Social Science & Medicine 292 (2022) 114334

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Social Science & Medicine

journal homepage: www.elsevier.com/locate/socscimed

Sexual violence and Australian women: A longitudinal analysis of

psychosocial and behavioral outcomes
Robyn Brunton a, *, Rachel Dryer b
a
Charles Sturt University, Bathurst, NSW, 2795, Australia
b
Australian Catholic University, Strathfield, NSW, 2135, Australia

A R T I C L E I N F O A B S T R A C T

Keywords: Rationale: Sexual violence (SV) is associated with adverse psychosocial and behavioural outcomes with revic­
Sexual assault timization likely. However, there are significant gaps in the current literature in regard to (a) whether over time
Sexual violence women’s levels of distress/behaviour change, and (b) whether social support mediates the relationship between
Rape
SV and adverse outcomes.
Child abuse
Intimate partner violence
Methods and results: This study aimed to address these two issues by analysing data from the Australian Longi­
Mental health tudinal Women’s Health Survey, surveys 4 (2006) to 8 (2018). Using repeated-measures data analytic procedures
Substance abuse we found that women who had suffered SV, in comparison to women with no SV history, had greater anxiety,
depression, stress, a lower mental health-related quality of life and less life satisfaction. Moreover, their level of
distress remained higher at all time points, in comparison to the other group. Women with a SV history were also
more likely to suffer re-victimization, consume more cigarettes and illicit drugs than other women. Moreover, SV
predicted all psychosocial outcomes (except life satisfaction) 12 years later, with social support mediating these
relationships. SV predicted drug status; however social support did not mediate this relationship.
Conclusions: These findings suggest that for women who have experienced SV their distress levels remain
elevated. The findings also provide additional insights into the long-term impact of SV in Australian women with
social support being identified as a resource that may assist in reducing some of the negative psychological
outcomes associated with SV.

1. Introduction
There is growing global recognition of the high cost of violence
against women and children (WHO, 2017), including sexual violence
(SV), which broadly defines any sexual act perpetrated against a per­
son’s will (Cox, 2015). SV subsumes a range of behaviors including child
sexual abuse, adult sexual assault and any type of sexual coercion where
the perpetrators may be either known or unknown to the victim (AIHW,
2019). Globally one in three women are thought to have been affected
by physical or sexual violence within an intimate relationship (WHO,
2017) however estimates are likely conservative for reasons such as
women not perceiving these acts as violence because they have occurred
within a relationship, or issues around disclosure such as feeling they
may not be believed or supported (Itzin et al., 2010). The occurrence of
SV in the community carries both a direct financial impact in the form of
increased healthcare and social services to address this issue, as well as
indirect costs that come from the ongoing physical and psychological
consequences that many victims suffer (Walsh et al., 2012). The esti­
mated cost of both physical and sexual violence in Australia exceeded
ten billion dollars in 2016 (KPMG, 2016). Therefore, it is important to
understand the sequelae of SV for women to develop appropriate and
effective support resources and intervention/treatment programs that
have both health-related and economic benefits.
Child sexual abuse is a form of SV and the associated trauma of this
abuse with adverse psychiatric outcomes is well-established (see Hill­
berg et al., 2011 for a review). Numerous reviews, meta-analyses and
reviews of reviews confirm that for many survivors of child sexual abuse
their likelihood of adult psychopathology is high (Maniglio, 2010, 2013;
Putnam, 2003). The longer term influence of adverse childhood expe­
riences (i.e., physical, sexual, psychological abuse and neglect) was
examined by Coe et al. (2021). These researchers found that mothers
with experiences of intimate partner violence (IPV) endorsed greater
prenatal depressive symptom and this was moderated by the woman’s
adverse childhood experiences. Prenatal depression can lead to less

* Corresponding author. School of Psychology, Building 1400, Charles Sturt University, Panorama Avenue, Bathurst, NSW, 2795, Australia.
E-mail address: rbrunton@csu.edu.au (R. Brunton).

https://doi.org/10.1016/j.socscimed.2021.114334
Received 15 December 2020; Received in revised form 27 July 2021; Accepted 19 August 2021
Available online 20 August 2021
0277-9536/© 2021 Elsevier Ltd. All rights reserved.
R. Brunton and R. Dryer
sensitive parenting behavior and concerningly this is an early indicator
of child maltreatment, suggesting child abuse may be a risk factor for
IPV and maltreatment of the children of mothers with experiences of
abuse. SV experienced as an adult (either by known or unknown per­
petrators) has also been associated with adverse outcomes. One
Australian study of 230 women from a general medical practice (M age
= 51.1, SD = 16.4), found that women who experienced adult SV (e.g.,
unwanted sexual acts and coercion experienced in the last year) had
higher levels of anxiety and depression than other women. This finding
remained even after adjusting for age and the occurrence of child sexual
abuse (Tarzia et al., 2017). Similarly, Pico-Alfonso et al. (2006) exam­
ined a community sample of 182 Spanish women and found that those
who suffered intimate partner sexual abuse had higher depression scores
and more suicide attempts than women with no history of this type of
abuse.
In contrast, literature reviews that have sought to synthesize research
findings for adult SV have resulted in inconsistent conclusions regarding
the longer-term sequelae of SV. One early review by Steketee and Foa
(1987), reported that while social and sexual functioning were signifi­
cantly impacted immediately after SV (i.e., victims of rape), most
women return to pre-assault levels of anxiety and depression within 12
months. In contrast, a more recent systematic and meta-analytic review
conducted by Dworkin et al. (2017) found the effect of SV (search terms
included sexual assault, rape, sexual victimization) on psychopathology
to be relatively durable across time. Inconsistencies in these findings
may be related to the reviews containing both cross-sectional and lon­
gitudinal studies. While causality is implied based on the temporal order
of the SV and these outcomes, longitudinal data are needed for this
conclusion to be stated with certainty.
The findings from subsequent studies on this issue have done little to
clarify the issue of stability and durability of psychopathology after SV.
However, they do identify a number of factors that may contribute to the
maintenance of distress and poorer psychosocial functioning. Shin et al.
(2020) examined PTSD symptomology of 94 female survivors of sexual
assault (M = 24.78, SD = 6.89) perpetrated by either a stranger or
partner. Women were assessed directly after the assault and one month
later and based on their PTSD scores were classified as high distress or
low distress. While the highly distressed women showed a decrease in
symptom severity, the low distress women did not show significant
changes in their symptoms. Negative thoughts and beliefs about the SV
were found to be strongly correlated with PTSD symptoms in both
groups which led these researchers to suggest that post-trauma cogni­
tions may play a significant role in the maintenance of psychopathology.
By comparison, Chang et al. (2020) examined negative psychological
outcomes in 151 female college students (M = 20.23, SD = 1.63). For
these women sexual assault victimization (i.e., verbal, unwanted
touching, attempted and completed penetration) was a stronger pre­
dictor of adverse outcomes (e.g., anxiety and alcohol use) whereas
negative life events (e.g., financial problems, death of a loved one), was
a stronger predictor of negative psychological outcomes such as lower
life satisfaction. Similarly, Jamison et al. (2021) found that more
frequent IPV experiences were associated with depressive symptomol­
ogy in their cross sectional study of 112 women (M = 32.26, SD = 5.84).
In this sample, 60% of the women reported sexual IPV in the last 6
months.
Not surprisingly, survivors of SV have also been reported to engage
in greater substance use/abuse (i.e., alcohol, cigarettes, and drugs) and
have a higher incidence of dependence or substance abuse disorders
than other individuals. Support for this relationship comes from studies
that have focused on specific populations such as Indigenous peoples,
incarcerated women or certain socio-economic groups (e.g., Bohn, 2002
examined lifetime and current sexual abuse; Libby, 2005 examined
childhood sexual abuse). While a consensus exists that child sexual
abuse (a form of SV) is a risk factor for substance abuse (see Halpern
et al., 2018; Simpson and Miller, 2002 for reviews), few studies have
examined the longitudinal effects of any form of SV. Also, and
2
Social Science & Medicine 292 (2022) 114334
importantly, the pattern of substance use is less considered, which is
important in assessing changes over time.
Increased alcohol consumption can be a consequence of SV (see
Devries et al., 2014 for a review). Messman-Moore and Long (2003)
propose that alcohol and drugs are used to reduce negative feelings,
forget the abuse, or avoid abuse-specific memories and affective re­
sponses. Longitudinal studies have confirmed this cause-and-effect
relationship. A two-year study of 4009 women examined violent as­
sault (physical and sexual) and alcohol and illicit drug abuse, and found
that assault led to increased odds for alcohol abuse and drug use (Kil­
patrick et al., 1997). Hedtke et al. (2008) examined substance use and
interpersonal violence by interviewing 4008 women annually, over 3
years about their lifetime history of interpersonal violence (sexual and
physical assault and witnessing violence), and mental health and sub­
stance use. For women who with a SV history, past year substance abuse
problems (alcohol and non-experimental drugs), were predictive of
substance abuse problems during the first year of the study (OR = 1.64)
but not predictive of substance abuse in the third year of the study,
relative to no history of SV. While these findings suggest that the risk of
substance use problems may not remain stable over time, few studies
have directly examined whether the risk for substance use increases or
decreases over time.
While the pattern of risk for substance use is unclear, what is well
established is that the risk of revictimization of women with past sexual
abuse experience is high. Up to 70% of child sexual abuse survivors are
sexually victimized in adulthood (see Classen et al., 2005 for a review;
Elliott et al., 2004). Concerningly, the risk for revictimization is also
present for women who have no past child sexual abuse but who expe­
rience sexual victimization in adulthood (Classen et al., 2005). Several
theories seek to explain this vulnerability (e.g., situational and person­
ality variables, see Breitenbecher (2001) for a review) with social
learning theories having good empirical support for explaining child
sexual abuse and later revictimization (Cochran et al., 2011). For sur­
vivors of child sexual abuse, learning theories propose that abuse
modelled in childhood may normalize the behavior leading to increased
acceptance of abuse in later adult relationships. Evidence around adult
victimization and revictimization is less compelling likely due to the
complexity of this issue. That is, the risk of revictimization may be
related to various factors such as when the assault occurred or rela­
tionship to the perpetrator (see Classen et al., 2005 for a review).
Notwithstanding, learning theories may also account for why some
women do not perceive sexual violence within an intimate partner
relationship as such, which further increases their risk of revictimization
(Cox, 2015).
However not all studies are unanimous in their conclusions
regarding SV and deleterious outcomes. Bensley et al. (2003) surveyed
3527 women (18–46 years) but did not find any relationship between
child sexual abuse and recent IPV. Others have similarly noted that some
adults sexually abused in childhood do not exhibit later psychopathol­
ogy. In one study, children around 10 years of age were interviewed and
again as adults. Approximately 50% of children who had been previ­
ously abused in childhood reported no psychopathology. Moreover,
these survivors had significantly better psychosocial functioning than
other adults who had not been abused and had no self-reported psy­
chiatric problems (Collishaw et al., 2007). The authors proposed that
some of these individuals may have a certain resilience that is linked to
quality relationships with parents, friends, and partners. In other words,
social support may mediate the relationship between sexual abuse and
psychological well-being.
This proposition is supported by studies such as the one conducted by
Littleton (2010) who noted that lower levels of social support predicted
post-sexual-assault psychopathology such as PTSD and depressive
symptomology. Littleton argued that social support may play an
important role in post-assault recovery by contributing to preserving
self-worth. Consistent with this finding, Brinker and Cheruvu (2017)
using data from a large telephone survey conducted in 2010 across five
R. Brunton and R. Dryer Social Science & Medicine 292 (2022) 114334

US states (N = 12,487), found that both perceived emotional and social Table 2
support (support characterized by empathy and love) mediated the Sample demographics, N = 9145.
relationship between adverse childhood experiences and adult Ageb M = 30.61 (1.46), range = 26–35a
depression. c
Marital status
Never married 2174 (23.77%)
1.1. The current study Married/Defacto (opposite-sex) 4870 (53.25%)
Defacto (same sex) 1648 (18.02%)
Separated/divorced/widowed 390 (4.26%)
The current study addressed some of the gaps in the literature by Household income d
examining the relationship between SV and psychosocial wellbeing (i.e., $1 - $699 ($1-$36,999 pa) 662 (7.24%)
anxiety, depression, stress, life satisfaction, mental health, and revic­ $700 - $1499 pw ($37,000 - $77,999 pa) 2595 (28.38%)
$1500 or more pw ($78,000 or more pa) 3628 (39.67%)
timization), and behavioral variables (alcohol consumption, smoking,
Other 1604 (17.54%)
illicit drug use) in a longitudinal data set involving five date collection ARIAþ e
timepoints over a period of 12 years (i.e., 2006 to 2018). We examined Major cities 6150 (67.25%)
the following three hypotheses: 1) women with a history of SV were Inner regional 1687 (18.45%)
expected to have more adverse psychosocial outcomes than women with Outer regional 905 (9.90%)
Remote 170 (1.86%)
no history of SV, 2) women with a history of SV would have a higher Very remote 71 (0.78%)
alcohol consumption, consume more cigarettes, and take more illicit SEIFA f 1016.85 (86.46), range =
drugs than women with no SV history, and 3) a history of SV would 556.51–1251.87
predict adverse psychological and behavioral outcomes mediated by Education g
No formal qualifications 70 (0.77%)
perceived social support. Lastly, no specific hypotheses are offered for
School certificate (year 10 or equivalent) 581 (6.36%)
the level of distress or behavior over time as these will be exploratory. Higher school certificate (year 12 or 1329 (14.53%)
equivalent)
2. Methods Trade/apprenticeship (e.g., hairdresser, 248 (2.71%)
chef)
Certificate diploma (e.g., technician) 2139 (23.39%)
2.1. Participants University degree 3134 (34.27%)
Higher university degree (Masters PhD) 1590 (17.39%)
Data for this study are from the 1973–78 cohort from the Australian
Note. Unless otherwise noted, demographics are from survey 4. b = age range
Longitudinal Women’s Health Survey (ALWHS). The ALWHS initially differs to Table 1 due to missing data. Missing data: b = 21 (0.23%), c = 63
sampled women from the Medicare insurance database from urban, (0.69%), d = 656 (7.17%), e = 140 (1.53%) f = 291 (3.18%), g = 54 (0.59%).
rural and remote zones (see Brown et al. (1998) for recruitment, attri­ Household income is the gross income of families including partners or parents
tion and participant details). This study utilized surveys obtained at in a household; Other = those who did not wish to answer or had no income/
timepoints 4 (2006) to 8 (2018) as they used the same measures in each lives alone.
survey. Table 1 provides details the response rates for these surveys.
Subsequent analysis has confirmed that despite attrition the sample is
still broadly representative of the same demographic in the Australian Table 3
population for making inferences despite some over representation of Women who experienced sexual violence, surveys 4 to 8.
women with tertiary education (Brown et al., 1998; Powers and Loxton, Survey Last 12 months More than 12 months ago
2010). Yes No Yes No
Table 2 shows the sample demographics from survey 4. In this
4 (2006)a 73 (0.8) 9055 (99.0) 581(6.4) 8547 (93.5)
sample most women were partnered, employed, and had a good edu­ 5 (2009) b 71 (0.9) 7626 (93.0) 484 (5.9) 7213 (88.0)
cation. The Accessibility and Remoteness Index of Australia (ARIA+) 6 (2012) c 55 (0.7) 7698 (96.1) 559 (7.0) 7194 (89.8)
and the Socio-Economic Indexes for Areas (SEIFA) indicated that women 7 (2015) d 54 (0.8) 7008 (97.5) 471 (6.6) 6591 (91.7)
were mostly from major cities and on average had good economic 8 (2018) e 72 (1.0) 6910 (97.0) 551 (7.7) 6431 (92.1)

resources. Note. Missing a = 17, b = 120, c = 256, d = 124, e = 139. Percentages in

Statistics on sexual victimization appear in Table 3. In each year parentheses.
nearly 1% of the sample reported recent SV and around 6–8% reported
SV more than 12 months prior to the survey. These figures are below possible and further assesses the psychometrics of the scales within the
national estimates of 18% for women who experienced SV since the age study. For further details on the scales and treatment of missing data see
of 15 years (Cox, 2015). Our lower prevalence is likely due to our survey https://www.alswh.org.au/for-researchers/data. All measures in this
only considering occurrence whereas national estimates include occur­ study were obtained in Survey 4 to Survey 8.
rence, attempt, and threat.
2.2.1. Psychosocial variables
2.2. Materials Anxiety. Anxiety was assessed by the 9-item subscale from the
Goldberg Anxiety and Depression Inventory (GADS, Goldberg et al.,
The ALWHS uses scales with published psychometric data where 1988). Items such as “Have you been irritable,” are scored dichoto­
mously 1 (yes) and 0 (no). Scores range from 0 to 9 with higher scored
indicating greater anxiety.
Table 1
Response and attrition surveys 4 to 8. Depression. Depression was assessed by the 10-item Center for
Epidemiologic Studies Depression Scale–Shortened Version (CES-D,
Survey Year Age N Response rate
Andresen et al., 1994). Participants rate their feelings over the past week
4 2006 28–33 9145 64% from 0 (rarely or none of the time) to 3 (most or all of the time) to items such
5 2009 31–36 8199 58%
as “I felt fearful.” Scores range from 0 to 30 with higher scores indicating
6 2012 34–39 8009 56%
7 2015 37–42 7186 50% greater distress.
8 2018 40–45 7121 50% Stress. Stress was assessed by the 14-item Perceived Stress Scale
Stress (PSS, Bell and Lee, 2002) which covers domains such as health,
Note. Survey 1 (1996) N = 14,247.

3
R. Brunton and R. Dryer
work/employment, money, and relationships. Psychometric analysis
after survey 1 (1996) resulted in redundant items such as “relationships
with boyfriends” being removed. Other items were revised for inclu­
siveness (i.e., ‘boyfriends’ changed to ‘friends’). For all surveys, re­
sponses were rated as 0 (not applicable, not at all stressed) to 4 (extremely
stressed). Scores range from 0 to 56 with higher scores indicative of
greater stress.
Mental Health Index. The SF-36 (Ware et al., 1993) is a 36-item
survey measuring health-related quality-of-life. This study utilized the
mental health index which includes items such as “Have you been a very
nervous person?” rated from, 1 (all of the time) to 6 (none of the time).
Scores are transformed into an index score ranging from 0 to 100 with
higher scores representing greater mental health-related quality of life.
Intimate Partner Violence. The 28-item revised Composite Abuse
Scale assessed IPV (Loxton et al., 2013). The scale has three factors:
emotional (13-items, e.g., told me I was stupid), physical (10-items, e.g.,
beat me up), harassment (4-items, e.g., harassed me at work) and a
single item that indicates SV (“forced me to take part in unwanted sexual
activity”) that was not used in this study. For survey 4 the three sub­
scales were scored on 6 response options, reflecting the frequency of the
experience (never to daily), higher scores indicate greater frequency. For
survey 8, responses were scored dichotomously as 1 = yes and 0 = no.
For both surveys an additional response of 8 indicated never had a
partner/spouse and these respondents were excluded from any analyses
for this variable. The scale has good reliability and validity as reported in
Loxton et al. (2013).
Sexual Violence. One question assessed a history of sexual violence
and was asked under the Life Events section (i.e., being forced to take
part in any unwanted sexual activity). This question was scored
dichotomously (1 = yes, 2 = no) for two time periods (in the last 12
months and more than 12 months ago).
Life Satisfaction. This 8-item scale was custom developed for the
ALWHS. A single question asks participants how satisfied they are in
their achievements in certain aspects of their life (e.g. work, career,
study). Responses are scored from 1 (very satisfied) to 4 (very dissatisfied).
Scores range from 8 to 24 with higher scores representing greater life
satisfaction.
Social Support. The abbreviated 6-item version of the Medical Out­
comes Study Social Support Index (MOS, Sherbourne and Stewart, 1991)
was used. The MOS provides a measure of social support (i.e., the degree
to which interpersonal relationships serve functions) with the brief
version comprised of 2 items from each MOS subscale (emotiona­
l/informational support, tangible support, affectionate support, positive
social interaction). Responses are coded from 1 (none of the time) to 5 (all
of the time) to items following a stem question “How often is the
following support available to you if you need it?” Items are summed to
obtain a total score that can range from 6 to 30. Higher scores indicate
greater social support.
2.2.2. Behavioral variables
Demographics. Variables from survey 4 provided an overall picture
of the sample including age, employment, marital status, rurality, in­
come, education, and country of birth. The ARIA+ variable provided an
indication of location with categories of, major cities, inner regional,
outer regional, remote, and very remote. The SEIFA index of economic
resources ranges from 245 to 1281 and is an index of financial aspects of
relative socio-economic advantage and disadvantage including high/
low income and variables correlating with high/low wealth. Areas with
higher scores have relatively greater access to economic resources than
areas with lower scores.
Alcohol. Alcohol consumption was determined using three fre­
quency questions (e.g., “How often do you usually drink alcohol?”) rated
from I never drink alcohol to every day, and one quantity question (“…
how many standard drinks do you usually have?”). Responses range from 1
or 2 drinks per day to 9 or more. This study used the National Health and
Medical Research Council guidelines and assigned ordinal categories, 1)
4
Social Science & Medicine 292 (2022) 114334
non-drinker, 2) rarely drinks, 3) low long-term risk, ≤ 2 drinks per day,
4) risky, 3–4 drinks per day, 5), high risk, > 5 drinks per day.
Smoking. Smoking status was determined by two questions related
to frequency (e.g., “How often do you currently smoke cigarettes or any
tobacco products”). Responses ranged from daily to not at all. Using the
Australian Institute of Health and Welfare guidelines, five categories of
smoking status were derived, 1) never smoker, 2) ex-smoker, 3) irregular
smoker, 4) weekly smoker, 5) daily smoker.
Drug use. A history of the pattern of non-medical drug usage was
determined by questions related to ten commonly used drugs (i.e.,
marijuana, amphetamines, LSD, natural hallucinogens, tranquilizers,
cocaine, ecstasy, inhalants, heroin, or barbiturates). For this study they
were categorized as 1) Never used, 2) only ever used Marijuana but not in
last 12mths, 3) used multiple/single drug other than Marijuana but not in the
last 12mths, 4) only used Marijuana in the last 12mths, and 5) used mul­
tiple/single drug other than Marijuana more than 12mths.
2.3. Statistical analyses
This repeated-measures study examined SV group status over five
time periods. Women were included in the SV group if they indicated
they had suffered SV either in the last 12 months or more than 12
months ago in any of the five surveys. Women were allocated to the no
SV group if they indicated they had never suffered SV in any survey. All
analyses were weighted by area to account for the deliberate over­
sampling of rural and remote areas.
Using data from Survey 4, Spearman’s Rho correlations were
calculated between all psychosocial (i.e., anxiety, depression, stress,
mental-health index, IPV [emotional, physical and harassment], life
satisfaction, social support), behavioral (i.e., alcohol, smoking, drugs)
and demographic (i.e., marital status, education, income) variables to
identify covariates and assess multicollinearity between the dependent
variables.
SV and no SV group differences for the psychosocial and behavioral
variables were determined using Repeat Measures Factorial Multivariate
Analysis of Variance (MANOVA). All assumptions pertaining to
normality, homogeneity of covariance, homoscedasticity of residuals,
linearity, multivariate outliers and multicollinearity were assessed using
multiple measures as prescribed by Field (2013).
For the Repeat Measures Factorial MANOVA all individual scores for
the relevant variables were transformed into Percent of Maximum
Possible (POMP) scores. POMP scores provide a standardized measure­
ment of the different scales and enables more direct comparisons to be
evident. Given that the dependent variables all use different scoring
conventions this transformation provided a meaningful way to
communicate the magnitude of the observed relationships. Using POMP,
individual scores are converted to a percentage of the maximum possible
score of the scale. Given that this is a linear transformation of the scores
it does not change the output (i.e., test statistics). Cohen et al. (1999)
provides a detailed explanation of POMP.
Mediation analysis was conducted using Hayes (2013) PROCESS
macro (v3.4). The sample size satisfied the required ratio of cases to
predictors. Eleven mediation models (see Fig. 1) examined SV history at
survey 4 as a predictor (X) of the eight psychosocial and three behavioral
outcomes (Y) at survey 8. Social support (M) (average support across the
five time periods) was included as a mediator in all models. All relevant
outcome variables from Survey 4 and any identified covariates (C) were
controlled for in all mediation models (e.g., when examining anxiety as
an outcome from survey 8, anxiety from survey 4 was controlled). Given
the design of the models (examining SV from survey 4 and outcomes
from survey 8), it was not possible to examine any revictimization that
occurred in surveys 5–7.
3. Results
Spearman’s Rho correlations between the demographic (age
R. Brunton and R. Dryer Social Science & Medicine 292 (2022) 114334

Table 4
Psychosocial variables, between group differences.
Sexual violence history No sexual violence history

Measure Mean (SE) 95% CI Mean (SE) 95% CI

Anxiety 54.86 (.79) 53.31–56.41 43.52 (.57) 42.41–44.63

**** ****
Depression 26.52 (.47) 25.60–27.43 18.82 (.34) 18.16–19.48
**** ****
Stress 25.15 (.35) 24.46–25.84 19.35 (.25) 18.86–19.85
**** ****
Mental health 68.33 (.43) 67.47–69.17 74.01 (.31) 73.40–74.62
Index **** ****
Life satisfaction 72.88 (.42) 72.05–73.71 77.68 (.30) 77.08–78.28
**** ****
Fig. 1. Mediation model.
Note. POMP scores used. SE = standard error, CI = confidence intervals. Sig­
nificance denoted as ****p < .0001.
excluded given the restricted range) and the study variables (survey 4)
were all small with most between r = -0.15 and 0.15 and statistically
significant (likely due to the sample size). One exception was IPV and with a subsequent improvement.
marital status (rs 0.38-0.50, p < .001) but this was to be expected
therefore no covariates were included in the analyses. Multicollinearity 3.1.2. Behavioral variables
was not evident as no dependent variables had correlations > r = 0.80 Using the same equal groups, both between and within-subject ef­
(Field, 2013). fects were examined over the same five time periods for the categorical
outcomes (examined as ordinal scales) of alcohol consumption, smoking
and drug use. The overall model was significant for both between sub­
3.1. Repeat Measures Factorial MANOVA
ject, F(3, 2527) = 45.26, p < .0001, partial ή2 = 0.05 and within subject
F(12, 2518) = 31.08, p < .0001, partial ή2 = 0.13 differences indicating
3.1.1. Psychological variables
that both groups differed on these outcomes and also over time. Pair-
Both between and within-subject effects were examined by SV status
wise comparisons are reported in Table 5 for between groups. As
and time (2006–2018), for the continuous outcome measures of anxiety,
shown only alcohol consumption did not significantly differ between
depression, stress, mental-health index, and life satisfaction. A signifi­
groups (p = .21).
cant Box’s M test (p < .0001) indicated that the assumption of homo­
There was a significant within-subjects interaction observed between
geneity of covariance could not be assumed and this was further
time and SV status F(12, 2518) = 2.34, p = .006, ή2 = 0.01. The
confirmed by the observable variances in the covariance matrix
assumption of sphericity was again violated, and the Bonferroni
(Tabachnick and Fidell, 2001). Therefore, two equal SV/no SV groups
adjustment was applied and Greenhouse-Geisser statistic used to assess
were created. This was done by allocating all 1740 participants who had
the interactions. All three dependent variables showed a significant time
a history of SV in survey 4 into one group and randomly sampling 1740
by SV status interaction with alcohol consumption showing a cross over
participants from the 3853 women who indicated they had not suffered
interaction in the absence of a main effect (alcohol, F(3.70) 2.64, p =
any SV into the second group. As recommended by Field (2013),
.04, partial ή2 = 0.01; smoking F(3.16) 2.77, p = .04, partial ή2 = 0.01;
Hotelling’s Trace statistic was used given that it is robust to violations of
drugs F(3.49), 3.29, p = .01. partial ή2 = 0.01). Supplementary Table S2
this assumption when equal groups are used. This approach also satis­
contains the pairwise comparisons.
fied the assumptions of independence and random sampling.
Fig. 3 depicts the three behavioral variables across the five time
The overall model was significant for both between-subject, F(5,
periods. Of note is the increase in alcohol consumption for the women in
2418) = 45.61, p < .0001, partial ή2 = 0.09 and within-subject F(20,
the no-SV group from 2006 (Time 3) onwards with a cross over inter­
2403) = 35.78, p < .0001, partial ή2 = 0.23 differences indicating that
action between time 4 and 5. For both groups their consumption of
women with an SV history had greater anxiety, depression, stress, and
cigarettes decreased, and illicit drug use followed a similar downward
lower mental health index and life satisfaction. Within group difference
trend over time.
indicated that the levels of these outcomes measures differed over time
but there was no significant time by SV status interaction, F(20, 2403) =
0.95, p = .52 (note that the differences in group sizes are due to missing 3.2. Mediation models
data on some variables with pair wise deletion used). A significant
Mauchly’s Test for all dependent variables indicated that the assumption Table 6 presents the results from the eleven mediation analyses.
of sphericity was not met therefore a Bonferroni adjusted significance Apart from life satisfaction, a history of SV significantly predicted all
level of p = 01 was used for all group comparisons (Field, 2013). anxiety, depression, stress, mental health and revictimization
Comparisons are presented in Table 4. (emotional, physical and harassment) with social support mediating
There was also significant variability across time. Supplementary these relationships (consistent with Hayes (2013) we make no distinc­
Table S1 presents the within groups differences between time 1 (2006) tion between full and partial mediation). For the behavioral variables, a
and each other time point (2009–2018) and between group differences history of SV significantly predicted drug use, but social support did not
for each time point and variable. Despite no significant interaction, the mediate this relationship. For alcohol and smoking the results were not
means for each group across time are reported to show trends. statistically significant.
Fig. 2 graphically depicts the SV groups and psychosocial variables
across the five time periods. For all variables, both groups had a marked 4. Discussion
decrease in depression, anxiety, and stress from 2012 (time 3) and an
upward trend thereafter. Similarly, the mental health index was rela­ This study examined the psychosocial and behavioral correlates of
tively stable until 2012 (time 3) and then showed a downward trajectory SV and their sequelae over time. As expected, women who had experi­
indicating that for both groups their mental health-related quality of life, enced SV had greater anxiety, depression, stress, and a lower mental
while stable from 2006 to 2012 then decreased. There was also a sig­ health index and less life satisfaction. As expected, women with a history
nificant decrease in life satisfaction for both groups from 2006 to 2009 of SV had a higher consumption of alcohol, consumed more cigarettes,

5
R. Brunton and R. Dryer
Fig. 2. Psychosocial variables.
Note. For all figures the dashed line indicates the SV ‘yes’ group and the solid line indicates to SV ‘no’ group. All scores are estimated marginal means.
and used more illicit drugs than other women. We also determined that
for women who had experienced SV their level of distress remained
higher over time than other women however, this distress followed the
same pattern as women with no SV history. Our expectation that SV
would predict adverse psychosocial and behavioral outcomes was sup­
ported except for life satisfaction, alcohol consumption and smoking.
Further, for anxiety, depression, stress, and the mental health index,
social support mediated these relationships. The findings of this study
contribute, the literature by firmer conclusions able, be drawn regarding
6
Social Science & Medicine 292 (2022) 114334
the causality of SV and these outcomes.
Our findings that women with a SV history had greater distress than
other women is consistent with studies into the longer term effect of
child sexual abuse and sexual violence in adulthood, such as Pico-Al­
fonso et al. (2006) who examined lifetime sexual IPV (child sexual abuse
and adulthood victimization) and Tarzia et al. (2017) study of any type
of SV in the past 12 months. A significant finding was that a woman’s
level of distress (i.e., anxiety, depression, and stress) was not influenced
by time. That is, for women who had experienced SV their post-assault
R. Brunton and R. Dryer Social Science & Medicine 292 (2022) 114334

Table 5 Of interest was the notable decrease, for both groups, in life satis­
Behavioral variables, between group differences. faction in 2009 (time 2) and the distress measures and mental health
Sexual violence history No sexual violence history index in 2012 (time 3). These ‘dips’ in the trend are consistent with the
cohort’s developmental life stage which would include key milestones
Measure Mean (SE) 95% CI Mean (SE) 95% CI
such as childbirth, and the transition from young, older adulthood. Both
Alcohol 41.04 (.54) 39.98–42.11 40.20 (.39) 39.43–40.97 milestones are linked, mood disorders and lower life satisfaction (Lee,
Smoking 23.11 (.88) **** 21.39–24.83 14.04 (.63) **** 12.80–15.29
Drug use 35.61 (.89) **** 33.85–37.36 23.82 (.65) **** 22.56–25.08
2020; Qu and de Vaus, 2015). While these life stages offer a possible
explanation of these decreases, what is important, note is that while
Note. POMP scores used. SE = standard error, CI = confidence intervals. Sig­ women with a history of SV retain their post-assault levels of distress, it
nificance denoted as, *p < .05, ****p < .0001.
can be influenced by individual variables suggesting that positive in­
terventions may reduce these adverse effects.
distress remained consistently higher than other women. The longitu­ One such intervention is social support. Mediation analyses
dinal data analyzed for this study did not include pre-assault measures of confirmed that SV predicted anxiety, depression, stress, and mental
distress (and therefore it was not possible, directly examine whether health-related quality of life, and that this relationship was mediated by
women with SV experience returned, pre-assault levels of psychosocial social support. Of note was the stronger effects obtained for depression
functioning), however, our findings suggest that these women did not and the mental health index, indicating that for many women who have
return, pre-assault levels within 12 months as has previously been sug­ been victims of SV they will likely have greater psychopathology if they
gested in the literature (Steketee and Foa, 1987). Moreover, despite have lower levels of perceived social support. This is consistent with the
significant differences between the groups in levels of distress, both stress buffering hypothesis, which suggests that for these women,
groups showed a similar pattern of change over time akin, trends in the ensuring they have the necessary support either formally (agencies) or
general population (from 2001, 2018 mood disorders/issues increased informally (friends/family) is integral, their well-being. The non-
by 1%, ABS, 2018). It should be noted that given the issues around significant findings for life satisfaction were unexpected and poten­
self-report (e.g., accuracy of responding Gravetter and Forzano, 2016) tially reflects the diversity of areas which were included in the measure
and that these outcomes were not diagnosed clinically, we make no used, assess their judgement of quality of life. It is possible that for these
distinction about clinical levels of anxiety or depression but rather women while their wellbeing may have been lower in some areas (i.e.,
examine these outcomes as they pertain, significant between group career/study), their global assessment showed more life satisfaction
differences. (Diener et al., 1985).

Fig. 3. Trends in alcohol, smoking and drug status across time.

Note. For all figures the dashed line indicates the SV ‘yes’ group and the solid line indicates to SV ‘no’ group. All scores are estimated marginal means.

7
R. Brunton and R. Dryer Social Science & Medicine 292 (2022) 114334

Table 6 knowledge of health relationships were exploited by perpetrators and

Total and indirect effect of sexual violence on psychosocial and behavioral led, later victimization (Tarzia, 2020). This suggests that perpetrator
variables. variables play a role in adult victimization and revictimization.
Total effect (path c) Indirect effect (path ab) Important, breaking this cycle of violence is perceived social support.
IV →DV R2 IV →DV 95% CI
Our findings confirm that greater social support reduces the risk of
revictimization consistent with Dias et al. (2019). Therefore, the
Psychosocial variables
importance of social support for women who have experienced SV as an
Anxiety 0.50 (.15) *** .23 0.15 (.03) 0.09, 0.21
Depression 1.54 (.30) **** .23 0.43 (.09) 0.26, 0.63 intervention against further revictimization cannot be underestimated.
Stress 0.10 (.03) *** .25 0.03 (.01) 0.02, 0.05 All types of social support (i.e., structural, functional or satisfaction) are
Life satisfaction − 0.05 (.03) .18 − 0.04 (.01) − 0.06, − 0.02 associated with a positive change in IPV victims (Zapor et al., 2018)
Mental health − 4.23 (.92) **** .21 − 1.30 (.24) − 1.75, − 0.83 including improved self-efficacy in help-seeking, leaving the abusive
IPV Emotional 3.55 (.33) **** .16 0.54 (.11) 0.35, 0.76
IPV Physical 2.43 (.22) **** .15 0.25 (.06) 0.15, 0.38
relationship and greater disclosure.
IPV Harassment 1.35 (.13) **** .10 0.16 (.03) 0.10, 0.23 Our findings in relation, the alcohol consumption showed that
Behavioral variables despite no significant differences in consumption between groups, over
Alcohol risk of harm − 0.04 (.04) .29 − 0.03 (.01) − 0.04, − 0.01 time SV status contributes, changes in these behaviors. That is, while
Smoking status 0.05 (.04) .57 0.01 (.01) 0.01, 0.02
both groups of women did not show a significant increase in consump­
Drug status 0.11 (.05) ** .53 0.01 (.01) − 0.01, 0.02
tion over the time periods examined, women with no SV history had a
Note. Predictor (IV) = sexual violence, outcome (DVs) = psychosocial and sharper increase in consumption over time. Notwithstanding this, these
behavioral variables as shown. IPV = intimate partner violence. Analysis based findings should be cautiously interpreted given that both groups of
on 1000 bootstrap resamples. The sample size for each model varied due,
women were in the ‘rarely drinks’, ‘low long-term risk’ categories. What
missing data but ranged from 3771 to 4631. Statistical significance donated as
is important, note is that for these women their level of consumption was
****p < .0001, ***p < .001, **p < .01. Standard error reported in parentheses.
low and for most, this may indicate a level of consumption consistent
with self-medicating.
Social support as an intervention for IPV has good empirical support.
In comparison, for smoking and drug use, both groups decreased
A recent scoping review that examined IPV interventions focused on
their usage over time with the women who had experienced SV showing
improving social support found that these were linked, improved mental
a greater decrease across time. Again, the same caution is warranted in
health outcomes. Social support, in this review, was classified as advo­
interpretation. That is, for smoking, both groups were in the low range
cacy (trained professionals providing supportive relationships and re­
(e.g., non-smoker, ex-smoker) consistent with population trends, ward a
sources), advocacy with psychotherapy, and community-based social
decline in smoking. However, our results for smoking, that show higher
support interventions. These community-based interventions aimed,
consumption, are consistent with extant research which posits that
change community attitudes or involved group therapy. All in­
smoking is a stress reliever for women with a history of SV (Jun et al.,
terventions provided support and those with strong community links
2008). While smoking initiation often occurs in adolescence and these
contributed, improved social support for survivors of violence as well as
women’s pre-abuse smoking was not included here, we cannot say with
more positive mental health outcomes (Ogbe et al., 2020).
certainty that SV was a cause of smoking. Regardless smoking is a public
A significant finding of this study was that women with a history of
health issue and recent campaigns aimed, reduce consumptions likely
SV have a greater risk of being revictimized or continually victimized
explain the decrease.
physically, sexually, or psychologically by their intimate partner. While
By comparison, the drug use of both groups were in the lower ranges
this is consistent with extant research (see Breitenbecher, 2001 for a
(never used - not used in the last 12 months) which is inconsistent with
review), examination of specific IPV subtypes (i.e., emotional, physical
population trends of increased drug use (from 2006, 2019 there was a
and harassment) allowed for greater insights about the long-term IPV-­
2.5% increase, AIHW, 2020). The decreased usage however was
related consequences of SV, particularly in terms of emotional abuse. SV
consistent for the age group of these women; this pattern has trended
significantly predicted all three IPV sub-types with emotional abuse the
downward since 2016 (age 35–44, 2.3% decrease for any illicit drugs).
strongest predictor. This indicates that the negative effect of previous SV
The results for substance use were further elucidated in the media­
may create or increase a woman’s vulnerability for later victimization
tion analyses with SV not significantly predicting alcohol consumption
(Messman-Moore and Long, 2003). The finding that this later victimi­
or smoking. SV history was however a significant predictor of drug use,
zation is more likely in the form of emotional abuse is concerning given
but this relationship was not mediated by social support. For our find­
that this form of abuse is a known precursor for later instances of all
ings relating, smoking and drug use, while SV women had significantly
forms of abuse (Karakurt and Silver, 2013).
higher usage the decrease over time was greater compared, women with
Emotional abuse is considered distinct for other forms of IPV (Jun
no SV history. Further, alcohol consumption did not increase signifi­
et al., 2008). Several theoretical perspectives offer explanations for
cantly over time for women with a history of SV. Therefore, despite their
previously victimized women being more vulnerable, emotional abuse.
distress remaining higher than other women they were not using these
These include cognitive attribution theories (i.e., learned helplessness)
substances at a level, or increasing their level of usage, that would be
or traumatic bonding which proposes that women may form intense
considered harmful, them.
emotional bonds with their abusers motivating them, stay in abusive
The modest effect sizes in the mediation models should not detract
relationships (Bandura, 1986; Dutton, 1988). However as yet no one
from the importance of these findings. A key consideration is that these
theory offers an adequate explanation (Messman-Moore and Long,
effect sizes may be indicative of confounding variables such as women
2003) and we propose that this is due, most theories seeking, explain
exposed, trauma having difficulty noticing, reporting and understanding
revictimization by focusing on victim-related variables only (e.g., low
their emotional states which may be related, limited awareness or an
self-esteem, inability, perceive threats). By focusing on victim only
implicit fear of emotions themselves (Goldsmith et al., 2012). The low
variables, one could argue that responsibility for this revictimization is
effect sizes may also indicate that for some women SV is not perceived as
attributed, them while the perpetrator’s motivations/behavior are
such in intimate relationships, and this is a potential issue in accurate
excluded. Perpetrator characteristics such as seeking women they can
measurement (Loxton, 2013).
control should be considered alongside victim vulnerabilities (see
Messman-Moore and Long, 2003 for a helpful framework). Indeed pre­
4.1. Strengths and limitations
viously abused women (physical, sexual or emotional) felt that conse­
quences of the previous abuse such as low self-esteem or poor
This study had several strengths and some limitations. The use of

8
R. Brunton and R. Dryer
longitudinal data over a period of 12 years for a large representative
sample enabled causal inferences, be drawn concerning SV and is a key
strength of this study. The findings however were limited by self-report
with respondents known, under-report their exposure, IPV (Chan, 2011)
thus our estimates are likely conservative. As with all self-report data
caution is needed in interpreting the results. Future studies that assess
SV using interview data would be beneficial, further elucidating these
results. The measure used, assess SV was also limited as it did not
distinguish between child sexual abuse and adult SV. We also did not
control for revictimization of women between the initial survey (4) and
outcome survey (8) nor obtain perpetrator details of the SV. This may
have limited our findings as repeated victimization and perpetrator
characteristics (e.g., known/unknown) may influence mental health
outcomes (see Shin et al., 2020 for example). Also, this study did not
make a distinction between SV suffered in heterosexual relationships or
same-sex relationships and further research that delineates these rela­
tionship types are needed.
5. Conclusion
The findings from this study provide additional insights into the
sequelae of SV in Australian women. The greater psychological distress
women with a history of SV suffer, lower mental-health related quality
of life and less life satisfaction, it would seem, remains constant over
time. Moreover, the experience of SV also places these women at greater
risk of revictimization but the mechanisms that this occurs through are
unclear. Finally, while women with a history of SV partake in more
substance use than other women, their usage is not considered at levels
that are categorized as harmful and does not increase over time. For
these women, the role of social support is critical, their wellbeing. Social
support provides a positive intervention and for some women may break
the cycle of intimate partner violence and/or reduce their level of
distress.
Declaration of competing interest
None declared.
Acknowledgments
The research on which this paper is based was conducted as part of
the Australian Longitudinal Study on Women’s Health by the University
of Queensland and the University of Newcastle. We are grateful to the
Australian Government Department of Health for funding and to the
women who provided the survey data.
Appendix A. Supplementary data
Supplementary data to this article can be found online at https://doi.
org/10.1016/j.socscimed.2021.114334.
Credit roles
Robyn Brunton: Conceptualisation, Methodology, data Formal
analysis and interpretation and writing reviewing, and editing the
manuscript. Rachel Dryer: Conceptualisation, Methodology, data inter­
pretation, reviewing and editing the manuscript.
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