Sexual Violence Stigma: Construct Development, Multi-Level Measurement, and Psychosocial Consequences

Abstract

Sexual violence (SV) is a stigmatized form of trauma, yet the stigma attached to SV has received limited empirical attention. The SV stigma literature is underdeveloped, fractionalized by SV subtype, and lacks validated and comprehensive measurement approaches for quantifying SV stigma. In this dissertation, I seek to advance this literature by developing the construct of SV stigma using multi-level measurement approaches, connecting SV stigma to numerous adverse psychosocial outcomes, and identifying mechanisms underlying the relationship between SV stigma and psychopathology. In Study 1, I conducted a scoping review of the available literature (n=63 studies), summarizing available evidence for SV stigmatization and associated psychosocial outcomes and identifying gaps in the literature. In Studies 2-5 of my dissertation, I provide an empirical investigation of four of these identified gaps. In Study 2, I adapted and tested a new measure of SV stigma, the Sexual Violence Related Stigma Scale (SVRSS), and incorporated this scale into a population-based sample of Swedish young adults (n=453) in order to investigate the associations between SV stigma and symptoms of psychopathology (anxiety, depression, PTSD), alcohol misuse, and treatment need, as well as a behavioral measure of shame. Results indicated that SV stigma burden is associated with more severe symptoms of anxiety, depression, and PTSD as well as an behavioral measure of shame and perceived need for treatment in the past year. Unexpectedly, SV stigma burden was associated with less alcohol misuse. In Study 3, I replicated these findings from Study 2 using longitudinal data, showing that SV stigma predicted psychopathology outcomes (anxiety, depression, PTSD) at two-year follow-up after controlling for baseline symptoms. In addition, I identified two mechanisms, rumination and event centrality, that mediated this longitudinal relationship. Specifically, rumination was a strong mediator of the relationship between SV stigma and both anxiety and depression (accounting for 51% and 60% of variance explained, respectively) and event centrality was a strong mediator of the relationship between SV stigma and PTSD, accounting for 43% of variance. Our results demonstrate that SV stigma creates risk for psychopathology symptoms through distinct, potentially reinforcing, mechanisms and that targeting SV stigma itself may be an important step forward for improving psychotherapy for patients who have experienced SV. Next, in Study 4, I extend these findings to the United States by launching the National Sexual Violence Stigma Study (NSVSS), a new population-based sample (n=555) of survivors of multiple forms of SV, including rape, sexual assault, intimate partner sexual violence, childhood sexual abuse, and image based sexual abuse. Results connected SV stigma to a wide range of adverse mental health (e.g., anxiety, depression, PTSD), physical health (e.g., chronic pain, frequent headaches, difficulty sleeping), psychosocial (e.g., hypervigilance, rumination, event centrality), event-related (e.g., disclosure, help-seeking), and treatment-related (e.g., treatment use, treatment preferences) outcomes. Finally, in Study 5, I developed and tested the first multi-indicator composite measure of state-level structural SV stigma, comprising both laws/policies and community attitudes that systematically disadvantage survivors of SV. Integrating this objective structural measure into the NSVSS, I investigated whether survivors’ state-level social context is associated with adverse mental health outcomes, finding that survivors living in high SV states have 19% greater anxiety symptoms than survivors living in low structural SV stigma states. Among birth-assigned female survivors, the effect size is even stronger, with female survivors in high SV stigma states demonstrating 29% more anxiety symptoms, 13% more depression symptoms, and 18% more symptoms of PTSD. Collectively, results from this set of five studies demonstrate that SV is a stigmatized form of trauma associated with a wide range of adverse health outcomes. I demonstrate this association both cross-sectionally and longitudinally, across two population-based samples in two countries, and among a diverse set of SV experiences. Additionally, I identify two mechanisms that help to explain this relationship. Further, I develop and test two novel multi-level measurement approaches for SV stigma, one subjective and one objective, which are designed to improve the validity and consistency of SV stigma measurement in the literature going forward. I close by arguing for a unifying construct of SV stigma and discussing implications of this work for both treatment and policy.