Development of a brief bedside tool to screen women sexual assault survivors for risk of persistent posttraumatic stress six months after sexual assault.

This study aims to develop and validate a brief bedside tool to screen women survivors presenting for emergency care following sexual assault for risk of persistent elevated posttraumatic stress symptoms (PTSS) six months after assault. Participants were 547 cisgender women sexual assault survivors who presented to one of 13 sexual assault nurse examiner (SANE) programs for medical care within 72 h of a sexual assault and completed surveys one week and six months after the assault. Data on 222 potential predictors from the SANE visit and the week one survey spanning seven broadly-defined risk factor domains were candidates for inclusion in the screening tool. Elevated PTSS six months after assault were defined as PCL-5 > 38. LASSO logistic regression was applied to 20 randomly selected bootstrapped samples to evaluate variable importance. Logistic regression models comprised of the top 10, 20, and 30 candidate predictors were tested in 10 cross-validation samples drawn from 80% of the sample. The resulting instrument was validated in the remaining 20% of the sample. AUC of the finalized eight-item prediction tool was 0.77 and the Brier Score was 0.19. A raw score of 41 on the screener corresponds to a 70% risk of elevated PTSS at 6 months. Similar performance was observed for elevated PTSS at one year. This brief, eight-item risk stratification tool consists of easy-to-collect information and, if validated, may be useful for clinical trial enrichment and/or patient screening.

Trauma- and Violence-Informed Empowering Care for Sexual Assault Survivors.

BACKGROUND: Forensic nurse examiners, including sexual assault nurse examiners, provide care for survivors holistically through healthcare, emotional support, connection to follow-up care, safety planning, and, if desired, evidence collection to aid in the prosecution of sexual assault. There is increasing recognition that trauma-informed care must also include an understanding of the impacts of structural violence on minoritized patients to ensure health equity. AIM: To help address this guidance gap, we expanded Campbell and colleagues' empowering care model using a trauma- and violence-informed care (TVIC) lens. METHODS: We used an iterative discussion-based process that included five joint meetings between a seven-member transdisciplinary research team and a five-member nurse advisory board. RESULTS: In a TVIC-informed empowering care model, we propose behavioral examples for forensic nurses for each of Campbell et al.'s five key domains of empowering care for forensic nurse examinations (i.e., build rapport and establish trust, show compassion, provide patient-directed care, convey professionalism, and provide resource referral and follow-up). CONCLUSIONS: These behavioral examples for nurses can help guide forensic nurse training and practice to reduce disparities in treatment and follow-up support. Structures and systems are needed that enable forensic nurses to provide trauma- and violence-informed empowering care to survivors of sexual assault and, over time, increase the accessibility of forensic nurse examinations and improve patient outcomes.

"I'm not going to do it alone": A qualitative study of barriers to sexual assault service-seeking among college students.

Objective: To understand barriers to seeking post-sexual assault services for students of color and lesbian, gay, bisexual, transgender, queer, and questioning (LGBTQ+) students. Methods: Qualitative interviews about campus and community resources for sexual and relationship violence were conducted with 29 undergraduate and graduate students who held diverse sexual, gender, and racial identities (n = 15 disclosed violence-related service-seeking). Results: Organized within trauma-informed care pillars, thematic coding revealed aspects of campus environment/culture that prevent students from accessing support including challenges identifying experiences as violence; limited cultural and identity-affirming care; limited clarity about resources; confidentiality concerns; difficulty accessing resources; and navigating resources alone. Suggestions to address concerns included regular prevention training; better coordinated care and systems with increased accountability, increased survivor support and peer support, and heightened transparency on websites/trainings about processes and confidentiality. Conclusions: Findings suggest promising avenues to improve support, particularly for minoritized survivors of violence, at this campus.

From Philosophy to Practice: Designing a Multi-Method, Multi-Stage Program Evaluation of the Wisconsin Domestic Violence Housing First Pilot Program.

Safe and secure housing is a pressing concern for survivors of domestic violence (DV). Domestic Violence Housing First (DVHF) is a policy that serves DV survivors' needs by removing barriers to housing stability via flexible financial assistance, mobile advocacy, trauma-informed practice, and partnerships with community housing providers. In this paper, we outline a study protocol developed to evaluate the efficacy of the Wisconsin Domestic Violence Housing First Pilot Program (WI-DVHF). Funding was provided to 9 social service programs across the state and implemented in novel ways. We develop a multi-site, multi-level, longitudinal analysis of WI-DVHF at the individual, site, and community levels. WI-DVHF includes 4 elements differentiating it from previous studies, including analysis of DVHF in rural and urban locations, unique implementation across different sites, and access to a WI rental education program. We also include data from comparable non-WI-DVHF sites and clients served during the study period. This will address concerns about comparing survivors within a site as DVHF funding may free up funds that can benefit other survivors at that site and to better understand the general challenges and trends these organizations face during the study period. The US housing crisis emphasizes the importance of identifying unique and flexible ways to meet the housing needs of DV survivors. This study highlights the potential for DVHF to improve the lives of survivors, and its adaptability to previously understudied cultural groups and across the rural-urban divide. Further, WI-DVHF funds may positively benefit other programs and participants within a site by freeing up valuable space in DV shelters and other resources.

Stress and DNA Methylation of Blood Leukocytes among Pregnant Latina Women.

Latinas experience physical and psychological stressors in pregnancy leading to increased morbidity and higher risk for adverse birth outcomes. Epigenetic changes, including DNA methylation (DNAm), have been proposed as markers to create more refined risk stratification, yet few of these studies have examined these changes in Latinas. We conducted a secondary analysis of stored blood leukocytes of Latina women (n = 58) enrolled in a larger National Institutes of Health funded R01 project (2011-2016). We examined DNAm on eight candidate stress genes to compare physically and psychologically stressed participants to healthy (low stress) participants. We found unique CpGs that were differentially methylated in stressed women early- and mid-pregnancy compared to the healthy group, though none remained significant after FDR correction. Both physical and psychological stress were associated with hypomethylation at two consecutive CpG sites on NR3C1 in early pregnancy and one CpG site on NR3C1 in mid-pregnancy before adjustment. Stress was also associated with hypomethylation at two CpG sites on FKBP5 in early and mid-pregnancy but were no longer significant after FDR adjustment. Though we did not find statistically significant differences in DNAm during pregnancy between stressed and healthy women in this sample, signals were consistent with previous findings. Future work in larger samples should further examine the associations between stress and DNAm in pregnancy as this mechanism may explain underlying perinatal health inequities.

Toward a Multi-item Measure to Identify Involvement in and Circumstances of the Sex Trades: Findings from Cognitive Interviews.

Quantitative studies in the United States that identify involvement in the sex trades predominantly use a single item to address a complex, stigmatized phenomenon. This item typically does not differentiate between in-person or virtual forms, nor does it assess the associated compensation types, circumstances, and perceived consequences. University students' involvement in the sex trades is also critically understudied. Therefore, we sought to adapt, develop, and refine a multiitem measure from the perspectives of undergraduate and graduate students who were familiar with sex trading. We conducted 34 cognitive interviews with students to understand how they perceived items on our measure. Results indicated that language used in single item studies may not reflect participants' views of the sex trades. Participants suggested the necessity of introducing survey items with inclusive introductory statements that recognize the range of circumstances, benefits, and potential harms. Items that address the circumstances of sex trading (including economic needs, wants, exploitation, empowerment/pleasure) were important in capturing diverse experiences. We make recommendations for multi-item measures to identify involvement in and circumstances of the sex trades. Implications for future research using this measure to broaden the field's understanding of the sex trades are discussed.

A preliminary examination of sexual and physical victimization 6 months after recent rape.

One in four US women will experience a completed or attempted rape in their lifetime, and more than 50% of survivors will experience two or more rapes. Rape and physical violence also co-occur. Multiple experiences of sexual and physical violence are associated with elevated mental and physical health problems. This secondary analysis examined the prevalence and correlates of experiencing sexual or physical violence within 6 months of a sexual assault medical forensic exam (SAMFE). Between May 2009 and December 2013, 233 female rape survivors aged 15 and older were enrolled in a randomized controlled trial during a SAMFE in the emergency department (ED). Demographics, rape characteristics, distress at the ED, and pre-rape history of sexual or physical victimization were assessed. New sexual and physical victimization was assessed 6 months after the SAMFE via telephone interview. Six months after the exam, 21.7% reported a new sexual or physical victimization. Predictors of revictimization during follow-up included sexual or physical victimization prior to the index rape, making less than $10,000 annually, remembering the rape well, life threat during the rape, and higher distress at the ED. In adjusted models, only pre-rape victimization and making less than $10,000 annually were associated with revictimization. Factors assessed at the ED can inform subsequent victimization risk. More research is needed to prevent revictimization among recent rape victims. Policies to provide financial support to recent rape victims and/or targeted prevention for those with pre-rape victimization at the SAMFE could reduce revictimization risk. TRIAL REGISTRATION: NCT01430624.

A prospective longitudinal study of multidomain resilience among youths with and without maltreatment histories.

The majority of children with maltreatment histories do not go on to develop depression in their adolescent and adult years. These individuals are often identified as being "resilient", but this characterization may conceal difficulties that individuals with maltreatment histories might face in their interpersonal relationships, substance use, physical health, and/or socioeconomic outcomes in their later lives. This study examined how adolescents with maltreatment histories who exhibit low levels of depression function in other domains during their adult years. Longitudinal trajectories of depression (across ages 13-32) in individuals with (n = 3,809) and without (n = 8,249) maltreatment histories were modeled in the National Longitudinal Study of Adolescent to Adult Health. The same "Low," "increasing," and "declining" depression trajectories in both individuals with and without maltreatment histories were identified. Youths with maltreatment histories in the "low" depression trajectory reported lower romantic relationship satisfaction, more exposure to intimate partner and sexual violence, more alcohol abuse/dependency, and poorer general physical health compared to individuals without maltreatment histories in the same "low" depression trajectory in adulthood. Findings add further caution against labeling individuals as "resilient" based on a just single domain of functioning (low depression), as childhood maltreatment has harmful effects on a broad spectrum of functional domains.

The socio-ecological context of U.S. college student drinking: A latent class analysis.

BACKGROUND: U.S. college student drinking typologies often consider quantity and frequency but not the socio-environmental contexts in which students obtain alcohol and drink. Understanding context could be important for preventive interventions. METHODS: We used latent class analysis (LCA), a person-centered approach to understanding behavior patterns, to identify drinking typologies among 1390 college student drinkers from a representative survey at two interconnected private colleges in the Northeast. Classes were derived from drinking frequency and quantity as well as how students obtain alcohol, where they drink, and their perceptions of peer drinking. Resulting classes were correlated with demographic and developmental characteristics, participation in campus activities and connectedness, and alcohol consequences and protective behaviors. RESULTS: Four distinct drinking profiles emerged. 'Tasters' (n = 290) included infrequent and low quantity drinkers who drank in dorms with alcohol provided by others. 'Bargoers' (n = 271) included low quantity and moderate frequency drinkers who purchased their own alcohol and drank at bars. 'Partiers' (n = 483) included moderate frequency and quantity drinkers who obtained alcohol from several sources and drank in many locations. 'Bingers' (n = 345) included high frequency and quantity drinkers and binge drinkers, who drank in many locations with alcohol obtained from multiple sources. Classes differed in demographics, age of first drink, campus activities and connectedness, alcohol protective behaviors, and alcohol problems. CONCLUSION: Heterogeneous patterns of drinking based on quantity, frequency and social/environmental context emerged and suggested the need for different tailored interventions.

A Systematic Review of Campus Characteristics Associated With Sexual Violence and Other Forms of Victimization.

Violence researchers have highlighted a need to understand connections between campus characteristics and violent victimization among students. Responding to those calls, we systematically reviewed research examining the characteristics of secondary and post-secondary educational settings associated with sexual violence and related victimization experiences, including dating/intimate partner violence, stalking, bullying, hate crimes, and crime more broadly. We screened 1124 quantitative and qualitative records, 43 of which met the inclusion criteria for this systematic review. Evidence emerged for institution demographics, institution type, institution climate, institution financial characteristics, and educational characteristics being related to various forms of victimization; institution setting (urban vs. rural) was not associated with victimization. Additionally, evidence was observed for institution location and size/density. Some factors, including institution type and campus demographics, operated differently for different forms of victimization. We highlight limitations of existing data, including variability in the measurement of victimization outcomes, lack of power to detect differences at the campus level, and challenges of creating a database on victimization that contains campus identifiers. We also reinforce calls for more intersectional research, both in terms of the types of victimization experienced by students as well as in the disproportionate impact victimization may have on students with marginalized identities.

University Students Who Report Exchanging Sex for Money or Other Compensation: Findings from a Public University Sample.

Whether and how university students exchange sex for financial compensation in the USA is critically understudied. The purpose of this secondary analysis was to determine whether undergraduate and graduate students at a large public university report exchanging sex for financial or other compensation, and identify factors (e.g., demographics, childhood adversity, mental health) associated with exchanging sex. Participants were 600 college students (Mage = 21.3 years [SD = 3.8]); 72% cisgender women; 43.4% racial/ethnic minority) from a large public university in the Northeastern USA who completed cross-sectional, online questionnaires about lifetime trauma, adversity exposure, sexual behaviors, and current mental health and substance use symptoms. A total of 4.5% of participants reported exchanging sex for money, alcohol/drugs, or other forms of compensation. Bivariate analysis revealed that lesbian, gay, bisexual, and trans students (versus cisgender, heterosexual students), students who had more severe childhood trauma, who reported being removed from their family home in childhood, and students who were diagnosed with a mental health disorder before age 18 were more likely to report exchanging sex. In a multivariable model, only emotional neglect and greater alcohol use problems were significantly associated with likelihood of exchanging sex. To our knowledge, this is the first US study to determine whether university students exchange sex for money, alcohol/drugs, or other compensation. Findings suggest that universities could consider addressing exchanging sex in person-centered, supportive sexual health programming, university health services responses, and community spaces that support LGBTQ+ students. Future research is needed to understand students' circumstances in exchanging sex and differentiate compensation type.

Equity Rx: Boston Medical Center's Work to Accelerate Racial Health Justice.

In November 2021, after more than a year of investigating the racial health disparities across its organization, Boston Medical Center launched the Health Equity Accelerator, a system-wide approach to holistically address the root causes of health inequities among people of different races and ethnicities and speed improvements in health outcomes. This article discusses lessons learned during the institution's process of discovery, shares examples of the work to dismantle a structural narrative that impedes health justice, and outlines interventions that can be applied to other healthcare systems across the United States.

Sexual Assault Victimization: Latinx Identity as a Protective Factor for Sexual Minorities.

Sexual assault victimization is an experience that impacts many college students, and rates differ based on ethnicity and sexual minority status. However, little is known about the impact of the intersectionality of Latinx and sexual minority identities on sexual assault severity among college students. The current study examined past year sexual assault victimization severity based on sexual orientation and Latinx identities among a random sample of college students (n = 506). Further, factors associated with past year sexual assault victimization severity were examined among sexual minority participants (n = 170). Among all college students, identifying as a cisgender woman, sexual minority, or having a more severe sexual assault history was associated with higher past year sexual assault victimization severity. Further, among sexual minorities, identifying as Latinx or having fewer drinks per week were associated with less severe past year sexual assault victimization. Although preliminary, this finding suggests a need for future research to examine potential cultural factors associated with Latinx populations that may serve as protective factors for sexual assault victimization among college students.

The Role of Discrimination Experiences in Postrape Adjustment Among Racial and Ethnic Minority Women.

Although recent studies have linked discrimination frequency among Black and Latinx individuals to PTSD symptom severity, to our knowledge, these associations have yet to be examined among a diverse sample of recent rape survivors. The current secondary analysis of existing data examined the role of discrimination experiences in post-traumatic stress disorder (PTSD) symptoms, depression, and alcohol and drug problems among a racially and ethnically diverse sample of recent rape survivors. Participants were 139 Black (48.2%; n = 67), American Indian (18.7%; n = 26), Hispanic (15.1%; n = 21), and mixed race (17.3%; n = 24) girls and women age 15 or older who presented to the emergency department (ED) for a sexual assault forensic medical exam. They were randomly assigned to one of three intervention conditions, and completed a six-month postrape follow-up, including questions about mental health, substance use problems, and discrimination experiences. Regression analyses revealed that Black women experienced discrimination in significantly more situations and with greater frequency compared to American Indian and Hispanic women. Discrimination frequency was positively associated with PTSD and depression symptoms even after controlling for age, education, race, and intervention condition, but was not associated with alcohol or drug problems. Findings highlight the importance of attending to the heterogeneous experiences of discrimination among racial and ethnic minority women. Future work should adapt evidence-based early interventions to be maximally effective at combating both racial and sexual trauma exposures.

Latent Profiles of Internal and External Consent During a Recent Sexual Encounter.

Understanding how individuals conceptualize and communicate sexual consent is critical to sexual health and has important implications for the prevention of sexual assault. This study used a data-driven (vs. a theoretical) approach to understand how students' internal feelings of willingness (i.e., internal consent) and behavioral communication of consent (i.e., external consent) cluster together within sexual encounters. Using data from 610 college students (72% female) who reported on their most recent sexual encounter, latent profile analysis revealed five distinct consent profiles. Most students reported willing encounters that involved the use of several external consent cues (68.9%), a small group reported low levels of both internal and external consent (3.8%), and three groups (27.3% altogether) reported encounters with complex patterns of internal and external consent. Demographic and encounter-level differences were observed across profiles. Programming that trains students to attend to their own internal desires in addition to external consent behaviors could improve emotional health and shift social norms about sexual communication.

Rape Myth Acceptance Buffers the Association Between Sexual Assault and Posttraumatic Stress Disorder Symptoms Among College Students.

Rape myths are cultural beliefs that invalidate, blame, and stigmatize rape survivors, thereby perpetuating sexual violence. Few studies have explored associations between rape myth acceptance (RMA) and mental health outcomes, but evidence suggests that RMA can buffer the mental health impact of some forms of sexual assault. The current study examined the buffering effect of RMA on depression and posttraumatic stress disorder (PTSD) symptoms using self-report data from an online survey of 500 female college students. Findings provided support for the buffering effect of RMA on the association between any sexual assault and PTSD symptoms. Experiencing any sexual assault was significantly associated with greater PTSD symptoms among participants with low RMA, whereas this association was only marginally significant among those with high RMA. Findings demonstrate that there are some contexts in which high RMA might lessen the mental health impact of sexual assault. Thus, it is possible that as progress is made to dismantle rape myths in society, mental health symptoms amongst some survivors may exacerbate, thereby increasing the demand for mental health services.

Pediatric behavioral sleep medicine in the era of telemedicine: psychology trainee perspectives.

The worldwide coronavirus pandemic in 2020 radically changed the landscape of psychology service provision and training, with rapid rollouts of telemedicine to promote safe access to care. In this perspective article, we share the experiences of 4 psychology trainees, all of whom worked as psychology interns or postdoctoral fellows in pediatric behavioral sleep medicine during the pandemic. With restricted in-person visits and upheaval of children's normative sleep and school schedules, we directly observed growth in both need for psychological care and opportunity to provide this care remotely. Here, we summarize the unique challenges and learning opportunities we faced when trying to learn and implement evidence-based assessment and treatment of child and adolescent sleep difficulties during the pandemic. CITATION: McQuillan ME, Anderson A, Russo KD, Truss A, Honaker SM, Walsh KL. Pediatric behavioral sleep medicine in the era of telemedicine: psychology trainee perspectives. J Clin Sleep Med. 2021;17(9):1965-1967.

A secondary analysis of a brief video intervention on suicidal ideation among recent rape victims.

Although rape has been linked to risk for suicidal ideation and attempts, there are scant data on the efficacy of brief interventions to reduce suicidality among recent rape victims. This secondary analysis of a randomized controlled trial investigated whether a video intervention delivered in the emergency department (ED), cortisol measured at the ED, and prior rape history predicted postrape suicidal ideation independently or in combination with the other predictors. Participants were 235 women aged 15-71 years who presented to the ED for a sexual assault medical forensic examination and were randomly assigned to either receive a video intervention that addressed avoidance and promoted healthy coping strategies or standard care prior to the examination. Participants also provided a blood sample for cortisol and completed at least one of three follow-ups at 6 weeks, 3 months, or 6 months postrape. The intervention conferred protection against suicidal ideation among women with elevated cortisol and a prior rape; however, it did not reduce risk for women without a prior rape, particularly those with elevated cortisol. It may be important to consider the influence of prior rape and neuroendocrine reactivity in developing treatments to address suicidal ideation among rape victims. More specifically, there appears to be value in screening victims for prior rape and administering this brief intervention to reduce suicidal ideation; however, other avenues should be explored for victims without a prior rape history. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Post-Sexual Assault Mental Health: A Randomized Clinical Trial of a Video-Based Intervention.

The current study assessed the efficacy of a brief video intervention (Prevention of Post-Rape Stress [PPRS]) delivered in the emergency department to recent sexual assault (SA) victims. PPRS was compared to treatment as usual (TAU) and an active control condition (Pleasant Imagery and Relaxation Instruction [PIRI]). Primary outcomes were posttraumatic stress disorder (PTSD) symptoms and perceived present control. Prior SA was examined as a moderator of treatment effects. Women (n = 233; aged 15 years and older; 59.70% identified as a racial or ethnic minority) who received a post-SA medical forensic exam participated in the study (NCT01430624). Participants were randomized to watch the PPRS video (n = 77), the PIRI video (n = 77), or receive TAU (n = 79). Participants completed measures of PTSD symptoms and perceived present control 1.5-, 3-, and 6-months post-SA. An interaction between condition and prior SA was found on PTSD symptom frequency and on perceived present control. Among women with a prior SA, women in the PPRS versus TAU condition reported less frequent PTSD symptoms 6-months post-SA. Those in the PPRS condition had lower perceived present control than those in the TAU condition among those with no prior SA 3-months post-SA. However, at 6-months post-SA, among women with a prior SA, women in the PPRS reported higher perceived present control than those in TAU. These findings partially replicate a prior study in which PPRS was found to be beneficial in mitigating the development of PTSD symptoms, but only for women with a prior SA.

Prevalence and Correlates of Sexual Assault Perpetration and Ambiguous Consent in a Representative Sample of College Students.

The primary aim of the current study was to examine the prevalence and correlates of self-reported sexual assault (SA) perpetration, defined as nonconsensual sexualized touching or attempted or completed oral, vaginal, or anal penetration since starting college among men, women, and gender nonconforming (GNC) students. A secondary aim was to examine the prevalence and correlates of self-reported sexual encounters when the respondent was unsure that their partner consented (ambiguous consent). In spring 2016, 1,671 randomly sampled students (67% response rate) at two interconnected urban undergraduate institutions participated in an online survey about sexual experiences and personal and social contextual correlates. Prevalence estimates for SA perpetration and ambiguous consent were estimated and logistic regression was used to test bivariate associations between these two outcomes and a range of potential correlates. Approximately 2% of students self-reported any SA perpetration and 9% reported any ambiguous consent experiences since starting college. Pre-college SA perpetration, past-year SA victimization, belief in and use of nonverbal consent strategies, binge drinking, and depression symptoms were associated with higher odds of both SA perpetration and ambiguous consent while at college. Hookups were associated with higher odds of ambiguous consent; family social support was associated with lower odds of ambiguous consent. Findings of similar correlates for SA perpetration and ambiguous consent point to prevention programming focused on verbal consent strategies, alcohol harm reduction approaches, and pre-college interventions.