (p. 17). Qualitative meta-summary can be the final product in a synthesis project, as it is in the current project, or it can be used as an initial step in a meta-synthesis project. “Qualitative metasynthesis is an interpretive integration of qualitative findings that are themselves interpretive syntheses of data…” (Sandelowski & Barroso, 2007, p. 18). Qualitative meta-summary was selected for this project because the findings in the majority of the studies were at the topical or thematic level rather than at the interpretive level.

Sandelowski and Barroso’s (2007) approach for synthesizing qualitative research was closely followed for this project. Studies were included in the synthesis project if they were qualitative regardless of whether they were labeled as such. Qualitative studies were defined as “empirical research with human participants conducted in any research paradigm that used what are commonly viewed as qualitative techniques for sampling, data collection, data analysis, and interpretation” (Sandelowski & Barroso, 2003, p. 154). Only studies conducted in the United States or Canada, and published in peer-reviewed journals before January 1, 2006, were included in the synthesis project. Because cultural context affects survivors’ responses to sexual violence, the research team decided to limit this synthesis project to studies conducted in North America in an effort to eliminate some of the cultural variability in the findings. The team acknowledges that limiting our project to studies published in peer-reviewed journals may create some selection bias. We reached consensus about this decision for several reasons. First, the team believes that the peer-review process increases the credibility of the findings. Second, the majority of unpublished research is in the form of dissertations which must be retrieved in order to determine if the study meets inclusion criteria for the project. This process is very time-intensive with low yield of applicable studies. Finally, the team realized that many dissertations are published. Including a dissertation in both its unpublished and published forms necessitates accounting for duplicate findings when conducting the synthesis project (Sandelowski & Barroso, 2007). The research synthesis process described below is a very methodical process which takes several years to complete. The research team members began the process on January 1, 2006 and made the decision to maintain the rigor of the review and analysis process rather than to attempt to include studies published after that date.

With the assistance of a research librarian, an exhaustive search was made of the following databases: CINAHL, Medline, Sociological Abstracts, PsychInfo. Search terms used included: sexual violence, domestic violence, intimate partner violence, childhood sexual abuse, qualitative research, phenomenology, ethnography, grounded theory, and historical research. Studies were included if they met the following inclusion criteria: (a) the focus of the study must be on women’s and/or men’s responses to sexual violence of any type at any point in the lifespan, (b) the study must be a qualitative study regardless of whether the researchers labeled it as such, (c) studies that are incorrectly labeled as a specific qualitative research methodology and are another type of qualitative methodology were included, (d) the study must be conducted in the U.S. or Canada and can include participants of any race, ethnicity, nationality or class, (e) study findings must be reported before January 1, 2006, and (f) the study must be reported in a peer-reviewed journal. Studies were excluded if: (a) they had no human subjects (i.e., as in analyses of media representations), (b) participants had not experienced sexual violence (such as mothers of children who experienced sexual violence), (c) studies of children who experienced sexual violence and were children at the time of the study, (d) mixed-method studies in which qualitative findings could not be separated from quantitative findings, (e) mixed-sample studies in which findings about women’s and/or men’s responses to sexual violence could not be separated from those of other participants who did not experience sexual violence, and (f) they were unpublished dissertations or theses.

Seventy-three articles met inclusion criteria. The first study in this set of articles was published in 1992. Using procedures developed by Sandelowski and Barraso (2007), we closely examined the background of the authors, the literature review, study purpose and research questions, methodology, results, discussion, and limitations. Two members of the research team appraised each article, and we met weekly to compare appraisals and to determine whether the study met criteria for inclusion in the meta-synthesis project. We eliminated 26 studies because they did not have findings, but simply presented raw data without interpretation by the researchers.

Thirty-one of the 47 studies in the sample of qualitative studies on women’s and men’s responses to sexual violence contained findings related to use of professional services. A professional services finding was defined as any finding that includes a reference to survivors’ use or non-use of the assistance of a person who is qualified in a specialized way (based on education, training, licensing, credentialing, or job description) to help ameliorate the negative effects of sexual violence experiences.

First-author disciplinary affiliation in the 31 studies included nursing (n=16), psychology (n=7), psychiatry (n=1), counseling (n=1), sociology (n=2), health sciences (n=1), education (n=1), and unknown (n=2). Range of sample size was five to 251; total sample size, including all 31 reports, was 1030 (mean sample size = 33, median sample size = 12, and modal sample size = 10). Twenty-six of the 31 reports included only female participants (total sample size = 970 women). Three studies included men only (n= 36). One study included both men and women (men, n=10; women, n=14), and one study included couples (five heterosexual, one lesbian).

The stated purpose of the research in eight of the 31 reports was to examine experiences related to professional services use by survivors of sexual violence. The stated research purposes of the remaining 23 studies included examination of the context of the social or cultural environment in which the violence occurs, outcomes of the violence, and how survivors manage the violence. Approximately one-half of the 31 studies indicated a guiding theoretical orientation. Six of the 16 reports in which a theoretical stance was explicitly stated were based on trauma models (e.g., Finkelhor & Browne, 1985), three on social constructionism, three on feminism, two on ecologic models, and one on symbolic interactionism. Research methods included: long interview method (n=1); content analysis (n=5); qualitative interpretive (n =3); ethnography (n=1); phenomenology (n=8); grounded theory (n=8); focus group (n=1); critical narrative analysis (n=1); life history analysis (n=1), discourse analysis (n=1); McCracken five stage analysis (n=1; McCracken, 1988).

The findings in the 31 studies were primarily at the level of topics or themes (Sandelowski & Barroso, 2003), rather than at the conceptual or interpretive level. As suggested by Sandelowski and Barroso, we first extracted all the findings in each study related to professional service use by survivors of sexual violence. A total of 271 findings on this topic were extracted and then edited into complete sentences that could be understood by readers who had not read the original report. These 271 findings were then consolidated into 16 more abstract statements by eliminating redundant statements by combining like statements. A frequency effect size was calculated for each of the 16 statements by dividing the number of articles containing that finding by the total number of articles (n=31). Table 1 summarizes the eight findings with effect sizes greater than 15%, which is the effect size selected by Sandelowski and colleagues (Sandelowski, Lambe, & Barroso, 2004).

Table 1.

Professional Services Findings with Effect sizes ≥ 15%

Statement of Findings (n=16)	Effect Size
Professional services that are perceived positively by survivors of sexual violence include being seen as competent, providing support (both physical and emotional), providing acceptance, being nonjudgmental, providing validation of feelings and experience, being present and available, not rushing the client, listening, giving clear information, and providing a safe environment (Draucker, 1992 Draucker & Stern, 2000; Edmond et al., 2004; Ericksen et al., 2002; Gallop et al., 1999; Glaister & Abel, 2001; Hall, 2000; Harned, 2005; Kondora, 1993; Konradi, 1996; Logan et al., 2005; Mills & Daniluk, 2002; Phillips & Daniluk, 2004; Rhodes & Hutchinson, 1994; Smith & Kelly, 2001; Tyagi, 2001; Wood & Rennie, 1994).	.50
Many survivors of sexual violence experience negative behaviors or personal characteristics of therapists and other health care professionals including not being present or available, victim blaming, pushing the client to talk or leave an abuser before being ready, not recognizing client behaviors as being indicative of sexual abuse, giving overwhelming information, having inappropriate sexual boundaries, not allowing the client to direct the therapy including when it ends, being incompetent, and being culturally/racially or gender different from the client. (Draucker, 1993, 1999a, 1999b; Draucker & Petrovic, 1997; Draucker & Stern, 2000; Edmond et al., 2004; Gallop et al., 1999; Gill & Tutty, 1999; Glaister & Abel, 2001; Logan et al., 2005; Rhodes & Hutchinson, 1994; Symes, 2000; Washington, 2001; Wood & Rennie, 1994)	.42
Female survivors felt that the relationship with a therapist or health care provider (hcp) was a safe place and provided positive responses for coping and healing when the therapists/(hcp) were gentle, treated them like individuals with unique needs, really listened, considered their type of sexual violence, did not tell them what to do, made them feel worthy, built up their self confidence, told them no one deserves abuse, help them deal with powerful emotions, explored issues depth, took active steps to help them through difficult times (Alaggia, 2004; Draucker, 1992, 1999a, 1999b; Draucker & Stern, 2000; Edmond et al., 2004; Gallop et al., 1999; Glaister & Abel, 2001; Godbey & Hutchinson, 1996; Phillips & Daniluk, 2004; Symes, 2000; Tyagi, 2001).	.35
Survivors of sexual violence have generally positive outcomes when receiving professional health services or therapy regardless of specific type of professional service or therapy (e.g., eclectic, EMDR, specialized sexual assault services, dance, or support groups) if the therapy focuses on the abuse while survivors who receive services which ignore the trauma history tend to have many negative outcomes (Alaggia, 2004; Edmond et al., 2004; Ericksen et al., 2002; Gallop et al., 1999; Glaister & Abel, 2001; Godbey & Hutchinson, 1996; Mills & Daniluk, 2002; Phillips & Daniluk, 2004; Smith & Kelly, 2001; Wing & Oertle, 1999).	.32
Many survivors of sexual violence experience negative responses from “society” or the “whole community” including stigmatization, backlash related to identifying the perpetrator, siding with the perpetrator, gossip (or community knowledge of one’s private affairs), ignoring or denying the societal problem of sexual abuse, and assumption that sexual orientation is related to CSA experiences (Draucker, 1993; Draucker & Stern, 2000; Fater & Mullaney, 2000; Leibowitz & Roth, 1994; Logan et al., 2005; Robohm, Litzenberger, & Pearlman, 2003; Tyagi, 2001; Washington, 2001).	.26
Professional services that are perceived negatively by survivors of sexual violence include lack of attention to gender, rushing the client or giving overwhelming information, not listening to the client (especially about the abuse history), treating the client insensitively, and not being competent; these types of services have negative outcomes for survivors (Draucker, 1999b; Ericksen et al., 2002; Gallop et al., 1999; Gill & Tutty, 1999; Konradi, 1996; Logan et al., 2005; Rhodes & Hutchinson, 1994).	.23
Positive outcomes of professional services for survivors of sexual violence include improvements in self- esteem, mood, behavior, and overall ability to function and cope; these outcomes can be felt immediately or later and can be long term (Edmond et al., 2004; Ericksen et al., 2002; Hall, 2000; Mills & Daniluk, 2002; Phillips & Daniluk, 2004; Wing & Oertle, 1999).	.19
The expectation of a negative response (not being believed, being blamed, minimizing, being a burden) from others is often enough of a reason for survivors not to disclose their experiences of sexual violence to another person or to only partially disclose (Alaggia, 2004; Gill & Tutty, 1999; Tyagi, 2001; Washington, 2001; Wiersma, 2003).	.16

Findings

When given the opportunity to talk about their experiences with professional services, survivors of sexual violence are not neutral about these experiences. Rather, they articulate: (a) positive qualities of professional service providers; (b) negative qualities of professional service providers; (c) positive and negative outcomes related to services provided. Common qualities and outcomes were observed in professionals across a variety of disciplines. Disciplines represented in the 31 studies included: therapists/mental health clinicians/counselors; sexual assault specialists; inpatient mental health staff; health-care providers (physicians and nurses); police/legal system professionals. Sixty-six percent (n=31) of the articles in the overall project (n=47) had at least one finding related to survivors’ perceptions about professional services and related outcomes, although only eight studies specifically examined these perceptions.

Positive qualities of professional service providers

Table 2 lists the positive qualities of professional service providers identified by survivors of sexual violence. The qualities fell into three general categories: (a) abuse focus; (b) interpersonal interactions; (c) professional competence.

Table 2.

Qualities of Professional Service Providers and Outcomes of Services

	Positive	Negative
Qualities of Professionals	Abuse focus:	Abuse focus:
	Focuses on the abuse history	Ignores the abuse history
	Believes and validates the sexual violence experience	Does not believe or minimizes the sexual violence experience
	States that no one deserves abuse	Blames the victim
	Interpersonal interactions	Interpersonal interactions
	Listens	Does not listen
	Present & available	Not present or unavailable
	Sensitive	Insensitive
	Accepting Gentle Nonjudgmental Supportive	Labeling Intimidating Judgmental Aloof
	Takes time	Rushes
	Follows survivor’s lead	Pushes
	Professional competence	Professional competence
	Competent	Incompetent (including violating sexual boundaries)
	Considers gender issues	Ignores gender issues
	Gives clear information	Gives overwhelming information
Professional Services Outcomes	Improved:	Feeling:
	Behavior
	Coping
	Functioning	Powerless
	Mood
	Self-esteem	Demeaned

In general, participants in these studies wanted professionals to focus on their abuse history as being important, even if the services were being provided (for example, health care) for something that might be viewed as unrelated. Regardless of service type, survivors wanted to be believed and validated about the abuse. In fact, the expectation that they might not be believed prevented some participants from seeking or using professional services. In addition to being believed, participants positively perceived professionals who told them that no one deserves to be abused.

Survivors identified several positive interpersonal qualities demonstrated by professionals during an encounter. When professionals were present and available, took time, were sensitive, listened, and followed the survivor’s lead, they were perceived positively by participants.

Survivors were particularly concerned about the competence of professionals. Competence was related to the professional’s ability and willingness to use his/her specialized training or position to assist the survivor in dealing with or recovering from the negative effects of the violence. Competence was also seen as resulting in positive outcomes. In particular, survivors wanted to be given clear information and have consideration given to their gender.

Negative qualities of professional health providers

By definition, professionals are those who are qualified in a specialized way to help ameliorate the negative effects of sexual violence experiences. Thus, the expectation is that professionals will demonstrate qualities that are helpful to survivors of sexual violence. However, participants in these studies described common qualities of professionals that do not help ameliorate the violence experience. As shown in Table 2, the negative qualities identified by survivors are mirror images of the positive qualities. The negative qualities fell into the identical general categories: (a) abuse focus; (b) interpersonal interactions; (c) professional competence.

The tendency by professionals to ignore the history of sexual violence, especially in situations in which services may not appear to be directly related to the violence experience, was perceived as negative. Even in situations in which services were being sought for direct sequelae of the violence (such as legal services in rape cases), participants were doubted, blamed, or advised to ignore or forget the violence.

Interpersonal encounters with professionals were often not helpful in ameliorating the effects of the violence. Participants responded negatively to professionals who were not available or not truly present in an encounter. Professionals who were insensitive, rushed survivors, or pushed them to make changes too quickly were viewed negatively.

The findings of incompetence in some professionals were the most disturbing. Some professionals seemed unable or unwilling to use their specialized training, knowledge, or job position to effectively help the survivors deal with or recover from the sexual violence. In some cases, participants indicated that the professionals lacked sufficient or current knowledge or training to adequately perform their jobs. Sexual boundary violations were described by participants in several studies. Some professionals did not provide information in a competent, clear manner; instead, they overwhelmed the survivor with information. Professionals who were unaware of, or lacked knowledge about, gender issues were problematic for survivors.

Outcomes of professional services

Participants in these studies indicated that outcomes of professional services were related to the qualities demonstrated by the professionals. Thus, positive qualities tended to foster positive outcomes, while negative qualities tended to foster negative outcomes.

Positive outcomes were identified in five general areas: (a) behavior; (b) coping; (c) functioning; (d) mood; (e) self-esteem. Positive behavioral outcomes included such changes as decreases in self-harm behaviors. Coping changes included an increased ability to be spontaneous, and decreased minimization or denial of problems. Increased functioning included such changes as an increased ability to accomplish tasks of daily living, both work and play, and an increased sense of personal agency. Common mood changes included decreases in depression and anxiety, feelings of guilt, and overwhelming, unmanageable, and undesired emotions. Self-esteem changes included the ability to view oneself as having an identity and worth beyond being a survivor of sexual abuse.

Two specific negative outcomes were seen to be direct results of negative qualities demonstrated by professionals; both were feeling states, rather than behaviors or functions. Feeling powerless was the first negative outcome directly related to professional services. It resulted from negative professional qualities, such as violation of sexual boundaries, not believing the abuse history, or overwhelming the survivor with information. The second negative outcome was feeling demeaned. It occurred when the professional blamed the victim, did not listen, or ignored gender issues.

The negative outcomes are mirror images of two of the positive outcomes. Feeling powerless is the opposite of having an increase in one’s ability to function using personal agency. Likewise, feeling demeaned is the opposite of experiencing an increase in self-esteem.

Discussion and Conclusions

A meta-summary of findings in 31 qualitative studies on women’s and men’s responses to sexual violence was conducted in order to extract those findings related to survivors’ experiences with professional services. Professional disciplines represented in these findings included therapists/mental health clinicians/counselors; sexual assault specialists; inpatient mental health staff; health-care providers (physicians and nurses); and police/legal system professionals. Over 270 findings in these studies were abstracted into 16 general findings about professional services provided for survivors of sexual violence. Findings indicated that survivors of sexual violence tend to identify positive and negative qualities of service providers in three areas: (a) abuse focus; (b) interpersonal interactions; (c) professional competence. Furthermore, the positive and negative qualities identified were essentially mirror images of each other. Both positive and negative outcomes of professional services were also identified in this meta-summary. While the positive outcomes were global (behavioral, mood, coping, overall functioning, and self-esteem), negative outcomes were feelings of powerlessness and being demeaned.

The purpose of this meta-summary of qualitatively-generated findings was to extend knowledge from prior findings in quantitative studies on sexual violence survivors’ use of professional service. This meta-summary extends knowledge by presenting abstracted findings from studies about numerous disciplines, and summarizing similar findings across disciplines. Findings in most prior studies were based on samples in which only one or two closely-related professional disciplines were evaluated.

This summary suggests that both positive and negative professional qualities were identified by survivors, a finding discussed in several quantitative studies. Campbell and colleagues (2001) found that rape survivors reported both positive and negative experiences with professionals (primarily medical and criminal justice). Likewise, Holmberg (2004) found that rape and assault victims perceived most polices officers as calm and helpful. Some officers, however, were perceived to be dominating, and survivors interviewed by these officers provided less information about the assault.

Furthermore, this meta-summary provides support for the importance of the interactions between victims and professionals as noted by Campbell (2005) and Havig (2008). The three areas identified in the meta-summary (abuse focus; interpersonal interactions; competence) were strikingly similar to the findings of a qualitative study that was not in our sample (it was published after 2005). McGregor, Thomas, and Read (2006) gathered information from women survivors of childhood sexual abuse (CSA) about their therapy experiences. Participants in the McGregor et al. study indicated that three particular areas of therapy were important to them: “(a) establishing a therapeutic relationship, (b) talking about experiences and effects of CSA, and (c) dealing with errors in therapy” (p. 36). The McGregor et al. finding about the importance of establishing a therapeutic relationship is similar to our finding about interpersonal interactions in which the professional listens, is present and available, is sensitive, takes time, and follows the survivor’s lead. The McGregor et al., finding of the importance of talking about CSA is similar to the importance of the abuse focus in the current study. Likewise, the McGregor et al. finding of dealing with errors in therapy is similar to the meta-summary finding of the importance of professional competence.

The concept of “second rape” has been presented in findings from other studies, most notably the one by Campbell and colleagues (2001). The findings of this meta-summary support the idea that survivors perceive some professional services as demeaning and rendering them powerless.

Five of the studies used for this meta-summary included men; the need to attend to gender issues was a finding for both men and women. However, a limitation to the current study was that the preponderance of study participants were female. Most qualitative or quantitative studies of professional service use by survivors of sexual violence are based on findings from female participants.

In addition to the limitation related to gender noted above, our meta-summary is limited in several ways. First, the decision to include only those studies conducted before January 1, 2006 may limit our findings. The research team acknowledged that searching for studies published after that date and evaluating them with the same rigor used in the synthesis project would delay dissemination of the findings. Thus, we determined that maintaining the rigor of the research synthesis process, while completing the project in a timely fashion, was paramount. However, a literature search of studies conducted since 2006 yielded the McGregor et al. (2006) study with findings that support this meta-summary.

Another limitation of this research synthesis project is that six of the 31 studies included in the meta-summary were conducted by the second author. We attempted to avoid bias by having two members of the research team, other than the second author, conduct the appraisal reviews for these six studies. Sandelowski and Barroso (2007) suggest that research teams contact the researcher when questions arise about information in a report. We found that having the researcher who conducted six of the studies on our research team was helpful when we wanted clarification.

This meta-summary project has implications for researchers, both primary researchers in the area of sexual violence and those who conduct meta-synthesis projects. The body of knowledge about sexual violence is extensive. However, knowledge about men’s responses to sexual violence continues to be limited. Future research should be focused on men and on comparing and contrasting women’s and men’s sexual violence experiences and responses to those experiences. Researchers who conduct qualitative synthesis projects will need to grapple with the problem of maintaining the rigor of the process while closing the gap between publication date of a study and its inclusion in a qualitative synthesis.

Professionals who work in disciplines ranging from health care to criminal justice can use the findings from this meta-summary as an impetus to examine their daily interactions with survivors of sexual violence. Professionals are trained, educated, licensed, or credentialed to provide services to help ameliorate the effects of violence. Findings from this study indicate that these services can be provided in a way that helps or hinders the process of amelioration. Survivors who participated in these studies provided data that categorized professional actions as positive or negative. The fact that some professionals do not focus on the abuse, or are insensitive and uncaring in their interactions, is disturbing. Professionals who have learned the basic principles of focusing on the abuse by acknowledging it, listening attentively, and responding sensitively can use these findings to reinforce their current practices. Professionals who have not learned the importance of these principles would benefit from continuing education that directly addresses effective strategies for working with survivors. The findings in this meta-summary of 31 qualitative studies are presented with the hope that professionals will exhibit the positive qualities identified by these survivors and engage in professional practices that ameliorate the effects of sexual violence.

Biography

Donna S. Martsolf is a professor at the Kent State University College of Nursing. Her research interests include interpersonal violence, women’s mental health, and cross-cultural aspects of health.

Claire Draucker is a distinguished professor at Kent State University College of Nursing. Her research interests include violence across the lifespan, adolescent mental health, and qualitative methods. Claire Draucker, PhD, CS; 311 Henderson Hall, College of Nursing, Kent State University, Kent, OH 44242-0001; Phone: 330-672-8805; Fax: 330-672-2433; cdraucke@kent.edu

Christina B. Cook is an Assistant Professor at Kent State University. Her research interests are Sexual Violence and Multiple Grief. Christina B Cook PhD, RN, CNS; 343 Henderson Hall; College of Nursing, Kent State University, Kent, OH 44242; Phone: 330.672.2825; Fax: 330.672.1564; cbcook@kent.edu

Ratchneewan Ross is an Associate Professor at the Kent State University College of Nursing. Her areas of research include sexual violence and mental health of women and vulnerable populations. Ratchneewan Ross, PhD, RN; 362 Henderson Hall, College of Nursing, Kent State University, Kent, OH 44242; Phone: 330-672-8785 (Office); Fax: 330-672-2433; rross1@kent.edu

Andrea Warner Stidham is an assistant professor at the Kent State University College of Nursing. Her research interests include sexual violence and pediatric mental health. Andrea Warner Stidham, RN, Ph.D.; Assistant Professor, College of Nursing, Kent State University, P.O. Box 5190, Kent, OH 44242; Phone: 330.672.8831; awarner@kent.edu

Prudencia Mweemba is a lecturer in the Department of Nursing Sciences at the University of Zambia. Her research interests are quality of life in persons with chronic illness, compliance/adherence with medication, emergency care, sexual abuse and motivation. Prudencia Mweemba, PhD; University of Zambia, School of Medicine, Department of Nursing Sciences, P.O. Box 50110, Lusaka, Zambia, C. Africa; Phone: +260-211-252453; Fax: +260-211-250753; prudencia.mweemba@unza.zm