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. Author manuscript; available in PMC: 2022 May 6.
Published in final edited form as: J Aggress Maltreat Trauma. 2020 Aug 4;30(5):625–640. doi: 10.1080/10926771.2020.1783737

Gendered Sexual Violence: Betrayal Trauma, Dissociation, and PTSD in Diverse College Students

Jennifer M Gómez 1
PMCID: PMC9075698  NIHMSID: NIHMS1751795  PMID: 35527804

Abstract

Young adults’ transition into college includes risk for onset of mental health problems and sexual violence, particularly for women. Compared to men and boys, women and girls across the lifespan are more likely to be sexually abused, with the perpetrators often being someone close to them. High betrayal trauma is linked to varied mental health outcomes. Despite literature depth, many samples are not ethnically diverse, which results in uncertainty about the generalizability of these findings outside of majority White American populations. The purpose of the current study is to assess gender and high betrayal in sexual violence and mental health outcomes among ethnically diverse college students in the U.S. Participants (N = 368) were ethnically diverse college students attending a public university in the Pacific Northwest, who completed online measures assessing sexual violence and mental health outcomes. When controlling for medium betrayal sexual trauma (perpetrator: unclose other), the associations between high betrayal sexual trauma and dissociation and anxiety, respectively, were moderated by the female gender. The findings point to the utility of relational cultural therapy as a feminist framework that can identify sexism as a contributing factor to young women’s increased risk for sexual violence and associated mental health problems.

Keywords: Betrayal trauma theory, dissociation, PTSD, minority college students, sexual abuse

For students who traditionally matriculate, college is a time of transition in which emergence into adulthood includes increased independence and responsibility. Unfortunately, two other aspects can characterize this transition: risk for onset of mental health problems (Hunt & Eisenberg, 2010) and sexual violence, particularly for women (e.g., Gómez, Rosenthal et al., 2015). Researchers have found that women and girls are more likely to be sexually abused throughout their lives (Goldberg & Freyd, 2006), often by someone close to them; this type of abuse is often called high betrayal trauma (Freyd, 1996) and has been linked to varied mental health outcomes for the victims (DePrince et al., 2012; DePrince & Freyd, 2002; Gómez, 2019d; Gómez, Smith et al., 2014; Tang & Freyd, 2012; Yalch & Levendosky, 2019). As mentioned in the abstract, many of the samples that have been previously studied were not ethnically diverse, which increases uncertainty that these findings generalize to populations outside of the racial majority. Therefore, the current study examines an ethnically diverse college student sample in the United States and focuses on the impact of gender and betrayal in sexual violence on a wide range of mental health incomes.

Cisgender women & sexual violence

Sexual violence includes, but is not limited to, molestation, sexual assault, and attempted or completed oral, vaginal, and anal rape. Compared to men and boys, perpetrators put women and girls across the lifespan at higher risk for sexual violence (Goldberg & Freyd, 2006; Gómez et al., 2015; Gross et al., 2006; Koss et al., 1987; Ullman et al., 1999). In addition to sexual violence generally, gender may also play a role in dimensions of harm within sexual violence, including the nature of the relationship with the perpetrator(s). Specifically, sexually abusive perpetrators may more often choose to victimize those they know when perpetrating against women and girls. This makes women and girls more likely than men and boys to be sexually abused by someone close to them (Tang & Freyd, 2012).

Cisgender women & betrayal trauma theory

Betrayal trauma theory (BTT; Freyd, 1996, 1997) conceptualizes trauma within the relational context in which it occurs. Specifically, BTT identifies two dimensions of harm in trauma: 1) terror/fear-inducing; and 2) social-betrayal (see Figure 1). Though the fear component in trauma has dominated the literature (e.g., Gómez, Smith et al., 2014), BTT highlights the vulnerability present in close relationships, including those where trust and/or dependence are likely (e.g., father-daughter; husband-wife). According to BTT (e.g., Freyd, 1997), when abuse happens within close relationships, betrayal through the trauma, such as rape, coincides with any experience of fear or terror. Compared with medium betrayal traumas, such as a sexual assault perpetrated by a stranger, these high betrayal traumas that are perpetrated by someone close have a toxic betrayal that is associated with exacerbated negative mental health outcomes (e.g., DePrince et al., 2012).

Figure 1.

Figure 1.

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Betrayal trauma theory, reprinted with permission.

In BTT (e.g., Freyd, 1996), these exacerbated outcomes, such as PTSD (e.g., Kelley et al., 2012), are conceptualized as understandable responses to unspeakable harm and betrayal. Compared to medium betrayal where the perpetrator(s) are not someone close, women may be more likely to experience high betrayal trauma (DePrince & Freyd, 2002; Goldberg & Freyd, 2006; Martin et al., 2013; Tang & Freyd, 2012). Moreover, high betrayal in sexual violence is linked with mental health outcomes, including PTSD (Kelley et al., 2012; Tang & Freyd, 2012) and other trauma symptomatology, such as depression, anxiety, and dissociation (Goldberg & Freyd, 2006; Kelley et al., 2012; Gómez, 2019a; Gómez & Freyd, 2017; Gómez, Kaehler et al., 2014; Martin et al., 2013; Ullman, 2007). Therefore, a systematic difference in betrayal as measured by the relationship with the perpetrator(s) may have downstream affects for gender disparities in mental health. As such, the gendered nature of sexual violence may contribute to increased risk for gendered mental health problems (DePrince & Freyd, 2002; Tang & Freyd, 2012).

Though similar findings regarding high betrayal have been found in ethnically diverse samples (Allard, 2009; Keng et al., 2019; Klest et al., 2013; J. M. Gómez, 2019b; Walton, 2014), the majority of this work is with predominantly White samples. Though there are reasons to believe in the generalizability of these findings, there are also reasons for pause. First, rigorous research necessitates that findings regarding complex sequelae be replicated and extended across populations (Bonett, 2012; Muthukrishna & Henrich, 2019). Second, differential contexts related to ethnic minority status, White privilege, and culture may limit generalizability from predominantly White populations to diverse and underrepresented minority populations (Gosling et al., 2010).

Purpose of the study

Across the lifespan, women and girls are at higher risk for both sexual violence (e.g., Gómez et al., 2015) and high betrayal (perpetrator: close other) within the violence (e.g., Martin et al., 2013). Sexual violence (e.g., Ullman, 2007) and high betrayal trauma (e.g., Goldsmith et al., 2012) are associated with many mental health problems. Moreover, college provides a setting for increased risk of gendered sexual violence (Gómez et al., 2015) and mental health problems (Hunt & Eisenberg, 2010). Despite the evidence of the gendered nature of sexual violence (e.g., Koss et al., 1987) and high betrayal trauma (e.g., Tang & Freyd, 2012), the majority of this work utilizes predominantly White American samples. Therefore, the hypotheses of this current study include the following:

Hypothesis 1: Compared to young men, young women have higher prevalence rates of sexual violence (any sexual violence, medium betrayal sexual trauma, and high betrayal sexual trauma).

Hypothesis 2: Compared to young men, young women have higher prevalence rates of mental health outcomes (trauma symptoms [total], dissociation, anxiety, depression, sexual violence sequelae, sleep disturbances, sexual problems, and clinically significant symptoms of PTSD).

Hypothesis 3: Controlling for medium betrayal sexual trauma (perpetrator: unclose other), high betrayal sexual trauma (perpetrator: close other) is associated with all mental health outcomes.

Hypothesis 4: Controlling for medium betrayal sexual trauma, the association between high betrayal sexual trauma and mental health outcomes is moderated by gender, such that the link is stronger for young women.

Method

Participants & procedure

Participants (N = 368) were ethnically diverse college students in the Human Subjects Pool at a predominantly White public university in the U.S. (Mage = 19.80 years, SDage = 2.30 years). Participants self-identified their gender (64.9% female, 33.7% male, 1.4% “other gender,” such as trans, a-gender, and gender queer) and ethnicity, which was subsequently categorized by the author: 53.0% White/Caucasian, 17.7% Asian/Asian American, 10.6% Latina/o, 6.3% Black/African American, 5.7% Arab/Middle Eastern, 2.7% Other, 2.4% Native Hawaiian/Pacific Islander, 1.1% Jewish, and .54% Decline to Answer. In the SONA online system, the author listed two items in the pre-screen survey that is offered to potential participants; these items assessed self-identification as a minority and absence of self-identification as a minority. The author then set up two studies in the SONA system – one for minority participants and one for majority participants – and combined the studies into one data set following data collection. This process ensured that there would be approximately half of participants who identified as minorities in the current study. Following completing the pre-screen survey, participants were shown a list of studies named after composers that they were eligible to participate in. Therefore, students chose the current study based on characteristics (e.g., 30-minute online study) without prior knowledge of content. This guards against self-selection into studies based on interest in the topic. After signing up, participants reviewed the informed consent form and participated in the study at a time and location of their own choosing. At regular intervals (e.g., approximately every 10 questions), participants were given the opportunity to opt out of the survey without penalty. A debriefing form with community resources was provided at the end of the survey. Participants were compensated with course credit. The university Institutional Review Board (IRB) approved the study.

Measures

These data are part of a larger data collection; therefore, only some of the measures are reported here (Gómez, 2018).

Sexual experiences survey

The Sexual Experiences Survey (SES; Koss & Gidycz, 1985) was modified to assess for the relationship with and in-group identity of the perpetrator, which resulted in 28 items. In the current study, only the dimension regarding the relationship with the perpetrator, from medium betrayal to high betrayal, was analyzed. Responses were on a Likert scale between 1- never to 4- often. A sample item is: A trusted or depended upon in-group member obtained sexual acts with you such as anal or oral intercourse when you didn’t want to by using threats or physical force (twisting your arm, holding you down, etc.). Because the SES assesses for different sexually traumatic events, a measure of internal consistency is not appropriate (Koss et al., 2007). However, prior validation on a sample of mostly White female and male college students shows that the original SES is a sound measure of sexual victimization (Koss & Gidycz, 1985). Three dichotomous variables (1- any sexual violence reported, 0- no sexual violence reported) were used in analyses: any sexual violence, medium betrayal sexual trauma, and high betrayal sexual trauma.

Trauma symptom checklist

The Trauma Symptom Checklist (TSC; Elliott & Briere, 1992) is a 40-item questionnaire that assesses total trauma symptoms and subscales: dissociation, anxiety, depression, sexual violence sequelae, sleep disturbances, and sexual problems. A sample item is: How often have you experienced each of the following in the last two months? Flashbacks (sudden, vivid, distracting memories). A Likert scale was used indicating between 1- never to 4- very often. The TSC-40 was found to have excellent predictive validity from sexual victimization in a national sample of majority White professional women (Elliott & Briere, 1992). Internal consistency across the full measure and subscales ranged from good to excellent: trauma symptoms [total], α = .96; dissociation, α = .77, anxiety, α = .82; depression, α = .85; sexual violence sequelae, α = .76; sleep disturbances, α = .81; and sexual problems, α = .86. Dichotomous variables, 1- any symptoms reported, 0- no symptoms reported, were created for the TSC [total] and subscales and used in descriptive analyses. Mean continuous variables were used in inferential statistical analyses.

PTSD checklist – civilian version

The PTSD Checklist – Civilian Version (PCL-C; Ruggiero et al., 2003) is a 17-item questionnaire that assesses symptoms of PTSD as defined in the Diagnostic & Statistics Manual, 4th Edition, text revision (DSM-IV; American Psychiatric Association, 2000). A sample item would be: “ … indicate how much you have been bothered by that problem in the last month – Suddenly acting or feeling as if a stressful experience were happening again (as if you were reliving it)?” A Likert scale from 1- not at all to 5-extremely was used. The PCL-C was found to be a valid measure of PTSD, with good test re-test reliability in a sample of majority White female and male college students (Ruggiero et al., 2003). In the current sample, internal consistency was excellent, α = .96. For descriptive analyses, a dichotomous variable of 1- clinically significant symptoms reported (based on cut off score of ‘44;’ Weathers et al., 1993) and 0- sub-clinical or no symptoms reported. A continuous mean variable was used in inferential analyses.

Data analysis

Descriptive analyses were run on all variables for the total sample and by binary gender (young women, young men). Chi-square analyses were run to determine female/male gender differences in the prevalence of any sexual violence, medium betrayal sexual trauma (perpetrator: an unclose other), high betrayal sexual trauma (perpetrator: a close other), trauma symptoms [total], dissociation, anxiety, depression, sexual violence sequelae, sleep disturbance, sexual problems, and clinically significant symptoms of PTSD. Finally, a multivariate analysis of covariance (MANCOVA) was run, with medium betrayal sexual trauma as a covariate, high betrayal sexual trauma, gender, and the interaction as the independent variables, and trauma symptoms [total], dissociation, anxiety, depression, sexual violence sequelae, sleep disturbance, sexual problems, and PTSD symptoms as the dependent variables. Effect sizes were calculated in the MANCOVA.

Results

In a sample of ethnically diverse college students in the U.S., I examined gender differences and betrayal in sexual violence victimization and related mental health outcomes. Descriptive statistics are found in Table 1 (see below). Approximately one-fifth of the sample reported any type of sexual violence. In line with Hypothesis 1, young women reported higher rates of any sexual violence, medium betrayal sexual trauma (perpetrator: unclose other), and high betrayal sexual trauma (perpetrator: close other) than young men. Moreover, the majority of the sample reported any dissociation, anxiety, depression, sexual violence sequelae, sleep disturbances, and sexual problems, with approximately 20% of the sample reporting clinically relevant symptoms of PTSD.

Table 1.

Percentages of sexual violence, trauma symptoms, and PTSD symptoms by gender.

Total Sample
N = 368		 Young Women
N = 239		 Young Men
N = 124		 X2
(df = 1)+
Any Sexual Violence 20.1% 23.4% 13.7% 5.17*
 Medium Betrayal 17.6% 20.5% 12.1% 4.28*
 High Betrayal 12.8% 15.1% 8.1% 3.91*
Trauma Symptoms [Total] 89.1% 90.4% 86.3% 6.00*
 Dissociation 71.7% 75.7% 62.9% 9.78**
 Anxiety 80.4% 84.1% 72.6% 12.02**
 Depression 84.2% 87.0% 78.2% 10.15**
 Sexual Violence Sequelae 85.1% 87.0% 80.6% 6.60*
 Sleep Disturbances 80.4% 84.5% 71.8% 14.31***
 Sexual Problems 86.1% 88.3% 81.5% 8.22**
 PTSD Symptoms++ 19.8% 21.8% 15.3% 2.37
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+

Due to low N of “Other Gender,” analyses include only Young Women/Young Men comparison

++

Clinically significant symptoms of PTSD, utilizing the cutoff score of 44 (Weathers et al., 1993).

*

p < .05.

**

p < .01.

***

p < .001

Mostly supporting Hypothesis 2, young women reported more trauma symptoms [total], dissociation, anxiety, depression, sexual violence sequelae, sleep disturbances, and sexual problems, with no significant gender differences in PTSD. Hypothesis 3 was supported, when controlling for medium betrayal sexual trauma, high betrayal sexual trauma was associated with all mental health outcomes. Of note, gender also significantly predicted all outcomes in this model (see Table 2). Hypothesis 4 was partially supported (Table 2), with the interaction between high betrayal sexual trauma and gender predicting dissociation (Figure 2) and anxiety (Figure 3), such that the link was stronger for young women.

Table 2.

Multivariate analysis of covariance (MANCOVA): Medium betrayal sexual trauma, high betrayal sexual trauma, gender, and high betrayal sexual trauma gender predicting trauma symptoms and PTSD symptoms.

Medium Betrayal (covariate)
F (1, 335)
(η2)		 High Betrayal
F (1, 335)
(η2)		 Gender
F (1, 335)
(η2)		 High Betrayal*Gender
F (1, 335)
(η2)
Trauma Symptoms [Total] 1.58
(.01)		 14.58***
(.04)		 14.54***
(.04)		 2.20
(.01)
Dissociation 2.98
(.01)		 7.28**
(.02)		 21.23***
(.06)		 6.63*
(.02)
Anxiety 1.40
(.00)		 11.79**
(.03)		 18.57***
(.05)		 4.38*
(.01)
Depression 2.34
(.01)		 10.00**
(.03)		 7.02**
(.02)		 .20
(.00)
Sexual Violence Sequelae 1.95
(.01)		 12.23**
(.04)		 14.97***
(.04)		 3.50
(.01)
Sleep Disturbance 1.60
(.01)		 8.91**
(.03)		 13.14***
(.04)		 2.94
(.01)
Sexual Problems .15
(.00)		 20.35***
(.06)		 17.33***
(.05)		 2.41
(.01)
PTSD 1.09
(.00)		 11.56**
(.03)		 6.99**
(.02)		 .74
(.00)
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*

p <.05.

**

p <.01.

***

p <.001

Figure 2.

Figure 2.

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High Betrayal sexual trauma*Gender is associated with dissociation.

Figure 3.

Figure 3.

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High Betrayal sexual trauma*Gender is associated with anxiety.

Discussion

In the current study, I examined gender differences in levels of betrayal and mental health outcomes in a sample of ethnically diverse college students in the U.S. With approximately 20% of the total sample reporting any sexual violence, gender differences in sexual violence and mental health were found. Specifically, in line with prior literature (Gómez et al., 2015; Gross et al., 2006; Howard et al., 2019; Vázquez et al., 2012) and in support of Hypothesis 1, almost one in four young women reported any sexual violence victimization, which was significantly higher in prevalence than the young men in the sample. This trend continued, with young women reporting significantly higher rates of both medium betrayal sexual trauma and high betrayal sexual trauma. Contrary to prior literature on betrayal trauma theory (e.g., Freyd, 1996), rates for medium betrayal sexual trauma were higher than those for high betrayal sexual trauma. Potential explanations for this discrepancy include the college context, in which predatory perpetration may occur at social gatherings, like parties (Flack et al., 2007).

Next, the vast majority of the total sample reported all trauma symptoms, with just under 20% indicating clinically significant levels of PTSD. As such, Hypothesis 2 was mostly supported. Young women reported significantly higher rates of trauma symptoms [total], dissociation, anxiety, depression, sexual violence sequelae, sleep disturbances, and sexual problems, however, there was no significant gender difference in rates of PTSD. These findings correspond with other research suggesting gender differences in mental and behavioral health (e.g., Gómez et al., 2015), with mixed findings for PTSD symptomatology (Tang & Freyd, 2012). While these findings suggest that college women are more susceptible to the increased risk for mental health problems in emerging adulthood (e.g., American College Health Association, 2012; Hunt & Eisenberg, 2010; Kessler et al., 2007), it is important to note that externalizing mental health problems, such as aggression, was not included in the current study. Therefore, the findings should be interpreted as lending support to increased internalizing symptoms for young women.

Hypothesis 3 was fully supported when controlling for medium betrayal sexual trauma, high betrayal sexual trauma predicted all mental health outcomes. These findings are in line with the theoretical and empirical research on betrayal trauma theory, as it suggests that close relationship with the perpetrator is a contributor to costly outcomes (e.g., Freyd, 1996; Goldsmith et al., 2012; Kelley et al., 2012; Gómez, 2019a; Gómez & Freyd, 2017; Martin et al., 2013; Ullman, 2007). Hypothesis 4 was partially supported, with the association between high betrayal sexual trauma and dissociation and anxiety being moderated by the female gender. This finding is in line with research suggesting that perpetrators and society put women and girls across the lifespan at increased risk for both sexual violence and related mental health problems (Brown, 2004; Burstow, 2003; Freyd, 1997; Gómez et al., 2015; Herman, 1997; Tang & Freyd, 2012).

Clinical implications

Feminist therapeutic approaches, such as relational cultural therapy (RCT; Miller, 1976; Miller & Stiver, 1997; Walker, 2011), may be particularly useful in addressing gendered sexual violence (Gómez et al., 2016; Gómez, 2020). RCT posits that the primary cause of human distress is relational disconnections with other people and intra-personal disconnections with oneself (e.g., Birrell & Freyd, 2006; Miller & Stiver, 1997). Through harnessing the therapeutic relationship as the primary mechanism of change, RCT can promote healing through mutual empowerment, mutual growth, and repair and reconnection following relational ruptures (e.g., Birrell, 2011). As such, clients, including those who have been traumatized, can heal relationally, while learning how to foster healthy relationships outside of therapy (e.g., Walker, 2011).

Moreover, as a feminist approach, RCT calls on the importance of deliberately incorporating the broader context of inequality, including sexism, into the understanding of the incidence and impact of sexual violence (Brown, 2004, 2008, 2008; Burstow, 2003, 2005; Comstock et al., 2008). As such, RCT promotes a non-pathologizing approach to clinically working with trauma survivors by implicating the role of violence and inequality in trauma while combating the notion that abused young women are deficient (Becker-Blease, 2017; Brown, 2004; Gómez et al., 2016). This is particularly important given that, in line with past literature, the current study found that being a cisgender young woman was a risk factor for any type of sexual victimization, high betrayal in victimization (perpetrator being someone close or trusted), and internalizing trauma symptoms. With an RCT approach, addressing this victimization in the context of sexism includes incorporating this larger context of inequality, discrimination, and gendered violence into psychoeducation, case conceptualization, and treatment planning and implementation. Moreover, adding in other aspects of the sociocultural context (e.g., Comstock et al., 2008; Sue, 1978), such as cultural betrayal (perpetrator[s]: shared minority identity[ies]; e.g., Gómez, 2019b, 2019c; Gómez & Gobin, 2020) can additionally shed light on culturally competent care in interventions for diverse survivors of sexual violence.

Limitations & future directions

The current study adds to the body of work suggesting that both gender and betrayal matter in mental health outcomes related to sexual violence. However, the limitations of the current study should be addressed in the future research. Studies should attempt to replicate these findings with a measure of PTSD that corresponds to the current diagnostic criteria (e.g., Blevins et al., 2015). Additionally, future studies should assess age in which sexual violence occurred, in order to examine the developmental impact and revictimization (e.g., Gómez, 2019a). In addition to sexual abuse/assault, measures of sexual violence should include items regarding sexism, sexual harassment, and sex trafficking, in order to gain a fuller picture of sexual victimization across all genders. Though used in ethnically diverse samples previously, the current study’s measures have not been validated in ethnically diverse samples or underrepresented minority samples, to the author’s knowledge. Though there is value in examining BTT in ethnically diverse samples (e.g., Klest et al., 2013), future work can use validated measures to examine constructs of interest within ethnic populations. Moreover, given the role that betrayal trauma can have on subsequent relationships (Gómez et al., 2016; Herman, 1997; St. Vil et al., 2018), outcomes of violence should be expanded to include relational outcomes as well. Finally, given the high rates of sexual violence (Cantor et al., 2015) and other forms of abuse and trauma (Lombardi et al., 2002) experienced by gender minorities, researchers should engage in targeted recruitment to oversample diverse gender minority populations in order to have large enough sample sizes to meaningfully examine trauma and outcomes. Doing so will de facto expand the definition of “gendered violence” to include, trans and gender non-conforming individuals (Jauk, 2013), which can foment research with diverse gender populations. This would allow researchers to better grasp the gendered nature of sexual violence and inform culturally congruent, efficacious interventions (Mizock & Lewis, 2008).

Concluding thoughts

Within a sample of ethnically diverse college students, the current study examines gender differences in sexual violence and mental health outcomes. The findings show that young women report higher rates of sexual violence than young men, with sexual violence that is perpetrated by a trusted person – high betrayal – being associated with dissociation, depression, PTSD, and other mental health outcomes. Taken together, these findings provide a sobering snapshot of undergraduate life as impacted by sexual violence, with implications for cultural competency in trauma interventions for diverse survivors of sexual violence.

Footnotes

Disclosure of interest

The author declares that they have no conflicts to report.

Ethical standards and informed consent

All procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation [institutional and national] and with the Helsinki Declaration of 1975, as revised in 2000. Informed consent was obtained from all participants for being included in the study.

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