Racial Disparities in Sexual Assault Characteristics and Mental Health Care After Sexual Assault Medical Forensic Exams

Introduction

While sexual violence against women is ubiquitous across race, ethnicity, class, and nationality, some evidence suggests Black* women are at increased risk of sexual victimization and negative health sequelae compared with White women.^1–3 Sexual violence is broadly defined as aggressive behaviors of a sexual nature, including rape (i.e., any completed or attempted unwanted vaginal, oral, or anal penetration through the use of physical force or threats), unwanted sexual contact (e.g., forced penetration, unwanted fondling), and noncontact unwanted sexual experiences (e.g., verbal harassment) acts.⁴

Rates and prevalence of sexual violence differ by sample, method of data collection, and type of sexual violence with some studies suggesting Black women experience higher risk of sexual violence in their lifetime, while others suggest similar rates of sexual violence between White and Black women.^1–4 For example, Kilpatrick et al.'s national telephone survey found 23.4% of Black women had been raped in their lifetime compared with 15.4% of White women, but the authors noted this was inconsistent with previous studies that found similar prevalence by race/ethnicity.⁵ Research indicates that several risk factors associated with sexual violence disproportionally impact Black women, such as poverty and child sexual abuse, and these likely contribute to sexual vulnerability as well as long-term health consequences are linked with sexual victimization.^1,2

Evidence more consistently shows that Black women are at higher risk of developing post-traumatic stress disorder (PTSD) and sexually transmitted infections, including HIV following sexual violence.^1,2 One area of research has focused on racial differences in disclosure and social support, which could explain some of the racial health inequities among sexual violence survivors.⁶ For example, Black people are more likely to experience or witness police brutality, so Black survivors must navigate their own concerns about and distrust of police in addition to community pressure to not engage with police due to concerns of safety.⁷

Compared with White women, Black women also tend to experience more negative social reactions when disclosing sexual violence, particularly among formal support providers (e.g., police, medical personnel).^6,8 Negative reactions to disclosure are, in turn, associated with higher risk of PTSD among Black women.⁸ These negative experiences with formal and informal supports following sexual victimization may discourage women from seeking care. This highlights the need for evidence-based practices that are structurally competent, culturally tailored, and trauma informed.

Medical and mental health care following sexual violence can reduce the risk of long-term mental and physical health consequences, but structural racism within health systems impedes access to effective, appropriate care for Black survivors. Cognitive behavioral therapy and cognitive processing therapy have been shown to decrease symptoms of depression, anxiety, and PTSD, and may reduce risk of revictimization among women survivors.^9,10 Yet there is consistent evidence of barriers to mental health care services for Black women stemming from mental health stigma, financial inequities, and mistrust of providers due to experiences of racism.^11–13

The U.S. healthcare system as well as legal system have enduring historical legacies of oppression toward Black women, and these interlocking systems of oppression are intimately tied to Black women's postassault responses (i.e., mental and physical health care, legal action).^12,14 Indeed, Bryant-Davis et al. note that trauma experiences, including sexual violence, must be contextualized in research by considering sociocultural factors that involve both race and gender to more readily understand racial disparities in mental health care in the United States.¹⁴ Therefore, further research is needed examining differences in postsexual assault (SA) experiences of Black and White women survivors that takes into account sociocultural contexts.

There are limitations to the scientific knowledge in terms of differences in SA characteristics by race, including relationship to perpetrators, use of weapons, alcohol, and drug involvement, and injuries. It is also unclear how access to mental health care following SA might differ by race. Our current study addresses these gaps in our understanding of sexual violence and asks:

• 1.

  How do experiences of SA differ by race among survivors who receive a SA medical forensic exam (SAMFE)?

• 2.

  How does utilization of mental health care following SA differ by race?

• 3.

  Are racial differences in post-SAMFE mental health care moderated by characteristics of the SA?

Materials and Methods

Results

Discussion

The primary aims of the current study were to examine racial differences in SA characteristics and utilization of postassault mental health care. We also tested whether racial differences in mental health care utilization were moderated by SA characteristics. These questions were investigated using a retrospective cohort design in a large sample of 690 non-Hispanic White and non-Hispanic Black adults who received a SAMFE exam at an academic medical center.

First, we found that IPV reversed the positive association between Black race and number of mental health care visits in the year following the assault. Black survivors had a significantly lower number of mental health care visits if they were assaulted by their intimate partner as compared with White survivors or to Black survivors who were assaulted by non-intimate acquaintances or strangers. Other notable racial differences emerged with regard to SA characteristics. For one, Black survivors were more likely than White survivors to be assaulted by an intimate partner and were less likely to sustain bodily injuries during the SA. Second, White survivors were significantly more likely to report alcohol or drug involvement. Third, Black survivors attended a greater number of outpatient mental health visits in the year following the assault than White survivors. This effect was attenuated after controlling for sex, age, weapon use, alcohol/drug involvement, IPV, and injuries.

These findings must be carefully situated in existing evidence of racial disparities in SA and IPV within the structural contexts of intersectional oppression. Some previous research has suggested Black women might be at increased risk of sexual violence and IPV.^2,18,19 Our results echo these findings by showing that Black survivors receiving SAMFE were more likely than White survivors to have been assaulted by an intimate partner. These disparities must be placed into appropriate context, namely the intersectional oppression of Black women,^‡18–20 including racialized and gendered poverty—wherein Black individuals, and particularly Black women, are more likely to live in poverty because of structural racism and sexism, such as discrimination in education, employment, and housing.²¹

In American society, Black women experience sexism, racism, economic oppression, and sexual and reproductive oppression simultaneously.^{18,19,22–24} Our study found that Black survivors who were assaulted by an intimate partner were significantly less likely to access post-SAMFE at the hospital. Perhaps this is because they may be both hypersexualized and blamed for their own sexual victimization^18,24—for example, the “Jezebel” stereotype—and expected to be strong, resilient, and responsible in the face of unsurmountable inequality and disadvantage—the “Sojourner Truth Syndrome.”²⁵ Altogether, these double binds require that Black women—like the survivors in our study—navigate both increased risk of sexual and IPV and the social effects of structural racism, including mass incarceration, which disproportionately affects and destabilizes Black communities.²²

Due to multilevel factors like those structural inequities described above as well as community-level and internalized stigma and mistrust, Black women are less likely than White counterparts to report experiences of SA to authorities¹⁸ and less likely to see mental health care for sexual or IPV.^19,26 In our study, we actually found that post-SAMFE mental health care at the hospital was being utilized more often by Black survivors than White survivors, perhaps because White survivors sought health care outside the hospital setting. Nevertheless, this highlights hospital-based mental health care as a unique opportunity to diminish racial/ethnic disparities in postsexual violence treatment and support.

At baseline, stigma against mental health care is a major barrier for individuals who experience violence and trauma, particularly in the Black community, at least in part because of medical mistrust and negative experiences with the health care system.^11,12 For example, Black communities have been historically exploited for scientific and medical research, including 20th century eugenics campaigns that pathologized poverty as an inheritable mental illness.²⁷ The lack of culturally appropriate (i.e., developed by and for Black people) and structurally competent (e.g., acknowledging structural racism, sexism, homophobia, and economic disadvantage) care further compounds mental health disparities following SA.^7,11–13 In response, Black survivors of violence have developed and are more likely to rely on informal and spiritual sources of social support following traumatic events.^19,26

At the same time, our results further suggest that when perpetrators are intimate partners, Black survivors are significantly less likely to follow-up for mental health care. Although more research is needed to better understand the mechanisms that account for this effect, it may be due to the sociocultural and psychological challenges Black women face when they are sexually victimized by Black men they know or who are intimate partners. Gómez proposes a “cultural betrayal trauma theory” to conceptualize how “intracultural pressure,” simultaneously coupled with loss of “intracultural trust,” prevents Black women from reporting intraracial sexual violence or seeking care.⁷ However, the current study did not include information on the race of the perpetrator, and there were not enough men in the study to examine race by gender interactions. Therefore, more research is needed.

Founded by Black women, who are survivors of intimate, sexual, and incestual violence within the Black community, the reproductive justice movement similarly provides a well-suited framework for understanding and addressing these intersectional challenges at the sociostructural levels.²³ Put simply, “[a]ddressing the racial and socioeconomic inequities that deny… reproductive justice will also reduce instances of violence and help victims escape their abusive relationship.”²⁸ Culturally appropriate mental health care interventions are needed post-SAMFE that can encourage survivors to seek and maintain mental health care treatment. At the same time, structural interventions are also needed that reduce racialized poverty and discrimination.

At the “2019 Let's Talk About Sex Conference” in Atlanta, reproductive justice organization SisterSong hosted a plenary “Accountability Panel” on intersections of the #MeToo and #BlackLivesMatter movements. Panelists including Kenyette Barnes (cofounder of the #MuteRKelly movement) emphasized the need for reproductive justice approaches to sexual and IPV in Black communities that simultaneously acknowledge historical reproductive racism (e.g., rape during slavery), ongoing socioeconomic inequality for Black communities (e.g., lack of living wage jobs and class instability), sexual oppression and stereotyping of Black women, and police brutality and mass incarceration of Black men and women.^18,29,30

Applying this framework to our current study implies that (1) post-SAMFE mental health care providers need to be trained in critical medical history³¹; (2) hospitals need to assess and address their own diversity, equity, and inclusion practices both at the clinical and institutional levels; (3) hospitals could partner with other institutions to address social determinants of health³²; and (4) hospitals need clear protocols for the provision of post-SAMFE mental health care that does not trigger engagement with the criminal justice system.

The “Accountability” panelists and other reproductive justice advocates have called for “transformational justice,” an abolitionist framework that seeks justice for survivors of sexual violence in ways that do not rely on or reinforce structural racism inherent to the U.S. justice system.³³ Grounded in the assertion that gender-based violence and state violence are interconnected, a “transformational” approach emphasizes primary prevention of the root causes of violence, including racialized economic deprivation, disruption of communities, and support networks through mass incarceration, and misogynoir gender socialization.^30,33,34

Our findings from the current study are notable and useful for several reasons. First, the dataset comprised a large, cohort-based sample of survivors who sought emergency department services postassault at a large southeastern academic medical center. SA and demographic characteristics were documented by SAMFE nurse examiners, enabling the collection of clinical data from a critical point in time postassault, and minimizing recall bias that might affect the accuracy of more retrospective study methods. The large size of the sample enabled the study of racial differences within this population, which have been previously understudied in the field of sexual violence. Finally, mental health care visits in the year following the assault were also available in the electronic medical record, which allows for the testing of hypotheses about postassault service utilization.

Despite these notable strengths, the findings from the current study should be interpreted in the context of several important limitations. First, because the data are observational, causality cannot be inferred. Second, because data were collected as part of routine clinical care, some variables relating to participant demographics and SA characteristics were limited. For example, information about survivors' socioeconomic status. Therefore, our results on racial differences likely reflect underlying socioeconomic differences in our sample that were unobserved in the study. Future research should incorporate these socioeconomic variables as potential moderators of the findings reported here. Disentangling racial differences from socioeconomic differences will be imperative for understanding and appropriately addressing SA in difference communities, because racial and economic disadvantage/privilege may impact exposure to violence and access to resources, including mental health care.

Moreover, race was not self-reported but rather based on provider perceptions then recorded in the electronic medical record. It is possible the races of some survivors were misclassified. Third, mental health care visits in the current sample were limited to those in the academic medical center system where data collection occurred. It could be that some participants, such as those with higher socioeconomic status, or those who lived in rural locations where travel to the academic medical center was difficult or inconvenient, might have been more likely to seek mental health care outside of that hospital system.

Our sample is also predominantly women survivors, which limits our ability to make extrapolations about the experiences of men, and data were not available for self-identified gender. Further research is needed to increase understanding of and solutions to disproportionate risk of SA among Black men and—particularly—Black trans women compared with other racial/ethnic and gender groups.²⁰ Finally, although the current study investigated racial differences in SA characteristics and follow-up mental health care, these differences are likely to be the result of underlying racism, racial discrimination, or systematic bias. Future studies should include measures of participants' perceptions of racial discrimination in health care, or other measures of systematic bias in the health care system.

Conclusions

This was a unique study that used data from SAMFE to explore racial disparities in SA characteristics and follow-up care, which are not yet well understood. We found significant racial differences in both the characteristics of SA and the follow-up mental health care after assault. In particular, Black survivors were more likely than White survivors to have been assaulted by an intimate partner, but less likely to have had alcohol/drug involvement or to have sustained nonbodily injuries. Notably, because Black survivors had more mental health follow-up visits at the hospital than White survivors, there is a potential opportunity to mitigate racial disparities in post-SA health outcomes, including higher risk of PTSD and poorer access to mental health care for Black survivors.

This is complicated, however, by the context of IPV. Black survivors who were assaulted by their intimate partner were significantly less likely than other Black survivors to receive follow-up mental health care at the hospital. If hospitals, where survivors receive SAMFE, are to successfully reduce racial disparities in SA outcomes and subsequent mental health care, they will need to attend carefully to those survivors who are experiencing IPV with culturally appropriate and structurally competent care. Further research grounded in the reproductive justice framework and cultural betrayal trauma theory is needed to better understand racial differences in SA characteristics and outcomes, and about ways to develop and improve access to culturally appropriate, structurally competent health care following SA—especially for Black survivors experiencing IPV.

Authors' Contributions

E.A.M.: Conducted analyses, outlined entire article, wrote Results section, Discussion, and Conclusion; coordinated coauthors; edited article; and led submission. J.R.P.: Wrote Introduction; formatted article for the publisher; assisted with revisions. G.B.M.: Cleaned data, wrote Methods and Discussion, edited article, assisted with revisions. S.E.C.: Wrote Introduction, edited article. R.M.L.: Added racial disparities in intimate partner violence evidence and literature, reviewed, and edited article. K.G.-H.: Supervisor of sexual assault forensic exams and data; reviewed and edited entire article. A.K.G.: Study principal investigator, data acquisition, conducted preliminary data analysis, mentored Dr. Mosley, and edited entire article

Copyright Statement

Since G.B.M. is an employee of the U.S. Government and contributed to the article “Racial Disparities in Sexual Assault Characteristics and Follow-Up Care: Results from Sexual Assault Medical Forensics Examinations” as part of her official duties, the work is not subject to U.S. copyright.

Disclaimer

The contents of this article do not represent the views of the U.S. Department of Veterans Affairs or the United States Government.

Author Disclosure Statement

No competing financial interests exist.

Funding Information

E.A.M.'s contributions are funded by the Mark Chaffin Center for Healthy Development at Georgia State University. Article preparation was partially funded by the National Institute on Drug Abuse (K23DA042935; PI: Gilmore). G.B.M. receives support from the Department of Veterans Affairs Office of Academic Affiliations Advanced Fellowship Program in Mental Illness Research and Treatment, the Medical Research Service of the Veterans Affairs Central Virginia Health Care System, and the Department of Veterans Affairs Mid-Atlantic Mental Illness Research, Education, and Clinical Center (MIRECC).