Abstract
To date, little work specifically addresses empirical studies concerning barriers and facilitators to health service use among college female sexual violence victims. The following objectives were addressed: (1) analyze studies of college-aged women who have been victims of sexual violence to examine the frequency and moderating characteristics of utilization of university-based resources available, (2) identify inconsistencies and gaps in the literature concerning sexual victimization and service utilization, and (3) provide next steps for researchers and clinical care coordinators. Six electronic databases were searched from 1990 to May 2016. Inclusion criteria for the review were (1) university or college setting or sample, (2) empirical design, and (3) inclusion of some discussion or measurement of health service use. Following preferred reporting items for systematic reviews and meta-analyses (PRISMA) procedures, 22 articles were identified for the review. Although prevalence rates of sexual victimization were high (4.7–58%), rates of service utilization were lower (0–42%). There were significant discrepancies between hypothetical use of services and actual rates of service use. Identified barriers included feelings of shame, guilt and embarrassment, not wanting friends and family to find out, and thinking the victimization was not serious enough to report. Identified facilitators included acknowledging the sexual violence victimization as a crime, receiving encouragement from friends and family to utilize health services, and receiving a positive response during the initial informal disclosure. Finally, measurement of victimization was inconsistent across studies. Recommendations are offered for college campus prevention programming and future research.
The Centers for Disease Control and Prevention (CDC) defines sexual violence victimization (SVV) as a sexual act that is committed or attempted by another person without freely given consent of the victim or against someone who is unable to consent or refuse (Basile, Smith, Breiding, Black, & Mahendra, 2014). It is estimated that in the United States, nearly 20% of women have experienced rape or attempted rape in their lifetime and over 40% have experienced another form of SVV, including unwanted sexual contact and sexual coercion (Breiding, Chen, & Black, 2014). Based on data from the National Crime Victimization Survey, females aged 18–24 experience higher rates of rape and sexual assault than any other age-group (Sinozich & Langton, 2014). This group is of particular importance as this is the time period when females are matriculating for the first time (Arnett, 2000), often away from home. Data from a large, cross-sectional survey revealed that nearly 20% of college females reported being victims of SVV since their first year of college (Krebs, Lindquist, Warner, Fisher, & Martin, 2007), while national-level data revealed that 23% of women were victims of sexual assault through physical force, violence, or incapacitation during their undergraduate years (Sinozich & Langton, 2014), and the National Intimate Partner and Sexual Violence Survey reported that 37% of women rape victims were first raped between the ages of 18 and 24 (Black et al., 2011).
SVV is associated with several short- and long-term physical and psychological health consequences. Victims may suffer from immediate bruising, reoccurring gynecological and sexual health programs, depression, anxiety, suicidal thoughts, post-traumatic stress disorder (PTSD; Basile et al., 2014), and decreased self-esteem (Perilloux, Duntley, & Buss, 2012). Victims are also more likely to engage in risky health behaviors such as sex with multiple partners, low rates of condom use, and sex with strangers (Jewkes, Sen, & Garcia-Moreno, 2002). College women in particular are more likely to suffer from substance abuse issues including drug use and binge drinking (Turchik & Hassija, 2014) in large part due to the social environment of the college campus itself. Finally, SVV is negatively associated with academic achievement among college females. Women who are victimized during their first year of college report lower overall grade point averages compared to nonvictims (Jordan, Combs, & Smith, 2014). Taking into account the negative outcomes associated with SVV, it is important to examine the ways in which victims seek assistance for the assault and health-related impacts.
Compared with the general population, college women are consistently less likely to disclose an experience of sexual assault (Fisher, Cullen, & Turner, 2000). Despite the high rates of SVV against college females, only 11% of rapes are reported to college authorities, making SVV the most underreported violent crime among this population (Kilpatrick, Resnick, Ruggiero, Conoscenti, & McCauley, 2007). College students are 13% less likely to report an incident of SVV to police versus nonstudents in the same age-group (Sinozich & Langton, 2014), and one third of female students never tell anyone about the assault (Fisher et al., 2000). SVV literature commonly breaks down reporting into two disclosure sources: formal (e.g., physician, law enforcement) and informal (e.g., family member, friend). Research on formal disclosure primarily focuses on reports made to campus police or law enforcement agencies. To date, very few studies have focused on university-based health services and little remains known about help-seeking behaviors among victims of SVV as they relate to the utilization of health-related services. Health services are defined as student health centers, crisis response centers, counseling and psychological services, women’s resource centers, and counseling centers (American College Health Association, 2010). Moreover, little exists in the way of understanding barriers and facilitators to utilizing university-based health services. From what does exist, a number of themes in barriers to use have emerged including fear, embarrassment, concerns over confidentiality, and the victim’s belief that the assault was not serious enough to be considered a crime (Sabina & Ho, 2014). Facilitators to reporting SVV often include the desire to prevent the incident from happening to someone else and wanting to educating the public about SVV on campus (Sabina & Ho, 2014). It is noteworthy that many of the victimization-specific barriers and facilitators differ substantially from documented demographic (e.g., age, ethnicity) and school-specific (e.g., private vs. public) barriers and facilitators associated with use among the general college population (Turner & Keller, 2015).
The Present Study
SVV among college women is a prevalent public health problem and has been discussed extensively within the criminal justice, psychology, and women’s health literature. Yet, there has been no evidence of a reduction in rates over the past 15 years (Kilpatrick et al., 2007). This review examines empirical studies on formal disclosure, informal disclosure, and service use among college females with a specific focus on health services utilization. This review adds to the current literature by focusing on empirical studies specific to female college victims who report episodes of SVV to a university-based health-care provider. This systematic review builds on prior literature that focused on reporting to criminal justice and law enforcement personnel, including a recent systematic review (SR) conducted by Sabina and Ho (2014). While there is some overlap in the inclusion criteria between the current study and Sabina and Ho’s (2014) SR, the prior included articles focused on intimate partner violence (IPV), whereas this SR did not. University-based health services such as college counseling and women’s resource centers provide distinct services and programs for victims, necessitating independent evaluation of existing evidence apart from criminal justice–involved personnel and processes. The following objectives were addressed: (1) analyze studies of college-aged women who have been victims of SVV to examine the frequency and moderating characteristics of utilization of university-based resources available, (2) identify inconsistencies and gaps in the literature concerning sexual victimization and service utilization, and (3) provide next steps for researchers and clinical care coordinators.
Method
Search Strategy
An SR of the literature was conducted between July and August 2016. Studies were identified using six major search engines: Criminal Justice Abstracts, ERIC, MedLine, PsychArticles, PsychInfo, and PubMed. The PRISMA 2009 Checklist (Moher, Liberati, Tetzlaff, & Altman, 2009) was used to guide parameters for the SR. Items on the checklist associated with meta-analysis were excluded, as these were outside the scope of the present article. The second author served as the additional reviewer for the final list of articles to ensure interrater consistency.
Four groups of search terms were identified with the purpose of identifying all available literature on SVV, health service utilization, sample population, and sample setting. Consistent with the CDC definition above, to address SVV, search terms included rape, sexual assault, forced sexual coercion, and sexual victimization. To address health service utilization, the following terms were searched: student health center, crisis response center, counseling and psychological services, women’s resource center, counseling center, mental health, medical, and help seeking. The sample population terms included college student, young adult, emerging adult, survivor, and female, and the sample setting terms included university, college, and campus. Figure 1 represents the stepwise approach to identifying key articles for the review.
Flow diagram of article selection.
Inclusion and Exclusion Criteria
Inclusion criteria for the review included (1) university or college setting or sample, (2) empirical (quantitative, qualitative, or mixed-method) design, and (3) some discussion or measurement of health service use. The search was limited to English language, peer-reviewed publications between 1990 and May 2016. Articles prior to 1990 were excluded, as prior to this date federal legislation in the form of the Clery Act (updated as the Jeanne Clery Disclosure of Campus Security Policy and Campus Crime Statistics Act, 2000) addressing campus SVV did not exist. Specifically, the Clery Act requires any college or university participating in the federal student aid program to disclose all forcible and nonforcible sexual offenses and to make available campus safety information, campus crime statistics, and campus security policies on an annual basis. Exclusion criteria for the review included (1) male and/or female-to-male populations, (2) articles focused on IPV or dating violence, and (3) articles that mainly focused on sexual assault disclosure to criminal justice or law enforcement personnel.
Results
Overview of Methods of Studies Reviewed
Table 1 presents the prevalence rates, sample characteristics, procedures, pertinent findings, barriers and facilitators to service use, domains of service utilization, and SVV measurement tools for each of the 22 studies included in this review. The studies utilized a range of study methods, including cross-sectional surveys (e.g., Allen, Ridgeway, & Swan, 2015; Eisenberg, Lust, Hannan, & Porta, 2016; Lindquist et al., 2013), longitudinal studies (Breitenbecher & Scarce, 2001; Littleton, 2010; Orchowski & Gidycz, 2012), a qualitative study (Guerette & Caron, 2007), and an SR (Sabina & Ho, 2014). Sampling strategies largely consisted of convenience samples, recruited through campus advertisements, courses, or specific academic departments. Seven studies (e.g., Amstadter et al., 2010; Fisher, Daigle, Cullen, & Turner, 2003; Wolitzky-Taylor et al., 2011) used nationally representative samples of college students, including three that used random sampling through the American Student List which lists over 6 million students currently enrolled in college in the United States. The diversity of study designs and larger sample sizes increase the generalizability of the studies. However, many studies used the same sample or data set to answer different research questions.
Studies on Health Services Utilization by College Females Post-SVV.
Note. SVV = sexual violence victimization; GSA = group sexual assault; ISA = individual sexual assault; STDs = sexually transmitted diseases; DFR = drug and alcohol facilitated rape; IR = incapacitated rape; FR = forcible rape; FSA = forced sexual assault; ISA = incapacitated sexual assault; AV = acknowledged victim; UV = unacknowledged victim.
Themes in Service Use
The prevalence rates of SVV on college campuses were routinely high, with an overall range of 4.7% (Eisenberg et al., 2016) to 58% (Amstadter et al., 2010) in reviewed studies. Studies consistently revealed low rates of service utilization, except when hypothetical reporting was explored. In these cases, large discrepancies were revealed between perceived and actual use of campus services. A survey of 633 undergraduate students revealed 62% of nonvictims reported that they would be somewhat or very likely to utilize the campus rape crisis center if they experienced an unwanted sexual assault (Banyard et al., 2007). To the contrary, only 5% of victims from the same sample reported actually using the same rape crisis center after an unwanted sexual assault (Banyard et al., 2007). Nasta et al. (2005) found similar significant differences between hypothesized utilization of services and actual utilization of services by victims. Reported hypothetical use of campus health services was 81%, while actual reported use by victims after a sexual assault was only 12% (Nasta et al., 2005).
Prior research has suggested that awareness of campus resources is positively associated with utilization (Amar, 2008). Victims frequently reported being unaware of available resources as reasons for not seeking help after a sexual assault. Two studies in this review focused on resource awareness (Nasta et al., 2005; Walsh, Banyard, Moynihan, Ward, & Cohn, 2010). The findings varied significantly. Nasta et al. (2005) reported that 97% of victims were familiar with at least one on-campus resource, while Walsh, Banyard, Moynihan, Ward, and Cohn (2010), who surveyed a similar sample, found that only 50% of victims could locate the support center on campus. Yet, both studies revealed high rates of hypothesized use of resources; 63% and 45%, respectively, of nonvictims in each study reported high-perceived willingness to use resources if they experienced a sexual assault. This finding suggests that knowledge and utilization of resources are relatively unrelated.
Nearly every study differentiated between formal and informal sources of disclosure. Formal sources included campus counseling centers, rape crisis centers, student health centers, professional counselors or therapists, women’s centers, and physicians (e.g., Amar, 2008; Fisher, Cullen, & Turner, 1999; Walsh et al., 2010). Informal sources included friends, family members, roommates, and romantic partners (e.g., Banyard et al., 2007; Orchowski & Gidycz, 2012; Sipsma, Cerrato, Isabel, & Everaerd, 2000). Rates of disclosure to formal sources ranged from 5% of undergraduate students in a convenience study (Banyard et al., 2007) to 48% of undergraduate rape victims using a national sample (Amstadter et al., 2010), whereas rates of disclosure to informal sources ranged from 32% of rape victims in a follow-up study (Littleton, 2010) to 88% of victims in a large, nationally representative study (Fisher et al., 2003), suggesting that victims of an unwanted sexual encounter are more likely to seek help from an informal source.
Facilitators to Health Service Use
There were a number of factors observed that enhanced the likelihood of health service utilization. The most common reason that female students utilized the available health services was because she believed that what she experienced was a crime (Guerette & Caron, 2007; Littleton, Axsom, Breitkopf, & Berenson, 2006; Orchowski, Untied, & Gidycz, 2013). Further, women who acknowledged the sexual assault as a criminal act were significantly more likely to utilize formal health services than women who did not acknowledge the victimization as crime (Littleton et al., 2006). In a study of 1,253 college females, 256 (20%) screened as having at least one experience of SVV since the age of 14, yet only 101 (40%) of the victims acknowledged that they had been victimized (Littleton et al., 2006). Between the two groups, victims who acknowledged the criminal act were significantly more likely to have reported the victimization than those individuals who did not acknowledge the crime. Females who received encouragement from family and friends to utilize formal resources and women who received a positive response during the initial informal disclosure (Guerette & Caron, 2007; Littleton, 2010) are also more likely to utilize health services after a sexual assault. Sustaining physical injury was also associated with higher rates of utilization (e.g., Fisher et al., 2003; Lindquist et al., 2013; Wolitzky-Taylor et al., 2011). Among women who were physically injured, 52% reported their rape versus 14% of those who were not harmed (Wolitzky-Taylor et al., 2011). Additionally, females who experienced symptoms of PTSD were more likely to utilize health services (Amstader et al., 2010; Littleton, 2010) and females who were assaulted by more than one offender sought help at higher rates (Gidycz & Koss, 1990). Other factors positively associated with use of health services included wanting to prevent another assault (Guerette & Caron, 2007), having a designated person on campus as a resource (Amar, 2008), and being concerned with STDs and pregnancy (Guerette & Caron, 2007).
Barriers to Health Service Use
Feelings of shame, guilt and embarrassment (e.g., Allen et al., 2015; Guerette & Caron, 2007; Orchowski & Gidycz, 2012), not wanting friends and family to find out (e.g., Allen et al., 2015; Fisher et al., 2003; Walsh et al., 2010), and thinking the victimization was not serious enough to report (e.g., Fisher et al., 1999; Orchowski et al., 2013; Walsh et al., 2010) were among the top reasons why women did not access health services after a sexual victimization. For instance, using mean Likert-type scale scores (where 1 was never and 5 was very often), shame and guilt and embarrassment received a mean score of 4.45 among female college students rating perceived barriers to service use. In the same study, not wanting friends and family to find out about the victimization resulted in a mean score of 4.26 (Allen et al., 2015). Findings from one of the largest studies using a national college-age sample found that 81.7% of college women failed to utilize a health service because they did not believe the events surround the sexual assault were serious enough (Fisher et al., 1999; Fisher et al., 2003). Rape classification also had an impact on whether a woman utilized health services. Victims of incapacitated assault (i.e., unable to provide consent) were less likely to utilize health services when compared to victims of forced assault (i.e., where physical force was used; e.g., Amar, 2008; Fisher et al., 2003; Wolitzky-Taylor et al., 2011). For example, when compared to victims of forced rape (13.9%), victims of incapacitated rape only sought out medical and psychological care 7.6% of the time (Lindquist et al., 2013). Females who received a negative response during an informal disclosure were also less likely to utilize services (e.g., Guerette & Caron, 2007; Littleton, 2010; Walsh et al., 2010). Other factors negatively associated with service use included fear of retaliation from the perpetrator (Allen et al., 2015; Fisher et al., 1999; Walsh et al., 2010), having a relationship with the perpetrator (Orchowski & Gidycz, 2012; Sipsma et al., 2000), and alcohol use during the time of the attack (Amar, 2008; Lindquist et al., 2013).
Measurement Themes
Although not an original intent of this review, a theme that emerged was inconsistency in the measurement of victimization, both with respect to the time frame and measurement tools. There were wide-ranging time periods measured among the articles: six articles (e.g., Littleton, 2010; Orchowski, Meyer, & Gidycz, 2009; Sipsma et al., 2000) measured SVV from the age of 14, which is aligned with the Sexual Experiences Survey (SES), four articles measured SVV over the lifetime (e.g., Amstadter et al., 2010; Wolitzky-Taylor et al., 2011) or over the academic year (e.g., Banyard et al., 2007; Fisher et al., 1999), two articles (Breitenbecher & Scarce, 2001; Walsh et al., 2010) measured using multiple methods, and one article (Eisenberg et al., 2016) measured using the prior calendar year. Finally, two articles (Gidycz & Koss, 1990; Guerette & Caron, 2007) measured SVV using a range of time frames (i.e., between 2 months and 6 years). The two most common measurement tools used were the SES (Koss & Gidycz, 1985; Koss, Gidycz, & Wisniewski, 1987; Koss & Oros, 1982) and researcher-developed surveys. Other survey instruments included the Rape and Sexual Assault Campus Awareness Survey (Sable, Danis, Mauzy, & Gallagher, 2006), the National College Health Assessment (American National College Health Association, 2014), and the Child Sexual Abuse Questionnaire (Finkelhor, 1979).
Discussion
Despite the high rates of SVV identified in this review, little research has been done on the utilization of health services on college campuses after a female student has been sexually assaulted. Our findings suggest a mismatch between high rates of victimization and low use of health services.
Research Implications
This review revealed significant inconsistencies in how SVV is measured. First, the way in which unwanted sexual experience was assessed varied. For example, although the SES was the most commonly used tool for measuring unwanted sexual experiences, only 5 (e.g., Gidycz & Koss, 1990; Orchowski et al., 2009, 2013; Sipsma et al., 2000) of the 10 studies that used the SES kept its original format of 10 items. Other forms of the SES were modified to include between 2 and 9 items (e.g., Allen et al., 2015; Breitenbecher & Scarce, 2001; Littleton, 2010). Further, a number of studies (e.g., Amar, 2008; Banyard et al., 2007; Fisher et al., 1999) utilized an investigator-developed survey to measure unwanted sexual experiences. These surveys often lack reliability and validity and do not allow for comparison across studies. Another important limitation of SVV measurement is a lack of consistency with legal definitions. The time period measured was diverse, ranging from 7 months (Fisher et al., 2003) to the period of a lifetime (Amstadter et al., 2010). Further, the time period measured did not necessarily relate to the tool being utilized. Traditionally, the SES examines unwanted sexual experiences beginning at age 14 (Koss & Oros, 1982); however, Walsh et al. (2010) employed the SES in their cross-sectional study of undergraduate women and examined SVV over the course of the lifetime, creating a discrepancy between measurement tool and time period. Lack of a uniform time period makes it difficult to isolate when the sexual assault occurred. The SVV literature would largely benefit from the establishment of measurement tool that is reliable and valid and consistently measures unwanted sexual experiences under the legal definition.
Reflective of the inconsistent definitions is the wide range of SVV rates (i.e., 4–58%). Such a wide range is problematic in gaining a true sense of the commonality of SVV. Perhaps rates should be stratified by level of severity. That is, a potential solution for empirical research and college health surveillance data moving forward would be to define subtypes or gradations of severity. For example, rates may range from unwanted touching to forcible penetration.
The majority of studies reviewed utilized a cross-sectional research approach (e.g., Allen et al., 2015; Amar, 2008; Amstadter et al., 2010; Banyard et al., 2007). Although this method has produced meaningful information, it prohibits the researcher from establishing a causal relationship between SVV and health service utilization. Future research would benefit from prospective and longitudinal approaches, allowing for better understanding long-term, how SVV affects an individual and the choices they make, ultimately helping to determine where to focus prevention and intervention efforts.
Prevention Implications
Over the past three decades, it has become increasingly common for a woman to reveal an episode of SVV to a friend or peer (Baumer, 2004). This review supports prior research that indicates 88% of victims reported an unwanted incident to a friend (Fisher et al., 2003). The high rates of disclosure raise two important issues. First, victims see their friends as valued confidants, yet it is unlikely that friends of victims are prepared for the disclosure, resulting in a possible unintended negative response. This is troublesome as negative reactions often discourage further disclosures and hamper recovery. Educating college students, particularly women, on how to best respond to a disclosure in a way that allows the survivor to tell her story without feeling blamed or stigmatized is an important first step in a victim’s healing process. Second, peers often serve as the gateway to formal healthcare services. Unfortunately, very few college students are knowledgeable about the available campus resources. It is important that individuals are informed and able to provide the victim with recommendations to the most appropriate campus providers.
Victims of sexual violence are most comfortable reporting unwanted experiences to their friends. This provides a natural pathway for setting up peer educator programs focused on preventing and responding to SVV on college campuses. Peer health education (PHE) programs have been used on college campuses to address topics, including alcohol use, obesity, and nutrition (White, Park, Israel, & Cordero, 2009). For example, a 3-year longitudinal study examining the impact of PHE on alcohol and drug use, eating and nutrition, and sexual health found that students who had contact with a peer educator were significantly less likely to consume alcohol, had fewer negative outcomes due to alcohol use, and decreased unhealthy eating habits (White et al., 2009). The advantage of a peer educator program is that having student status allows the peer educator access to situations that university administrators, faculty, and health professionals do not have. Regarding sexual victimization, students are already serving as peer educators but lacking the proper training. We recommend comprehensive PHE programs with training on the definitions of sexual violence (i.e., what defines a criminal act), the role of alcohol and drugs, strategies on how to appropriately respond during a sexual assault disclosure, and what to avoid when responding. Further, all peer educators should be trained on the campus resources available to victims and the way in which a victim can connect with each resource.
When discussing low rates of service utilization, the focus tends to rest on the victim. Building on a recommendation made by Sabina and Ho (2014), we must also look at the college environment for reasons for low disclosure. Research supports a team-based approach to responding to sexual assault involving medical and psychological providers, sexual assault counselors, and campus police (Nasta et al., 2005). Yet, on nearly all college campuses, these providers are housed in separate buildings, on different parts of the campus. This forces the student to make multiple visits to multiple providers during a time when motivation is already low. We recommend transitioning to medical home model where students would receive comprehensive health care and resources in one place.
Limitations and Future Directions
The following are noted limitations of this review. First, campuses often vary in noted health services, and very few studies reviewed or provided this information. Second, a review of on-campus health service utilization fails to account for student use of external health resources, such as off-campus physicians or therapists. Moving forward, college health surveillance data should track use of these resources. Third, in line with the limitation of gradation of severity discussed above, it is plausible that a victim is resilient enough not to need health services in instances of minor victimization (e.g., unwanted touch). Moreover, posttraumatic growth literature suggests that some victims develop strength postvictimization. Collectively, these are noted exceptions to the victimization health services link worth of future research. Finally, reputation and quality of services may mitigate service use. This potential barrier is also worthy of future investigation.
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.