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. Author manuscript; available in PMC: 2020 Aug 14.
Published in final edited form as: Arch Womens Ment Health. 2019 Feb 14;23(1):81–89. doi: 10.1007/s00737-019-0947-1

Acute Mental Health Symptoms among Individuals Receiving a Sexual Assault Medical Forensic Exam: The Role of Previous Intimate Partner Violence Victimization

Amanda K Gilmore 1,2, Julianne C Flanagan 2
PMCID: PMC6733667  NIHMSID: NIHMS1521713  PMID: 30762148

Abstract

Sexual assault and intimate partner violence (IPV) are common in the United States, and they often co-occur. Individuals with multiple victimization experiences have more severe mental health outcomes compared to those with one victimization. The current study examined mental health symptoms and their association with IPV victimization history among a sample of individuals who experienced a recent sexual assault and received a sexual assault medical forensic examination. A total of 82 participants (92.70% female) completed a post-sexual assault survey as part of clinical care to coordinate follow-up services. IPV history and prior sexual assault were assessed as well as mental health symptoms including acute stress and depressive symptoms. It was found that individuals with an IPV history reported more acute stress and depressive symptoms compared to those without an IPV history. No differences were found based on prior sexual assault history. These findings highlight the importance of screening for IPV history during the sexual assault medical forensic examination to coordinate care.

Introduction

Intimate partner violence (IPV) and sexual assault are highly prevalent and persistent public health problems that result in severe negative health sequelae worldwide (World Health Organization 2013). While women experience IPV and sexual assault at disproportionally high rates compared to men, interpersonal violence victimization impacts individuals of any gender or sexual orientation (Edwards et al. 2015; Whitton et al. 2016). For example, findings from the National Intimate Partner and Sexual Violence Survey (Black et al. 2011) indicate that over 12 million Americans experience IPV victimization each year. One in four women experience IPV victimization during their lifetime while one in seven men report IPV victimization. Similarly, one in five women experience rape (which is only one of many forms of sexual assault) during their lifetime compared to one in 71 men.

Existing literature also demonstrates that social and environmental risk factors for IPV and sexual assault commonly overlap within individuals (Campbell et al. 2008; Overstreet et al. 2015). Additionally, individuals who experience any type of interpersonal violence victimization, whether in childhood or adulthood, incur heightened risk for revictimization (Alexander 2009; Cole et al. 2008; Desai et al. 2002; Exner-Cortens et al. 2017; Trickett et al. 2011), which can include multiple victimization (e.g., experiencing more than one type of victimization) or poly victimization (e.g., experiencing both more than one type and more than one instance of victimization). Thus, IPV and sexual assault co-occur at alarmingly high rates, which may compound the risk for negative health outcomes (Adams et al. 2016; Burns et al. 2016; Cavanagh et al. 2013; Pico-Alfonso et al. 2006).

The negative health outcomes among individuals who experience IPV or sexual assault are pervasive and often, they are both severe and long lasting (Campbell 2002; Campbell et al. 2009; García-Moreno et al. 2005; Ullman and Brecklin 2003). Posttraumatic stress disorder (PTSD) and depression, as well as their co-occurrence, are two of the most common and impactful mental health problems that emerge following IPV or sexual assault (Campbell et al. 2009; Dworkin et al. 2017; Jaquier et al. 2013; Nixon et al. 2004; Zlotnick et al. 2006). For example, one study found that IPV victimization accounted for over half of new-onset depression in a nationally representative sample of women (Ouellet-Morin et al. 2015). Similarly, over 80% of individuals who experience IPV or sexual assault report at least one symptom of PTSD related to their victimization experiences during their lifetime (Black et al., 2011; Hellmuth et al. 2014). While some individuals’ symptoms do not progress to meet full diagnostic criteria for PTSD or depression, abundant literature suggests a strong causal association between the severity of acute stress responses and later PTSD diagnosis. This association has also been examined extensively using preclinical models (Musazzi et al. 2018; Raio and Phelps 2015; Zoladz and Diamond 2016). Notably, in the immediate aftermath of interpersonal violence victimization, many individuals endorse PTSD symptoms sufficient to meet full diagnostic criteria with the exception of the required one month duration (Elklit & Christiansen 2010; Kleim et al. 2007). Indeed, an acute stress response is normative following interpersonal violence victimization, and a critical feature of PTSD is both symptom exacerbation over time and the failure of the immediate stress response to resolve (Bryant et al 2017; Steenkamp et al 2012).

One remaining limitation of this literature is that clinical research has focused primarily on the role of acute stress symptoms in the development of symptoms that meet full diagnostic criteria for PTSD and related conditions such as depression (Bryant 2003; Hammen et al. 2009; Tol et al. 2013). Several studies have examined the role of acute stress immediately following the event in relation to later PTSD or depression (Frazier 2000; Frazier et al 2001; Gutner et al 2006; Rothbaum et al 1992; Steenkamp et al 2012). However, few studies to date have examined the association between the acute stress response pertaining to violence victimization and PTSD (Brewin et al. 1999; Elklit and Brink 2004; Guay et al. 2018), and none of these studies focused specifically on individuals receiving a sexual assault medical forensic exam.

Sexual Assault Medical Forensic Exam

There is a scarcity of research examining acute mental health symptoms after interpersonal violence victimization. Therefore, it is imperative to examine the relative and collective contribution of different forms of interpersonal violence victimization to mental health in this high-risk population. Specifically, individuals who receive a sexual assault medical forensic exam (SAMFE) are in a unique acute care environment compared to typical mental health treatment settings. It is possible for post-violence victimization mental health symptoms to be assessed and to begin to be addressed through various pathways such as during their immediate hospital visit or following their release. SAMFEs are available free of cost within days of a sexual assault. These exams not only collect forensic evidence that can be stored anonymously for up to one year or reported formally to the police, they also provide an opportunity for individuals who have recently experienced sexual assault to receive free sexual health care immediately after the sexual assault to prevent pregnancy and sexually transmitted infections. The majority of individuals presenting for a SAMFE have some form of interpersonal violence history including a history of IPV or prior sexual assault (Resnick et al. 2007; Walsh et al. 2017). Although the relationship of the perpetrator to the victim is typically assessed during the SAMFE, a thorough assessment of one’s history of IPV and prior sexual assault is rarely examined concurrently in a forensic sample.

Current Study

The role of previous IPV victimization in post-SAMFE is unknown. The current study addresses that gap by examining the relative contribution of IPV history and prior sexual assault on depression and acute stress symptoms among individuals who experienced a recent sexual assault and received a SAMFE. We hypothesized that individuals with a history of IPV would have more mental health symptoms after a recent sexual assault compared to those without a history of IPV. Further, we hypothesized that individuals with a prior sexual assault would have more mental health symptoms after a recent sexual assault compared to those whose recent sexual assault was their first sexual assault experience.

Methods

Participants and Procedure

A total of 234 individuals who received a sexual assault medical forensic exam (SAMFE) within 120 hours of a sexual assault between November 2016 and January 2018 were given a form by the sexual assault nurse examiner asking if they were interested in follow-up care by the hospital related to the sexual assault. A total of 41 (17.5%) denied follow-up care from the hospital and were not recruited for the current study. Of the 193 individuals who were recruited to complete a mental health screen over the phone, video, or in person, 89 (46.1%) completed the screen. Individuals who experienced the sexual assault in the context of IPV were less likely to complete the screen (Gilmore et al., 2018). Of those, 82 (92.13%) answered the question about IPV history, those who chose not to answer that question were not included in the current study. These questionnaires were completed as part of clinical care and were conducted by a bachelor’s level case manager, a social worker, pre-doctoral clinical psychology interns, or a psychologist, and all cases were reviewed and supervised by a licensed psychologist. The current study is an IRB-approved record review of clinical services, therefore, participants were not provided with payment for participation.

Measures

Demographics and assault characteristics.

Participants were asked to their gender identification, race/ethnicity, and sexual minority status. Age and number of days since the SAMFE were calculated using the medical chart. Prior sexual assault history was assessed by asking participants “Have you experienced sexual violence / sexual assault / rape in the past?” and participants answered yes or no indicating a prior sexual assault history or no prior sexual assault history (Gilmore et al., 2018).

Sexual assault characteristics.

Participants were asked if they knew the perpetrator (=1) or the most recent sexual assault or if the perpetrator was a stranger (=0). This question was developed by the research team for the clinic.

Intimate partner violence history.

Participants were asked “Has a partner (or other loved one) ever physically hurt you or threatened to hurt you?” and “Have you ever experienced any other type of violence or abuse from a partner or loved one?” If participants answered yes to either of those two questions, they were labeled as having an IPV history. These items are consistent with validated screening tools commonly employed in medical settings to identify current or previous intimate partner violence victimziation (ACOG 2003; Davis et al 2003; Family Violence Prevention Fund 2002; McFarlane et al 1995; Sherin et al 1998).

Acute stress symptoms.

To assess symptoms of acute stress (within 30 days of the assault) and posttraumatic stress (after 30 days of the assault), participants completed the Posttraumatic Stress Disorder Checklist (PCL-5; Weathers 2013). Participants answered 20 items on a scale from 0 (not at all) to 4 (extremely) about how much they were bothered by each item. The PCL-5 is among the most commonly used measures to screen for PTSD symptoms, and has strong psychometric properties across clinical populations (Elhai & Palmieri 2011; Wilkins et al 2011). Clinical cut off scores indicative of problematic PTSD are 33 (Bovin et al. 2016; α = .96; current sample α = .93) and scores range from 0 to 80.

Depressive symptoms.

The Patient Health Questionnaire (PHQ-9; Kroenke et al. 2001) was used to assess depressive symptoms in the past 2 weeks. Participants rated nine items on a scale from 0 (not at all) to 3 (nearly every day). Total scores range from 0 to 27. Scores of 12 or higher are considered clinically significant (current sample α = .86). The PHQ-9 has demonstrated excellent psychometric properties including diagnostic specificity and severity sensitivity across a variety of clinical populations (Kroenke et al 2010).

Analysis Plan

Initial analyses were conducted using t-tests and chi-squared analyses to examine univariate associations for each variable based on IPV history and prior sexual assault history. Two separate linear regressions using a poisson distribution were conducted for post-sexual assault acute stress symptoms and depressive symptoms. A multivariate regression was not conducted because the acute stress and depressive symptoms were highly correlated (r = .81). In both regressions, number of days since the SAMFE, gender (% male), race/ethnicity, age, sexual minority status, type of perpetrator of most recent sexual assault, and prior history of sexual assault were control variables. IPV was the predictor of post-sexual assault mental health symptoms in both analyses.

Results

Descriptives

The majority of participants identified as female (92.70%; n = 76) and the remainder identified as male (7.30%, n = 6). The majority of participants had not experienced a prior sexual assault (56.10%; n = 46), and had an IPV history (53.70%; n = 44). The majority of participants identified as White (68.30%; n = 56) and the remainder identified as Black/African American (24.40%; n = 20), Hispanic/Latina (2.4%; n = 2), or multiracial (4.90%; n = 4). On average, participants were 28.92 years old (SD = 9.88 years) and completed the questionnaires 17.26 days (SD = 24.98 days) after the SAMFE, ranging from 0 to 76 days.

Initial t-tests revealed significant differences in acute stress and depressive symptoms based on IPV history such that those with an IPV history had more acute stress symptoms (t (76) = 4.167, p < .001) and more depressive symptoms (t (77) = 3.874, p < .001; see Table 1). Further, there was a significant difference in age based on prior sexual assault history such that participants with a prior sexual assault history were older than those without a prior sexual assault history ((t (81) = 2.179, p = .032; see Table 1). No other differences based on IPV history or prior sexual assault history were found using initial t-tests and chi-squared analyses.

Table 1.

Descriptive Statistics

Variable Total
(M, SD or %, n)		 IPV
(M, SD or %, n)		 No IPV
(M, SD or %, n)		 Prior SA
(M, SD or %, n)		 No Prior SA
(M, SD or %, n)
Age 28.92, 9.88 30.54, 9.75 27.04, 9.84 31.68, 9.73c,d 26.75, 9.55c,d
Days since assault 17.66, 25.23 16.31, 25.83 19.19, 24.81 22.26, 31.96 14.18, 18.27
Gender (% male) 7.300%, 6 6.80%, 3 7.90%, 3 8.30%, 3 6.50%, 3
Racial/ethnic minority 28.00%, 23 25.00%, 11 31.60%, 12 25.00%, 9 30.40%, 14
Sexual minority 14.60%, 12 18.20%, 8 10.50%, 4 19.40%, 7 10.90%, 5
Known perpetrator 58.50%, 48* 68.20%, 30 50.00%, 18 66.70%, 24 52.20%, 24
Acute stress symptoms 44.99, 19.03 52.73, 16.35a,b 36.41, 18.26a,b 47.87, 19.02 42.98, 18.98
Depressive symptoms 14.62, 6.76 17.17, 6.16a,b 11.73, 6.30a,b 15.45, 7.04 14.02, 6.56
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Note.

*

3 participants chose not to answer this question and were missing;

a,b

indicates significant differences (p < .05) based on IPV history using a t-test for continuous variables and χ2 for dichotomous variables;

c,d

indicates significant differences (p < .05) based on prior sexual assault history using a t-test for continuous variables and χ2 for dichotomous variables

Acute Stress Symptoms

It was found that individuals with an IPV history had significantly more post-sexual assault acute stress symptoms than those without an IPV history (see Table 3). Days since the SAMFE were also associated with post-sexual assault acute stress symptoms. More days after the SAMFE was associated with less acute stress symptoms.

Table 3.

Linear Regressions with Poisson Distribution

Variable B SE p
Acute Stress Symptoms
Age 0.008 0.004 .063
Days since assault −0.005 0.002 .008
Gender (% male) .245 0.127 .054
Racial/ethnic minority 0.94 0.101 .350
Sexual minority 0.054 0.093 .562
Known perpetrator 0.095 0.092 .303
IPV history 0.306 0.092 .001
Prior sexual assault −0.018 0.082 .829
Depressive Symptoms
Age 0.010 0.005 .024
Days since assault −0.008 0.002 .001
Gender (% male) 0.008 0.146 .954
Racial/ethnic minority −0.099 0.125 .425
Sexual minority 0.148 0.108 .171
Known perpetrator 0.083 0.089 .358
IPV history 0.298 0.104 .004
Prior sexual assault −0.085 0.095 .367
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Note. IPV= intimate partner violence

Depressive Symptoms

In relation to post-sexual assault depressive symptoms, individuals in with an IPV history had significantly more depressive symptoms than those without an IPV history in this sample (see Table 3). Age and days since the SAMFE were associated with depressive symptoms. Older individuals reported more depressive symptoms than younger. Further, more days after the SAMFE was associated with less depressive symptoms.

Discussion

This study extends the literature by examining the influence of previous interpersonal violence victimization, specifically prior sexual assault and IPV history, on acute stress and depressive symptoms in a sample of participants presenting for a SAMFE. The findings that IPV history was associated with more acute stress and depressive symptoms post-sexual assault suggest that IPV history may be an important factor to consider in post-sexual assault mental health care.

As hypothesized, it was found that IPV history was associated with more acute stress and depressive symptoms post- sexual assault. It was surprising that IPV history was associated with greater severity of post-sexual assault mental health symptoms, while prior sexual assault was not. Although the current study did not assess some details of the prior interpersonal victimization history, it is likely that the IPV history included repeated victimization over an extended period of time, consistent with abundant literature demonstrating the high prevalence of repeated lifetime IPV exposure (Black et al. 2011; Thompson et al. 2006). Sexual assault can be, although is not always, a time-limited traumatic experience, meaning that some individuals might experience sexual assault once in their lifetime and repeat victimization does not occur. It is possible that the number of IPV victimization exposures among participants in this sample was greater than the number of sexual assault exposures. One possible explanation for the significant association between IPV history and post- sexual assault mental health symptoms may be that a history of repeated and pervasive victimization like IPV may be more impactful in mental health symptoms compared to a potential one time victimization. Future research is needed to assess the difference between IPV and prior sexual assault in post- sexual assault mental health symptoms and the influence of chronicity of either type of interpersonal violence on mental health outcomes. It should be noted that the average acute stress symptoms among individuals who did not report an IPV history were above recommended clinical cut off scores for PTSD (Bovin et al. 2016). The average depression scores among individuals without an IPV history were approaching clinical cut off scores (Kroenke et al. 2001). Therefore, the findings suggest that individuals with, as well as without, an IPV history are experiencing significant mental health symptoms after a sexual assault.

Also consistent with the hypotheses, findings from the current study indicated that days since the sexual assault were negatively associated with post- sexual assault acute stress and depressive symptoms. In other words, as time passed, mental health symptoms lowered. It is important to note that this study was cross-sectional and, therefore, directionality cannot be determined. It is possible that individuals with less severe mental health symptoms did not complete the post-sexual assault survey as soon after the SAMFE because they did not need to be connected to mental health treatment. Depression is a chronically relapsing-remitting condition, and extensive research demonstrates that untreated PTSD is likely to become increasingly debilitating over time (Hoge 2013; Kessler 2000; Sher 2004). Although these findings suggest that some mental health symptoms can decline over time, early intervention may still be beneficial to prevent onset of psychiatric diagnoses, especially for those at highest risk for post-sexual assault mental health symptoms including those with an IPV history (Sher 2004; Zimmerman and Mattia 1999).

Women are disproportionately exposed to events that precipitate PTSD and depression such as IPV and sexual assault (Tolin and Foa 2006). The neurobiology literature suggests that women may also incur greater risk, compared to men, for the translation of a normative acute stress response to diagnostic criteria compared to men (Brewin et al. 2000; Kokras and Dalla 2014; Ramikie and Ressler 2017). Although there was not a significant effect of gender on post-sexual assault mental health symptoms in the current study, it is not possible to conclude that there were no gender differences given that only 7.3% of the sample identified as a man. Therefore, more research is needed to assess post-sexual assault acute mental health symptoms among men, sexual minority populations, and individuals who do not receive a SAMFE.

Implications for Practice and/or Policy

Although findings from the current study did not suggest that prior sexual assault was associated with more post- sexual assault mental health symptoms, early intervention work has found that interventions are more effective at reducing post- sexual assault mental health symptoms among women and girls who receive a SAMFE for those with a prior sexual assault compared to those without a prior SA (Resnick et al. 2007; Walsh et al. 2017). Similarly, substantial efforts are being made to more thoroughly integrate IPV screening and early intervention into medical settings such as primary care, obstetrics and gynecology, and emergency departments with promising preliminary findings (Ghandour et al. 2015; Miller et al. 2015). The previous literature on prior sexual assault and behavioral health outcomes combined with findings from the current study suggest that targeted post- sexual assault behavioral interventions for those with a prior interpersonal victimization history may be warranted. These interventions should be developed and implemented with caution, because although interventions that have been developed for individuals receiving a SAMFE have been effective at reducing post- sexual assault mental health symptoms (Resnick et al. 2007; Rothbaum et al. 2012; Walsh et al. 2017) some post-traumatic event exposure behavioral interventions can be harmful (Sijbrandij et al. 2006).

Further, the results from the current study suggest a need for a more integrated assessment approach regarding IPV and prior sexual assault. Assessing IPV history within the context of a SAMFE may not only provide important information for referral to post-sexual assault mental health treatment, it can also allow for patients to tap into resources and referrals for both IPV and sexual assault within the same visit. There are several brief assessments and intervention for IPV history that are integrated into medical settings (McCloskey et al. 2006; Miller et al. 2015). These assessments and interventions would require little to no modification to add to SAMFE protocols.

Finally, there is currently an emphasis on behavioral and pharmacological prevention in acute care settings, but with little success (Bisson 2008; Trusz et al. 2011; van Zuiden et al. 2016). However, post- sexual assault behavioral interventions have yielded some success when delivered within the context of a SAMFE (Gilmore et al. 2018), suggesting that it may be useful to consider pharmacological prevention in this setting as well. Individuals who receive a SAMFE already have the option to receive prophylaxis for sexually transmitted infections and pregnancy prevention, therefore, providing a psychopharmacological option may be useful. However, research is needed to determine what psychopharmacological options are beneficial for this population for prevention of mental health symptoms post-sexual assault.

Strengths and Limitations

There are several strengths to the current study. This is the first study to examine the relative contribution of IPV history and prior sexual assault on depression and acute stress symptoms among those who experienced a recent sexual assault. It is a strength of the study that mental health symptoms were assessed after a recent sexual assault, rather than months or years later. Therefore, it is possible that the symptoms associated with the recent sexual assault are more accurate in this study compared to some previous studies. However, it is also possible that mental health symptoms reported could be related to the IPV history, prior sexual assault, or another traumatic or violent exposure. It is also unknown how much acute stress might influence PTSD symptom exacerbation in this specific setting because posttraumatic stress prior to the recent sexual assault was not assessed in this sample. Further, the majority of individuals who experience a sexual assault do not receive a SAMFE, likely due to the significant barriers associated with receiving a SAMFE (Gilmore et al. 2018). Therefore, the current findings cannot be generalized to all individuals who experience a sexual assault. Instead, they are specific to those who receive a SAMFE. Additionally, the current study lacks a follow-up assessment period. Future studies can improve on the current design by examining whether PTSD diagnostic criteria are met following the SAMFE and factors that might contribute to resilience versus symptom exacerbation.

One related limitation of the current study is that the IPV assessment did not asses or allow us to distinguish between psychological, physical, and sexual IPV victimization, which might have differential impacts on mental health (Pico-Alfonso et al 2006). In addition, chronicity and severity of IPV victimization, and the amount of time that had passed since the most recent instance of IPV victimization or violent relationship was not assessed. Future studies are necessary to replicate and extend these findings with a more thorough IPV assessment. Mental health symptoms were only assessed among individuals who received a follow-up mental health screen. Therefore, it is likely that individuals who did not receive a mental health screen may be less symptomatic and these results may only generalize to treatment seeking samples. The mental health screens were completed in person, by video, and by phone rather than a standardized method. Future research should allow for self-report either by paper-and-pencil or computerized survey. Future research should also include a more comprehensive assessment of demographic data including marital status, socioeconomic status, and education.

Finally, the current study only examined the mental health symptoms of individuals who completed a mental health screen, which was less than half of those who were recruited to complete a mental health screen. Further, individuals who experienced the recent sexual assault in the context of IPV were less likely to complete a mental health screen (Gilmore at el., 2018). Therefore, it is likely that the mental health symptoms of those with IPV history are underestimated in the current sample and future research should examined symptoms during the SAMFE to examine mental health differences among all individuals who attended the SAMFE based on IPV history.

Conclusion

In summary, this study examined the relative association of past IPV victimization, and prior sexual assault on acute stress and depression symptom severity among individuals presenting for a post-sexual assault SAMFE. Finding suggest that IPV victimization history was associated with more severe mental health symptoms in this sample. These findings support existing literature indicating that the cumulative risk for mental health problems incurred by individuals in this population is high, and that different forms of victimization might differentially impact the assessment and treatment needs of individuals in a post-sexual assault acute care setting. More research is necessary to examine assessment, intervention, referral, and follow-up strategies to improve treatment access and utilization among individuals with interpersonal violence victimization histories.

Table 2.

Correlations among key variables

Variables 1 2 3 4 5 6 7 8 9 10
1. Age 1
2. Days since assault .001 1
3. Gender (% male) −.073 .124 1
4. Racial/ethnic minority .132 −.035 −.137 1
5. Sexual minority −.120 <.001 .281* .182 1
6. Known perpetrator −.045 .080 .169 .037 −.024 1
7. IPV history .178 −.057 −.021 .073 .108 −.202 1
8. Prior sexual assault .249* .160 .035 .060 .120 −.175 .477** 1
9. Acute stress symptoms .195 −.289* <.001 −.022 .100 −.164 .431** .127
10. Depressive symptoms .277* −.373** −.133 .188 .108 −.157 .404** .105 .816** 1
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Note. IPV= intimate partner violence;

*

p < .05;

**

p < .01,

***

p < .001.

Acknowledgements

Manuscript preparation was partially supported by a grant from the National Institute on Drug Abuse (K23DA042935 to the first author), the National Institute on Alcohol Abuse and Alcoholism (K23AA023845 to the second author), and by the South Carolina Clinical & Translation Research (SCTR) Institute, with an academic home at the Medical University of South Carolina NIH - NCATS Grant Number UL1 TR001450. We would like to acknowledge the clinical staff, volunteers on the project, and individuals and community partners who assisted with project coordination which include, but are not limited to Dr. Christine Hahn, Dr. Anna Jaffe, Mollie Selmanoff, Dr. Kathleen Gill-Hopple, Dr. Gweneth Lazenby, Dr. Ryan Byrne, Dr. Ally Dir, Dr. Rosaura Orengo-Aguayo, Karen Hughes, People Against Rape, and Dr. Heidi Resnick. We would also like to acknowledge the grant that funded the follow-up clinic that was awarded to the first author (AKG): This project is supported by the Federal Formula Grant # 2015 VA GX 0001, awarded by the Office of Victims of Crime, U.S. Department of Justice through the South Carolina Department of Public Safety. Any points of view or opinions contained within this document are those of the author and do not necessarily represent the official positions or policies of the U.S. Department of Justice.

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