Abstract
Survivors of intimate partner violence (IPV) have an elevated risk for negative sexual health outcomes, including HIV and sexually transmitted infection (STI). Given the unique risk contexts for survivors, there is a need for effective sexual health interventions that take into account the imbalances of power for women who are survivors of IPV. Toward the aim of informing contextually relevant intervention approaches, this article describes women’s strategies toward maintaining their sexual health in the context of violent, controlling relationships. Strategies are examined across women’s healing process. Data were collected through semi-structured, in-person interviews with women who had experienced IPV (N = 28). Participants had a wide range of negative sexual health outcomes and commonly used an analogy of a journey to describe their healing. Throughout these journeys, women gained more confidence and ownership over their sexuality. Themes centered around enhanced self-acceptance, ownership of personal sexuality, and readiness for desirable sexual partnerships.
Keywords
Intimate partner violence (IPV) is a widespread concern. Defined as physical, sexual, and psychological abuse and stalking by an intimate partner (Saltzman, Fanslow, McMahon, & Shelley, 2002), 1 in 3 women in the United States reports lifetime IPV (Black et al., 2011). There are long-lasting health consequences for women who experience IPV. In particular, research has consistently demonstrated associations between IPV and negative sexual health outcomes. Types of negative sexual health outcomes are sexually transmitted infections (STI), including HIV/AIDS infection, having an unintended pregnancy or induced abortion, miscarriage, sexual dysfunction, cervical cancer, and general gynecological problems, such as menstrual irregularities and pain or bleeding during intercourse (Campbell et al., 2008; Coker, 2007; El-Bassel, Witte, Wada, Gilbert, & Wallace, 2001; Hindin, Btoush, Brown, & Munet-Vilaro, 2015; Josephs & Abel, 2009; Loeffen, Wong, Wester, Laurant, & Lagro-Janssen, 2016; McFarlane et al., 2005; Miller et al., 2010; Sareen, Pagura, & Grant, 2008).
IPV survivors report barriers to maintaining their sexual health, including inability to control sexual decision making with a partner (Lichtenstien, 2004), fear of requesting condom use with a violent intimate partner (El-Bassel, Gilbert, Rajah, Foleno, & Frye, 2000), and limited access to necessary health care (Martino, Balar, Cragun, & Hoffman, 2005; Mechanic, Weaver, & Resick, 2008). While it is not solely women’s responsibility to make safer sex decisions (e.g., control condom use), the power imbalances that occur in the context of IPV reduce women’s sexual agency in the decision-making process (Bergmann & Stockman, 2015; Lucea, Hindin, Kub, & Campbell, 2012; Seth, Wingood, Robinson, Raiford, & DiClemente, 2015). For example, in one study, a participant described her lack of sexual power in the relationship by saying, “you’re made to do things that you don’t want to” because “you’re his woman and, you know what? You belong to him” (Rountree & Mulraney, 2010, p. 212).
This imbalance of power, which is a characteristic of relationships with IPV, is an expression of high-risk masculinity. High-risk masculinity is a social construct that reifies male strength and dominance over women (Dunkle & Decker, 2013). Although not all men adhere to high-risk masculinity, it is a pervasive social construct that encourages violence and sexual aggression as exemplary expressions of masculinity (Peacock & Barker, 2014). According to the theory of gender and power (Connell, 1987), power imbalances based on gender reach beyond individuals and interpersonal relationships: Power differentials are imbedded in social structures that occur on institutional and societal levels. These power imbalances impact sexual norms and expectations and, in turn, influence women’s sexual health and sexual risk (Wingood & DiClemente, 2000).
As manifestations of high-risk masculinity, men who are abusive are more likely to engage in sexual risk behaviors compared with men who are not abusive, such as having sex outside the primary relationship, multiple sex partners, unprotected sex, and sex under the influence of drugs or alcohol (Campbell, 2002; Decker et al., 2009; Raj et al., 2006). Men who are abusive toward their partners are also more likely to use forceful and coercive tactics to obtain sex: In average prevalence rates, 36% of women in relationships with IPV report sexual assault by an intimate partner compared with 9% of the U.S. population; similarly, 25% of women in relationships with IPV report sexual coercion by an intimate partner compared with 10% of the U.S. population (Bagwell-Gray, Messing, & Baldwin-White, 2015). For women who experience IPV, forced and coerced sex lead to negative sexual health outcomes, including HIV/STI risk (Campbell, 2002; Josephs & Abel, 2009).
Exacerbating their sexual risk, women who experience IPV are more likely to engage in their own sexual risk behaviors, such as not using condoms, partner non-monogamy, sex outside the primary relationship, trading sex for money or goods, and sex under the influence of drugs or alcohol (El-Bassel et al., 2001; Frye, El-Bassel, Gilbert, Rajah, & Christie, 2001; Johnson, Cunningham-Williams, & Cottler, 2003; Raj, Silverman, & Amaro, 2004; Ramos, Carlson, & McNutt, 2004). Women have described this risk behavior as a coping response to IPV (Rountree & Mulraney, 2010). Congruently, IPV is associated with a host of mental health consequences, including depression (Mechanic et al., 2008; Weaver et al., 2007), posttraumatic stress disorder (PTSD; Feinstein, Bovin, Humphreys, Marx, & Resick, 2011; Messing, Thaller, & Bagwell, 2014), and low self-esteem (Offman & Kimberly, 2004), which then have an impact on women’s sexual behaviors. In addition to the behavioral risk factors, women’s biology also increases their susceptibility to STI/HIV risk. As receptive sexual partners, the vaginal lining is more likely to tear during intercourse, and the presence of a current STI infection can hinder the immune response in the vaginal wall, increasing women’s susceptibility to further infection (McCree & Rompalo, 2007; Wingood & DiClemente, 2000).
Given these unique risk contexts, there is a need for effective HIV risk-reduction interventions that take into account the imbalances of power for women who are survivors of IPV. Yet, the current best evidence HIV interventions are lacking in substantial IPV content (Prowse, Logue, Fantasia, & Sutherland, 2011). Although not specific to IPV survivors, numerous empowerment-based sexual and reproductive health interventions have addressed gender-related power imbalances (for reviews, see Logan, Cole, & Leukefeld, 2002; Robinson et al., 2017). Intervention trials have shown success in increasing variables related to women’s individual empowerment, such as their HIV knowledge and feelings of self-efficacy (Diallo et al., 2010; Dunbar et al., 2010; Essien et al., 2011; Gollub et al., 2010; Sikkema et al., 2010), as well as positive results in increasing condom use (Diallo et al., 2010; Essien et al., 2011; Fogel et al., 2015; Gollub et al., 2010; Sikkema et al., 2010), and decreasing STI incidence (Saleh-Onoya et al., 2009; Wingood et al., 2004). Two studies included IPV content and found decreased IPV among the intervention participants at follow-up (Fogel et al., 2015; Pronyk et al., 2006). These promising results indicate the possibility of effective sexual risk-reduction programs for IPV survivors. Given the prevalent link between IPV and negative sexual health outcomes, there is a need for continued research to strengthen the repertoire of successful interventions to address IPV and attendant sexual and reproductive health outcomes.
As a noteworthy gap in the literature, however, there is limited understanding of women’s strategies to maintain their sexual health in the context of past or present IPV. Such information would be useful to informing effective interventions. Although the association between IPV and negative sexual health outcomes has been studied in depth, only one study to date included findings on women’s positive sexual health practices in the context of IPV (Sutherland, Fantasia, & Adkison, 2014). In this study, a single effective sexual safety strategy was described. After having disorganized reproductive health histories, older women sometimes chose permanent methods of birth control as a way to regain power and control over their reproductive choices.
Given this gap in the literature, the purpose of this article is to understand and describe women’s strategies toward maintaining their sexual health and sexual safety in the context of IPV and negative sexual health outcomes. It specifically answers the question, How do women describe their sexual health as they heal from IPV?
Constructs of Sexual Health and Healing
Sexual Health
For the purposes of this research, sexual health is defined as, a state of physical, emotional, mental and social well-being in relation to sexuality; it is not merely the absence of disease, dysfunction or infirmity. Sexual health requires a positive and respectful approach to sexuality and sexual relationships, as well as the possibility of having pleasurable and safe sexual experiences, free of coercion, discrimination and violence. For sexual health to be attained and maintained, the sexual rights of all persons must be respected, protected and fulfilled. (World Health Organization, 2006, p. 5)
With this definition, the term sexual health encompasses healing processes and healthy relationships rather than narrowly focusing on an individual’s risk for disease. Furthermore, this definition of sexual health incorporates sexual experiences free of coercion and violence. Therefore, in this study, women’s experiences of sexual IPV will be emphasized as a salient component of IPV, particularly as these experiences relate to women’s sexual health.
Healing
In the IPV literature, healing has been portrayed as a journey (Smith, 2003; Wozniak, 2009). Along the healing journey from IPV, women leave the abusive partner, reach out to informal and formal support systems, and express relief in newfound freedom (Smith, 2003). Leaving an abusive relationship is a particularly salient part of this healing process. For example, one study found that leaving an abusive relationship is associated with greater posttraumatic growth for IPV survivors compared with staying in the relationship (Cobb, Tedeschi, Calhoun, & Cann, 2006).
Posttraumatic growth, a concept related to healing, is defined as “positive psychological change as a result of the struggle with highly challenging life circumstances” (Tedeschi & Calhoun, 2004, p. 1). When a person experiences posttraumatic growth, they become stronger after the trauma compared with before it. As the definition of posttraumatic growth indicates, healing involves struggle and challenges. In fact, IPV survivors grieve many losses and confront regrets and painful feelings (Messing, Mohr, & Durfee, 2015; Smith, 2003). For this reason, Wozniak (2009) argues IPV interventions that occur for a short period of time when women separate from an abusive partner are insufficient, asserting that “surviving outside an abusive relationship is not the same as healing” (p. 455). Healing, she expounds, is “social and personal identity change” in which “women no longer [define] themselves and their futures in terms of the past traumas,” and, instead, see themselves as women with a hope for a new future (p. 455). Similarly, Wuest and Merritt-Gray (2001) describe the process of leaving an abusive relationship as a process of reclaiming self in which the final stage of the process, moving on, includes a shift wherein experiencing abuse and being a survivor no longer occupy the center of women’s existence.
As women heal and grow from their experiences of IPV, it might be expected that they also grow in terms of their sexual health. However, little is known in this regard. This study describes women’s negative sexual health outcomes and their preferred and actual sexual health behaviors as they correspond with their descriptions of healing and growth from IPV. The intent for this research is to inform sexual health interventions that are grounded in women’s experiences of IPV, healing, and growth.
Method
Design
Qualitative description (Sandelowski, 2000, p. 339, 2010) was selected as the method of choice for understanding of women’s sexual health and their healing from IPV. Qualitative description is a pragmatic approach to research with origins in naturalistic inquiry. It is helpful for understanding contexts, processes, and experiences. The main goal of qualitative descriptive research is to provide a complete overview of events in the typical language of those events (Sandelowski, 2000, 2010).
Sample and Setting
This study took place in a metropolitan region in the southwestern United States. University institutional review board gave approval prior to conducting this study.
Recruitment
Variation was sought in this sample by recruiting both service-seeking survivors (n = 22) and non-service-seeking survivors (n = 6). Service-seeking survivors were recruited in collaboration with a domestic violence agency. Case managers, client advocates, and client therapists helped the study investigator recruit from among their shelter-seeking clients (n = 16) and non-residential counseling clients (n = 6). All clients were told about the study and given the option of participation. In an effort to be inclusive of non-service-seeking survivors, a survivor advocacy group affiliated with a statewide coalition against domestic violence and sexual assault disseminated knowledge of the study by e-mail (n = 3). In addition, the study investigator disseminated flyers and advertisements through social media to recruit women from the community (n = 3). These different recruitment strategies were chosen to reflect a range of perspectives contingent upon the level of healing and length of time since the abusive relationship. In accordance with standards of qualitative research, random sampling was not utilized; rather, generalizability was sought by using thick and rich description of the participants and their contexts, which allows others to consider the applicability of the present study’s findings to different settings (Denzin & Lincoln, 1994). The sample was increased until informational redundancy was reached—that is, until no new themes became apparent in these data. Because of the richness and depth of women’s described experiences, 28 interviews were sufficient for the study purpose.
Screening and inclusion criteria
The emphasis in this study was women’s sexual health; therefore, only women were included for participation. Using a criterion sampling strategy (Creswell, 2013; Miles & Huberman, 1994), women met eligibility criteria if they reported lifetime experience of at least one type of IPV, including fear of an intimate partner. It was not necessary for women to report sexual IPV in their relationships. This decision was made with the anticipation that participants would describe sexual IPV during their interviews that they did not disclose during the initial screening (Currie & MacLean, 1997; Russell, 1982). Other inclusion criteria were being 18 years of age or older and speaking English. There were no exclusions based on sexual orientation, as it was not necessary for women to have male partners. (Although, in the sample, all women described IPV perpetrated by male partners.) When women expressed interest in the study, their eligibility was confirmed with a brief screening checklist prior to scheduling an interview.
Data Collection
Locations
Interview sites were chosen by each participant based on her assessment of what constituted a private and safe place. These locations, agreed upon within the confines of ethical and safety considerations, included the private offices within the collaborating domestic violence shelter, outreach counseling program, and university campus; homes of participants; and public places where participants felt they could meet discretely, such as coffeeshops and a shopping mall.
Procedures
At the time of the appointed interview, eligible women were asked to confirm they understood the purpose and use of the study, provide verbal consent, and affirm they willingly chose to participate in a 60- to 80-minute interview. The study investigator, who conducted all of the interviews, assured the women they were participating anonymously, their identities would be kept confidential, and that no identifying information would link them to their participation in this study. In addition, service-seeking participants were assured that declining to participate would not affect their receipt of services. Consent to audio-record the interview was obtained at this time.
At the beginning of each semi-structured interview, women completed a brief demographic form to contextualize the qualitative data. Interview questions centered on women’s current, former, and anticipated sexual behaviors. For example, “In your relationship, how did you make decisions about whether to use birth control or not? If you chose birth control, how did you determine what type to use? How did you decide whether to have sex with your partner?” (For a complete list of questions, see Table 1). Interviews ranged from 27 to 110 minutes with an average of 59 minutes long. Participants were compensated for their time with a US$20.00 gift card to a retail or grocery store.
Interview Questions.
Data Analysis
The study investigator converted audio-recordings to verbatim transcripts and conducted all analysis. Data analysis began during data collection, as emergent codes were identified in interview transcripts, memos, and reflective notes (Miles, Huberman, & Saldaña, 2014). In qualitative analysis, codes are defined as words or phrases used to “encompass units of data” (Sandelowski & Leeman, 2012, p. 1407). In the present analysis, codes were written in the gerund form (with verbs ending in “ing”). This approach was selected to illustrate the actions of participants and their partners as women described them, for example, “having sex outside the relationship”; “controlling reproductive decision-making” (Charmaz, 2006; Saldaña, 2012).
A coding manual was developed to maintain important information about codes, such as inclusion and exclusion criteria and exemplars from the data. In coding each additional interview, codes were refined with new information, meaning they were at times subdivided into smaller units or at times merged into larger units. Because the investigator was the singular coder, peer debriefing with two uninvolved researchers was used to vet the coding manual. These independent researchers reviewed the codebook and three sample coded interviews and provided feedback, which the investigator incorporated to improve objectivity and trustworthiness of the findings. Iterations of the coding manual were filed to keep an audit trail of changes to codes. To increase auditability, first-round codes were manually written in the margins of hard copies of interview transcripts.
To increase researcher reflexivity, reflective notes were written in transcript margins. This was crucial to the integrity of the research because I was the sole investigator, conducting all interviews, transcription, and analysis. Thus, it was important to note how my positionality could impact the study findings. I am a White woman with a doctorate degree, who has studied domestic violence for more than 10 years. As a licensed social worker, I have worked as a domestic violence advocate and therapist. During analysis, I took into account how my position and perspective, including my feminist orientation, impacted my approach to participants and these data. Furthermore, my educational level and affiliation with a university could have impacted the way participants viewed me and spoke to me about their sexual health.
Upon completion of the coding manual, data were analyzed a second time for thematic analysis and synthesis (Saldaña, 2012; Sandelowski & Leeman, 2012) using NVivo 10 Software (QSR International Pty Ltd., Version 10, 2014). In qualitative research, thematic analysis is the “search for something recurrent in a data set” whereas thematic synthesis is “the integration of data segments into some unifying idea” (Sandelowski & Leeman, 2012, p. 1407). During thematic analysis and synthesis, patterns were identified within each participant’s case and then collectively across participants’ cases. Then, patterns were compared and critiqued (Miles et al., 2014; Sandelowski & Leeman, 2012). Across all of the women’s cases, descriptions of healing and sexual health strategies were compared with one another. Triangulation was sought across differing sources of data, meaning among different participants, who were interviewed at different time points since their abusive relationship, and who were recruited from different settings. Themes were only reported as findings here if they occurred across these data (i.e., in more than one participant case; Golafshani, 2003; Miles & Huberman, 1994, p. 267).
Data Representation
During data representation, descriptions were kept rich with context and meaning toward the goal of verisimilitude (meaning truth-likeness) that they may “ring true” to the reader. Toward increasing transferability to other samples, settings, and processes, results were presented with plentiful detail, including sample characteristics, so that readers are able to relate these findings to their own experiences and settings. In congruence with this qualitative descriptive study design, actual language of participants was used to stay close to these data (Sandelowski, 2000), and so women’s experiences were expressed in their own words through a mixture of embedded and blocked quotations (Miles et al., 2014; Sandelowski, 2000).
To guard participants’ anonymity, there are no names or pseudonyms, and identifying information (such as places) were removed from direct quotations.
Findings
Women ranged in age from 22 to 60 years. Sample participants were White (n = 16, 57%), African American/Black (n = 4, 14%), Hispanic (n = 3, 11%), American Indian (n = 2, 7%), multiracial (n = 2, 7%), and East Asian immigrant (n = 1, 4%). Women were not directly asked about their socioeconomic status; although, through the course of their interviews, women’s narratives indicated socioeconomic differences. For example, some women were unemployed and homeless at the time of the interview, while others had more education and greater access to resources (e.g., evidenced by travel, access to quality health care, graduate education).
All women reported male-perpetrated IPV; one woman mentioned having a prior female sexual partner, but this was not the relationship she focused on during her interview. Four women (14% of the sample) were still in their abusive relationships, either living with an abusive partner, doing a trial separation, or were not separated by choice (i.e., partner was incarcerated). A total of 19 participants (68% of the sample) had separated from abusive partners and were not in a sexual relationship at the time of the interview. Five women (18% of the sample) described healing past their abusive relationships to the point that they engaged in healthy sexual relationships with new partners. Participant characteristics are displayed in Table 2.
Participant Demographics and Relationship Characteristics.
Note. IPV = intimate partner violence.
Sexual Safety Interrupted
During relationships characterized by IPV, women reported a history of personal and partner risk behaviors and negative sexual health outcomes (see Table 3 for complete list of themes). Primarily, all but one participant had experienced sexual IPV, including intimate partner sexual abuse (96%), intimate partner sexual coercion (68%), and intimate partner sexual assault (50%; for definitions of these types of sexual violence, see Bagwell-Gray et al., 2015). Women’s most common personal risk behavior was unprotected sex with an abusive partner (75%); women’s partners’ most common risk factor was infidelity/concurrency (64%). Within these risk contexts, a majority of women reported negative sexual health outcomes, including unplanned pregnancy (54%), STI (32%), miscarriage (21%), and endometriosis (14%).
Themes.
Note. IPV = intimate partner violence.
At the time of their interviews, participants demonstrated high awareness and positive intentions toward practicing safer sex strategies, such as using condoms with a new partner, getting tested for HIV/STIs (both individually and with a partner), and practicing monogamy with a trusted partner; yet, these safer sex strategies were interrupted during their violent relationships, particularly with the intimate partner sexual abuse they experienced. One participant, for example, compared the difference between her HIV risk-reduction knowledge and typical sexual health practices with her sexual behaviors during her abusive relationship: You’ve got to be with somebody, know that they’re monogamous with you, . . . and then get tested, you know, 6 months down the line to make sure that they’re actually clean before you have sex . . . [We] had sex without all of that, which was a big departure from what I had been doing.
Furthermore, as women dealt with the violence and disentangled themselves from their abusive pasts, some engaged in personal sexual risk-taking, such as concurrent sexual relationships and sex outside the primary relationship. Women described this sexual risk-taking as a repercussion from the violence they experienced as they struggled with feelings of powerlessness in relationships, generalized feelings of low self-worth, and lack of agency in sexual decision making: I had very little self-esteem. I was just beaten to a pulp . . . I was so damaged; I wasn’t able to relate to anybody. So, I just had sex with guys all the time. I needed to feel like I was valuable . . . because I had it so beaten out of me.
In the context of IPV, women could maintain certain sexual health care and safety strategies but never all of them. For example, one woman said she successfully negotiated condom use as an agreed-upon method of birth control with her husband, but she did not have a say in how or when to have sex. Furthermore, due in part to her husband’s economic abuse and financial control, she had discontinued well woman exams. In another example, a participant said she felt she had equal sexual decision making in regard to her reproductive health choices “except for the condom use”; she, too, described other types of sexual IPV, including forced sex with threats of physical force and actual physical force.
During their abusive relationships, women described how their partners’ controlling behaviors were a significant barrier to accessing sexual health care. Some abusive partners who were extremely jealous would not allow women out of the house to meet any health care needs, including sexual health care: “I wasn’t allowed to do anything, go anywhere, call any of my friends. I was isolated”; “I didn’t really get a chance to take care of my sexual health. My health period.” Because of partner control, women either submitted to their partner’s demands and avoided sexual health care (“instead of arguing with him and it turning into a fight where I was gonna get hit, I just cancelled the appointment”), went to visit a sexual health care provider in secret (“the first time I went there was definitely in secret and it was definitely very scary”), or waited until they separated from their partners (“when I got away . . . once I got home, I went straight to the emergency room”).
As these cases illustrate, women could take some steps to care for their sexual health during their violent relationships. Yet, it was not possible to do so comprehensively until they ended the relationship with their abusive partners.
The Healing Journey: Sexual Safety Incorporated
As women began healing from the violence, they gained more confidence and ownership over their sexuality and sexual health behaviors. The establishment of positive sexual health behaviors co-occurred with mental, emotional, physical, and spiritual growth: “I just went on a six-week spiritual tour, healing tour, upstate, seeing old family and old friends . . . it was really quite amazing.” Women commonly used the analogy of a journey to express their healing process: “[I’m] a million steps away from where I was [two years ago] . . . probably still have 22 million steps left”; “I’m just starting that journey. . . . Emotionally, I’m not in the dark tunnel. Well, I think I am, but I see a little ray of light.” These journey metaphors demonstrate that women view themselves as having made progress, but still see more healing to continue in their future, with continued pain to work through: I’m taking steps that I need to take care of me. To say that I’m important and nobody else is right now. So I put a real block on that other place [the past relationship with IPV] and I built up that road block and said “Dead End,” you know . . ., that’s biohazard over there . . . It’s really hard for me . . . to have to go to start this whole entire road again in my life, you know. Stop that life and I have to start this own life, right here. Start all over and become this new person, you know, and heal. And I think after that I’ll be ok with myself, because I do love me. I love me and there’s not nobody else like me on this earth. It’s just that I’m hurt a lot, so it’s hard.
As women described their experiences, three major themes characterized their journeys: (a) enhanced self-acceptance, (b) ownership of personal sexuality, and (c) readiness for desirable sexual partnerships.
Enhanced self-acceptance
In one salient theme, enhanced self-acceptance, women discussed the importance of increasing self-understanding, self-love, and self-affirmation. Women explained how self-acceptance was developed by understanding, loving, and affirming their value. Within this category, women were adamant that separating from their violent partners was necessary for self-acceptance to occur: “You can’t get free until, you know, until you walk out the door”; “Get out as soon as they possibly can and get somewhere safe. Honestly. Don’t go back.” Self-acceptance was difficult, if not impossible, to develop while the person who was supposed to love them was, instead, hurting them physically, emotionally, psychologically, and sexually. Women described a reciprocity between self-acceptance and ending an abusive relationship. In other words, the more women loved and accepted themselves, the more motivated they were to leave the relationship: After “a lot of soul searching,” for example, one woman realized it was “time to go” because she “didn’t deserve to be treated like that. That there’s a better way of living, I guess.” In turn, leaving the relationship allowed them the space to cultivate love and acceptance of themselves: “first and foremost get out, and then lots of self-love and digging and therapy and utilizing all the resources that are available and reclaiming worth.”
Participants acknowledged that it was easier to advise someone else to “get out” than it had been to get out in their own experience: “If it was somebody that you love, you know, you’ll hear a thousand I’ll changes. I’m gonna change. I didn’t mean it. I’m changing . . . You hear all of that”; “I always thought that he would stop me at the door. My nerves. I couldn’t go.” Yet, participants were able to overcome these obstacles: “Every day I’d just visualize me leaving the house. I was gonna do it, you know . . . I prepared for like six months.”
After leaving their violent relationships, women frequently described a commitment to a period of abstinence to facilitate their healing and self-acceptance: “In a perfect world, I wouldn’t really have sexual partners.” Women who chose abstinence described sex as a lower priority. “At this point right now, my sexuality is: I’m not interested. I’d rather do without. I don’t need it.” Having sex again was for a future stage of healing: “I do have issues with that [sexual] intimacy. It’ll be, it’s something I work on . . . [an area] I’m saving for last.” Until further healing, they were unready for a new sexual relationship: [I’m] staying abstinent right now, I mean, maybe for a year or so, just so I can find myself, you know. To not have that relationship, so I can build up my self-confidence, and I can look at me in the mirror and actually know who’s staring back. And I could forgive myself for everything that happened and I could forgive everybody else and just start off new.
Another salient factor in developing self-acceptance was building social support through informal and formal networks. Women reported the importance of strengthening relationships with co-workers, friends, and family. These relationships were key in helping women get out of their abusive situations: “if it wasn’t for my mom, I probably would [have] went back”; “if [my friend] wasn’t there, I think that my ex probably would have killed me.” These key social supports helped women reevaluate their beliefs about relationships. As one participant described, getting out of isolation and building friendships was “probably the main ingredient” for her change: I now found myself free, totally free, to go where I wanted to go . . . and many times it was to couples’ homes. . . . For the first time in my life, [I was] able to see how they interacted . . . so I learned how people communicate.
She further elaborated on how her newfound social support increased her agency and confidence: “Then, I can make decisions: Well, how is it that I want my life? How do I want to be treated?”.
Formal support services were also fundamental to women’s self-acceptance. These formal supports included domestic violence shelters, individual therapists and counselors, and support groups. In particular, formal social supports provided life-changing information to help women understand the dynamics of IPV: by “taking what you know, the personal experience, and putting it with what the scholars [know],” a domestic violence class explains “why things were happening and makes you aware to see ’em sooner.”
In this way, learning about IPV was another essential part of self-acceptance. Primarily, women emphasized how power and control played an important role in their sexual relationships: “This [sex] was not about intimacy; it was about control. He’s hugely about control.” It was important to understand and name their experiences of sexual IPV because “a lot of women come in and don’t think it is sexual abuse because it was their husband.” Furthermore, there was immense emotional conflict associated with loving a partner who was hurting them. It was confusing to experience sexual violence and sexual pleasure from the same person at different times: A couple of days after I go back [to the relationship] it’s like—What did you do? And I just put myself in a whole bunch of danger again. But it’s amazing what sex—that sex hold—what it could do.
Talking with an advocate or practitioner in a safe, confidential setting can help women reflect on their experiences in new ways and process the conundrums associated with sexual IPV, “it’s like, the more that I’m sitting here talking about this, you know, like . . . it’s really disturbing. You know, no wonder I don’t want to have sex with him anymore.”
Speaking up about violence and sharing personal stories with IPV was also associated with women’s healing: “I think it’s important, especially for women, to feel comfortable to tell their stories and to tell their stories without judgment and without fear.” One avenue of speaking out about violence was private disclosure in either an informal or formal support setting. Disclosure to a supportive individual affirmed women’s experiences as legitimate and affirmed themselves as valuable people, “make sure that the person you speak to . . . will take you at your word and not make you feel as if you imagined it or if you deserved it.” Another avenue for speaking up about violence was through public advocacy. For example, women produced the vagina monologues, participated in research interviews (for this project and others), and mentored other women in shelter: “I can give my advice to them and some of them will listen and some of them won’t. But they appreciate me talking to them.” Women said it was empowering, therapeutic, and meaningful to speak out in these arenas, especially if doing so could help other women in similar situations: “I want to help other people. . . . just to say, you’ve got to stand up for yourself”; “I hope I could help somebody one day. If I just help one person, that’ll make me happy.”
Finally, women reported that learning to love their bodies was an essential aspect of self-acceptance after their self-esteem had been damaged: “I try really hard to love the body I’m in, but I have a hard time with it . . . I still remember comments that he would say and I still sometimes judge myself off of those”; “I still remember some remarks that he would say to me. Different things and I get self-conscious. It’s like there’s always a little voice in the back of my mind throwing out the insults.” Women commonly expressed that body image was connected to their sexuality and sexual health: “it feels like it plays a huge role in people’s, women’s ability to enjoy sex.” For example, one participant worked hard to grow in self-love and acceptance of her body: “It took me a long time to kind of learn how to love my stretch marks that I have on my thighs, you know.” With this self-acceptance, she also reported regular visits to her gynecologist, high levels of consistent condom use (“I know how to make sure condoms are used properly”), and confidence in ensuring that her partners were tested for HIV and other STIs (“I’m adamant about literally, physically seeing their STD test results”). This woman’s case exemplifies how her high level of sexual self-acceptance corresponded with her practice of sexually protective behaviors.
Ownership of personal sexuality
An important aspect of healing was developing ownership of one’s personal sexuality, wherein women gained a sense of agency in sexual decision making. In this process, women began establishing sexual boundaries as informed by their own desires and values and in accordance with their own sexual expectations. An important component of developing a personal sexuality was defining what sex means: “Because for me [sex] has always been about intimacy and trust and sharing”; “[I want] more of a spiritual connection . . . and emotional hold.” Throughout the interviews, women were in a thoughtful state of evaluating the meaning of sex to them.
The way women defined sex impacted their sexual expectations as described throughout their interviews. For example, one woman believed, “I can separate sex from love . . . it’s a real important trait.” Her corresponding sexual expectations were “being respected” and ensuring that “both parties know it’s not a relationship . . . it’s just sex and safe.” For another participant, sex meant an “emotional connection.” Her corresponding sexual expectations were “I want to be loved” and “I want to be told how beautiful I am.”
Women could distinguish their own sexual expectations from the expectations of family, friends, community members, or society at large. At times, women’s sexual expectations aligned with these other sources. For example, when a woman embraced and affirmed a faith system or cultural belief system, it informed her sexual expectations and sexual health choices: “I’m really into my culture and my values my traditions . . . And [not using birth control is] just what Creator wants us for us, what he wants in our lives.” However, at other times, women resisted the expectations placed upon them by others. For example, they had pressures to conform to their intimate partners’ sexual preferences: “he started introducing let’s watch this porn . . . it was just kinda like a gradual step into the dark side.” They also experienced pressures from new dating partners: “There are guys that are like, ‘Ok, I’ve spent three hours talking to you now we’re going to go have sex, right?’ And I’m like, um, where is this coming from? How does this happen?”
Women wrestled between accepting and rejecting these messages as they worked toward defining their own meaning of sex and began setting their own sexual boundaries: I’m just not a hang-off-the-chandeliers kind of sex person, you know. I’m just not crazy in the sack. I have my favorite positions and I’ll let that person know what those positions are, um, you know. Whatever they want, we can talk about it. But, sorry, I’m just not into watching porn. I’m not into wild and crazy, that’s all. Interviewer: And you sound very confident and comfortable with that. I am. I am. Because you know what? I’ve learned with my husband [that] even if you’re like, ok, we’ll do it your way. We’ll do it wild and crazy. It gets you nowhere. You’re not gonna satisfy them. You know, you think you’re doing the right thing, you being obedient. And you know, you have an obligation to satisfy their sexual desires. So you do things that you think you would never do. Like me in my case, you know. Like, I never would have believed I would have allowed him to have anal sex with me. It’s so disgusting. But at the time it was like, well, you know, if this is what he wants. Well, no. No! No more. No more. . . . To be compliant is a mistake, and that’s what I’ve learned.
As this excerpt from an interview exemplifies, identifying and clarifying what sex means now, and contrasting this current perspective with past experiences, was connected to setting sexual expectations and establishing boundaries for potential future relationships.
Envisioning desirable sexual partnerships
In addition to discussing self-acceptance and personal sexuality, women discussed sexual health in terms of desirable sexual partnerships. In this area, women emphasized the dynamics of healthy relationships. Healing in this area was not solely about women’s sexuality within and of themselves; it was inclusive of their sexuality in relation to an intimate sexual partner. It is important to note that not many women attained desirable sexual partnerships (only 5 in this sample did). Nonetheless, the women could still envision healthy sexual partnerships as they hoped for continued healing in their future. All women could speak to what their ideal sexuality would look like.
In a desirable sexual relationship, women described wanting to feel comfortable being themselves—expressing their true, authentic selves, without embarrassment or shame, “it’s gonna be natural and comfortable . . . I’m not going to do something I’m not comfortable with.” This involves the type of sex acts they want to participate in (“maybe sex in different positions . . . but not any other forms of it, like the oral, anal. I don’t think—that’s nasty to me”; “we kinda maintain the same thing every time and that’s fine with me. Sometime new stuff scares me. And I get very anxious about what could happen, so I think that it’s good the way that it is”) and how those acts will be performed (e.g., “gentle and slow”; “passionate, I guess, or primal”). It furthermore includes whether they want to have sex or not: “In an ideal world . . . I would hope . . . more than anything that it was just healthy and consensual and actually felt good.”
Women emphasized that communication in healthy sexual relationships should be honest and open: “When we first got together, we were honest and open about everything, because I’m like . . . this is what I’m looking for.” It should also be easy: “It would be a normal thing. Just talk about it. Whatever his idea is, whatever my idea is.” This is closely associated to the idea that women want to feel comfortable being themselves; they also want to feel comfortable verbally expressing themselves, “to actually assert my wants and my desires and dislikes freely without judgment, scorn or something, it’s been great”; “In an ideal situation, I would be more, uh, vocal to what pleased me, you know.” Women wanted to respectfully discuss their sexual histories: “We have to be able to exchange details and it not be, well, not be uncomfortable.” Ultimately, “if they’re not willing to, um, have that communication, well, then they’re not worth having sex with.”
Although communication was a priority, participants were inexperienced in regard to communicating sexual expectations (“I’m not very good at saying I like this or I like that”) and keeping sexual boundaries (“I did a lot of things that I wasn’t really comfortable with just because . . . I was very controlled by him and so I basically just did what he wanted me to do to keep him happy”). Women struggled with this part of personal sexuality even as they progressed in their healing. For example, although in a healthy relationship at the time of the interview, one participant still found it difficult to believe that her partner respected her sexual boundaries: “I feel like sometimes I approach my boyfriend now like that, like he expects it from me. . . . or he’ll leave me for someone else.” Thus, even for a woman who had been out of abusive relationship for 10 years, this area required practice and application.
Women emphasized the importance of joint decision making and shared responsibility. For example, women had hopes that partners would come together with them and collaborate in making reproductive decisions, such as whether to use birth control or not and if so, what types of birth control to use. They also emphasized deciding together whether to have sex or not. In regard to sharing sexual responsibility, women emphasized that they wanted their partners to prioritize sexual health, too, by getting tested for HIV/STIs and using condoms: “Whether they want to take responsibility on their end tells me whether I need to go there [have sex] or not, and if they don’t, I just don’t”; If I ever meet a special somebody . . . I think it would behoove us both to just go in for one of those blood tests just have ourselves checked . . . And uh and then, then if he really loves [me] . . . then he will really do it.
Women even expressed the idea that getting the tests together could be a bonding experience that brings them together.
Finally, having sex with partners who were sexually giving, as opposed to sexually selfish, was an important deviation from their experiences of sex in their relationships with abusive partners. One woman described her transition in her current healthy relationship: “So then, when I met my boyfriend, he was all about making sure I felt good. And I was like, this is weird. I’m not used to being given my own time.” Some women did not even know how to envision this mutuality. For so long, they had experienced androcentric sex—where the man’s needs were prioritized and male orgasm epitomized as the climax of a sexual encounter—that they could not imagine enjoyable sex that was free of violence or coercion. Furthermore, some women did not know how to identify a healthy relationship given childhood abuse (including sexual abuse, physical abuse, and neglect) and unhealthy messages about sex from their families of origin. Thus, there was tension between women’s ability to articulate what they wanted sex to be like and their lived experiences: Knowing what one wants is not the same as knowing how to achieve it. This space between preferred sexuality and actual sexuality is an important area of focus for interventions.
Discussion
This research contributes to the current understanding of women’s sexual health in the context of IPV. It looks beyond the barriers and risks women face on account of their violent intimate partners, demonstrating how women adopt new sexual health behaviors. Given that women’s risks are predominantly understood to occur based on power dynamics associated with IPV (Wingood & DiClemente, 2000) and social structure factors that limit women’s choices within their environment (Wyatt et al., 2013), this research is a meaningful step in understanding how to increase women’s sexual power in these contexts.
Because sexual IPV co-occurs with physical and emotional IPV and stalking, it is impossible to tease apart the impact of sexual IPV from other types of IPV in participants’ experiences. Furthermore, IPV is best described as a pattern of coercive control, characterized by psychological manipulation that keeps women trapped in their abusive relationships (Stark, 2007). Multiple forms of violence, together with coercive control, cumulatively impact survivors’ sexual health. Yet, in their storytelling, women in this sample emphasized the importance of sexual IPV to their sexual health. During the interview, several women said they disclosed types of sexual violence they had never before discussed. Even women residing in a domestic violence shelter, who had talked with domestic violence advocates and therapists, had not discussed the sexual aspects of their relationships. With an opportunity and invitation to freely discuss sexual IPV, the prevalence of sexual violence disclosed by participants in this study was higher compared with other samples of IPV survivors (Bagwell-Gray et al., 2015).
Consistent with prior research, barriers to women’s sexual health in the context of IPV were profound. Yet, women did not passively accept their risk contexts. Instead, they assessed their sexual risks and calculated the costs and benefits of sexual health behaviors, such as seeking sexual health care and acting with sexual assertiveness. While in their relationships, the costs of being sexually assertive and seeking sexual health care typically outweighed the benefits. Women’s primary cost was having their physical safety jeopardized by their intimate partners’ physical and sexual violence. However, women’s stories did not end there. This research demonstrates that as women separated from their abusive partners and began to focus on their personal healing, they gained newfound opportunities to take care of their sexual health.
Women’s sexual health journeys, as presented in the current study’s findings, share many similarities with prior scholarship on healing and leaving violent relationships. According to Wozniak (2009), women separate from the past, cross through a state of liminality, and move into integration. In this process, women reconstruct their identities outside of the context of IPV as they move toward healing. Similarly, Wuest and Merritt-Gray (2001) describe that moving on “consist[s] of shedding the identities of ‘victim and ‘survivor’” (p. 83). In the present study, many women said they were not the same as the “self” they had left behind; that is, their identities and their sexual health behaviors were no longer defined and restrained by their abusive partners or their past trauma. Yet, they were still not who they were becoming. They looked forward to healing in their future. In this state of liminality, women were shedding a past version of themselves, defined by sexual violence and IPV, and putting on a new version of themselves, characterized by love and acceptance, ownership of personal sexuality, and hope for healthy sexual relationships. As women focused on their prospective futures, they could create a new identity, one where their sexual well-being could be prioritized as a part of their comprehensive health.
Findings from this study also reveal challenges in the healing process. Women struggled with body image, negotiated tension between experiencing enjoyable sex and sexual violence from the same partner, lacked experience communicating boundaries long after the abuse had occurred, found it difficult to accept that they could receive sexual pleasure, and contended with unhealthy messages about sex inherited from their families of origin. It is at these intersections where growth is painful. Some women may make little (or no) progress in their healing journey. For practitioners, it is important to recognize these areas of growth and engage women in therapeutic work at these intersections. Participating in the research interview itself was therapeutic for some women, as the following excerpt from an interview demonstrates: Interviewer: So, what are the things that are you—your strengths that have helped you in these situations? You know, to be honest, I don’t really actually know that—if I have ever gotten through them. Because every issue, everything that has happened or I’ve gone through, we’ve gone through, is still there . . . I’ve been standing in the same spot since I was a little girl. Does that make sense? I do believe—and it’s sad. It’s really sad—I am, I am still that little girl . . . Interviewer: What does that little girl need? A lot of therapy. . . . I’ve got to do something because this is not good. It has ruined and messed up everything. . . . Everyone is like, “You’re so strong.” Honey, no I’m not. It’s just me fakin’ it through the problems, through the issues, through life. Interviewer: So do you see a potential for getting unstuck? Oh yeah.
Even when women have been “stuck” in their healing journey, “faking it through,” like this participant describes, there is still the possibility for getting unstuck. Talking about sexual health in a safe place and disclosing her past sexual violence was the beginning of her recognition for the need to become unstuck.
A limitation of this study is that findings come from a small sample of women from a single city in the Southwestern United States. Women were primarily recruited through domestic violence social services, and participants were those who volunteered. All women reported that their abusive partners were male. Thus, scope of application and transferability is limited to English-speaking women, living in the United States, who experience IPV from a male partner. Despite this limitation, the interviews provided richness in depth of experience among women with shared similarities in their experiences. Furthermore, the sample represents diversity in regard to race/ethnicity, origin of city and state (many women had travelled cross-country to escape abusive partners), age, socioeconomic status, and degree of healing along their healing journey. In this analysis, no differences emerged based on demographic factors. Subsequent analysis could be conducted using an intersectional lens (Wyatt et al., 2013) to hone in on any differences. Yet, overwhelmingly, thematic content was similar given the similarity across the different groups represented in the sample; thus, there remain meaningful implications from the study results in terms of intervention development.
Interventions are needed that take into account women’s risk based on IPV (Prowse et al., 2011). Current empowerment-based HIV risk-reduction interventions have incorporated some important elements relevant to IPV survivors, such as discussions of power and control, gendered sexual norms, negotiating condoms and communication, and relationship dynamics (Fogel et al., 2015; Gollub, Cyrus-Cameron, Armstrong, Boney, & Chhatre, 2013; Pronyk et al., 2006). These programs contribute to global efforts to reduce the incidence of HIV; and some have even reduced IPV among intervention participants. Findings from this study build upon the knowledge from those interventions. For example, women in this sample had relatively high levels of knowledge about their sexual health and knew how to reduce sexual risks. They knew to use condoms, get tested for STIs, and make sure to know a sexual partner’s STI status. This suggests that focusing primarily on HIV/STI knowledge would miss the mark for this population. Participants wanted and needed to address the emotional trauma and psychological impact of domestic violence on their sexual risk. Furthermore, women knew what they wanted in healthy sexual relationships. They did not need education on what a healthy relationship looks like. Instead, they wanted to address the impact of chronic trauma, as it prevented them from attaining that ideal. For example, previous trauma led them to choose unhealthy relationships, try to please men sexually to earn affection, and engage in sexual risk to regain a sense of power. Thus, healing from IPV, particularly sexual IPV and antecedent childhood sexual abuse, ought to be the core focus of sexual risk reduction for this population, not an ancillary session or two. As women themselves described, healing from IPV holistically is necessary for sexual health. This article outlines women’s self-described strategies for healing, which can inform such interventions. Specifically, the specific themes of developing healthy sexuality—enhancing self-acceptance, owning personal sexuality, and setting goals for sexual partnerships—can be useful to guiding trauma-informed sexual health programs for IPV survivors.
Although individual-level interventions have the potential to meaningfully impact the lives of survivors who participate in them, their impact is limited in terms of long-term social change. Thus, there is a need beyond individual-level interventions for large-scale social change efforts to end violence against women. Primary interventions to target youth and adolescents are needed, as are interventions to prevent male-perpetrated violence and change social norms around toxic masculinity. Meaningful work is currently being done in these areas (Coker, Banyard, & Recktenwald, 2017; Jaime et al., 2016; Niolon et al., 2017; Tolman, Walsh, & Nieves, 2017) and ought to continue in different settings with emphasis on different community groups.
Women consistently reiterated the theme that separating from an abusive relationship was fundamental to their ability to change, move toward self-acceptance, and develop sexual health strategies. This finding adheres with previous research on posttraumatic growth after leaving a violent relationship: Women still in an abusive relationship showed less posttraumatic growth compared with women out of the relationship, demonstrating that growth occurs after resolution of the trauma (Cobb et al., 2006). Because of the importance of leaving an abusive relationship, one primary aim of sexual risk-reduction interventions for women with IPV-related risk contexts should be to reduce women’s likelihood of returning to a violent relationship or entering another one. This aim coincides with increasing safer sex strategies, as the more women experience agency in their own lives, the more sexual safety strategies they can employ.
However, it is important to acknowledge that leaving an abusive relationship is not always the safest or most helpful safety strategy (Goodkind, Sullivan, & Bybee, 2004; Goodman, Dutton, Vankos, & Weinfurt, 2005). In fact, leaving a relationship has been associated with intimate partner homicide and can, therefore, be one of the riskiest strategies (Campbell et al., 2003). Social supports and formal services are needed to mitigate this risky time in women’s lives. According to Merritt-Gray and Wuest (1995), leaving an abusive relationship is a process that includes breaking free, not going back, and moving on; thus, it is not a singular event. This process takes time, calling for continued funding for domestic violence shelters and longer term transitional housing facilities. These service centers provide a safe place for many women along their healing journey, enabling them to more safely end an abusive relationship and, therefore, take steps toward better sexual health. For women still in their abusive relationships, sexual health interventions should help women plan for safety, including accessing domestic violence resources, in tandem with addressing trauma and meeting their needs for sexual health.
This research has implications for collaborative service provision between sexual health providers and IPV social service providers. Sexual health providers may be uniquely positioned to recognize IPV, as repeated pregnancy tests and repeated STI testing could indicate reproductive coercion and IPV (Kazmerski et al., 2015). Bridging service gaps between these two types of providers could be instrumental in addressing sexual health needs for IPV survivors. For example, community health workers trained in both IPV and sexual and reproductive health can serve as important advocates to bridge these issues in the community (Moya, Chávez-Baray, Martínez, & Aguirre-Polanco, 2016). Similarly, IPV advocates trained in sexual and reproductive health issues can develop confidence in talking about sexual and reproductive health with IPV survivors (Foster, Núñez, Spencer, Wolf, & Robertson-James, 2015). Thus, in addition to continued intervention research, more research is needed on collaborative partnerships between sexual and reproductive health providers, community health workers, and IPV advocates to address the problem comprehensively.
Conclusion
Within a large body of literature on the linkages between sexual risk and IPV, this research is innovative in that it is the first study to emphasize women’s strengths and healing from IPV in regard to sexual health. Instead of emphasizing what does not work during the period when women’s sexual safety strategies are interrupted, it follows women’s path of healing as they adopt strategies that do work and that they hope will work in the future. Throughout their healing, women establish an ownership of their personal sexuality and look toward future healthy sexual relationships. It is useful to understand the sexual component of healing from IPV, as sexuality is a core component of health and well-being. These findings can be utilized to shape appropriate interventions that address intersecting IPV and risk for HIV.
Footnotes
Declaration of Conflicting Interests
The author declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author received no financial support for the research, authorship, and/or publication of this article.
