The impact of sociocultural contexts on mental health following sexual violence: A conceptual model

Abstract

Objective:

Sexual violence has substantial mental health effects on survivors around the globe. Although there has been increasing attention to the ways that sociocultural environments can affect survivors’ recovery, there has been no review to our knowledge of the specific factors within sociocultural environments that offer risk or protection, or the mechanisms by which these factors affect recovery.

Method:

To address this gap, we present a conceptual model supported by a theoretical and empirical review that prioritizes research conducted with ethnic minority and global samples.

Results:

We identify three components of global sociocultural settings—norms, structures, and environmental stressors—that may affect mental health following sexual violence. We propose that these components may affect survivors’ mental health by (1) influencing how survivors themselves, survivors’ social contexts, and the systems with which survivors come into contact think about and respond to sexual violence, and (2) creating additional sources of stress, burden, or protection for survivors.

Conclusions:

We argue that future research, practice, and policy could have a greater effect on survivors by attending to sociocultural factors in recovery.

Introduction

Sexual violence is a global phenomenon (Anderson, Flynn, & Pilgrim, 2017; International Society of Traumatic Stress Studies, 2018) with mental health effects that are both broad and targeted (Ba & Bhopal, 2017; Dworkin, Menon, Bystrynski, & Allen, 2017) and often enduring (Darves-Bornoz et al., 1998; Foa, Riggs, Dancu, & Rothbaum, 1993). Sexual violence is perpetrated within a societal and cultural context (Campbell, Dworkin, & Cabral, 2009) and therefore, the factors that influence the development of post-assault mental disorders are best conceptualized within socioculturally-aware ecological models (Campbell, Dworkin, et al., 2009; Neville & Heppner, 1999). These models recognize the person in context and acknowledge that post-assault outcomes are shaped by inter-related individual, assault and multi-level environmental contexts.

While a substantial amount of research has examined characteristics of survivors, their assaults, their immediate social contexts, and the service systems with which they interact in terms of their recovery outcomes, very little research has directly investigated the influence of the broadest levels of the social ecology—characteristics of societies and cultures—that may affect survivors’ recovery. Although several past reviews have attended—at least in part—to the role of specific aspects of societies and cultures in survivors’ recovery (e.g., Bryant-Davis, Chung, & Tillman, 2009; Campbell et al., 2009; Flood & Pease, 2006; Neville & Heppner, 1999), and there are multiple reviews on recovery from sexual violence within specific ethnoracial populations (Chan, 2009; Gebhardt & Woody, 2012; Low & Organista, 2000; Tillman et al., 2010), no review to our knowledge has addressed the range of sociocultural factors that may influence recovery from sexual violence.

As distinct from extant reviews, the purpose of this paper is to provide an in-depth model of the potential ways that sociocultural factors can influence sexual violence recovery, with a focus on application to ethnic minority and global populations, to guide the development of research—and ultimately, systemic change—in this area. We investigate sociocultural factors guided by the concept of the macrosystem put forth by Bronfenbrenner (1994). Macrosystems include overarching patterns that characterize a given culture or subculture, incorporating the styles, meaning, routines, customs, and materials associated with each of these broader systems, and can be thought of as “a societal blueprint for a particular culture or subculture” (Bronfenbrenner, 1994). Macrosystems include cross-setting patterns in economic, social, educational, legal, and political systems (Bronfenbrenner, 1977). They imbue information, meaning, and incentive to roles, activities, and social interactions. Macrosystems include aspects of shared identity, including nationality, race, ethnicity, religion and sexual orientation. Formal and informal societal and cultural groups, such as the military and college sororities and fraternities, are also macrosystems. In contrast, the microsystem is defined as survivors’ immediate social environment (e.g., their friends, families, and romantic partners), and the exosystem includes the organizations and social systems with which survivors may interact (e.g., the mental health service system, the criminal justice system, medical settings).

We present a conceptual model of sociocultural influences on recovery from sexual violence, including three components of sociocultural settings—norms, structures, and environmental stressors—and the mechanisms by which they may affect survivors’ recovery. We then describe each of the three components and the mechanisms by which they operate in depth. Given the limited research on sociocultural factors in recovery from sexual violence, we primarily focus on the development of a conceptual model that could guide future research and systemic change initiatives in this area. However, to guide model development, we leverage relevant research on racial/ethnic minority and global populations whenever possible. We conclude by suggesting implications for research, policy, and practice.

Conceptual Model of Sociocultural Influences on Recovery from Sexual Violence

Our conceptual model focuses on sociocultural factors that could affect recovery from sexual victimization including their mechanisms of influence (Figure 1). This model is not intended to be an exhaustive list of relevant sociocultural variables or their mechanisms. We also do not intend to suggest that survivors’ experiences in a given sociocultural setting are universal, or that between-group differences are more important than within-group differences. Instead, we offer a theoretical framework for exploring potential factors that vary across survivors’ sociocultural contexts with the aim of promoting further research and theory development.

Figure 1:

Conceptual Model of Sociocultural Influences on Sexual Assault Recovery

We conceptualize sociocultural contexts as settings consisting of three central, interrelated, mutually-influential components: (1) norms (i.e., the normative ideas, beliefs, ideologies, and values held in a society, culture, or subculture), (2), structures (i.e., concrete systems and entities present at the level of a society or culture), and (3) environmental stressors (i.e., acute or ongoing environmental conditions, traumas, and challenges at the level of a society or culture). Each of these three components has the potential to directly affect survivors’ recovery or indirectly affect survivors via intermediary levels of the survivors’ post-assault social ecology, such as individuals (e.g., survivors’ supporters) or settings (e.g., local service systems). Importantly, the components of a survivor’s own culture—including their multiple intersecting cultural identities—could affect them or their interactions with microsystems or exosystems within their culture(s). However, survivors may experience a different set of sociocultural influences on their recovery when they interact with microsystems and exosystems that are associated with a different culture than their own.

We propose two mechanisms by which these components could exert direct or indirect influence on survivors’ recovery. The first mechanism pertains to helpful or harmful influences on how survivors or intermediary levels of the social ecology (i.e., microsystems and exosystems) think about and respond to sexual violence. This includes influences on survivors’ thoughts, whether and how survivors disclose an assault and/or seek help, and survivors’ experiences with microsystems and exosystems (e.g., when they disclose or seek help). The second mechanism pertains to the presence of additional sources of stress, burden, or protection for survivors, microsystems, or exosystems, that are not directly related to the assault itself, but which may offer risk for or protection from psychopathology.

The Role of Sociocultural Norms in Recovery

The first component of sociocultural contexts that may have relevance to recovery from sexual violence is norms. We define norms as the shared ideas, beliefs, ideologies, and values held in a society, culture, or subculture. Norms may be observable and measurable via shared attitudes and behaviors of members of the culture, or via their reflection in systems-level structures (e.g., laws). Next, we review four types of norms that may affect recovery: sexual-violence-supportive norms (e.g., beliefs about sexual violence, sex, and gender), cultural values and expectations, cultural views of emotions, trauma, and psychopathology, and oppressive belief systems (e.g., racism, sexism, heterosexism).

Sexual-violence-supportive norms: Beliefs about sexual violence, sex, and gender.

Sexual-violence-supportive norms, the first type of norm with relevance to recovery from sexual violence, include sex role stereotyping (traditional ideas about acceptable behaviors for men and women), adversarial sexual beliefs (the idea that sexual relationships are inherently exploitative), acceptance of interpersonal violence (the idea that it is acceptable to use force or coercion to obtain sex), and acceptance of rape myths (false assumptions about sexual violence and its survivors, such as victim blame) (Burt, 1980). In this section, we review the limited research on how sexual-violence-related norms may affect mental health among racial/ethnic minority and global populations of survivors.

Although sexual-violence-supportive norms exist across societies and cultural groups, as well as culturally embedded survivor-serving systems (e.g., criminal justice, medical, mental health) (Lee, Lee, & Lee, 2012; Neville & Heppner, 1999; Ullman & Filipas, 2001), sociocultural differences may manifest in the strength of endorsement as well as culturally-specific ways that these norms are communicated (Barn & Powers, in press; Flood & Pease, 2006; Fontes & Plummer, 2010; Krahé, 2016; Nayak, Byrne, Martin, & Abraham, 2003). We hypothesize that sexual-violence-supportive norms affect recovery from victimization (see Flood & Pease (2006) and Fontes & Plummer (2010) for reviews) primarily via the first mechanism (influencing how survivors or intermediary levels of the social ecology think about and respond to sexual violence).

Sexual-violence-supportive norms may affect survivors by influencing their own negative beliefs about themselves, other people, and the world, including self-blame. For example, Koo et al. (2014) assessed cognitions, sexual violence history, and mental health in Asian American and White American trauma-exposed college women. Asian American women were more likely than White American women to endorse negative trauma-related cognitions about themselves and the world, which was associated with higher PTSD symptom severity. The authors attributed the presence of these negative cognitions among Asian American women to stronger endorsement of rape myths among Asian Americans, which they in turn attributed to Asian cultural beliefs and values regarding gender and sex (e.g., traditional gender roles and patriarchal values) (Koo, Stephens, Lindgren, & George, 2012). These and other sexual-violence-supportive norms may thus affect mental health via increasing or confirming cognitions that maintain psychopathology.

Sexual-violence-supportive norms could also influence how survivors are treated within microsystems and exosystems. When individuals in these systems endorse rape myths, they may react in negative ways toward survivors. toward survivors. For example, in the Democratic Republic of Congo, sexual assault survivors are seen as “soiled” or shameful, and most are thrown out of their homes by their husbands or families, leading to homelessness (Mukenge et al., 2010). Such negative social reactions are associated with worse mental health in survivors (Dworkin, Brill, & Ullman, 2019).

Survivors may also experience more distress if they believe that others endorse such norms, regardless of the actual reactions of others. For example, feminist analysis of interviews with 10 female Taiwanese childhood sexual abuse survivors revealed that survivor perceptions of the Taiwanese sociocultural context affected their recovery (Wang & Heppner, 2011). Female survivors said that the Taiwanese emphasis on virginity led them to feel distressed that they would not be accepted by future romantic partners. In addition, survivors noted that they were distressed by rape myths held by others, including those that equated child sexual abuse survivors with sex workers. A second qualitative study of Taiwanese sexual violence survivors amplified these themes (Luo, 2000) with a fear of ostracism that was so great that one woman said, “if they (coworkers) learned about the event, I will kill myself.” These quotes underscore the interconnection between survivors’ experience, perception and anticipation of rape stigma and the effects on their mental health.

Survivors’ help-seeking behavior may also be affected by sexual-violence-supportive norms, even when survivors do not personally endorse these norms (Kennedy & Prock, 2018). First, norms regarding victim blame may affect survivors’ help-seeking. If a survivor perceives that survivors are typically blamed when they disclose sexual violence, or believes that the assault was their fault, that survivor may not disclose or seek help, thereby reducing the likelihood that they will obtain effective support (Maier, 2012). Second, norms regarding expected gender roles in sexual interactions could especially affect male survivors’ help-seeking. In cultures that emphasize masculine agency in sexual interactions, male survivors might decide not to disclose sexual violence or change how they describe aspects of the assault in order to preserve others’ perceptions of their masculinity (Cermak & Molidor, 1996; Fontes & Plummer, 2010). For example, a study of boys in Mexico City found that when sexual violence was perpetrated by older women, boys re-cast these experiences to attribute greater agency and power to themselves in the interaction (Marston, 2005). Finally, norms regarding what is considered to be “real” sexual violence, such as stereotypes that define sexual violence as an assault by a stranger that includes physical injury, may also influence whether survivors understand their experience to be a form of victimization. Endorsement of these stereotyped sexual-violence-supportive norms could then decrease the likelihood of disclosure and police reporting when the characteristics of an experienced assault do not match these norms (Krahé, 2016).

Despite the evidence that contexts with stronger sexual-violence-supportive norms may negatively affect survivors’ mental health, we are aware of only two studies—neither of which focused on racial/ethnic minorities or global populations—that have directly tested this premise. In a study by Paul and colleagues (2009), US college students with a history of sexual violence who perceived that their peers had a greater belief in rape myths had worse PTSD symptoms, whereas their personal rape myth acceptance was not associated with PTSD symptoms. Next, Dworkin and colleagues (2017) found that high school sexual violence survivors in the US who had grade-level peers with higher levels of rape denial were more likely to report depressed mood, and female survivors who had grade-level peers with higher levels of traditional gender expectations were more likely to report alcohol use. Survivors’ own endorsement of these norms was not significantly associated with mental health outcomes when grade- and school-level norm endorsement was accounted for statistically. More studies are needed that directly assess sexual-violence-supportive norms in the contexts surrounding survivors, while simultaneously assessing survivors’ mental health.

Cultural values and expectations.

The second type of norm with relevance to recovery from sexual violence, culturally-communicated norms, dictates how members of a culture see themselves individually and in relation to each other, and sets expectations for appropriate behavior (e.g., with regard to coping). These norms—which may stem from any or all of survivors’ multiple intersecting cultural identities—may affect how survivors cope with an assault, including whether and how they seek help, as well as how microsystems and exosystems within a given culture respond to survivors. These values and expectations may be a source of resilience or may increase risk for negative outcomes.

Survivors from cultural groups that encourage personal responsibility generally (as in individualistic societies) or personal responsibility for collective welfare specifically (as in collectivistic societies) may experience more self-blame, shame, and internalization of stigma following an assault (Fontes, 2007). For example, in a qualitative study of female South Asian immigrants in the US who had survived childhood sexual abuse (Singh, Hays, Chung, & Watson, 2010), one survivor discussed shame stemming from how the abuse affected her family’s image: “being raped destroyed my family’s virginal status, too, so to speak. It was a double blow, and I felt like I let my family down by what had occurred to me.” This example highlights how survivors from cultures that emphasize collectivism may experience an augmentation of their distress related to the effects of their assault on those in their family and/or community.

Collectivist values may prioritize the needs of their community ahead of individual needs, which could discourage discussing sexual violence victimization generally or identifying perpetrators (e.g., from one’s own group) specifically. Survivors may fear that identifying a perpetrator from within their cultural group or sharing stigmatized experiences with others (Bryant-Davis et al., 2009), may bring shame or stigma to their immediate family, broader cultural group (Maier, 2012) or reify narratives of discrimination. For example, Jewish survivors may be reluctant to disclose to non-Jewish individuals based on the concept of “shandeh fur die Goyim,” which roughly translates as a shameful situation that non-Jews might use against Jews (Fontes & Plummer, 2010). This may be especially true in cultures that have been subject to historical and/or ongoing marginalization. In cultures that are highly interdependent, accusing a member of one’s own community may risk the removal of an essential community member (Deer, Flies-Away, Garrow, Naswood, & Payne, 2004). In addition, many cultures, including Anglo American, South Asian, and East Asian cultures, emphasize respect or deference toward fathers or other older male relatives, which could reduce disclosure if such an individual perpetrates an assault (Fontes & Plummer, 2010). Thus, when disclosure is culturally discouraged, sexual violence survivors may have fewer options for getting support and services.

Collectivist norms may also serve as a protective factor. Survivors in cultures that place great value on relationships who are able to mobilize their community may receive substantial support. Indeed, Fontes & Plummer (2010) highlight how cultures that value strong and central mother-child relationships may encourage disclosure of child sexual abuse and promote access to social support for the child, which could lead to improved mental health. Other authors have highlighted how values in Latino culture for the extended family unit can provide protection for survivors, while the cultural values for the role of women within the family can convey self-esteem and elicit care following victimization (Low & Organista, 2000). These and other collectivist norms may increase survivors’ sense of support, or the support they actually receive, thereby conveying protection against negative mental health outcomes.

Racial/ethnic identity may itself serve as a source of resilience for survivors. In interviews with female South Asian immigrants in the US who had survived childhood sexual abuse (Singh et al., 2010), participants highlighted that ethnic pride and practices were beneficial. One participant said, “I feel proud to be South Asian. I have more access to resources and healing practices like yoga and meditation.” A second said, “Reconnecting to the South Asian community [after sexual abuse] really brought me to tears, because it made me realize how important it was.” The importance of shared ethnic identity was also highlighted among Bosnian women who had survived systematic sexual violence as a tool of ethnic cleansing (Skjelsbæk, 2006). For example, one participant said, “My husband is very supportive. When we met for the first time, he said to me, ‘Do not tell me. I know everything’.” This exemplifies how shared ethnic identity may be a protective factor against distress for some survivors.

The effects of social reactions on survivors might also differ based on an interaction between societal values and the nature of the reaction. For example, while general findings suggest that receiving positive social reactions to interpersonal violence disclosure is not predictive of better survivor mental health (Dworkin et al., 2019), there is some evidence from the broader social support literature (not specific to SA) that positive reactions might be more beneficial in cultures that value interdependence (Uchida, Kitayama, Mesquita, Reyes, & Morling, 2008). Supporting this idea, in one study, perceived emotional support was only weakly associated with well-being among European American college students, but was associated with well-being even when self-esteem was statistically controlled for in Japanese and Filipino adults living in Asia (Uchida et al., 2008). Thus, the helpfulness or hurtfulness of various social reactions may vary cross-culturally.

Cultural views of emotions, trauma, and psychopathology.

The third type of norm with relevance to recovery from sexual violence includes culturally-specific views about emotions, trauma, and psychopathology. There are differences in what cultures consider to be pathological and expectations for how emotions generally and psychopathology specifically are manifested (Droždek, 2007, p. 7), as well as beliefs about what is traumatic and how trauma survivors are impacted. For example, one study found that White American individuals perceived that sexual violence survivors would recover physically more quickly than Hispanic Americna individuals, whereas no ethnic differences were identified in estimated time for emotional recovery (Schneider, Mori, Lambert, & Wong, 2009). Such cultural expectations for recovery may affect survivors directly, or indirectly via their interactions with others.

Norms may affect how survivors experience and react to traumatic stress. Regarding the concept of PTSD within traditional Chinese medicine, Zheng and Gray (2015) highlight differences from Western conceptualizations of PTSD, including that Chinese trauma survivors may be more likely to report physical symptoms than Western survivors. They may also be more likely to view emotions like sadness or fear as valuable in balance with other emotions, whereas Western conceptualizations may frame these emotions as negative and thus encourage potentially-harmful emotional avoidance. Norms encouraging coping on one’s own could discourage (potentially-beneficial) help-seeking. For example, Catholic values emphasize enduring or resigning oneself to “bear the cross” of one’s own personal difficulties (Fontes & Plummer, 2010). Similarly, cultural expectations of strong Black womanhood convey strength and resilience, while also placing tremendous expectations for self-reliance on Black women (Fontes & Plummer, 2010; Maier, 2012; Tillman et al., 2010). For example, in a qualitative study of help-seeking among African American women who had experienced sexual violence (Ullman & Lorenz, in press), one participant stated, “I was raised as African American back in those times it’s like we were almost raised to believe that getting psychiatric help was a sign of weakness.” As highlighted by this quote, norms regarding the appropriateness of various help-seeking decisions may affect survivors’ decisions about accessing various services and supports, which could in turn affect their mental health.

Similarly, cultural norms influence how trauma and emotions should be discussed with others. In individualistic cultures, sharing one’s distress with others is thought to be beneficial, whereas emotional self-control and discretion in sharing personal troubles may be more highly valued in collectivist cultures (Mueller, Orth, Wang, & Maercker, 2009). Survivors from cultures that discourage emotional expression, have a high limit on tolerating strong emotions, or frame disclosure as unhelpful may decide not to disclose their trauma-related emotions to others. For example, in a study of German versus Chinese crime survivors, German survivors reported greater urges to expressively talk about their victimization experience, whereas Chinese survivors were reluctant to discuss the experience (Mueller et al., 2009). Cultural values for internalizing emotional problems may reduce access to external support and have been theorized to contribute to outcomes such as suicidal ideation in Asian survivors of sexual violence (Rao et al., 1992). Emotional problems may be framed as physical health problems in such cultures, which may lead to presentation to healthcare rather than mental health professionals (Zheng & Gray, 2015). Thus, cultural differences in norms around discussing trauma and trauma-related emotions could either discourage or encourage survivors from engaging with helpful coping strategies or resources that could mitigate the harm of sexual violence.

Varying conceptualizations of trauma and trauma-related psychopathology may lead survivors to have different experiences when they attempt to access help. For example, since there is no clear definition of “trauma” or “PTSD” in traditional Chinese medicine (Zheng & Gray, 2015), survivors’ distress may be attributed to causes other than the assault specifically. There is evidence that traditional versus modern values, in particular, may affect whether crime survivors’ experiences are acknowledged as victimization, and this may differ from country to country (Maercker et al., 2009). In German crime survivors, modern values were associated with the perception that others acknowledged survivors’ victimhood and were associated with lower PTSD symptoms, whereas traditional values were associated with decreased perceptions of acknowledgement. In contrast, only traditional values were associated with acknowledgement among Chinese crime survivors, and these values were not associated with PTSD symptoms. Cultures may also vary in terms of what they consider to be sexual violence. For example, in qualitative interviews about sexual violence in marriage with Mexican-American women who had experienced partner violence with Latino men (Valdovinos & Mechanic, 2017), one woman said, “…we do not call it sexual abuse because we feel we need to satisfy them because we are the wives and we have to satisfy them regardless if we want to or not…” Such norms may to complete denial or failure to acknowledge (by survivors and those with whom they come into contact) the magnitude of survivors’ victimization experiences, which could have implications for their mental health.

Values for appropriate responses to mental health problems may differ cross-culturally, and service systems are often centered around the practices of the dominant group in a culture. Survivors who seek help within their culture may be offered culturally-specific practices for recovery. Survivors who seek help outside of their culture may encounter limited services that attend to their culturally-specific needs. For example, non-English-speaking survivors in the United States may have difficulty accessing services in their native language (Macy et al., 2009). Service systems may also fail to offer culturally-tailored practices, which could lead to a disconnect with survivors’ needs or preferences.

Isms: Racism, sexism, heterosexism, and other oppressive belief systems.

Oppressive belief systems, the fourth type of norm with relevance to recovery from sexual violence, systematically devalue groups of individuals and are institutionalized in systems with which survivors interact. Importantly, survivors of sexual violence occupy multiple intersecting identities that may be associated with both unique and interacting forms of oppression and marginalization (Crenshaw, 1991). Unfortunately, little research has taken an intersectional approach to examining how oppressive belief systems may affect recovery from sexual assault.

According to minority stress theory (Meyer, 2013), individuals from minority groups are at greater risk of exposure to traumas and stressors than individuals from majority groups, but also experience ongoing minority-specific stressors (e.g., racism, heterosexism) not experienced by members of majority groups. Survivors from minority groups also may cope with stress related to historical trauma, defined as the systemic and institutionalized marginalization experienced by members of one’s group across generations (Bryant-Davis et al., 2009). For example, in a study of trauma-exposed sexual minority women, Dworkin and colleagues (2018) found that daily heterosexist experiences predicted PTSD symptoms longitudinally via negative cognitions about the self. Thus, the greater overall stress burden of occupying a marginalized identity could exacerbate the effects of sexual violence.

Group-specific experiences with marginalization within survivor-serving systems, both modern-day and historical, may affect survivors’ help-seeking decisions (Neville & Heppner, 1999). For example, in homophobic cultures, men may be concerned that they will face homophobia if they report an assault perpetrated by a man (Cermak & Molidor, 1996; Fontes & Plummer, 2010). Similarly, in many countries, survivors from minority groups may be reluctant to report an assault for fear of being treated with bias in the criminal justice and legal systems (Maier, 2012; Neville & Heppner, 1999). This has been documented among Indigenous women in Australia, who indicated that concerns about racism and a lack of services in their native language as reasons why they did not report their assault (Taylor & Putt, 2007). African American women who have been assaulted by African American men recognize that African American men experience disproportionate penalties within the criminal justice system than men of other racial or ethnic groups, which could reduce their willingness to implicate them in an assault (Donovan & Williams, 2002). Similarly, the child welfare system’s disproportionate effects on ethnic minority communities may discourage reporting of child sexual abuse, given that reporting may risk family dissolution (Fontes & Plummer, 2010). Thus, survivors who occupy marginalized identities face additional barriers to accessing supports and services based on historical and contemporary bias within these systems.

Survivors of color may experience barriers to obtaining effective support that are not experienced by White survivors when they report (Martin, 2005), including biased treatment and a failure of service systems to respond to their needs. This is exemplified in a study of Aboriginal survivors in Canada, who reported extensive experiences with racism when they sought help from the criminal justice system (Dylan, Regehr, & Alaggia, 2008). Further, because individuals with high rape myth acceptance tend to have higher rates of other oppressive beliefs (Aosved & Long, 2006), survivors from marginalized groups may be more likely to be treated in a manner consistent with rape myths when they disclose (Tillman et al., 2010). For example, racism against African American women can lead systems to blame or discredit survivors and reduce the likelihood that their cases will be successfully prosecuted (Maier, 2012). In particular, biased treatment of African American survivors may be based in prejudicial stereotypes of African American women as sexually promiscuous, immoral, and/or “unrapeable” (e.g., the “Jezebel” stereotype) (Donovan & Williams, 2002). Such stereotypes may affect how survivors are viewed and treated by service systems, which may in turn affect their recovery.

The Role of Sociocultural Structures in Recovery

The second component of sociocultural contexts with potential relevance to recovery from sexual violence is structures. We define structures as the concrete systems and entities present in sociocultural contexts, including (but not limited to) laws, policies, and media. These structures are theorized to be relevant to recovery primarily in that they influence and are influenced by the previously-described norms; in many cases, they may be the vehicles by which norms are communicated or institutionalized. For example, although the previous section addressed racist norms, racism as a system of oppression goes beyond these beliefs via its institutionalization in sociocultural structures (e.g., laws). Importantly, survivors’ local structures (e.g., police), with which they may directly interact following an assault, are typically considered to be part of their exosystem. However, exosystems that exist at the level of the subculture/culture and reflect the norms of that subculture/culture, as well as overarching patterns or commonalities across exosystems, are considered to be macrosystems (Bronfenbrenner, 1977). We thus consider structures to be macrosystems rather than exosystems when they have the potential to affect survivors regardless of whether survivors come into direct contact with them. Next, we review types of structures that may impact recovery from sexual violence: laws and resolutions, policies and practices in systems with which survivors interact, and the media.

Laws and policies.

The first type of structure that may affect recovery includes regional and national laws and governmental policies, and how (and whether) those laws and policies are implemented.

Criminal code defines what is considered to be sexual violence, the type of evidence needed, and procedures for trials. Criminal code affects how survivors are treated in the criminal justice system, and potentially their mental health as a result. It also may exert an indirect effect by affecting societal norms, which could affect how survivors are treated via the mechanisms described previously. Sexual violence was historically seen as a property crime, and the evidentiary burden for sexual violence (e.g., requiring prompt reporting and the presence of physical injuries) was higher than for other crimes (Bott et al., 2005). In the United States, sexual violence laws were specific to racial groups and did not recognize sexual violence against African American women (West, 2006). Comprehensive sexual violence law reform—which occurred in the United States and Australia in the 1970s, Canada in the 1980s, and in England and Wales in the 2000s—aimed to increase successful prosecutions and improve attention to the experiences of survivors in the criminal justice process (e.g., prohibit consideration of the behavior or character of survivors in criminal justice proceedings) (Daly & Bouhours, 2010). However, many countries still have discriminatory laws related to sexual violence. For example, in Scotland, “rape” was defined by common law as penile-vaginal penetration until a broader definition of rape was introduced in statutory law in 2009. Limitations within the previous criminal language excluded many types of sexual violence (e.g., anal or oral penetration), as well as assaults perpetrated by women or assaults against men (Stationery Office, 2007). Currently, Scottish law still requires corroboration to prove charges, which poses great challenges for successful prosecution of a crime that typically occurs in private (Inspectorate of Prosecution in Scotland, 2017). Such restrictive laws may deny survivors’ access to justice, which could have implications for their mental health.

Laws and policies can affect funding in survivor-serving systems. The Violence Against Women Act in the United States affected survivors by increasing funding for services and supports related to sexual violence and encouraging changes to local policies (Ford et al., 2002). In contrast, in England and Wales, the state sponsored survivor services organizations until the early 2000s, when policies changed to give Police and Crime Commissioners authority over which agencies receive funding through a competitive bid and outcome monitoring process (Simmonds, 2016). This change may have led to reduced funding for agencies that could not afford staff to conduct such evaluations. Thus, survivors in various regions may have different options available to them as a function of regional funding policies.

Laws unrelated to sexual violence specifically, as well as changes in the way that they are enacted, may also compound survivors’ stress and decrease their access to services and supports. For example, in the United States, Latina survivors who are undocumented may experience ongoing stress in the wake of changes in immigration policy, and may also be less willing to report their assault to formal services (e.g., the police) for fear of deportation (Messing, Becerra, Ward-Lasher, & Androff, 2015). Changes to detainment policies for undocumented immigrants may similarly affect undocumented Latina survivors, and survivors who are actually detained may lose access to critical supports while increasing stress. Changes in healthcare policy may also alter the ability of survivors to get treatment for conditions stemming from the assault. In Latin America, many governments have passed laws obligating health care professionals to address violence against women (Bott et al., 2005), although there is evidence that these laws have not been effectively enacted (Velzeboer et al., 2003). In these ways, access to services and supports may simply not be a viable or safe option for survivors based on their culture and/or country of origin.

Service system policies and practices.

Policies and practices that are common across systems with which survivors may have contact in a region are the second type of structure that may affect recovery. Many systems within specific regions have instituted policies that require individuals in that system to respond to sexual violence, which could potentially increase the likelihood that survivors are referred to formal services and supports. In the United States, changes in Title IX guidance led universities to change their response to sexual violence to avoid loss of federal funding, including mandating reporting by staff members and reducing the evidentiary burden for disciplinary procedures (Holland, Cortina, & Freyd, 2018).

Policies and practices may affect survivors’ experiences in the criminal justice system. = Consistent with this, Dobie (2011) highlighted how Native American survivors feel hopeless that police reporting will result in justice given limited tribal police resources and a general unwillingness of federal prosecutors to charge crimes. These inconsistencies indicate that survivors in some regions who seek justice in the criminal justice system may be denied, which could affect their recovery.

Policies and practices in the healthcare system may also affect survivors. For example, in Afghanistan, the Transnational Health Training Project implemented trauma-sensitive services for survivors of gender-based violence that involved linking survivors to law enforcement and mental health services (Zupancic, Huber, & Gilmore, 2016). In addition, the degree to which systems (e.g., the United Kingdom’s National Health Service) require the use of evidence-based practices when treating traumatic stress may affect survivors’ access to potentially-beneficial treatments (Mindlin et al., 2011), which could ultimately affect their recovery. Across all of these dimensions, sexual violence policy and consistent policy implementation for all survivors can hinder or support survivor recovery.

Media.

The media, including social media, news media, and entertainment media, is the third type of structure that may affect survivors’ recovery. The media reflect and influence norms regarding sexual violence, which may influence survivors’ recovery in that they provide a channel by which the norms are communicated. For example, in a study in the United States, television watching was associated with greater rape myth acceptance, although crime show viewing was associated with less rape myth acceptance (Kahlor & Eastin, 2011). Other research has implicated pornography specifically, with an experimental study in the United States demonstrating that men who viewed film clips objectifying women were more likely to say that people who were sexually assaulted in the context of a date “got what they wanted” (Milburn, Mather, & Conrad, 2000). Recent qualitative work has demonstrated that rape myths are reflected in tweets on the social media platform Twitter, and that tweets of rape myths were more likely to be retweeted and posted by accounts with more followers than tweets supporting survivors (Stubbs-Richardson, Rader, & Cosby, 2018). These patterns are also present internationally. For example, an analysis of international news media representations of the sexual violence of a South African woman highlighted how Western media reflect racist and colonial tropes in their portrayal of the Global South (Frost, 2018). Survivors in cultures, subcultures, or countries where the media communicates these norms may experience negative mental health effects, although this remains to be tested empirically.

Events and movements.

The final type of structure is events and movements. Movements are often launched by prominent cultural events (e.g., highly-publicized trials, political controversies), which can bring existing sociocultural norms to greater prominence or result in rapid changes in sociocultural norms. This was reflected in the #MeToo movement, which increased awareness of sexual violence, and provided an opportunity for public expressions of social support to survivors (Hosterman et al., 2018). Parallel movements emerged in other countries, such as the #YoTambién movement in Mexico (Nicolas-Gavilan, Baptista-Lucio, & Padilla-Lavin, 2019). Importantly, the #MeToo movement was criticized for reflecting and reifying other problematic societal norms, such as failing to attend to the experiences of women of color (Onwuachi-Willig, 2018), and its lasting effects remain to be seen. In addition, in the Democratic Republic of Congo, numerous women’s advocacy groups emerged following peace accords signed in 2002, and these movements have advocated for societal changes to improve the experiences of survivors in the region (Mukenge et al., 2002). Additional research is needed that examines the effects of such cultural events and movements on the mental health of survivors.

The Role of Environmental Stressors in Recovery

The final component of sociocultural contexts that may have relevance to recovery from sexual violence is environmental stressors. We define environmental stressors as acute or ongoing environmental conditions, traumas, and challenges unrelated to a given survivors’ experience of sexual violence that exist at the level of a culture or subculture (i.e., beyond a survivor’s immediate environment), including (but not limited to) mass traumas and economic conditions (Miller & Rasmussen, 2010). Although less researched, we theorize that these stressors could influence recovery by compounding survivors’ stress, changing their options for coping with the assault, and interfering with the effectiveness of services and supports. They could also deplete resources within survivors’ microsystems or exosystems, or complicate efforts to access resources at these levels. Next, we review two types of environmental stressors that could affect survivors: mass traumas and economic conditions.

Mass traumas.

Mass traumas—the first type of environmental stressor that may affect survivors—include wars and conflict, natural disasters, pandemics internal displacement, genocide, terrorism, and other events that could potentially have a traumatic effect on a large group of people. When sexual violence takes place during or in the aftermath of a mass trauma, this may create an additional source of trauma or stress for survivors, reduce the availability of services and supports to survivors, or make reporting difficult or impossible (Ba & Bhopal, 2017). This may be especially true for already-marginalized survivors, such as those who are internally displaced. These conditions may also increase the likelihood that survivors will experience additional assaults that could further harm mental health. This has been documented in a variety of countries after natural disaster, including post-tsunami Sri Lanka and surrounding areas (Fisher, 2010). In the aftermath of the tsunami, police reporting was difficult in camps and accommodation centers, and police were not trained to respond to violence. Health workers were focused primarily on physical injuries rather than emotional needs, and officials reportedly either neglected or responded insensitively to sexual violence reports. Similarly, when sexual violence occurs in the context of war, assaults may be especially horrific in nature, or may involve control of survivors following assault (e.g., being kept as sex slaves, being forbidden to get an abortion) (Ba & Bhopal, 2017). Thus, there are multiple mechanisms by which mass trauma may worsen sexual assault survivors’ mental health, although these mechanisms have not been explicitly examined empirically.

Economic conditions.

Poor societal-level economic conditions—the second type of environmental stressor that may affect survivors’ recovery—disproportionally affect racial/ethnic minority survivors in the United States and survivors in developing countries. These conditions may lead survivors to lack access to stable housing, medical and psychological treatment, transportation, and food, which could increase their daily stress. Existing services in these areas might be lower quality, and survivors in these settings may, by necessity, be more preoccupied with meeting their basic daily needs (e.g., caring for children without childcare, working multiple jobs) than accessing the such services (Holzman, 1996). Survivors in economically stressed areas may be at increased risk of further sexual violence or may be repeatedly exposed to community violence or sexual violence against others in their community (Abbey, Jacques-Tiura, & Parkhill, 2009; Jenkins, 2002).

It is evident that poverty, when measured at the individual level, is associated with survivors’ outcomes. Among African American survivors of sexual violence, poverty was associated with increased risk of depression, PTSD, and drug use (Bryant-Davis et al., 2009) However, only one study to knowledge has directly examined broader societal economic conditions in relation to survivor well-being. Among a diverse sample of sexual violence survivors, community-level poverty level and crime rate were not significantly associated with posttraumatic growth (Kirkner & Ullman, in press). More research is needed to understand if these findings also apply to mental health problems following sexual violence.

Discussion

This expanded perspective of sociocultural factors provides a unique contribution to the sexual violence recovery literature by broadening the theoretical and clinical level of inquiry. Theoretically, the identification of relevant macrosystem-level mechanisms holds potential for expanding the reach of post-sexual violence intervention efforts, ultimately creating greater public health impact. These mechanisms may also inform needed changes in sociocultural narratives and related social and criminal justice policies, which could benefit global populations of sexual violence survivors. In another theoretical vein, this shift in perspective takes the burden off individual survivors and instead situates the experience and recovery from sexual violence in a sociocultural context, which could combat victim-blaming narratives. This expanded focus also acknowledges ecological constraints and differential access to resources that influence post-assault recovery trajectories.

Limitations

Several limitations of this model are worth noting. First, because there is very little research on how mental health may be affected by aspects of sociocultural contexts, especially in racial/ethnic minority and global populations, aspects of this model remain speculative and warrant formal empirical testing. Second, also due to the lack of research in this area, this model is likely inexhaustive in terms of the relevant sociocultural variables that may affect recovery and the mechanisms by which they operate. Third, much of the research and theory development in this area—including the current manuscript—has been authored by White scholars in the United States, and as a result is highly vulnerable to reifying problematic frameworks, including centralizing White American perspectives and Whiteness as normative. We intend for this model to be critiqued and refined to increase its reflection of the perspectives of scholars, survivors, and communities who are Black, Indigenous, People of Color, and/or from countries outside of the United States.

Research Implications

First, we recommend framing the issue of psychological recovery from sexual violence within a sociocultural context. At minimum, researchers should consider that the factors that affect survivors’ recovery are not exclusively internal but may exist in the contexts that surround them. At the broadest level, the framing of the problem of sexual violence has implications for recruiting stakeholders, leveraging resources, shaping policy and ultimately, understanding the experience of and assisting with the recovery of survivors (Miller, 2008).

Second, we recommend that researchers directly measure each of these three components of contexts, potentially by identifying novel methods for assessing them and testing the ways in which they affect survivors. For example, a key priority for understanding how norms affect recovery from sexual violence involves understanding differences in survivor outcomes across sociocultural contexts that reflect varying levels of norm endorsement. However, this has been minimally studied. One strategy may be to sample groups of individuals to understand how the norms and practices of group members is associated with the mental health of survivors embedded in such groups. Such research may need to utilize statistical analyses that account for the nesting of survivors in sociocultural contexts, such as multilevel modeling. In addition, research methods that leverage assessment of large-scale behavior, such as sexual-assault-related terms used in searches on the internet (e.g., Makin & Morczek, 2015) or social media behavior can capture these shifting cultural trends. Finally, research examining survivor mental health before and after cultural events occur, or before and after policies change, could clarify the role of these factors in recovery.

Third, we recommend increasing attention to culture in the process of conducting research. For example, the terms used to describe sexual violence by researchers may have nuanced meaning across diverse sociocultural groups (Hamby & Koss, 2003). Culturally-situated research on the appropriate use of terminology for sexual violence is needed. As another example, in qualitative research, interviewer training could include an emphasis on cultural humility and cross-cultural research on survivor recommendations for effective content and process interviewing strategies (See Campbell, Adams, Wasco, Ahrens, & Sefl, 2009 for an example).

Finally, more research should be conducted on sexual violence recovery in global settings and with attention to intersectional cultural identities. To date, research on sexual violence recovery and sociocultural correlates of recovery has been disproportionately conducted with North American and European populations. For example, in a 2010 review of myths about sexual violence, 34 of 37 studies were conducted in the United States, and the remaining 3 were conducted in Canada (Suarez & Gadalla, 2010). More research in international and diverse populations is critically important to understanding the cross-cultural effect of sexual violence. It will also be important in conducting this research to consider the complexity of groups within cultures, including the intersectionality of different within-cultural identities. Indeed, research on racial/ethnic minority and global populations of survivors often attends only to one aspect of identity and does not consider how survivors’ identities may interact to affect their recovery.

Clinical and Policy Implications

Sexual violence policies are enacted within institutional contexts and cultures, so policy change can be a sociocultural factor that affects survivors’ mental health. In order to reduce the risk of unintended harm to sexual violence survivors, sexual violence policy developers need to consider the institutional cultures and constraints where these policies will be implemented and seek to avoid or redress downstream harm. By conceptualizing sexual violence within a sociocultural context, policies related to sexual violence should be also guided by the ethical principle that sexual rights and responsibilities are basic human rights and the implementation of any sexual violence policy should promote the health, safety and wellbeing for all regardless of racial/ethnic, sexual, social or cultural identity (see Dixon-Mueller, Germain, Fredrick & Bourne, 2009 for a proposed framework). Ongoing monitoring of the intended and actual effects of sexual violence policy on survivors is important (see Holland, Cortina, & Freyd, 2018 who discuss implications for compelled disclosure of college SA).

First, continued development and assessment of strategies for effecting changes in sociocultural settings are needed. Broadly, grassroots efforts to change sociocultural factors that may negatively influence survivors’ mental health are needed. The Start by Believing campaign is an example of one such effort that aims to educate the public about helpful and unhelpful reactions to sexual violence in the US and beyond. Healthcare providers, law enforcement and criminal justice professionals are in key positions to hinder or facilitate the recovery of individuals who experience sexual violence. Pedagogical approaches and activities that promote attitudinal change and shift institutional and cultural norms that harm survivors need continued development and assessment. Translating these findings to selection procedures for individuals who will be interacting with survivors (e.g., to identify and screen out those who endorse harmful sexual-violence-related norms or prejudicial beliefs), as well as ongoing development and assessment of trainings with professionals, is needed. Although trauma-focused interventions are often conceptualized as individually-focused interventions, improvement in the norms, conditions and structures of macrosystems may itself constitute a trauma-focused intervention. Further study is needed to evaluate the potential for changes in macrosystems as benefiting the recovery of sexual violence survivors at all levels of prevention (primary, secondary and tertiary).

Second, we recommend that psychological treatment for survivors of sexual violence attends to sociocultural factors. This may involve supporting survivors’ desire to draw from sociocultural strengths. While marginalization related to racial/ethnic or cultural identity may intersect with sexual violence distress, identity may also be a source of strength, resilience and recovery. Practice guidelines should support the ways in which sexual violence survivors’ cultural identities may promote meaning-making in the areas of esteem and positive regard during the recovery process. More broadly, relevant stakeholders should be included in creating cultural adaptations of evidence-based therapies. Finally, clinicians should consider how sociocultural factors may affect the accessibility, timing, and appropriateness of clinical interventions. Sociocultural stressors such as poverty, lack of childcare, and limited access to transportation may constrain survivors’ options for engagement in interventions. Culturally-tailored interventions should incorporate strategies to address these barriers to access to care.

Conclusion

Taken together, cultural or macro frames inform societal practices, collective and individual meaning-making processes and policies that influence risk for and recovery from sexual violence. Culture is not separate from individuals but instead, is the fabric that is woven by individual’s activities, routines and practices with a meaning-making system mediated by language (Markus & Kitayama, 2010; Vélez-Agosto, Soto-Crespo, Vizcarrondo-Oppenheimer, Vega-Molina, & García Coll, 2017). Thus, the macro frame influences the pathway and trajectories of post-assault recovery with implications for the multi-finality of outcomes, risk/resiliency profiles, progression from acute to chronic trajectories as well as survivor cognitive and emotional processing of their experience and decisional processes related to disclosure and legal redress.