Navigating Sex and Sexuality after Sexual Assault: A Qualitative Study of Survivors and Informal Support Providers

Abstract

Qualitative interview data from 45 matched pairs of survivors disclosing sexual assaults and their primary informal support provider (e.g. friend, family, significant other) were used to explore survivor-support provider perspectives on changes in sexuality post-assault and how those close to them have been affected as a result. Changes in sexuality included loss of interest in sex, increase or change in sexual partners, engaging in sex work, and increased sexual behavior. Support providers generally regarded promiscuity as a risky sexual behavior, and if they were the survivor’s sexual partner, they discussed exercising caution when navigating sexual intimacy with the survivor. Not all sexual encounters with romantic partners were positive; some survivors discussed being triggered (i.e., with PTSD flashbacks) or experiencing the dissolution of their relationships due to the sexual impacts of their assault. Counseling implications are discussed in the context of improving survivor’s sexual experiences in general and in romantic relationships post-assault. Implications can also be applied to prevention, scholarship on sex work, as well as sexuality research.

Research on sexual assault shows survivors experience various sexual problems post-assault (Van Berlo & Ensink, 2000), including sexual dysfunction and a decrease in sexual satisfaction. An early study of 372 sexual assault survivors discovered 71% of women who had a history of sexual trauma attributed their sexual functioning issues to their past assault (Becker, Skinner, Abel, & Cichon, 1986). Similarly, another study comprised of 371 women revealed the most common sexual problems were fear of sex, arousal dysfunction, and desire dysfunction with 88.2% of women indicating experiencing at least one (Becker, Skinner, Abel, Axelrod, & Cichon, 1984). Weaver’s (2009) literature review on the impacts of assault on sexuality concluded that women who had been assaulted reported several negative sexual effects, including more painful sex and reproductive health related medical issues. A study of Brazilian women showed that those with a past sexual abuse history (versus those without) had more sexual dysfunction and lower quality of life (Carreiro, Micelli, Sousa, Bahamondes, & Fernandes, 2016).

Beyond impacts on sexual functioning, research on sexual victimization finds that women vary in whether they increase their sexual behavior, decrease it, and/or have increased strain on intimate relationships, which may deteriorate or even break up due to the assault. Deliramich and Gray (2008) found that undergraduate and community women tended to increase their alcohol consumption and sexual activity post-assault relative to a comparison sample of women who experienced a motor vehicle accident. Weaver’s (2009) review came to a similar conclusion, namely that most women with a sexual assault history engaged in more high risk sexual behavior and had more lifetime sexual partners.

Van Berlo and Ensink (2000) reviewed research on sexual assault and sexuality and concluded that frequency of sexual contact decreased after sexual assault, while sexual satisfaction declined for many women at least a year post-assault. Problems could persist for years in some victims including response-inhibiting problems, such as fear, arousal and desire dysfunctions (Van Berlo & Ensink, 2000). They also found that being victimized at a young age, by a known offender, and experiencing penetration during assault were related to sexual problems and emotions felt during and immediately after the assault, such as anger towards self, shame, and guilt, could predict sexual problems. Avoiding sexual contact also appeared to be related to sexual problems, whereas having a loving, understanding partner appeared to be protective factor (Van Berlo & Ensink, 2000). Finally, sexual problems were related to posttraumatic stress symptoms and depression (Van Berlo & Ensink, 2000).

Perilloux, Duntley, and Buss’s (2012) study found women who experienced completed rape had many more negative outcomes in various domains compared to attempted rape victims, including large increases or decreases in sex frequency and decreased sexual interest. Effects on women’s sexuality also are likely affected and perhaps magnified by whether they have a history of child sexual abuse (CSA) and the nature of their revictimization experiences. One study of women in Quebec found that a history of CSA and multiple victimizations was associated with more adverse outcomes (risky sexual behaviors, negative sexual self-concept, other sexual problems) than women without CSA and multiple victimizations (Lacelle, Hébert, Lavoie, Vitaro, & Tremblay, 2012).

Post-Traumatic Stress Disorder (PTSD) has been documented in the literature as a common outcome for survivors of sexual assault. In a recent meta-analysis of over 40 years of literature, sexual assault was found to be strongly associated with PTSD (Dworkin, Menon, Bystrynski, & Allen, 2018) and a qualitative review found that 17–65% of sexual assault survivors develop PTSD (Campbell, Dworkin, & Cabral, 2009). Survivors who disclose their assault may face negative social reactions which have been documented to contribute to PTSD symptomatology (Ullman & Peter-Hagene, 2016). Given that PTSD flashbacks are common during sexual experiences post-assault, survivors may need PTSD-specific treatment post-assault (Yehuda, Lehrner, & Rosenbaum, 2015).

Another line of research has focused on the role of sexual victimization, including CSA, in sexual risk behaviors, which appear to mediate revictimization risk (Senn, Carey, & Vanable, 2012; Messman-Moore, Walsh, & DiLillo, 2010). In a community sample of adult female rape survivors, Campbell, Sefl, and Ahrens (2004) found distinct clusters of sexual health risk behaviors: high risk women with large increases post-rape in frequency of sex, number of sex partners, less condom use, and alcohol and/or drug use during sex. A moderate risk cluster had increased frequency of sex, number of partners but more condom use, while a low risk cluster said their sexual health behaviors became less risky post-rape (less sex, partners etc.). In a review of literature, Rellini (2008) concluded that women with a CSA history had both hyper (more) and hyposexuality (less) responses than women in comparison groups, suggesting that survivors may move to extremes of sexual behavior post-assault.

Finally, recent studies of college women show various sexual impacts of sexual assault on women’s sexual behaviors and/or sexuality. For example, Turchik and Hassija (2014) found sexual victimization history in female students was related to sexual risk taking and sexual dysfunctions such as a decrease in sexual desire and difficulty achieving orgasm. Women with more severe experiences like completed rape were most likely to report sexual functioning issues than those with less severe experiences. Similar work by Garneau-Fournier, McBain, Torres and Turchik (2017) indicates a large percentage (87%) of female college sexual assault survivors experienced sexual dysfunction issues such as difficulty achieving orgasm and decreased sexual desire/interest and were more likely to experience more than one type of sexual functioning issue.

Sexual impacts occurring in romantic relationships have been documented, typically from survivors’ perspectives or partners’ perspectives, but not both. For example, Connop and Petrak (2004) interviewed six men in London, England about their experiences following their partner’s disclosure of assault. Men reported difficulties providing support to female partners following an assault, communication between the partners, and effects of assault on the couple’s sexual relationship and male partners’ anger and blame in relation to the assault. Smith (2005) found that sexual assault not only negatively affected the survivor-significant other relationship, but also led to relationship dissolution. Similar to Connop and Petrak, Emm and McKenry (1988) interviewed males post-disclosure of assault by their female partners and found men tended to be more aware of post-assault sexual issues regarding sexual function and desire as compared to survivors who often minimized them. While important findings, in order to gain a broader view of how sexual impacts of sexual assault affect both partners in a relationship, more studies with a view are needed from both partners in research. These findings also relate only to male-female partnerships. There is no research to our knowledge to date involving same-gender partners examining the effects of sexual assault on sexual relationships.

It is important to understand how sexuality may affect the informal supports in a survivor’s life, given that informal support sources are more likely to be utilized by survivors when disclosing their assault (Filipas & Ullman, 2001; Sigurvinsdottir & Ullman, 2014). Informal support providers (e.g. friends, family, romantic partners) are also more likely to provide positive social reactions to a survivor’s sexual assault disclosure (Ahrens & Aldana, 2012; Ahrens & Campbell, 2000; Filipas & Ullman; Sigurvinsdottir & Ullman, 2014). However, negative reactions from informal supports are still experienced, and informal support providers report being unsure of how to respond to a sexual assault disclosure (Ahrens & Aldana, 2012; Ahrens & Campbell, 2000). The social support received from support providers is important; positive social support can affect a survivor’s recovery in a positive way (see Ullman, 2010 for a review).

Most research has examined the impact of CSA and adult sexual assault on sexuality in women looking at these forms of sexual victimization separately, even though much research shows that experiencing child sexual abuse is linked to victimization in adolescence and/or adulthood (Classen, Palesh, & Aggarwal, 2005). This could mean that many women who have histories of sexual revictimization may experience greater challenges with sexuality and intimate relationships in general, due to lost trust in men and/or problems with intimacy post-assault. Few studies have examined sexual behavior and/or sexuality in the context of relationships of survivors of sexual violence, so research is needed to understand how sexual victimization histories relate to women’s sexuality and their willingness and ability to have intimate relationships and the quality of those relationships, both sexual and in terms of intimacy, trust, and relationship satisfaction.

Current Study

Much of previous research has focused on how sexual assault has affected how a victim’s sexual behavior and their concept of sex have changed after the assault. However, research has yet to show how victims’ views toward sexual behavior and their sexuality can affect their support providers (SPs), mostly in the context of romantic relationships, and how those support providers can be helpful in this particular realm of recovery. We sought to study how both survivors and their SPs discuss how the sexual behavior or concept of sex has changed as a result of a sexual assault. Furthermore, if this has changed, we wanted to identify how this may have affected the relationship between the survivor and the SP, particularly highlighting romantic relationships. This study used survivor-SP interview data to investigate the following research questions: 1) How is survivors’ sexuality affected post-assault in positive and/or negative ways, 2) How are the sexual behaviors of survivors different post-assault, and 3) How are different SPs (significant others, family, and/or friends) affected by these potential changes in survivors’ sexuality and sexual behavior post-assault? For the purposes of this paper, we define sexuality as not only the behaviors that survivors may engage (or choose not to engage) in post-assault, but also how survivors describe sex and their own sexual identity, and how that has all been affected by their sexual assault experience. A prior study with these data looked at general impacts on relationships following sexual assault, but not impacts on sexuality specifically (O’Callaghan, Lorenz, Ullman, & Kirkner, under review).

Method

Participants

The sample of this study included adult female sexual assault survivors who disclosed their assault to an informal SP. Survivors had previously participated in a 3-year longitudinal survey (N = 1,863) regarding unwanted sexual experiences and the social reactions they received when disclosing these experiences (see Ullman & Peter-Hagene, 2016, for study description). Survivors who indicated interest in being contacted for interviews were also asked to provide contact information for a friend, family member, or significant other who they told about an unwanted sexual experience. SPs were contacted later for a separate interview that focused on their experience helping the survivor. Separate interviews with survivors and SPs (N=90) took place over 2 years, from 2013–2015 resulting in a sample of N=45 matched pairs of survivors and SP interviews. Written informed consent was obtained for all interviews immediately prior to the interview. The study was approved by the University of Illinois at Chicago IRB. Sampling saturation of participants was considered to be achieved by obtaining diverse participants in terms of relationship type, alcohol use, and race/ethnicity, as we sought to obtain a sample with diverse assault experiences with respect to alcohol use (a focus of the broader study) and relationship types for the interviews, as well as to oversample women of color in order to obtain greater racial/ethnic diversity of those interviewed.

Survivors were an average of 43 years old and ethnically diverse: 53.3% (n=24) African American, 28.9% (n=13) White, 26.7% (n=12) other, 15.6% (n=7) Hispanic, and 6.7% (n=3) not reported. All survivors who participated were female and approximately 65% (n=29) had children. About 65% (n=29) had attended or graduated from college; 24% (n=11) were currently enrolled in school, and 60% (n=27) were currently employed. On average, participants were interviewed 12 years after their most recent unwanted sexual experience (M=12.3; SD=11.7).

SPs were also an average of 43 years old. Two-thirds (62%, n=28) were female, and 64% (n=29) had children. Approximately 60% (n=27) were non-White (African American, Latino, Native American, or multi-racial), and 24% (n=11) were White, non-Hispanic, with about 16% (n=7) unknown, other, or not reported. Most had attended or graduated from college (66%, n=30) and were currently employed (60%, n=27). About half of the SPs interviewed were friends (51%, n=23), just over a third of SPs were family (33%, n=15), and significant others (e.g. romantic partners) made up 16% (n=7) of the SPs of survivors. For more descriptive information (e.g. SP relationship to survivor) on the matched pairs, see Table 1.

Table 1.

Demographic Information of Survivors and Support Providers

Survivor	Significant Other (n=7)	Family (n=15)	Friends (n=23)
Race
African American	4 (57%)	12 (80%)	12 (52%)
White	1 (14%)	2 (13%)	5 (22%)
American Indian	1 (14%)	0 (0%)	0 (0%)
Multiracial	0 (0%)	1 (6%)	4 (17%)
Unknown	1 (14%)	0 (0%)	2 (9%)
Support Provider
Race
African American	3 (43%)	11 (73%)	7 (30%)
White	3 (43%)	2 (13%)	6 (26%)
American Indian	0 (0%)	0 (0%)	2 (8%)
Multiracial	0 (0%)	1 (6%)	3 (13%)
Unknown	1 (14%)	1 (6%)	5 (22%)
Gender
Male	7 (100%)	3 (20%)	6 (27%)
Female	0 (0%)	12 (80%)	16 (73%)
Relationship to Survivor
Spouse	4 (57%)	---	---
Unmarried Partner	3 (43%)	---	---
Child	---	8 (53%)	---
Mother	---	3 (20%)	---
Sister	---	4 (27%)	---
Roommate	---	---	1 (4%)
Friend	---	---	21 (91%)
Sponsor	---	---	1 (4%)

Measures

The interview protocol for survivors and SPs focused on the survivor’s disclosure of an unwanted sexual experience, social support provided/received, and appraisals of the survivor-SP relationship. Interview participants were also asked to discuss the survivor’s post-assault experience in terms of recovery and coping, including coping methods and appraisals of the survivor’s recovery progress.

Interview questions were open-ended with follow-up probes. Interviews with survivors started with a question about their sexual assault experience(s) if they wished to discuss it, followed by a question asking about their experiences telling an informal support person and how they reacted to the disclosure. Then parallel questions were asked if they had an alcohol-related assault. We then asked about what their relationship was like with the person they told currently, when they first disclosed the assault, and how they felt the assault disclosure had affected the relationship. Then we asked if the other person had ever told them about a stressful life experience and how satisfied they are with the relationship currently. We then had a section on other disclosures to other people with parallel sets of questions regarding those disclosures. Interviews with SPs began by asking them to tell about the first time the survivor told them about their sexual assault experience, what they said to the survivor and did to try to help. The same questions were asked if they had an alcohol-related assault experience. We then asked if the SPs knew if the survivors had told others about their experience and if those disclosures had impacted her life, and if alcohol was involved how that impacted those disclosures. We asked if the SPs thought the experience had affected survivors’ lives and if they thought anything could be done now to help them now with their recovery. Then we asked the same questions of the SPs we had asked the survivors about their relationship with survivors as described above. We also asked how the disclosure had affected the SP’s life, whether they had told anyone else about the disclosure, and whether anyone else had disclosed a similar stressful life experience to them before. Finally, we closed by asking SPs if they had anything else to add, ideas about how to help women, or questions they wanted to ask us.

Procedure

Semi-structured face-to-face interviews were conducted by one of three trained interviewers on the research team. Initial mock interviews, reading about interviewing, and feedback from the research team’s faculty supervisor was provided to train interviewers on the protocol and on interviewing sexual assault survivors. Interviews lasted an average of one hour, but ranged from 30 minutes to 3 hours. Semi-structured qualitative interviews were used to provide survivors and their SPs a confidential open-ended safe space to talk about their experiences related to sexual assault, psychosocial impacts, and survivors’ recovery process.

Interviews were conducted in a variety of settings based on convenience and feasibility of participants including survivors’ homes, coffee shops, libraries, or the university, to name a few. Participants were compensated $30USD for the interview portion of the study.

Data Analysis

After each interview, interviewers created “summary” documents, which included interesting points, questions raised, final thoughts, and unanticipated feelings emerging from the interview. The research team followed the same semi-structured interview protocols, yet also were flexible if participants raised specific issues they wished to talk about, in which case interviewers would return to the protocol after allowing them space to diverge as they wished as a way to respect their needs to express material we may not have asked about. Saturation was considered to be achieved once new topics were no longer raised by participants in response to the interview protocol questions. Interviews were audio-recorded, transcribed, and checked by other members of the research team.

Data analysis of the interviews began following the transcription process. Brief summaries and identified patterns were added by the members of the research team during this process. Interviewers conducted a final review of their transcripts for accuracy. Interviewers and members of the research team met to discuss emerging themes and patterns following transcription, as an initial stage in developing the codebook. These emerging themes and patterns were later discussed among the research team in a process similar to that of thematic analysis (Braun & Clarke, 2006). The research team conducted several trials of interview coding and refinement to develop a codebook that covered the content of individual interviews and themes reflecting the matched pair relationships. Coding trials resulted in several revisions of the codebook whereby codes were added, renamed, redefined, and/or combined. The codes were descriptive in nature and were used to summarize and describe the primary topic of the excerpt (Saldana, 2012). We examined the context of the codes by reviewing transcripts and interviewer summaries when identifying relevant interview excerpts (i.e., quotes).

We used Atlas.ti Version 7 qualitative analysis software for coding and analysis. We identified codes that made the most analytic sense of the data (termed “focused” coding; Charmaz, 2006) and used the identified codes to pair with segments of the transcript. Specifically, we selected codes that best represented what was happening in the interview text. We coded the data separately and compared our interpretations of the content with other members of the research team to achieve consensus (Eisikovits & Koren, 2010). This process took place in several stages. First, pairs of coders separately coded each interview matched pair using the codebook. Second, one coder in the pair then reviewed both coded transcripts to identify any inconsistences in the assigned codes. Third, the coders discussed these disagreements until reaching a joint consensed version by both parties (Patton, 2009). In cases where agreement was not obtained, double coding (i.e., simultaneous coding; Saldana, 2009) was used as a compromise between the two codes. Fourth, the original interviewer reviewed the coded transcript for agreement with the assigned codes. The coders and interviewer discussed any disagreements and corrected the coded transcripts until consensus was reached between the three parties. During the coding process, researchers created memos within the transcripts to highlight any relationships or inconsistencies within and between the survivor and SP interviews, or to capture unanticipated themes in the data (Charmaz, 2006). The inclusion of memos allowed coders to pay attention to the relationships between different matched pair interviews.

Analysis took place using an iterative process in several stages after coding was completed. We analyzed the interview at both the individual level and at the level of the matched pair. First, we conducted queries in Atlas.ti software to identify the number of times each interviewee endorsed a particular code related to specific topics (e.g., substance use and recovery, the survivor-SP relationship, coping). We also noted the type of survivor-SP relationship (i.e., friend, family member, significant other). Second, like that of thematic analysis research team members individually reviewed quotes for each query in search of patterns and noteworthy findings (Braun & Clarke, 2006). Third, the team met several times to review the identified themes and patterns. During this process, we looked for similarities and contrasts within and between the 45 matched pairs in response to the proposed research questions of the present study. Data saturation was ensured through these several meetings by making sure every instance of a theme was identified in the interviews, and by looking through other codes to make sure that nothing was missed that could apply to the present study. Overall, there were 20 codes under the umbrella of the “recovery” category, though the focus of this study related to one particular recovery code: recovery_sex, which is described as the “extent to which survivor’s sexual activity/behavior as a result of her assault (e.g. more/less sexually active, engagement in risky sexual behavior).” The analysis process above for all codes is described, which also applied to the recovery_sex code examined in this study.

Results

Results are presented based on the changes in survivors’ sexuality and SP relationships that emerged in our analysis. We use the following abbreviations next to participant quotes to refer to demographic characteristics (S/SP Relationship, Gender, Age, Race/Ethnicity): SO = Significant Other, F = Family, FR = Friend; M = Male, F = Female; AA = African American, WH = White, N = Native American, H = Hispanic, Multi = Multi-Race, U = Unknown. Of the total sample of 45 S-SP’s, 56% of survivors (n=25) and 33% of SPs (n=15) discussed changes related to sexuality or effects on relationships (see Table 2).

Table 2.

Participants’ Changes in Sexuality and Behavior across Themes.

Theme	Survivor (n=25)	SP (n=15)
Changes in Sexuality
Losing Interest in Sex/Celibacy	n=8 (32%)	---
Having More Sexual Partners	n=7 (28%)	---
Engaging in Sex Work	n=3 (12%)	---
Sex Addiction	n=4 (16%)	---
”Choosing” Women as Intimate Partners	n=2 (8%)	---
SP Views of Sexual Behavior		n=4 (27%)
Changes in Survivor’s Sexual/Romantic Relationships
Positive Experiences	n=8 (32%)	n=7 (47%)
Negative Experiences	n=4 (16%)	n=4 (27%)

percentages of subthemes denote proportion to the subsample (n=25; n=15)

Changes in Sexuality Post-Assault

Of those who talked specifically about sex in their interviews, most (N=25) stated that how they viewed sex in general had changed as a result of being sexually assaulted. This often led to changes in their attitudes toward sex or their sexual behavior. Sometimes, both attitudes and behaviors were changed.

Losing interest in sex and being celibate

For many, having a history of multiple sexual assaults resulted in a more negative attitude towards sex. For example, several survivors (n=8) noted how they lost interest in sex after they were assaulted, with some still reflecting those sentiments even years after the assault:

I can’t say I really like having sex til this day. I mean I do but if I don’t have sex I’m okay um I learned how to satisfy myself but I was like almost 30 before I learned how to enjoy it. (S, SO, F, 42, AA).

I have been celibate for many years now and with my history, I’m not saying that I’m dead, I’m just saying if I never have sex again I don’t think I’d die. That’s not the priority today and only was the priority when I had low self-esteem and didn’t know better. (S, FR, F, 51, Multi).

The decision to abstain from sex, while tied to the unwanted experience, was also influenced by other factors. Three survivors said they were influenced by religion or belief in God to remain celibate after their sexual assault or after years of engaging in risky sexual behavior:

It was an experience because I had changed my religion and decided to follow the Lord and just didn’t want to have sex, didn’t want to. (S, F, F, 44, AA).

So I finally got back in the church and it’s not that I don’t want to have sex, I just want to be married. I want that that special connection you have when you’re married. You know, when you’re becoming one. So it’s been a year, over a year. (S, F, F, 46, AA).

Another survivor described remaining “abstinent” for now because she wanted to wait until she had a romantic partner who was more committed. She explained that even though she could have (and has) had a “one-night stand,” that is not how she wanted to engage in sexual activity:

I want a partner that I can share everything, I want them to grow with me and so I don’t want nobody that just for a nightstand. I can get a one nightstand, I’m just like a man, go give a one nightstand even though we don’t want to, we can do it. But I pretty much been staying away from like relationships with guys, you know, I do, I’m sure not a virgin, so even though I have been abstinent for a while, that’s OK. (S, F, F, 54, AA).

Having More Sexual Partners

While not all survivors wanted to stay away from sex completely, some survivors mentioned that their view of sex was altered due to the assault and this led them to engage in more sex (n=7) rather than to abstain or lose interest, as those described above. For some, having more sexual partners was due to their lack of experience with respectful, communicative partners while for others it was tied to their feelings of self-blame and shame:

That’s when it really hit me. So, of course I’m gonna think it’s my fault because I let him in my house. But it was never my fault. I just took that feeling and I took that responsibility for myself and I blamed myself. He looked at me and he’s like, that’s the summer you had your little slut summer. I said, yeah. That’s exactly why because I was trying to ease that pain and say, well, it was just sex. Whatever, I can just have sex with anybody and not mean anything. And that’s exactly what I did. I said so I had my little slut summer because of what happened. (S, SO, F, 32, Multi)

I kind of like put a lot of it in the back of my head, but I remember like being 14. I was a runaway and was very promiscuous. It started because I was molested as a child. (S, FR, F, 24, AA).

So therefore I became promiscuous, it got to the point where I just didn’t care about nothing. Just had the attitude of just not caring. That’s the only thing men want you for anyways so I just started being very promiscuous. (S, F, F, 46, AA).

When I first started, I was 14, it was just like something, I was very promiscuous after the first incident [assault]. (S, F, F, 22, AA).

Still, others engaged in more sexual activity as a way to cope and feel in control of their recovery. Engaging in sexual behavior was seen as taking control of their sexuality and their bodily autonomy. As these survivors explain:

I acted out sexually, a lot. I think to feel more in control of my sexuality, of my body, like and I guess I was promiscuous for about a year, while I was with my ex and he was a constant cheater. I kind of didn’t feel bad about it, I took it as my sort of liberation at the time, I kind of viewed it as my empowerment. (S, FR, F, 21, Multi).

I lived a fast life that consisted of sex being means or a weapon. (S, FR, F, 43, AA).

Some of the survivors said that they had more sexual partners as a way to feel “loved”-something they believed they would not feel without having sex. One survivor was in a relationship with a man she described as “toxic,” and told him that when they had sex that she felt like she was being “molested all over again.” She told him:

I said, my whole life, you know I had to go through life just having sex, just having sex so look for love. (S, FR, F, 43, AA).

Another survivor said that as an adolescent, she was “looking for love” when engaging in sex:

The abuse, sometimes I do think it’s my fault. I don’t talk about it to him cuz I feel like I was 14, I shouldn’t been hanging out with 20 year old guys and I should’ve been in the house instead of outside on the streets. I just think about all that and I’m like he’ll probably think it’s my fault too. He’ll just think I’m some slut and I’m not gonna lie, I was a slut. I was looking for myself. I was trying to find love, it doesn’t excuse my actions but I don’t want him to think I was trying to be a slut the times that I got raped. (S, FR, F, 24, AA)

Engaging in Sex Work

Three survivors disclosed their sex work histories in relation to their sexual assault histories. Women trade sex for money, drugs, shelter, or other things for varied reasons. Women in our study connected their engagement in sex work to their drug use and their sexual abuse.

I was a drug addict. Performing oral sex, a lot of times I would throw up, I would be some disgusted, but the drugs said you got to have me. (S, F, F, 57, Multi)

A couple of guys asked me, “well you’re not on drugs, you don’t drink, why are you doing this?” I need the money, that’s all, I need the money. That’s what I tell them, but deep down I know it’s from me being abused. I don’t use drugs or drink. But I do have an addiction for selling my body, I don’t do anything [sexually] without money. (S, FR, F, 52, AA).

One survivor and SP both discussed how they engaged in sex work. The SP mentioned how they both viewed their sex work:

Went into sex working, for me, I think that was a way of trying to escape. (SP, FR, F, 26, Multi).

Sexual assault survivors may engage in sex work for a variety of reasons that often overlap. Bodily autonomy, survival needs, and other reasons may be the source of motivation for engagement in sex work. In particular, women in this study linked their engagement in sex work to other coping mechanisms like drug use and increased sexual behavior post-assault. While we do not know details surrounding their sex work, these three narratives show that survivors in this study were not indifferent to having done sex work and viewed it as deeply connected to their trauma and therefore it should be recognized as a form of resilience (Shepp, O’Callaghan, Kirkner, Lorenz, & Ullman, under review).

Increased Sexual Behavior

Some survivors (n= 4) reported engaging in increased sexual behavior after their assaults. Survivors sometimes tied this behavior to their definition of “addiction”. Two survivors talked about their experiences with engaging in frequent sexual behavior in the context of engaging in sex work (one in the above section) and watching pornography, while for the others these experiences were tied to drug and alcohol addiction:

Even though I put the liquor down, I still have an alcoholic mind, that’s why when I was first sober, the first five years, I still behaved as if I was drinking and in retrospect, every sexual encounter with men that really wasn’t into me, but pretended to be, it was equivalent to taking a drink to be honest with you. (S, FR, F, 43, AA)

I went through the same addiction to porn… and porn and dating sites. Now at that point I never met anyone on there but I missed that attention I got from guys on the streets so bad that I literally sat at the computer for hours on end looking for someone online to give me that same attention. And from looking at that it went to pornography…I struggled with that for over a year or so and I remind him, I tell him I’ve been through it so and if I can get past it, so can you. (S, FR, F, 24, AA)

Researchers and practitioners are divided on the definition of sex addiction (see Derbyshire & Grant, 2015 for a recent review). While we could not diagnose anyone with sex addiction in this study, it was noteworthy that these four survivors disclosed feeling out of control or addicted to sex in some way. The survivor’s language around engaging in more sexual behaviors as a coping mechanism may also help to illuminate the behaviors that survivors in this study engaged in in order to deal with the trauma that had been inflicted on them. While some survivors did frame these behaviors as negative, we recognize that coping with trauma is incredibly difficult and survivors’ methods of coping should also be recognized as a form of strength and resilience.

Feeling Safer with Women as Intimate Partners

Two survivors connected the gender of their intimate partners and being sexually assaulted. One survivor came out as a lesbian later in life and expressed being able to feel closer to women as romantic partners. However, even though she enjoyed being with women in romantic partnerships, she was sex-avoidant in general and connected that to her trauma:

I just wanted to feel that companionship with another woman because I enjoy women. I like women. I just don’t like having sex with women. I don’t like having sex at all. (S, FR, F, 41, AA)

Another survivor, who identified as bisexual, had joined a youth program for lesbian/gay/bisexual (LGB) kids in her community at age 16. She explained how she felt after joining the program a few years after her assault:

After I left L (school) I swore off men. I don’t like them and all that other stuff. So I didn’t talk to her at first about what happened because I wanted to, I guess becoming a lesbian for me was a way of erasing my past. (S, FR, F, 24, AA)

While sexuality and sexual orientation are complex and never simply just a choice, these survivors reported feeling safer and more connected to women and some of this safety and connection, according to the survivors, was related to being assaulted by men. Sexuality and sexual expression are fluid features of the human experience and do not exist completely separate from people’s broader life experiences (Diamond, 2009).

Support Provider’s Views of Survivor’s Sexual Behavior

SPs who also recognized a survivor’s increased sexual partners generally viewed it as a negative effect of the sexual assault (n=4), especially when they knew the survivor did not feel positively about their sexual behavior:

Well I think the negative thing was she got a little bit more promiscuous. (SP, FR, F, U).

I feel like the guys she meet are taking advantage of her specifically sexually. (SP, FR, M, 53, AA).

She was pretty much all over the place, sexually as a teenager. (SP, F, F, 62, AA).

It was so negative with him and there was a guy that she [survivor] met on craigslist. She’ll go on the internet at night and flirt with guys. I don’t know why exactly, I didn’t understand it. But, there was one that she met that like didn’t make her, it wasn’t like she didn’t describe it to me as like “rape, rape,” but it didn’t sound to me like something anybody would just do willingly and she felt pretty terrible about it afterwards. She gave him a blow job in an alley, and she felt really shitty about herself after that. (SP, FR, F, 26, WH)

Whether out of concern for the survivor’s safety or general well-being and recovery, SPs often recognized when survivors were engaging with more sexual partners in ways that seemed risky or out of character - behavior they linked to the sexual assault.

Other than that she was a little bit more promiscuous than she should’ve probably had been. (SP, FR, F, U).

Because I’ve seen in my career, the results of usually women who have been battered or have some type of sexual assault. They kind of tend to gravitate, not so much to violence, but they don’t make, they’re not making the right decisions when it comes to hooking up with someone. (SP, FR, M, 53, AA).

While still supportive of the survivor in general, most SPs also felt that the survivor should not have been engaging in more sex after assault. Most SPs based their opinions on how the survivor felt about their own sexual behavior.

Changes in Survivor’s Sexual/Romantic Relationships

Some survivors talked about how their romantic relationships were affected by survivors’ post-assault changes in sexuality. These effects ranged from positive, such as being more communicative and understanding, to negative, such as pressuring survivors for sex. Some survivors mentioned being revictimized in their romantic relationships, even after they disclosed previous experiences to that partner. This suggests that even if someone discloses a history of sexual assault to their partner, it does not mean the partner will not revictimize them, or be able to recognize if their behavior is coercive.

Positive experiences in sexual/romantic relationships

All but one of the romantic relationship pairs (n=6) described positive ways in which they engaged sexually. For example, some S-SP pairs mentioned verbalizing what the survivor wants when being intimate, with SPs practicing caution with the survivors:

He said, “I’m not your grandfather. I love you and whatever you feel is uncomfortable, if oral sex bothers you, we don’t have to do it. We’ll just go at your own pace.” (S, SO, F, 44, AA).

I try not to approach her in that kind of fashion, I do it in a more softer way, something it makes you appreciate. Not to grope and hang all over her. (SP, SO, M, 53, WH).

I do think it took some adjusting on his part cuz when I’d be triggered by certain things he would just have to watch and he would always ask me consent wise, like “can I do this”, can I… He would be overly cautious about things like that, which I certainly appreciated but after a while it’s like I’m comfortable with you, it’s okay. (S, SO, F, 23, WH).

A sexual assault that’s gonna impact [sex life] very much. And there were a few times and we’ve [S and SP] worked really hard to fix. (SP, SO, M, 26, WH).

I talk to my husband and let him know. I know men have needs but if I say no I mean no and don’t pressure me and that’s how it goes… As far as husbands mistreating their wives, pressuring them for sex. My husband don’t do me like that. (S, SO, F, 54, AA).

It took a while before me and her got comfortable with, for her to get comfortable of being intimate, so I didn’t push her, I didn’t force her, I didn’t, I don’t do that. (SP, SO, M, 49, AA).

So I tell him…cuz he pictured the rape as I was bent over forced. And I was like no, actually I was forced to look at them. They were there looking at me while it was happening. I said that’s probably part of the reason why missionary is not…I guess that’s why they call it missionary cuz you’re just like giving in and it’s like I was forced so it wasn’t me giving in. It was me being forced to give in a certain sense. So you know what, I said I’ll let you know if I’m uncomfortable with anything. I said I have before. I said so far everything that we’ve done, it’s got nothin’ to do with that. No reminisce, no nothing. I said because even if we start missionary, we usually end up in some other position. (S, SO, F, 32, Multi).

Although the first survivor above mentioned having a warped view of what sex was “supposed” to be like, her current partner allowed her to experience why sex can be positive, and so her view of sex has changed into something she now enjoys with her partner. She went on to say:

I didn’t have, cuz I had a lot of problems and then when I met J (fiancé). I was like, oh my god, this is sex? Sex is great… I never knew sex could be, cuz it was always a dirty thing and I couldn’t understand that. (S, SO, F, 44, AA)

One former couple (who had been romantic partners but were friends at the time of the interview) described being very open with each other about many issues, including the survivor’s sexual assault history and how that affected her sexuality negatively.

At the same time I was being able to tell him my issues too because we were just sharing ‘em…then when he wanted to be intimate, I was like, you know, a lot of things come with that…And things that I’m not into, I don’t like…Now you wait for something to be over with. (S, FR, F, 58, AA)

I don’t think she is ever gonna recover, I think she’s scarred for life. What she’s looking for now is not a person to have sex, but somebody to rely on, somebody to go to talk, to be a friend. To be somebody positive for her when she needs comforting, she needs somebody to talk to that she can come to me with any questions, any kind of feeling she’s got, she can come to me and she’ll get the straight up truth. I won’t beat around the bush, I’ll tell her straight up. (SP, FR, M, 49, H)

The SP understood the survivor’s issues and, after being together for several years, had accepted that their relationship was more a platonic companionship rather than a sexual/romantic relationship (though he still expressed romantic feelings for her). The relationship was overall a supportive one. Lastly, while not in the context of a current or previous romantic relationship, one survivor stated that even though she has had these unwanted sexual experiences, she always saw sex as a positive thing:

Sex is supposed to be something you can enjoy with the other person, both parties need to be happy with it. That’s how I see sex, to be enjoyable with two people, not just somebody taking it and you don’t want it. No. (S, F, F, 49, AA).

Negative experiences in sexual/romantic relationships

Having an understanding and supportive romantic partner did not preclude the possibility of being triggered during sexual encounters. Two SPs (one, a romantic partner and one, who, though not a romantic partner, expressed that the survivor and SP shared romantic feelings for each other), discussed how the survivor could be triggered.

She went, when we laid out, when we start being intimate and after the intimacy you know and I would touch her through the night and she would jump always jump. (SP, SO, M, 46, AA)

She doesn’t like to be penetrated, she doesn’t like that. Cuz she says it makes her feel uncomfortable and kinda hurts so sexually she’s not intimate. (SP, FR, M, 26, Multi)

These SPs had some understanding of the survivor’s triggers. However, one SP talked about the difficulty he had being certain the survivor was really engaging in sexual behavior willingly:

It kind of made me say, “well, OK, if I have sex with her, is it going to be that maybe she’s doing it because she’s trying to go ahead and get it over with,” this is just me thinking, I mean I’m not talking to her about it. I’m like, “OK, so she feel comfortable in this way”, which I did. I just said to myself, well, mentally, really, I don’t know. (SP, SO, M, 49, AA)

The SP admitted he did not talk to the survivor about it, perhaps because he did not know how to communicate about their sexual relationship. Whatever the reason, the SP’s words could show the importance of checking in with a partner, especially when that partner has survived a sexual trauma.

Some survivors described past negative romantic relationships, and sometimes the reasoning (according to the survivor) for the dissolution of those relationships was because their sexual experiences with their romantic partner were not positive. As one survivor recalls:

I mean I just broke up with a guy a couple days ago and he was pressuring me to have sex with him and he was very attractive. But I told him I had a 90 day rule that I would sleep with someone unless I’d knew them for 90 days and we didn’t date for 90 days. (S, FR, F, 49, WH).

This survivor went on to explain that she has never really felt sexual intimacy with anyone not only because of her assault, but because after she disclosed her assault to her father, he responded negatively disparaging her as a “whore” and “slut” and claiming she seduced her assaulter. When engaging in sex in the past, she explained that she heard these words and the voice of her father in her head. Because of this, she said that she never felt like she “made love” to anyone and felt very sad about admitting that, and has since decided not to engage in sex in the future until she stops hearing her father’s words in her head during sex.

However, other survivors attributed blame to themselves for the dissolution of their relationships, sometimes recognizing a pattern over multiple relationships. One survivor described how she had three marriages fail because of the negative effects of her assaults. She explained that these marriages failed because her sexual behavior and how she thought about sex had been negatively affected due to her assault:

I’ve had three failed marriages and today I look back on those marriages except for one, I can truly say it was my fault. Cuz if you not taken care of home sexually they go outside. (S, F, F, 57, Multi).

This survivor went into more detail about one of her previous partners in particular who demanded oral sex from her. She explained that performing oral sex would make her “throw up,” and that she did not want to do that with her partner. However, he threatened her verbally with her life, and she felt that he took advantage of her after she disclosed her abuse and why oral sex was a problem for her. While this survivor may have blamed herself for the failure of her marriages, it is important to point out that in the case of this partner specifically, he clearly sexually assaulted and threatened her into having sex with him, which would not have, in any way, constituted a healthy, romantic relationship, nor been the survivor’s fault.

There were instances of partners not being understanding of the survivor’s needs and pressuring them into sexual activity.

When the kid was little, he [her husband] would want to have sex and it’s just like (laughs), it’s like, ‘Oh god’ it’s very (cries), self-sacrificing experience (continues crying) to have sex with someone when you don’t want to have sex with him and more often than I (laughs) want to have sex, I just did not, I don’t know, I have a low libido or something. (S, FR, F, 38, AA)

This survivor blamed herself for not wanting to engage more in sexual activity with her child’s father when they were still together.

In another example, a survivor described being coerced into sexual activity by the SP who was interviewed for the study. The two had a complex relationship that started as romantic, eventually leading to marriage and then divorce.

She felt a little bit more aggressive after we had sips of champagne and, and it gave her the thought to do what she did and she did it and I didn’t want her to do it and the more I pushed her to try to push her away, to try to stop her from doing what she was doing the stronger she got and she continued. By the time I screamed for her to stop, that’s the only reason, what got her attention to stop. I was steady pushing, telling her no, no, don’t, don’t and the more she did it, the more she did it, I didn’t want to hit her. I kept pushing her and the stronger she got, the more she forced and by the time I could really just tell her, scream at her, “will you just stop?” and that got her attention. She stopped. She laid down beside me and she just instantly started crying. (S, FR, F, 41, AA).

The survivor had an extreme emotional reaction to this experience, and later said how this affected her relationship with the SP:

After that happened it took a while before we would even have a conversation about any type of sexual experience. At least two months before, she couldn’t even touch me, and it drew us apart. It tore us apart. It wasn’t that I didn’t care for her or anything. It’s just the incident that happened, the more when she touched me it gave me a feeling inside that I didn’t want her to touch me. I didn’t want to be touched, I didn’t want to talk about sex. I didn’t want to have sex. I didn’t want to have no one touch me at all. It hurt her so bad. (S, FR, F, 41, AA).

The survivor was unable to regain trust in the SP after that, though the two have remained in each other’s lives as friends and occasional sexual partners. The SP acknowledged that the survivor had been triggered during this sexual encounter, but did not understand that her behavior was not okay, or that the survivor was assaulted and traumatized because of the encounter. The survivor also mentioned losing an interest in sex altogether after the dissolution of their marriage. While she did not explicitly mention the above experience as the sole reason for this, it could be plausible that after experiencing a triggering sexual experience with her female partner, she completely lost interest in sex altogether as a way to protect herself from potentially future triggering experiences, though this is difficult to definitively discern without the survivor explicitly mentioning the reason.

Discussion

The current study of survivor-SP matched pairs examined how survivors’ sexuality was affected by their assault experiences, as well as how their SP’s viewed the changes in sexual behavior and how this may have altered their relationship with the survivor. This impact was most evident in survivor’s romantic relationships. We sought to understand the changes, both positive and negative, in sexuality, sexual behavior, and sexual intimacy in survivors’ post-assault experiences as well as SP perceptions of those changes. We found five themes of how sexuality changed in general post-assault: losing interest in sex/celibacy, having more sexual partners, engaging in sex work, increased sexual behavior (sometimes labeled addiction), and feeling safer with female sexual partners. SP’s generally viewed survivor’s sexual behavior post-assault with concern if their sexual behavior or perceived sexual risk-taking increased. In romantic relationships, survivors experienced mainly positive sexual interactions with their current romantic partners. Survivors who experienced negative relationship impacts based on sex attributed it to their problems with intimacy (e.g. flashbacks) or lack of sexual desire. Getting past feeling addicted to sex was tied to survivors’ recovery and use of positive coping.

Some results did not reflect previous literature. Adding to the literature on sexual assault, our study expands beyond the narrative of sexual dysfunction as the sole sexual effect of sexual assault. For example, none of the survivors mentioned having an explicit fear of sex, but more so had “lost interest” or simply decided that they would not engage in sex anymore. This decision was often influenced by their victimization and compounded by repeated victimizations. Sexual dysfunction was also not widely reported among the women in our sample, though they did experience periods of time where they felt out of control with sex or engaged in behaviors that did not feel healthy to them.

This study was the first of its kind to present matched pair data. The researchers recognize that their role as sexual violence researchers interviewing sexual assault survivors and their support providers could influence interviewee responses, but every attempt was made to ensure the data collected was as unbiased as possible. This type of data is important because we can gauge survivors’ views of sex post-assault and also how their partners, friends, or family members appraise their behavior and relationships after sexual assault. Romantic partners generally had the most to say about survivors’ views on sex post-assault, which makes sense given that their romantic partners are more likely to have continuous dialogue about sex with the survivor as their partner. Overall, current romantic partners exercised caution when engaging in sex with the survivor, and some survivors reflected those sentiments as well as discussed learning how to recognize and have positive sexual experiences with the support of their partner. This contradicts some previous literature showing that male partners generally do not know how to support their partners who have experienced sexual assault (Connop & Petrak, 2004). It should be noted that we did not ask romantic partner SPs specifically if they felt confident in supporting their partner post-assault, but in general, sexual experiences in the romantic partner relationships were described as positive.

Limitations

This study used a small, volunteer, convenience sample of matched pairs that were more positive in their relationships by virtue of still being in relationships and willing to do interviews on this topic. Interviews of SPs were primarily about their relationships with survivors, as they were recruited via survivors, so less focus was on SPs and future studies should ask SPs more about their own experiences. Only one SP was interviewed for each survivor, but survivors often told multiple sources, so broader social networks warrant future study. The retrospective design meant 12 years on average had elapsed since assaults (M=12.3; SD=11.7), which may have influenced accounts by survivors and SPs. Due to this large gap in time, survivors or SPs could have experienced more adverse effects on their sexuality more immediately post-assault that they were unable to recall later, or their opinion on the effects in the present may have differed from their previous appraisals closer to the assault experience. SPs may have been cautious about what they said about survivors, even though confidentiality was promised.

Some pairs may have talked to each other about the study, which may have affected their discussions about sexual assault and relationships. Talking about sexual assault appears to be helpful to survivors with few reporting negative effects of study participation and some positive effects on help-seeking (Kirkner, Relyea, & Ullman, in press), so this may have been an opportunity for relationship partners to reflect on this topic and their relationships. Future research is needed in larger samples of survivor-SP matched pairs and/or their broader informal social networks to understand how to help them navigate the impact of sexual assault. Despite these limitations, the present study provides a rich understanding of sexuality, sexual behavior, and sexual encounters with romantic partners following sexual assault in the context of relationships over time by examining recovery and informal relationships.

Implications for Clinical Practice and Prevention

Beyond what this study adds to the body of literature on sexual assault, our study has clear implications for sexual assault clinical intervention and prevention, and scholarship on sex work. First, our findings have implications for couples counseling post-assault. Previous literature has had a strong focus on the clinical or medical aspects of sexual dysfunction after a sexual assault (e.g. painful sex, PTSD). However, given the results of this study, the sexual effects of sexual assault permeate through many more aspects of a survivor’s life and close relationships. Therapists working with survivors should consider how they navigate their sexual identity and sexuality in conjunction with their sexual experiences post-assault. For some survivors in our sample, being celibate was a conscious choice, in some cases seen as positive in the survivor’s life and taking her control back after assault. Therapists would also benefit from understanding the fluidity of survivors’ choices around sex and sexual partners. Many survivors charted a narrative that changed over the course of their recovery-some even reporting choosing at various points to be with women partly because it felt like a safer choice. While sexuality and sexual identity is never simply a choice for people, survivors may consider choosing sexual/romantic partners who feel the safest and gender/gender expression may be part of this choice. Several survivors in our study identified as lesbian, bisexual, or queer women. One survivor reported feeling safer with female partners and also felt a strong sense of identity when she was able to join an LGBTQ-focused youth group. Even engaging in sex work was not a permanent state for the women in our study and reflects the dynamic nature of recovery.

We also recommend therapists, other clinicians, and sexual assault/sexual health educators provide more tools for SP’s looking for ways to support their partners and engage in healthy sexual behavior as a couple. This could include strategies for open communication before, during and after engaging in sexual activity, if the survivor chooses to do so with their partner. Some survivors reported experiencing flashbacks in subsequent sexual encounters after their unwanted sexual experiences, which are likely PTSD symptoms (Foa, 1995). Previous research on psychological treatment for PTSD has shown little effect on improving sexual dysfunction post-assault, likely because sexual functioning in PTSD treatment is secondary, and not a targeted outcome of PTSD treatment (O’Driscoll & Flanagan, 2015). Future PTSD intervention should target sexual functioning post-assault specifically, and help survivors process the possibility of flashbacks in the future, how to have positive consensual sexual experiences, and how to communicate their needs with their sexual partners.

Sexual assault prevention efforts should be informed by these findings. Several survivors mentioned not knowing what a “good” sexual experience was supposed to look like, with some potentially never having had a positive sexual experience. This led some to remain celibate because of their assault while others worked to find a healthy sexual life, often with the support of partners. To date, only 24 states in the US require public schools to teach sex education and 20 of those states require the information to be ‘medically accurate’ (National Conference of State Legislatures, 2016). Only Iowa, California, and Oregon require schools to provide information about healthy sexual relationships and interpersonal violence (emphasizing safety), while other states with sex education policies focus on health and preventing or reducing sexual activity among youth (NCSL, 2016). Comprehensive sexual education should not only include discussions and definitions of sexual consent, but also help young people understand what sexual pleasure means for all parties engaged in consensual sexual activity. This would help young people understand what healthy sexuality looks like, so they can better communicate their boundaries and needs to partners. Sexual assault prevention should also include strategies for romantic partners about how to have these conversations with partners and how to ask about and be sensitive and respectful of their partner’s boundaries and desires.

Finally, although there were not many survivors in our sample who reported engaging in sex work after their unwanted sexual experiences, their accounts still inform research and understanding of how trauma and sex work can be related. Trauma (particularly sexual trauma) is prevalent among sex workers (Church, Henderson, Barnard, & Hart, 2001; Patton, Snyder, & Glassman, 2013). However, trauma symptoms, homelessness, poverty, and drug and alcohol abuse tend to covary, thus complicating the links between sexual assault and sex work (Lutnick et al., 2015). We also did not distinguish between street-based and indoor sex work, which have different levels of safety. Women in our sample who had engaged in sex work and connected it to their experiences of sexual assault did not feel positively about their experiences exchanging sex for money, but we do not know if they associated sex work with more trauma. Survivors’ connections between sex work and addiction suggest their experiences were a form of unhealthy coping and not necessarily an added trauma. Future studies should seek to understand the context in which women engage in sex work including safety in their environments, substance abuse problems, poverty, and homelessness, as these factors influence how women characterize their involvement with sex work. In general, more research is needed on the relationship of sexual assault and women’s sexuality in samples of sexually diverse women including impact on behavior, relationships and quality of life of both women, their partners, and informal support networks more generally.