An Evaluation of Adolescent and Young Adult (Re)Victimization Experiences: Problematic Substance Use and Negative Consequences

Abstract

We investigated substance use and negative consequences in women who experienced an initial sexual assault (SA) in high school and subsequently in college. More than 650 participants completed questionnaires assessing substance use/consequences, SA history, and posttraumatic stress disorder (PTSD) symptomology. Revictimized women reported differential substance use/consequences relative to controls underscoring the need to conceptualize adolescence as a key developmental period with a unique pathway to a subsequent SA, especially in association with substance use. We propose that prevention interventions should begin no later than ninth grade to limit the risk for an initial experience of SA and any consequential substance use and abuse.

Keywords

sexual assault substance use college women

Sexual assault (SA) may be defined as any type of nonconsensual oral, anal, or vaginal contact and/or penetration in which the perpetrator has used force, intimidation, coercion, and/or other means (e.g., purposeful intoxication) to acquire such sexual contact from a potential victim (Cantor et al., 2015). SA is a common experience for young women with estimates suggesting that 20% of female college students have been victimized during their undergraduate years and up to 80% of all victims reporting an occurrence prior to age 25 (Black et al., 2011; Krebs, Lindquist, Warner, Fisher, & Martin, 2009; Ross et al., 2011). While researchers have investigated and established SA risk in college, many women report that they have experienced an assault prior to the age of 18, suggesting high risk periods for victimization in childhood and adolescence (Himelein, Vogel, & Wachowiak, 1994; Tjaden & Thoennes, 2000). In fact, individuals with childhood sexual abuse (CSA) histories are 2-3 times more likely to experience adult sexual assault (ASA) than women without CSA histories, leading to a large literature focusing on this developmental pathway (Katz, May, Sörensen, & DelTosta, 2010).

However, there is evidence to suggest that an experience of SA in adolescence, more so than CSA, is linked to greater likelihood of victimization in young adulthood, and may be predictive of first-year collegiate victimization (Humphrey & White, 2000; Katz et al., 2010). While about 22% of women experience their first and only SA before age 12, over 32% of women report such experiences between ages 12 and 17 (Tjaden & Thoennes, 2006). About 14% of high school women reported experiencing some form of sexual violence (Kann et al., 2014), and longitudinal data suggest that experiencing SA at 13 years old is a significant predictor of experiencing ASA (East & Hokoda, 2015). Furthermore, female college students who experienced SA since age 14 are 4 times more likely to experience victimization in college than their peers without similar histories (Himelein et al., 1994; Humphrey & White, 2000; A. K. Miller, Markman, & Handley, 2007).

Researchers have identified several potential reasons for the high prevalence of SA during high school, including greater interaction with peers and new peer groups, newfound freedom from parental oversight, and access to illegal substances (Livingston, Hequembourg, Testa, & VanZile-Tamsen, 2007; O’Malley & Johnston, 2002; Ross et al., 2011). For instance, perpetrators often take advantage of the increased likelihood of adolescent women being alone or otherwise engaging their independence (e.g., walking home from a friend’s house or taking the bus). Also, given that social status is an important factor for adolescent women, potential perpetrators often use their status to coerce women to engage in unwanted sexual activity, justifying their behaviors and decreasing the likelihood that the SA will be reported (Livingston et al., 2007). High school students also engage in more peer-implicated risk behavior (e.g., marijuana and alcohol use) to appear socially competent, and these behaviors may carry over to college to foster acceptance with new peers (Barnett et al., 2013). Unfortunately, the saliency of social status, the limited experience understanding sexual cues, and the potential combination of substance intoxication may be associated with longer response latencies to identify situations as risky. As such, while adolescent women may be engaging in similar risk behaviors to their college-aged counterparts, their lack of knowledge and experiences around sexual activity may lead to increased risk for subsequent victimization experiences.

In general, the literature has used the term “revictimization” to describe an experience of CSA and subsequent SA as an adult (Messman-Moore & Long, 2000), and this pathway has been studied extensively. Yet, there is evidence suggesting that adolescence is a pivotal developmental time period where experiencing SA can be highly traumatic and linked to serious negative consequences. For example, experiencing a SA during adolescence is associated with clinical depression, self-esteem, and body image concerns (East & Hokoda, 2015; Nahapetyan, Orpinas, Song, & Holland, 2014; Silverman, Raj, Mucci, & Hathway 2001; Watkins et al., 2014). Despite these findings, adolescence is often overlooked within the context of revictimization, typically grouped with CSA, or otherwise viewed as error variance to be controlled for in research studies (Bramsen et al., 2013). While some researchers have acknowledged multiple SA experiences during any one developmental period as a form of revictimization, little is known about women who experience an initial SA in adolescence and are subsequently revictimized as young adults, especially with regard to potential negative sequelae (Breitenbecher, 2001; Hines, 2007; Humphrey & White, 2000; Kilpatrick, Acierno, Resnick, Saunders, & Best, 1997; Merrill et al., 1999). Taken together, SA among adolescence is a significant public health concern due to the prevalence and consequences associated with the behavior (Centers for Disease Control and Prevention, 2014). As such, the current study specifically focused on women who experienced their first assault in high school relative to college, and how these differential age and environmental contexts may be related to consequential substance use and abuse.

SA and Substance Use

SA has the potential for deleterious psychological effects on victims, regardless of when they occur. Using substances has especially potent and numbing effects on the negative affect and difficult emotional consequences of SA. While there is support for the relationship between sexual trauma and post-trauma substance use (Najdowski & Ullman, 2011; Ullman & Peter-Hagene, 2014), some researchers have argued that substance use is wholly a function of posttraumatic stress disorder (PTSD) symptomology (Dixon, Leen-Feldner, Ham, Feldner, & Lewis, 2009; Stappenbeck, Bedard-Gilligan, Lee, & Kaysen, 2013; Ullman & Peter-Hagene, 2014). Although substance use and PTSD are often comorbid and explained by a self-medication model (Corbin, Bernat, Calhoun, McNair, & Seals, 2001), post-assault experiences vary from survivor to survivor. Development of PTSD is a very possible consequence of experiencing a SA; however, substance use may also occur postassault without being linked to PTSD symptomology. In addition, post-SA substance use may be more related to coping behaviors than to mental health diagnoses and/or avoidance behaviors (Gutner, Rizvi, Monson, & Resick, 2006). Given the complex relationship between sexual trauma, PTSD, and substance use, we will control for PTSD symptomology in the current study to further evaluate substance use and consequences associated with sexual victimization at two distinct developmental time periods.

Accordingly, women with SA histories report higher rates of alcohol use postassault (Burnam et al., 1988; Corbin et al., 2001; Kilpatrick et al., 1997). Women with assault histories report drinking as a function of inhibiting negative affect and coping with difficult emotions more often than women without trauma exposure. Drinking as a means of coping is associated with greater drinking frequency, especially in trauma populations (Corbin et al., 2001). However, in comparison with alcohol, there is a dearth of literature regarding illicit drug use among college women with a SA history. Drug use is often as widespread in the college context as alcohol use, and is equally implicated in risky sexual activity and SA occurrence (Rostad, Silverman, & McDonald, 2014). In fact, rates of illicit and prescription drug use by college students are extremely high (Johnston, O’Malley, Bachman, & Schulenberg, 2005, 2012). College women, especially those with SA history, are particularly vulnerable to illicit and nonmedical prescription drug use, due to susceptibility to experiencing depression, anxiety, and adverse trauma-related reactions (Rostad et al., 2014). Yet, there is a gap in the literature concerning the use of illicit drugs and the relationship to SA.

Purpose and Hypotheses

The purpose of this study was to investigate the relationship between SA history and substance use in a sample of college women. Specifically, we sought to examine women who experienced SA at different developmental time periods, compared with a group of women with no SA histories, to understand their substance use and associated consequences. Limited research has assessed the adolescent developmental period as part of a revictimization pathway; thus, we focused on women with an initial experience of SA in adolescence and subsequent SA as an adult. We also attempted to clarify the relationship between SA and substances, especially illicit drug use, given the paucity of such data in the current literature.

For the current study, individuals were identified as either having never experienced SA (control), having experienced SA between the ages of 14-17 (high school only), having experienced SA at 18 or older (college only), or having experienced SA at both developmental time periods to represent a less conventional, yet important characterization of revictimization. We hypothesized that (a) women reporting SA experiences across the adolescent and young adulthood developmental periods (revictimization group) would report greater alcohol use, illicit drug use, and alcohol- and drug-related consequences than those with high school only, college only, or no SA histories. We also hypothesized that (b) women reporting their first SA experiences in either high school or college would report greater alcohol use, illicit drug use, and alcohol- and drug-related consequences than those no SA histories. Given the novelty of our developmental characterization and exploratory evaluation of illicit drug use in SA survivors, no specific hypotheses were identified regarding differences between individuals experiencing their first SA in high school and individuals experiencing their first SA in college.

Method

Participants

A total of 743 female undergraduates from a mid-sized public university in the northeastern United States completed the study. Given our focus on revictimization from an initial SA in adolescence, women who experienced CSA were removed from the analyses (n = 87); thus, the final number of participants was 656. The mean age of the participants at the time they completed the study was 19.2 years (SD = 1.4, range = 18-25). The majority of the participants identified as Caucasian/non-Hispanic (66.8%), followed by African American/Black (15.5%), Hispanic/Latina (9.3%), Asian/Pacific Islander (5.2%), or Other (4.2%). In regard to sexual orientation, the majority of participants identified as exclusively heterosexual (91%); however, 6% identified as bisexual and 2% identified as lesbian. The majority of participants were “freshmen” (56%) and 28% were “sophomores” at the time of the survey. A total of 99.5% reported enrollment as a full-time student. In terms of psychological treatment, 41% of women who experienced their first SA in high school, 25% of women who experienced their first SA in college, 38% of women experiencing SA in both high school and college, and 22% of women who experienced no SA reported attending therapy at some point for a psychological issue.

Measures

Students completed a battery of self-report measures to assess sexually assaultive experiences, alcohol and drug use, alcohol- and drug-related consequences, and PTSD symptoms. A short demographic survey assessing age, race, academic year, sexual orientation, and previous psychological treatment was also completed.

SA history

The Sexual Experiences Survey (SES; Koss, Gidycz, & Wisniewski, 1987) is a 10-item self-report measure aimed at identifying and classifying women’s experiences of unwanted sexual contact and victimization through behaviorally specific questions; the measure was slightly modified to demonstrate the interests of this project. Participants identified different behaviors they have experienced, ranging from verbal coercion to completed rape. An example item is “Have you given in to sexual intercourse when you didn’t want to because you were overwhelmed by a man’s continual arguments and pressure?” Participants were asked to respond with “yes” or “no.” If the participant answered “yes” to an item, she was directed to a modified follow-up question which assessed age at which the experience occurred (between 14 and 17, 18+, or both 14-17 and 18+). A final item assessed victimization prior to age 14 using a similar dichotomous yes–no response. Participants were categorized post hoc according to their responses. Participants were divided into one of four groups: control (no victimization), SA in high school only (between 14 and 17), SA in college only (from 18+), or SA in both high school and college (revictimization). Internal consistency coefficient for the current sample was .63, slightly below the level of .73 previously reported (Koss et al., 1987).

Alcohol use

The Daily Drinking Questionnaire–Revised (DDQ-R; Collins, Parks, & Marlatt, 1985) was used to establish alcohol consumption patterns. First, participants are provided a 7-day calendar (Sunday-Saturday) and asked to report the number of alcohol drinks consumed on these days during a “typical” week within the last 30 days. Scores were obtained by summing alcohol use during a “typical” week. A standard drink was defined as 1.5 ounces of hard liquor, 5 ounces of wine, or 12 ounces of beer. Two items followed the weekly calendar evaluation to assess frequency and peak drinking for participants in the last month. The first question asked participants, “How often did you drink during the last month?” The question was on a 7-point Likert-type scale ranging from “I did not drink at all” to “Once a day or more.” The second question asked participants to “Think of the occasion (any day of the week) you drank the most during the last 30 days. How many drinks did you have?” Participant responses ranged from 0-35. The DDQ-R has been found to have high reliability (Baer et al., 1992) and has been used frequently with college samples (Corbin, Mcnair, & Carter, 1996). Typical weekly drinking was strongly associated with both frequency in last month (r = .74, p < .001) and peak drinking in last month (r = .74, p < .001) in the present study.

Drug use

The Daily Drug Taking Questionnaire (DDTQ-R; R. L. Collins et al., 1985; G. A. Parks, 2001) was used to establish typical drug use patterns using a similar calendar method. However, due to a variety of responses that were ambiguous and difficult to assess (e.g., “one pill,” “a joint,” “I smoke”), the measure could not be used as intended. Instead, the follow-up question about the frequency of drug use was utilized. Participants were asked, “How often did you use the drug you specified on the previous page in the past month?” Responses ranged from (1) “not using drugs at all” to (7) “nearly every day.” The most commonly used drug was marijuana; however, 10 participants reported using at least one of the following: amphetamines, hallucinogens, sedatives, or prescription drugs.

Alcohol- and drug-related consequences

Substance use consequences were measured by the Rutgers Alcohol Problem Index (RAPI; White & Labouvie, 1989), an 18-item measure with a 3-point Likert-type scale, ranging from none (0) to 5 or more times (3). Responses indicate how frequently participants have experienced alcohol- and/or drug-related consequences within the last 30 days. An example item is “Not able to do your homework or study for a test,” “Got into fights with other people (friends, relatives, strangers),” and “Neglected your responsibilities.” Scores of eight and above are believed to indicate a need for treatment in college students (Neal, Corbin, & Fromme, 2006). The RAPI is a reliable instrument for measuring both alcohol- and drug-related consequences (Ginzler, Garrett, Baer, & Peterson, 2007). The RAPI had an internal consistency coefficient of .87 for the current study.

PTSD symptomology

The Posttraumatic Stress Disorder (PTSD) Checklist–Civilian Version (PCL-C; Weathers, Litz, Herman, Huska, & Keane, 1993) is a 17-item measure used to assess the Diagnostic and Statistical Manual of Mental Disorders (4th ed., text rev.; DSM-IV-TR; American Psychiatric Association, 2000) symptoms of PTSD. The PCL-C is comprised of a list of problems commonly associated with traumatic life experiences. Participants were asked to respond to the PCL-C relative to their experiences with SA. A 5-point Likert-type scale, ranging from 1 (not at all) to 5 (extremely), was used to assess how upsetting and/or “bothersome” the listed symptoms had been within the past 30 days. An example item was “Repeated, disturbing memories, thoughts, or images of a stressful experience from the past?” A total score was calculated by totaling all of the items. The current study demonstrated strong internal consistency with a coefficient of .93. Given the established relationship between PTSD symptomology and substance use, we controlled for PCL-C scores in our analyses of interest.

Procedure

Approval to conduct the study was initially obtained from the institutional review board of the university. Participants were female college students recruited via a psychology department electronic participant pool who received course credit for their time. A written description of the survey was available to all participants. Those interested in participating were directed to an electronic survey link and provided with an informed consent. The measures in the survey were presented in the following order: SES, PCL-C, DDQ-R, DDTQ-R, and RAPI. Upon completion of the survey, participants were debriefed in writing and provided with relevant resources about sexual violence.

Results

Data were collected from fall 2013 through spring 2015. A total of 15% of the final sample reported experiencing SA in high school, 19% reported experiencing SA in college, and 11% reported experiencing SA in both high school and college. Nearly 55% of the sample did not endorse any SA experiences and were used as the control group. Descriptive statistics/frequency analyses indicated that 80% of all participants did not endorse using illicit drugs. Approximately 16% endorsed marijuana use, which was described by participants in terms of “joints,” “grams,” and “blunts” in an open-ended question about use. About 65% of the total sample endorsed at least some alcohol use. See Table 1 for frequencies of alcohol and marijuana use across specific SA history groups.

Table 1.

Substance Use by SA Category.

SA category	Substance
SA category	Alcohol (%)	Illicit drug/marijuana (%)
Control	58.6	10.8
High school only	72.0	21.0
College only	74.2	18.6
Revictimization	76.1	45.1

Note. SA = sexual assault.

With regard to sexual orientation, a series of ANOVAs was conducted to examine differences on the variables of interest. These analyses revealed a significant difference for frequency of drug use in the past month, F(2, 645) = 4.35, p < .05, η² = .01, such that self-identified homosexual (M_adj = 2.2) and bisexual (M_adj = 1.9) women reported using drugs more often than heterosexual women (M_adj = 1.5). In addition, Pearson’s r correlations were conducted to assess for relationships between PTSD symptoms, alcohol use, drug use, and alcohol- and drug-related consequences. As expected, given the complex relationship that experiences with trauma can have on substance use, all constructs of interest were significantly and positively correlated with PTSD symptoms. As a result of these preliminary analyses, a MANCOVA was conducted, controlling for PCL-C scores and sexual orientation, to assess between-group differences across SA history groups (control, high school only, college only, revictimization) on alcohol use, drug use, and alcohol- and drug- related consequences. All five dependent variables were significant at the omnibus level, and the results partially supported hypotheses. Follow-up univariate F tests were conducted and least significant difference (LSD) post hoc tests were subsequently used to parse group differences.

Alcohol use

Typical weekly alcohol consumption differed significantly across groups when controlling for PTSD symptoms and sexual orientation, F(3, 638) = 3.67, p < .05, η² = .02. As hypothesized, revictimized women (M_adj = 8.4) reported significantly (p < .05) more alcohol consumption than controls (M_adj = 5.0). Also, women who reported SA in college (M_adj = 7.3), but not high school (M_adj = 6.3), reported significantly (p < .01) more alcohol consumption than controls. However, there were no differences between revictimized women and women who reported SA in college or women who reported SA in high school. There were also no differences between women reporting SA in high school and women reporting SA in college.

Frequency of drinking in the past month differed significantly across groups when controlling for PTSD symptoms and sexual orientation, F(3, 638) = 4.31, p < .01, η² = .02. As hypothesized, revictimized women reported drinking alcohol significantly (p < .01) more often (M_adj = 3.1) than controls (M_adj = 2.5). Also, women who reported SA in college (M_adj = 3.0), but not high school (M_adj = 2.8), reported drinking alcohol significantly (p < .01) more often than controls. However, there were no differences in frequency of alcohol consumption between revictimized women and women who reported SA in college or women who reported SA in high school. There were also no differences between women reporting SA in high school and women reporting SA in college.

In regard to “peak drinks” consumed in the past month, there were significant differences across groups when controlling for PTSD symptoms and sexual orientation, F(3, 638) = 5.42, p < .01, η² = .03. As hypothesized, revictimized women (M_adj = 5.4) reported significantly (p < .01) higher levels of peak alcohol consumption than controls (M_adj = 3.4). Also, women who reported SA in college (M_adj = 4.5) and women who reported SA in high school (M_adj = 4.5) reported significantly (ps < .05) greater peak drinking than controls. However, there were no differences in levels of peak alcohol consumption between revictimized women and women who reported SA in college or in high school. There were also no differences between women reporting SA in high school and women reporting SA in college.

Drug use

Frequency of drug use in the past month differed significantly across groups when controlling for PTSD symptoms and sexual orientation, F(3, 638) = 12.14, p < .001, η² = .05. As hypothesized, revictimized women (M_adj = 2.4) reported using drugs significantly more often than controls (M_adj = 1.4, p < .001), women with SA in high school (M_adj = 1.5, p < .001), and women with SA in college (M_adj = 1.4, p < .001). However, there were no differences in drug use between women who reported SA in college or women who reported SA in high school and controls. There were also no differences between women with SA in high school or women with SA in college.

Alcohol- and drug-related consequences

Finally, alcohol- and drug-related consequences differed significantly across groups when controlling for PTSD symptoms and sexual orientation, F(3, 638) = 7.86, p < .001, η² = .04. As hypothesized, revictimized women (M_adj = 4.8) reported significantly more alcohol- and drug-related consequences than controls (M_adj = 2.2, p < .001) and women who reported having experienced SA in high school (M_adj = 2.4, p < .05). Also, women who reported SA in college (M_adj = 3.6) reported significantly more alcohol- and drug-related consequences than controls (p < .01). Women who reported SA in high school also reported significantly more alcohol- and drug-related consequences than controls. However, there were no differences in consequences between revictimized women and women with SA in college only or between women with SA in high school and women with SA in college.

Discussion

The aim of this study was to examine the relationship between SA history and alcohol use, illicit drug use, and alcohol- and drug-related consequences, in women experiencing their first SA after the age of 14. The results from the current study indicate that revictimized women consume more alcohol, drink more frequently, engage in greater peak drinking, use more illicit substances, and demonstrate more serious consequences from their substance use than women who have never experienced SA. However, in regard to differences between revictimized women and those with SA experience in either high school or college, the data are more mixed. When compared with women with SA in high school only, revictimized women used illicit drugs more frequently and demonstrated greater consequences from their substance use. The revictimized women also used illicit drugs more frequently than women with SA in college only. Women who experienced SA in college only also demonstrated consistent differences in their substance use when compared with controls, with the sole exception being frequency of drug use. With regard to women who experienced SA in high school only, they engaged in greater peak drinking and demonstrated greater consequences from their substance use than controls. Finally, there were no differences between women who experienced SA in high school only and those who experienced SA in college only.

Taken together, our data add to the literature by establishing women with revictimization experiences consume alcohol at a higher rate than women with one or no experience of SA and expand this literature to demonstrate that illicit substance use is associated with SA. However, our data also suggest that any experience of SA in college, with or without an experience of SA in high school, is generally associated with increased substance use and consequences. Both peak drinking and consequences appear to be affected relative to controls in the high school only group. In other words, experiencing your first (and only) SA in high school is not associated with dramatic increases in quantity and frequency of substance use, beyond peak drinking. Thus, there appears to be differential relationships between SA and substance use and abuse, relative to the timing SA across two important developmental and environmental contexts.

On one hand, these data could be used to support the notion that substance use is a consequence of SA. In fact, women who were revictimized or reported SA in college have experienced their assault more recently than women who reported SA in high school, and may be attempting to deal with this sexual trauma. Indeed, increased substance use could be a method of coping, such that women are consuming alcohol or drugs to distract from their current assault experiences. In fact, using substances as a means of coping with trauma is a common occurrence (Najdowski & Ullman, 2009, 2011; Ullman & Peter-Hagene, 2014), though usually viewed as a maladaptive coping skill and related to further negative consequences (Gutner et al., 2006). On the other hand, the social norms of the college environment sanction frequent and high levels of alcohol consumption, making it difficult to discern women with a revictimization history from those who were assaulted in college only, as both groups may be drinking more often due to their environment. In fact, the majority of our sample were first-year college students, and periods of this freshman year have been described as a “red zone” due to reports of heavy drinking and elevated risk of SA (Kimble, Neacsiu, Flack, & Horner, 2008). Thus, it is possible that college women who drink or use drugs often are also at greater risk for experiencing SA. However, it is important to note that the research conducted here was cross-sectional in nature, and future longitudinal studies could help to truly clarify the direction of this relationship and explore the potential for a cyclical relationship.

Interestingly, revictimized women reported using illicit drugs, marijuana in particular, more often than any other group. In addition to using drugs as a means of coping, this may be reflective of a culture change. Marijuana use appears to have become more acceptable, both socially and legally, in recent years. For example, marijuana is legalized for recreational use in eight states and for medical use in 20 states (Governing Data & The State and Localities, 2016), and nearly 20 million people report using marijuana in the previous month (Substance Abuse and Mental Health Services Administration, 2014). Marijuana appears to alleviate PTSD symptoms and may assist individuals who are coping with their trauma (Bonn-Miller, Vujanovic, Feldner, Bernstein, & Zvolensky, 2007). Research examining trauma and marijuana use found that individuals had a greater likelihood of current and lifetime use post-trauma (Cougle, Bonn-Miller, Vujanovic, Zvolensky, & Hawkins, 2011), suggesting potential pharmacological or psychological effects that facilitate coping.

Furthermore, research has shown that the more severe the trauma, the more intense the marijuana use, further corroborating the concept that marijuana is being used as a coping method for trauma survivors (Kevorkian et al., 2015). However, to date, no controlled, randomized clinical trials have occurred with regard to marijuana use and PTSD. While research regarding the pharmacological effects of marijuana is still developing, it is possible that women with revictimization experiences are using the substance due to the environmental setting rather than or in addition to the physiological effects. That is, marijuana may be used more often in an intimate setting compared with alcohol (e.g., a friend/partner’s house compared with a party). In other words, while alcohol use may be a shared activity among any individuals (known or unknown), marijuana use tends to be an activity often shared between known individuals in private. Thus, intimate settings may provide more security to a woman with a revictimization history than a party setting and explain increased use.

Self-reported negative consequences for substance use were higher for women with revictimization history than the high school only and control groups. It is important to note that the consequences were related to drinking and drug use, making it difficult to discern if one substance resulted in more negative outcomes than the other. Moreover, revictimized women may be using substances for a longer period than women with no assault history or just one SA experience, suggesting they are more likely to experience a negative consequence. In addition, of the women who reported revictimization, only 38% attended treatment, suggesting that these women have not sought professional guidance for their trauma experience(s) and may be using substances to cope. While revictimized women reported using illicit substances more often than other groups, intentions behind their use are unclear.

Consequences may have been higher for women with revictimization history due to excessive use. Recent research has noted that substance use may serve as a consequence and precursor to victimization (Bryan et al., 2016), and our revictimization group provides evidence of a potential cyclical relationship. This cycle could include women using substances, experiencing an assault, continuing use, and increasing their risk of revictimization. All of our analyses controlled for PTSD symptomology, suggesting that participants’ substance use was not derived from suppressing trauma symptoms. Future researchers should work to longitudinally evaluate the progression from adolescence into young adulthood to examine the causality of SA and substance use as well as provide further detail into a potential cyclical pathway. Adolescence is a critical developmental period where youth are granted greater freedoms and fewer restrictions; therefore, the ability to access substances can be easier and may be the area to target for intervention. If substance use (alcohol and/or drugs) precedes SA, then interventions should target protective substance strategies for adolescents to further protect themselves from excessive use and SA risk.

Limitations

There are a few important limitations to note in this study. The participants were part of a college convenience sample and the racial/ethnic and self-reported sexual orientation were in accord with the university’s demographics. However, these demographics are not necessarily representative of the racial/ethnic and sexual identities reported in the larger body of SA literature (Long, Ullman, Long, Mason, & Starzynski, 2007). Given that the sample was predominantly Caucasian and heterosexual, the findings may not generalize to other groups; thus, future researchers should seek to examine more diverse samples.

Furthermore, it is unclear how many times our female participants experienced a SA in either temporal period, as SA was examined by a yes/no measure. Thus, it is possible that there are participants who were victimized multiple times in high school or college, but did not experience SA in both high school and college. Nonetheless, this study is part of a developing literature suggesting that experiencing SA across adolescence and young adulthood can serve as another pathway for conceptualizing revictimization with similar relationships to serious negative consequences to victimization occurring in childhood and subsequently in adulthood (Humphrey & White, 2000). It is also important to note that there may be a third variable operating to influence our findings leading to increases in both SA risk and substance use. As noted, the current study was cross sectional in nature and future researchers would do well to conduct a longitudinal study to examine experiences of SA across multiple developmental periods to compare the consequences of these experiences relative to multiple experiences within one developmental period.

In the current study, it is unclear why our participants sought treatment as they were simply queried about their history of therapy and not specifically about the goals of the treatment. Future researchers should examine if women have sought treatment and for which purpose, including SA, substance use problems, or some other related or unrelated issue. Finally, relationship status with regard to the perpetrator and the level of intoxication during the assault were not assessed in this study. While not necessarily a limitation, given that SA experiences are viewed as traumatic regardless of perpetrator relationship, it is a point for future research. By assessing the relationship status of victim and perpetrator, researchers can clarify another potential factor that may influence substance use and recovery. With regard to intoxication during the assault, research has suggested this may create either deleterious effects or minimal consequences, as the victim cannot recall the event as well (Bedard-Gilligan, Kaysen, Desai, & Lee, 2011). Future researchers should work to assess substance use during high school and college SA experiences as it may provide further understanding of the cyclical relationship between SA and substance use.

Implications for Research and Practice

Despite the acknowledged limitations, this study is a unique contribution to the SA literature with significant implications. This study is among the first to have highlighted several elements often overlooked–specifically, illicit drug use and high school-collegiate revictimization. Examination of these components in greater depth is essential to achieving a better understanding of risk factors for SA and the engagement in problematic substance use. However, this study provides a foundation for future researchers to further investigate the substance use–SA relationship. We believe the potential reciprocal connection between these constructs should be of considerable interest, as it may provide important insights that should inform future educational and/or systemic approaches with regard to prevention intervention.

As adolescence appears to elevate risk period for SA, interventions should begin as early as ninth grade. Given that 15% of our sample experienced their first SA in high school, we argue that waiting for women to arrive to college is too late in terms of intervening. It would be ideal for youth to be informed about the varying degrees of SA (e.g., coercion, completed rape, rape with use of substances) prior to entering college so that they may more fully understand the continuum of these behaviors, their implications, and potential means of coping with the possibility of these experiences occurring. Furthermore, as SA is occurring at such a pivotal point of development for individuals, education on rape myth acceptance, victim blame, and traditional gender roles should be provided to promote a culture that encourages survivors to seek help and speak out and prevent endorsement of SA.

It is also important for researchers to consider the sexual orientation of their participants when conducting follow-up studies. There is some literature to suggest that sexual minority adolescents are at increased risk for high-risk substance use and SA (Goldbach, Tanner-Smith, Bagwell, & Dunlap, 2014; Martin-Storey, 2015). Sexual minority women appeared to be affected by the substance use and SA relationship in this study; however, it is also possible that other factors may play a role relative to heterosexual women. Thus, it is important to not only control for these differences in our research, but to allocate dedicated resources to more fully examine this group of women who maintain such high risk. Finally, while substance use may precede, occur simultaneously, or be a consequence of experiencing SA, it is clear that heavy use can elevate a variety of risks for women. Intervention should work to educate adolescents and college students about the frequency by which their peers consume substances relative to their own use. Strategies could also be taught to young adults about how to stay safe while consuming substances in high-risk environments. Furthermore, targeted prevention strategies should be developed for different groups of women, including sexual minorities.

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Author Biographies

D. J. Angelone, PhD, earned his doctoral degree in clinical psychology from Kent State University. He is an associate professor of psychology at Rowan University where he codirects the Aggression, Substance, and Sexuality Research Team (ASSeRT). His primary research interests are on sexually aggressive behavior and sexual risk taking. He has developed several laboratory analogues of sexual aggression and has used these paradigms to examine a variety of factors related to perpetration and victimization. His research also focuses on understanding the factors that can influence observer perceptions of sexual assault.

Tiffany Marcantonio, MA, is a first-year doctoral student at the University of Arkansas (UArk) studying Community Health Promotion. Before attending UArk, she received a BA in psychology and an MA in Clinical and Mental Health Counseling from Rowan University. Her research interest includes understanding factors that contribute to, increase, and can prevent engagement in sexual aggression and risky sexual activity.

Jessica Melillo, MA, LAC, is an outpatient individual and group counselor specializing in children and adolescents with eating disorders. She received a bachelor’s degree in psychology from Wagner College and a master’s in Clinical Mental Health Counseling from Rowan University. She is interested in the interrelationships among substance use, sexual assault, and eating disorders.

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