Stark Findings About Sexual Assault: Implications for Sexual Minority Women and the Challenging Work Ahead

Nearly 23 million women in the United States—about one in every five—will experience a rape or an attempted sexual assault (i.e., sexual activity when consent is not obtained or not freely given) during their lifetime.¹ Annually, about 1.2 million women experience rape or attempted sexual assault.¹ These estimates are only for women aged 18 years and older, with less known about these experiences among minors. Advocates relay the breadth of sexual assault against women to command attention and funnel outrage into action (e.g., 23 million women is more than the entire population of Florida; 1.2 million women sexually assaulted in the past year is about two women each minute). Yet, the rate of sexual assault from 2017 to 2018 increased from 1.4 per 1000 to 2.7 per 1000 persons aged 12 years or older.²

In this issue of AJPH, McCauley et al. (p. 850) take a novel approach to the epidemic of sexual assault with longitudinal data from college-attending women who sought care from college health centers and enrolled in a cluster-randomized controlled trial to reduce alcohol-related sexual assault. Importantly, the authors’ study included a measure of sexual minority status (i.e., women who reported having same-sex or both same-sex and opposite-sex sexual partners), which revealed a stark finding: by the end of the study period, 87.3% of sexual minority young women in this sample reported being sexually assaulted.

The negative health sequelae associated with surviving sexual assault are additionally concerning. Interestingly, McCauley et al. found that the relative associations between sexual assault and alcohol use were smaller for the sexual minority women than for the heterosexual women. They offer a sobering potential explanation: for sexual minority women, college was too late to begin examining the association between sexual assault and alcohol use. In the authors’ study sample, nearly one third of sexual minority women reported experiencing sexual assault before college. Indeed, evidence shows disparities in sexual assault before aged 18 years between sexual minority and heterosexual adolescent girls.³ However, the etiologic factors are poorly understood, which stifles prevention. How do we prevent sexual assault against sexual minority adolescent girls and women when we do not fully understand why it is happening so frequently?

Several hypotheses, rooted in structural and interpersonal stigma, have been forwarded in the literature.⁴ For example, a “risky spaces” hypothesis postulates that societal stigma relegating sexual minority adolescent girls and women to marginal spaces (e.g., bars) elevates the risk of sexual assault, particularly alcohol-related sexual assault. A “disclosure” hypothesis suggests that if sexual minority adolescent girls and women are accustomed to divulging stigmatizing information about themselves (e.g., their sexual minority status), they may be more likely to disclose other potentially stigmatizing information (e.g., sexual assault). A “predator” hypothesis suggests that perpetrators disproportionately target sexual minority girls and women for a number of reasons (e.g., predators believe they can manipulate victims through fear of disclosure, predators recognize sexual minority girls or young women as more alienated or ostracized from peers). Finally, a “policing” hypothesis includes perpetrators using sexual violence to enforce sexuality and gender norms, which disproportionately makes sexual minority girls and women targets for violence. These hypotheses (and others) require scientists, supporting institutions, and funding agencies to forge into challenging research territory.

Exploring this territory requires a number of complex strategies—at individual, system, and societal levels—to mobilize prevention. First, prospective research among those younger than 18 years is needed to better understand the consequences of surviving sexual assault. Most knowledge about sexual orientation–related disparities in sexual assault are from cross-sectional studies of adult women.⁵ The few longitudinal studies of sexual minority adolescent girls performed to date, such as one with a relatively small regional sample,⁶ are foundational but highlight the current limited understanding of the temporal relation of sexual assault with health-compromising behaviors.

There are clear needs for intervention research for sexual minority adolescent girls and women who survive sexual assault. However, a wider lens is necessary to capture the ecology of recovery and healing from sexual assault (i.e., the systems, services, and providers of which survivors may avail themselves). For example, how do legal and justice, health care, school-based, and social service systems coordinate with each other to aid survivors? Sexual minority women experience several barriers that can jeopardize access to and continuity of care (e.g., insensitive providers, fear of stigma, heterosexism).⁷ Because sexual minority adolescent girls and women are overrepresented among sexual assault survivors, it is vitally important to understand how they experience supportive systems and how best to engage and retain them in care when they experience a sexual assault.

Moreover, we need to center efforts on sexual minority women at different intersections, such as race/ethnicity, socioeconomic position, gender minority status (e.g., transgender women), and disability status. Sexual minority women at these intersections face the simultaneous brunt of sexist, heterosexist, and racist hegemonies. Interestingly, McCauley et al. noted a significantly greater proportion of women of color in the sexual minority group than in the heterosexual group. However, the authors concede a similar limitation to other research focused on sexual minority women: the small sample size precluded intersectional analyses. We must ask how research can employ intentional approaches to actually address this limitation. Is it ensuring designs that can oversample women of color and tailoring recruitment to resonate with women of color? Is it inviting women of color to the table during study design or even earlier, during the project ideation phase? It is likely both of these approaches and more, including involving funders and peer reviewers who understand and support community-generated and community-based participatory research practices.

Furthermore, our understanding of resilience remains largely conceptual, and it is unclear how sexual assault survivors manage their experiences. The finding of McCauley et al. of a lower magnitude of relative association of alcohol use and sexual assault among sexual minority women may suggest resilience. However, explicating resilience is a continuing challenge for public health, and it encompasses complicated landscapes, including structural services and access, interpersonal emotional and instrumental supports, and the individual genetic and epigenetic underpinnings of grit.

Additionally, research about perpetrator prevention and intervention must be developed, including research on dismantling sociocultural scourges of misogyny, sexism, and the normalization of violence—particularly sexual harassment and violence. Because men are predominantly the perpetrators of sexual assault against both sexual minority and heterosexual women,¹ primary prevention of sexual assault includes eroding myths of masculinity (e.g., “real” men are supposed to be sexually aggressive), erasing prescribed gender roles that disadvantage women (e.g., women should capitulate to advances from men), and eradicating victim blaming (e.g., asking, “Well, what was she wearing?”).

Finally, advocating policy informed by evidence-based research is needed. For example, the progress of the Violence Against Women Act included funding for survivor services and enhancement of law enforcement initiatives. Yet, despite three congressional reauthorizations, the most recent reauthorization fell victim to politics in 2019, and, at the writing of this editorial, although Congress continues to appropriate funding for the Violence Against Women Act, it has not been reauthorized—a significant concern in light of the 2017 to 2018 increase in sexual assault in the United States.² Challenges remain in policy, research, and sociocultural change to end sexual assault against women, and the stakes are particularly high for women at the intersections of multiple socially and structurally disadvantaged identities, such as sexual minority women.