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. Author manuscript; available in PMC: 2020 Dec 1.
Published in final edited form as: Psychol Women Q. 2019 May 7;43(4):485–493. doi: 10.1177/0361684319845099

Acute Stress Symptoms After Forcible and Substance-Involved Rapes

Anna E Jaffe 1, Christine K Hahn 2, Amanda K Gilmore 2
PMCID: PMC6937134  NIHMSID: NIHMS1029215  PMID: 31889739

Abstract

In the early aftermath of a sexual assault, survivors often experience symptoms of distress including reexperiencing, avoidance, and hyperarousal symptoms. However, less is known about associations between rape characteristics and the nature of early reactions. We designed the current study to examine the unique and combined associations between force and substances during rape on acute stress symptoms. Participants were 56 women (ages 18 to 58) who completed a sexual assault medical forensic exam in the emergency department within 120 hours of the rape and then completed a follow-up clinical phone screening within 30 days of the forensic exam. Follow-up assessments included characteristics of the recent rape (force, substances), history of prior sexual assault, demographics, and symptoms of acute stress. Multivariate regression analyses revealed that, after controlling for prior sexual assault, sexual orientation, and race/ethnicity, there were no significant differences on any symptom cluster by rape type. However, this study involved a small, difficult-to-reach sample and, therefore, was only powered to detect large effect sizes. We encourage more research examining potentially unique, early symptom presentations for substance-involved rapes.

Keywords: emergency department, sexual assault nurse examiner, acute stress, alcohol-involved sexual assault, revictimization

Violence is a critical issue affecting the lives of women worldwide. Given global estimates that 35% of women experience sexual violence and/or violence by a partner (World Health Organization, 2013), sexual assault is a key component of the violence women experience across the lifespan (e.g., Ellsberg & Heise, 2005). In the United States, rape is a public health concern that disproportionately affects women; approximately one in five women report experiencing rape in their lifetime (Black et al., 2011; Breiding et al., 2014). Understanding the psychological consequences of sexual assault is vital to addressing the mental health concerns of women. Acute stress symptoms––such as intrusive memories and nightmares of the assault, avoidance of trauma reminders, and hypervigilance––are particularly common immediately after a rape, and although some survivors experience a natural recovery over time, symptoms persist for others (e.g., Rothbaum, Foa, Riggs, Murdock, & Walsh, 1992). Indeed, rape has a particularly strong association with acute stress symptoms and posttraumatic stress disorder (PTSD; Dworkin, Menon, Bystrynski, & Allen, 2017). Given the distress and physical health consequences associated with such psychopathology (Pacella, Hruska, & Delahanty, 2013), it is vital to identify women at risk for heightened trauma-related distress. One way to identify these individuals in the U.S. is during the initial services that a woman seeks after a rape, including the sexual assault medical forensic exam (SAMFE). The SAMFE is a cost-free examination conducted by nurse examiners typically conducted within a few days of a rape. Although only one in five women who are raped seeks medical attention (Zinzow, Resnick, Barr, Danielson, & Kilpatrick, 2012), the SAMFE represents an important opportunity to engage women in need with post-rape physical and mental health services. Identifying assault characteristics that are both observable through the SAMFE, and predict acute stress symptoms, may facilitate early intervention efforts.

Rape is defined as any nonconsensual sex involving penetration, but the nature of the assault can be categorized based on perpetrator tactics. Forcible rape, which involves threat of force or actual physical force, is reported by 14.4% of U.S. women (Smith et al., 2017), and over 70% of rapes involve force (Kilpatrick, Resnick, Ruggiero, Conoscenti, & McCauley, 2007). Substance-involved rape occurs when the victim is unable to consent due to the use of legal or illicit substances. This can involve a perpetrator giving a person alcohol or drugs to facilitate an assault or targeting an individual who is already intoxicated. Rape involving substance-related incapacitation is reported by 9.7% of U.S. women (Smith et al., 2017). Moreover, 46.0% of rapes experienced by college women, and 22.1% of rapes experienced by women in the general population, involve substance-related incapacitation (Kilpatrick et al., 2007).

Physical injury and force during rape are associated with heightened risk for PTSD (Brown, Testa, & Messman-Moore, 2009; Dworkin et al., 2017). Although rapes can involve both force and substances, there is typically less force and bodily injury during rapes that occur when an individual is intoxicated or incapacitated due to substances (Testa, Livingston, Vanzile-Tamsen, & Frone, 2003). Researchers have reported PTSD symptom severity to be moderate following substance-involved rape when compared to forcible rape (Brown et al., 2009; Peter-Hagene & Ullman, 2015; Zinzow et al., 2010). For example, among women in Sweden presenting to an emergency clinic following a rape, being under the influence of alcohol during the rape decreased the likelihood of being diagnosed with PTSD six months post-rape (Tiihonen Möller, Bäckström, Söndergaard, & Helström, 2014). Although acute stress symptoms were also associated with subsequent PTSD diagnosis in Tiihonen Möller and colleagues’ (2014) study, it remains unclear whether differences in distress level by rape type can be observed immediately post-rape.

Prior research on rape type and subsequent distress is limited by inconsistent categorization of rapes involving multiple tactics. Some researchers have grouped together rapes involving any force, regardless of substance-related intoxication or incapacitation (Brown et al., 2009; Zinzow et al., 2010), whereas others consider potential unique effects of rapes involving both force and substances compared to only force or substances (Zinzow, Resnick, McCauley, et al., 2012). Given that both perpetrator tactics may have distinct implications for post-rape recovery, it is important to consider their unique and combined effect. For example, forcible rapes may involve heightened fear of bodily injury during the assault, whereas substance-related intoxication or incapacitation may be followed by more self-blame (Donde, 2017; Peter-Hagene & Ullman, 2018). The combination of such tactics may lead to particularly heightened risk for post-assault distress. Indeed, Zinzow, Resnick, McCauley and colleagues (2012) reported that rapes involving both force and substances were associated with a heightened risk of lifetime and current PTSD when compared to rapes involving only force or substances. However, participants in that study were assessed more than ten years on average post-rape. More research is needed to determine the unique and combined effect of force and substances on acute stress symptoms.

Rape type may also be associated with the nature of individual symptom presentations. For example, individuals who are highly intoxicated during a sexual assault may have impaired memory for the trauma, which may have specific implications for the development of intrusive symptoms. Alcohol use––which is involved in over half of all sexual assaults (Abbey, Zawacki, Buck, Clinton, & McAuslan, 2004) and the vast majority of rapes involving incapacitation (Kilpatrick et al., 2007)––can interfere with memory encoding (Mintzer, 2007), stress response (Sayette, 1999), and fear conditioning (Weitemier & Ryabinin, 2003) at high levels of intoxication. Consistent with these effects, among 60 women who were recently physically or sexually assaulted, those who drank alcohol prior to the assault displayed fewer intrusion symptoms initially (two to five weeks post-assault), but no differences were observed for avoidance or hyperarousal symptoms (Kaysen et al., 2010). Although Kaysen and colleagues (2010) controlled for perceived threat, the influence of force (separate from that of substances) on acute symptoms remains unclear.

Although immediate post-rape reactions may be understood in the context of a recent rape and its characteristics, prior assault experiences could also shape reactions. For example, individuals with a prior sexual assault history may have had pre-existing PTSD symptoms and may view a new rape as confirmation of negative cognitions (e.g., the world is unsafe, others are untrustworthy), leading to increased distress. Indeed, individuals with multiple exposures to sexual violence typically have more severe PTSD in cross-sectional (see Classen, Palesh, & Aggarwal, 2005) and longitudinal studies (Ullman, 2016).

Demographic characteristics may also be related to acute stress symptoms. Sexual minorities are at greater risk for sexual victimization (Rothman, Exner, & Baughman, 2011) and report more PTSD symptoms following sexual assault than heterosexual women (Long, Ullman, Long, Mason, & Starzynski, 2007; Sigurvinsdottir & Ullman, 2015, 2016). Associations between race and PTSD are less clear. Sigurvinsdottir and Ullman (2016) reported that Black women endorsed higher rates of PTSD than White women, whereas Pegram and Abbey (2016) reported no such difference. Still, sexual orientation and race/ethnicity may be important to consider when examining risk for acute stress symptoms.

Current Study

We designed the current study to identify predictors of acute stress symptoms within one month of a SAMFE. We anticipated that findings from past research on longer-term PTSD (Brown et al., 2009; Peter-Hagene & Ullman, 2015; Tiihonen Möller et al., 2014; Zinzow et al., 2010; Zinzow, Resnick, McCauley, et al., 2012) would extend to symptoms displayed in the first month post-rape, given that acute stress symptoms are associated with later PTSD (albeit not a perfect predictor; Bryant, 2011). Accordingly, we hypothesized that acute stress symptoms in all clusters (intrusions, avoidance, negative alterations in cognitions and mood, arousal) would be greatest for rapes involving both force and substances, followed by forcible-only rapes, and then rapes involving only substances. Based on Kaysen and colleagues’ (2010) results for physical/sexual assault victims, we expected intrusion symptoms to be particularly low following rapes involving substances. Although the focus of this study was on determining differences between rape types, we considered the history of prior sexual assault as a covariate, because individuals tend to experience more severe PTSD symptoms following multiple sexual assaults (e.g., Classen, Palesh, & Aggarwal, 2005; Ullman, 2016). To gain further specificity, we included demographic covariates that could be identified by medical professionals at the time of the SAMFE, including sexual orientation and race/ethnicity.

Methods

Procedure and Participants

As part of clinical care, SAMFE nurses provided individuals with an invitation to complete a follow-up phone visit for referral to mental health and medical care. Clinical staff (case managers, psychology interns, licensed psychologists) then called interested individuals within 10 days of the SAMFE, though the phone visit could be completed later. A total of 234 individuals who received a SAMFE between November 2016 and January 2018 received invitations for follow-up care, of which 41 declined. Therefore, clinical staff contacted 193 individuals after the SAMFE, and 72 participated within the first 30 days post-SAMFE. Of these, 13 had incomplete data for acute stress, rape type, or prior sexual assault. There were no differences in demographics between those with complete and incomplete data, so we excluded the 13 individuals with incomplete data from analyses. Of the 59 remaining participants, 56 were women and 3 were men. Because gender comparisons could not be made with so few male participants, we also excluded men from analyses.

Participants were 56 women aged 18 to 58 (M = 28.16, SD = 10.44) who completed phone visits 0 to 22 days post-SAMFE (Mdn = 5.00; 80.4% within 10 days). Participants were 73.2% White/Caucasian (n = 41), 26.8% Black/African American (n = 15), and 5.4% Hispanic (n = 3) (5.4% endorsed more than one category; n = 3). In addition, 14.3% identified as a sexual or gender minority (n = 8).

Measures

Acute stress symptoms.

Consistent with other clinically focused research (e.g., Jaycox, Marshall, & Orlando, 2003; Kaysen et al., 2010; Zatzick et al., 2002), clinical staff assessed acute stress symptoms (aside from dissociation) via telephone within the first month post-rape using a standardized measure of PTSD to allow for clinical comparisons across time. Specifically, individuals completed the PTSD Checklist (PCL-5; Weathers et al., 2013) by indicating how much they were bothered by 20 symptoms on a scale from 0 (not at all) to 4 (extremely). We then computed mean scores for each symptom cluster corresponding to the DSM-5 conceptualization of PTSD (American Psychiatric Association, 2013) and PCL-5 scoring recommendations (Blevins, Weathers, Davis, Witte, & Domino, 2015). In the current study, coefficient alpha ranged from .68 to .89 for the cluster subscales, reflecting acceptable internal reliability. Prior work has also suggested the PCL-5 has strong test-retest reliability, and convergent and discriminant validity (Blevins et al., 2015).

Rape type.

Clinical staff asked participants to respond “yes” or “no” to three questions about characteristics of the rape that led them to seek the SAMFE (Dir, Hahn, Jaffe, Stanton, & Gilmore, 2018). Due to the clinical screening context of the interview, clinical staff did not include more detailed questions. Force was indicated by a “yes” response to: “The perpetrator used threats of force or force.” Substance-involvement was indicated by a “yes” response to: “I was intoxicated (due to alcohol or drugs)” or “I think the perpetrator drugged me.” The rape was categorized as involving (a) only force, (b) only substances, or (c) both force and substances.

Prior sexual assault.

Clinical staff also asked participants, “Have you experienced sexual violence / sexual assault / rape in the past?” Response options were “yes” or “no.” Consistent with prior work (Gilmore et al., 2018), we considered those who responded “yes” to this question to have a history of prior sexual assault.

Demographics.

Clinical staff asked participants to self-identify their gender identity (free response), race/ethnicity (response options: White, Black, Hispanic, Asian, Native American, Pacific Islander), and whether they identified as “LGBTQi” (lesbian, gay, bisexual, transgender, queer, or intersex; response options: yes or no). We gathered date of birth from a record review and used this to calculate age at time of the phone visit.

Analyses

To examine predictors of each symptom cluster simultaneously, we examined a multivariate regression model using maximum likelihood in SAS PROC MIXED. Distributions of dependent variables (i.e., average symptom cluster scores) were not substantially skewed or kurtotic (all indices < 1; all |z| < 3.10; Kline, 2016), and therefore, we employed a Gaussian distribution. Control variables were sexual minority status (LGBTQi vs. non-LGBTQi) and race/ethnicity (one dummy-coded variable represented those who identified as White [73.2%; n = 41] vs. Other [26.8%; n = 15]). Additional predictors were two dummy variables representing type of rape (force-only and substance-only, compared to a reference group involving both force and substances) and one dummy-coded variable representing history of prior sexual assault (any vs. none). To estimate the amount of variance explained (R2), we squared correlations between observed and predicted values.

Power considerations.

Given that archival clinical data were examined in this study, no specific sample size could be targeted for data collection. Instead, analyses included few significance tests and no interaction terms due to the small sample size. For a multiple regression with five predictors, one could expect to detect a large effect with N = 43, a medium effect with N = 91, and a small effect with N = 643, assuming a 5% significance level and 80% power (Soper, 2019). Therefore, our study was powered to detect only large effects.

Results

Descriptives

The rape that led to the SAMFE involved only force in 26.8% of participants, only substances in 32.1% of participants, and both force and substances in 41.1% of participants. In addition, 39.3% reported a prior sexual assault history, with no differences by rape type, χ2(2, N = 56) = 1.19, p = .551. Acute stress symptom clusters were highly correlated, ranging from r = .50 to r = .78, all ps < .001.

Multivariate Regression

Results of the multivariate model for symptom clusters are shown in Table 1. Contrary to expectations, there was no unique association between rape type and any symptom cluster (Figure 1). With regard to covariates, individuals with a history of a prior sexual assault reported more intrusive symptoms than those without a prior sexual assault, B = 0.63, SE = 0.31, p = .046, but were not significantly different on any other symptom cluster. Sexual orientation and race/ethnicity were also not uniquely associated with severity of any symptom cluster. As indicated by R2, the model accounted for 10.6% of the variance in intrusions, 8.0% in avoidance, 4.5% in cognitions/mood, and 9.1% in arousal.

Table 1.

Multivariate Regression Results

Predictor Intrusions Avoidance Cognitions/Mood Arousal
B (SE) p B (SE) p B (SE) p B (SE) p
Intercept 2.49 (0.33) <.001 2.97 (0.36) <.001 2.38 (0.34) <.001 2.21 (0.28) <.001
Substance-only (vs. combined) rape −0.31 (0.34) .366 −0.16 (0.36) .660 0.00 (0.35) .992 −0.20 (0.29) .484
Forcible-only (vs. combined) rape 0.05 (0.35) .896 −0.16 (0.38) .675 −0.35 (0.37) .345 −0.04 (0.30) .896
Prior sexual assault (vs. none) 0.63 (0.31) .046 0.45 (0.33) .182 0.35 (0.32) .272 0.43 (0.26) .108
Sexual minority (vs. non) 0.02 (0.42) .971 0.57 (0.45) .207 −0.06 (0.43) .884 −0.48 (0.35) .179
Race/ethnicity (White vs. Other) −0.41 (0.35) .256 −0.56 (0.38) .147 −0.01 (0.37) .976 −0.19 (0.30) .524
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Note. Combined rape refers to a rape involving both substances and force. Bold values are statistically significant (p < .05).

Figure 1.

Figure 1.

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Conditional mean symptom cluster scores based on type of rape. Mean symptom cluster scores did not significantly differ by rape type.

Discussion

The aim of this study was to determine whether acute stress symptoms differed following forcible, substance-involved, and combined rapes among women who completed a SAMFE. In contrast to prior work regarding longer-term PTSD (Brown et al., 2009; Peter-Hagene & Ullman, 2015; Tiihonen Möller et al., 2014; Zinzow et al., 2010), we observed no differences based on rape type in any symptom cluster within the first month of recovery. Given that many individuals with acute stress symptoms will recover naturally over time (e.g., Rothbaum et al., 1992), it is possible that the transient and highly variable nature of acute stress may not yet represent stable response patterns (Harvey & Bryant, 2002; Shalev, 2002). For example, immediately post-assault, rape-related intrusive thoughts and reminders may seem ubiquitous and avoidance inevitable. Patterns of avoidance and other coping strategies are likely to be developing within the first month post-rape and may not yet contribute to experiences of distress (Suliman, Troeman, Stein, & Seedat, 2013). In this way, differences in longer-term PTSD by rape type may not be detectable within the first month of recovery.

Alternatively, it is possible that differences in acute stress symptoms by rape type simply could not be observed within the current small sample, which was only powered to detect large effect sizes. For example, visual inspection of Figure 1 suggests that intrusive symptoms were lower for individuals with a recent substance-only rape than other types of rape, which would be consistent with Kaysen and colleagues’ (2010) findings that physical/sexual assaults involving alcohol (vs. no alcohol) resulted in fewer intrusion symptoms two to five weeks post-assault. Although we only had a sample size of N = 56 women who completed a recent SAMFE, a larger sample of this hard-to-reach population might have revealed a significant effect (e.g., N = 91 would have allowed for detection of a medium-sized effect). We therefore encourage subsequent research with larger samples to determine whether intrusions in the weeks following a first sexual assault are particularly susceptible to the effects of alcohol or drugs on memory.

Additional visual inspection of Figure 1 reveals that negative alterations in mood and cognitions may be lower following forcible-only rapes than rapes involving substances (with or without force). Such a difference would be consistent with past research suggesting that victim substance use prior to a rape is associated with heightened self-blame (Donde, 2017; Peter-Hagene & Ullman, 2018). Although this difference was not significant in the current small sample, future work with larger samples may determine whether substance-involved rapes indeed lead to elevated self-blame immediately post-rape, or whether differences in cognitions by rape type only emerge with more time, once response patterns have become more stable.

Partially consistent with expectations, there was an association between prior sexual assault and acute intrusion symptoms. Specifically, the recent rape (regardless of type) was followed by more intrusive symptoms in those with a prior sexual assault compared to those without a prior sexual assault. This finding is partially consistent with prior work showing more severe PTSD symptoms in individuals who have experienced multiple sexual assaults (Classen et al., 2005; Ullman, 2016). Repeat victimization may lead to more severe intrusive symptoms for a variety of reasons. For example, those with a prior sexual assault may have had higher levels of pre-existing PTSD (i.e., before the recent rape). However, the finding that prior sexual assault was only associated with differences in intrusive symptoms suggests the effect of revictimization was largest for intrusions and therefore most capable of being detected in this small sample of women who received a SAMFE. One plausible explanation is that a memory of a prior sexual assault was activated by the recent rape, and therefore contributed to the occurrence of acute intrusive symptoms. Another possibility is that individuals with a prior sexual assault were already experiencing heightened intrusive symptoms before the recent rape, although prospective research would be needed to examine this possibility.

Finally, sexual orientation and race/ethnicity were considered as potential covariates in the current study, but were not significant unique predictors of acute stress symptoms. Although associations between minority stress and PTSD have been examined in the past (Long et al., 2007; Sigurvinsdottir & Ullman, 2015, 2016), larger, more diverse samples are needed to comprehensively evaluate associations between minority status and acute stress symptoms.

Limitations and Future Research

Limitations of this study inform directions for future research. First, although we accessed a difficult-to-reach population, the sample was relatively small, which limited power to detect differences between rape types. This small sample also may not represent all sexual assault victims presenting for a SAMFE and these findings should be considered preliminary pending replication. Future research should include larger, more diverse samples of sexual assault survivors seeking medical forensic exams to examine differences in post-rape mental health symptoms by gender, race/ethnicity, and sexuality, and across multiple minority groups. Future work should also be extended to survivors who have not utilized rape-related medical services. Given that force during rape is associated with increased likelihood of receiving post-rape medical attention (Zinzow, Resnick, Barr, et al., 2012) and acute stress symptoms, such as avoidance, may differ between those who do and do not seek medical attention, it may be particularly important to include survivors who do not seek a SAMFE.

Second, because clinical data were examined, standardized measures typically used in research were not available. For example, the assessment of acute stress did not capture dissociative symptoms and the question regarding prior sexual assault was not behaviorally specific. In addition, questions used to assess rape type did not allow for reliable differentiation between voluntary and involuntary (i.e., perpetrator-administered) consumption of substances; therefore, we represented both scenarios as substance-involved rape in this study. Although prior work suggests incapacitated and drug-/alcohol-facilitated rapes are comparable in risk for PTSD (Zinzow et al., 2010), further research is needed to examine potential differences in acute stress. Relatedly, clinical staff did not assess the degree of intoxication or incapacitation. Prior research is mixed on whether degree of intoxication is related to PTSD severity. Although Littleton, Grills-Taquechel, and Axsom (2009) reported no differences in PTSD symptoms between sexual assaults when not impaired, impaired due to alcohol (e.g., had trouble walking), or incapacitated due to alcohol (unconscious), greater self-reported subjective intoxication has been associated with more severe PTSD (Blayney, Read, & Colder, 2016; Jaffe et al., 2017). Additional research is needed to determine whether degree of intoxication is associated with acute stress symptoms.

Finally, we focused on initial differences in stress symptoms, which may or may not translate to long-term differences in distress. Although there is some indication that acute stress experienced within the first month post-rape may increase risk for PTSD over time (Tiihonen Möller et al., 2014), the predictive capacity of acute stress is limited (Bryant, 2011), as over half of all acutely symptomatic trauma survivors remit within the following three to six months (Harvey & Bryant, 2002). Additional research is needed to determine how rape type and prior victimization influence psychological recovery in the long term.

Practice Implications

Preliminary findings from 56 women interested in post-SAMFE care revealed that a history of prior sexual assault was associated with more intrusion symptoms. This finding can be used to inform secondary prevention of PTSD after a rape. During a SAMFE, nurses could screen for history of prior sexual assault and provide referrals for individuals who may be struggling with pre-existing posttraumatic stress. Standardized programs could also be tailored. For example, there is some indication that the effectiveness of an early video-based intervention to prevent post-rape psychopathology may vary based on history of prior sexual assault (Miller, Cranston, Davis, Newman, & Resnick, 2015; Resnick et al., 2007), but more work is needed to determine the potential utility of further tailoring secondary interventions based on characteristics of the recent rape.

Although we did not observe significant differences in acute stress symptoms between rapes involving substances only, force only, or both substances and force, trends suggest rapes involving substances but no force may result in somewhat fewer initial intrusions. Because other acute stress symptoms were comparable, regardless of force or substance involvement, clinicians should continue to assess for acute stress symptoms and subsequent posttraumatic stress in individuals recovering from substance-involved rape, even if intrusions––often considered a hallmark symptom of PTSD (Foa, Steketee, & Rothbaum, 1989)––are not immediately present. Given that women’s symptoms of distress following sexual assault have at times been historically dismissed or overly pathologized (e.g., Herman, 1992), it is important to acknowledge rape-related distress in all forms, even if intrusive memories or nightmares are not reported. Trends also indicated rapes involving any substances may be followed by more negative mood and cognitions than forcible-only rapes in the month post-assault. This highlights the importance of providing supportive responses, particularly following substance-involved rapes, to avoid reinforcing negative cognitions through victim-blaming language (Relyea & Ullman, 2015; Ullman, 2010).

Conclusions

This study was the first we know of that examined how rape-related acute stress reactions vary as a function of rape type in women who completed a SAMFE. Preliminary findings from this small sample revealed no significant differences by rape type. We suggest replication efforts with larger samples to better understand the development of acute stress symptoms following substance-involved and forcible rapes.

Acknowledgments

Manuscript preparation was partially supported by a grant from the National Institute on Drug Abuse (K23DA042935 to the third 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 also like to acknowledge the grant that funded the follow-up clinic that was awarded to the third author: This project was 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.

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 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.

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