An ecological approach to understanding the impact of sexual violence: a systematic meta-review

Aim A systematic meta-review was conducted to examine (1) the broad range of negative and positive individual and interpersonal changes following adult sexual violence, as well as (2) the risk/protective factors at multiple levels of the social ecology (e.g., individual, assault, and micro/meso/exo/macro/chronosystem factors)—influencing the impact of sexual violence. Methods Searches of Web of Science, Pubmed, and ProQuest resulted in inclusion of 46 systematic reviews or meta-analyses. Review findings were extracted for summary and a deductive thematic analysis was conducted. Results Experiencing sexual violence is associated with many negative individual and sexual difficulties as well as revictimization risk. Only a limited number of reviews reported on interpersonal and positive changes. Factors at multiple levels of the social ecology play a role in the intensity of these changes. Reviews including macrolevel factors were non-existent, however. Conclusion Reviews on sexual violence are fragmented in nature. Although the use of an ecological approach is often lacking, adopting such a perspective in research is necessary for a fuller understanding of the multiple influences on survivor outcomes. Future research should evaluate the occurrence of social and positive changes following sexual violence, as well as the role of macrolevel factors in influencing post-assault outcomes.


Psychological changes
Social changes

Davis et al. (2023)
Survivors report feeling less confidence to refuse unwanted sexual advances, feeling less in control of themselves as a sexual being, feeling guilty about having sex with the perpetrator, feeling disrespected, exploited, upset, fearful, angry

de Souza Mezzavilla et al. (2018)
A greater likelihood of an early start of breastfeeding (OR = 2.38 but only significant in Zambia) and early termination of exclusively breastfeeding (1.68 < OR< 11.11 for Ghana, Liberia and Bangladesh, OR = .40 for Zambia) in survivors compared to nonsurvivors

Diez-Canseco et al. (2022)
Combined prevalence of 26% (prevalence rates range from 5.1% to 67.9%) of survivors of sexual harassment at the workplace who experienced depression, survivors who have experienced sexual harassment at the workplace have 2.69 higher odds (odds ranged between 1.92 to 4.12) of depression compared to employees without harassment experience, having experienced sexual harassment at the workplace is associated with higher depression scores.

Dillon et al. (2013)
Survivors of SIPV show a higher odd of depression (OR = 42.60) than survivors of physical (OR = 10.28) or emotional (OR = 5.83) abuse. SIPV survivors report more suicidal ideation, suicide attempts and lower mental health compared to controls. SIPV and physical abuse are associated with increased suicidal ideation (however, the latter is inconsistent). SIPV survivors report having decreased ability for sexual decision-making and negotiating condom use.
SIPV survivors report lower social functioning compared to controls

Dworkin et al. (2021)
Up to 81.42% of sexual violence survivors suffers from PTSD following the assault

Elderton et al. (2017)
18-80% of survivors experience post-traumatic growth among which lifestyle changes, material gain, enhanced self-efficacy, spirituality as well as changes in beliefs about the world, strength and recovery process from victim to survivor, a change in power (themes from retrieved from quantitative and qualitative analyses) 18-80% of survivors experience post-traumatic growth among which family closeness, community closeness, faith in people and compassion/empathy.

Feldner et al. (2007)
Higher odds of ever smoking (OR = 3.52), currently smoking (OR = 3.4) and nicotine dependence ( Sexual violence is associated with post-traumatic growth, depression, anger, low life satisfaction and PTSD, lower academic satisfaction, disordered eating

Klein et al. (2022)
Sexual violence is associated with suicide attempts, PTSD symptoms, depressive symptoms but not with being a smoker

Kouvelis et al. (2021)
Sexual violence is associated with greater self-perception impairments than not having experienced sexual violence, sexual violence is associated with greater self-perception impairments compared to other trauma-types

Kouyoumdjian et al. (2013)
Survivors report a low self-worth, negative changes regarding sexuality (e.g., increased and decreased sexual frequency), fear of rejecting men among survivors

Langdon et al. (2017)
Sexual violence is associated with alcohol use

Larijani et al. (2015)
No association of dental fear with adult sexual violence, but there was an association with adult sexual and physical violence combined

Lim et al. (2022)
Inconsistent results regarding the association of sexual violence with life satisfaction and mental health, depression and suicide attempts, sexual violence is associated with more risky sexual behavior, increased substance use, PTSD symptoms Sexual violence is associated with lower perceived control and power within an intimate relationship

Lombardi et al. (2023)
Inconsistent results regarding prenatal depression: 3 studies found significant results (OR = 1.60-3.43) whereas 1 study did not find a significant effect (OR ns). Meta-analytical results also show no significant association (OR ns).

Madowitz et al. (2015)
53% of survivors suffers from an eating disorder; 24.5% of patients with an eating disorder experienced sexual violence (according to one study this association is mediated by PTSD and depression), 13.7% of patients with anorexia have PTSD of which 35% was due to sexual violence, 85% of survivors reports aversion to sexual activity

Maman et al. (2000)
A greater likelihood of HIV risk behavior (26-32% of survivors vs. 13-22% of non-survivors, significant difference), engaging in exchange sex, being less acquainted with sex partner and being afraid of negotiating condom use than non-survivors A lower likelihood of condom use during the last sexual encounter than non-survivors. Survivors are 6 times more likely to have had sex >10 times in the last three months, 3 times more likely to have never used condoms during the last three months and 11 times more likely to have a physically abusive partner than non-survivors

Mauritz et al. (2013)
29-71% of the respondents with severe mental illness has experienced adult sexual violence, 37% of the respondents with bipolar disorder has experienced adult sexual violence, 8-37% of the respondents with depression has experienced adult sexual violence, 39-87% of the respondents with borderline personality disorder has experienced adult sexual violence, 6-48% of the respondents with schizophrenic spectrum disorder has experienced adult sexual violence

Mazza et al. (2021)
Sexual violence is associated with perinatal depression and PTSD

Messman-Moore et al. (2003)
Survivors report more alcohol use during dating, a higher number of sex partners, a higher number of consensual sexual experiences and a higher likelihood of sexual revictimization compared to non-survivors ASA survivors and revictimized survivors show a higher likelihood of having multiple partners and brief relationships compared to child sexual abuse survivors or nonsurvivors, adolescent sexual violence is associated with interpersonal problems

Meyer, et al. (2011)
Survivors report more substance abuse, a greater number of sex partners, more unprotected sex, less consistent condom use, less sexual assertiveness and a greater likelihood of experiencing intimate partner violence than non-survivors

Molstad et al. (2023)
Survivors report lower GPA scores than controls (inconsistent), sexual violence is associated with academic impact (r=.12; OR = 2.33) and academic disengagement (r = .06), increased college stress and lower academic efficacy

Nicholas et al. (2022)
Male survivors show a 3.6 times likelihood to report poor mental health including suicidal ideation, depression, anxiety, non-suicidal self-injury

Paulson (2020)
Having experienced lifetime and recent SIPV is associated with a higher likelihood of postnatal depression (r = .37; OR = 1.84-8.23; however, inconsistent) and antenatal depression (OR = 14.3) compared to non-exposed women

Pebole et al. (2021)
Weight trainers have a higher likelihood of having experienced sexual violence than regular runners, survivors of sexual violence report a higher likelihood of being sedentary, survivors of sexual violence show no higher likelihood of enrolling in a self-defense class however, they do report the assault as the reason for their enrollment.
Survivors may experience problems with interpersonal functioning: 18-20% reports decreased involvement in social activities, 66-75% feelings of distrust of others 63-71% nervousness around people, 68-65% discomfort being physically close to others and 81-90% social withdrawal and social changes

Pulverman et al. (2021)
Survivors of sexual violence show a higher likelihood of sexual dysfunctions and lower likelihood of reporting a decreased sexual satisfaction than non-survivors and survivors of other trauma types, survivors of sexual violence report more sexual problems than the norm, 74.4% of survivors reports at least one sexual dysfunction

Pulverman et al. (2019)
Higher number of sexual difficulties compared to the norm in military sexual violence survivors, no difference in sexual functioning between military sexual violence survivors and military controls, military survivors do report a lower sexual satisfaction than military controls; 74.4% of military survivors report sexual dysfunction; survivors are more likely to report depression, anxiety, abuse and sleep difficulties

Rani et al. (2022)
Survivors report fear, loss of control, sense of betrayal, feelings of guilt, powerlessness, anger, helplessness, developing a negative attitude towards men in general, developing an aversion towards sex, low self-esteem, self-blame and poor body image Survivors report isolation

Ribeiro et al. (2009)
A greater likelihood of suffering from anxiety and depression symptoms (OR = 9.7), common mental disorders (OR = 4.4 ; however one study showed an insignificant OR) than nonsurvivors. For suicidal ideation the OR was insignificant.

Romans et al. (2008)
87% of patients with IBS experienced sexual violence vs. 14.1% of healthy women (1.82 <OR <1.86), 23% of IBS patients experienced sexual violence vs 8% of physical gastrointestinal disease patients, 30% of functional gastro-intestinal disorder patients has experienced sexual violence vs 5% of organic gastro-intestinal disorder patients, this difference was significant).
One study shows no difference between IBS patients (28%), chronic idiopathic constipation patients (34%), Chron's disease patients (25.5%) and healthy women (22.6%) regarding the prevalence of sexual violence. In addition, no difference was found between Fibromyalgia/ chronic fatigue syndrome patients (0%) and controls (0%) with regard to the prevalence of having experienced sexual violence.

Salim et al. (2022)
Bisexual female survivors have a 37% increase in the odds for smoking compared to bisexual female controls in addition in bisexual women, there is an association between sexual violence and increased substance use

Scoglio et al. (2021)
Childhood sexual violence predicts adolescent sexual violence which in turn predicts adult sexual violence

Seth et al. (2013)
A decreased likelihood of condom use, having multiple sex partners, having 3 or more sex partners in the past 3 months, having sex while being intoxicated, having sex while partner is intoxicated and ever being pregnant than non-survivors A lower likelihood of no condom use at last sexual encounter than non-survivors A higher number of sex partners, more inconsistent condom use, more high-risk sexual behavior than non-survivors

Stewart et al. (2019)
The majority of included studies show how survivors report an increase in alcohol use following the assault, some show no change. Survivors report an increase/decrease (inconsistent results) in sexual activity following the assault. Eating behavior decreases and after a while increases. Survivors report dressing differently and report an increase in drug use and smoking.
Survivors report a decrease in school/work attendance and leisure occupations Survivors report a decrease in dating

Stockman et al. (2013)
A higher likelihood of >5 partners (OR = 1.8), casual partners (OR = 2.2) and exchange sex (OR = 1.8), unprotected sex (OR = 13.4), inconsistent condom use (OR = 3.31) and injection drug use (injection drug users are more likely to experience sexual violence, OR = 4.5) than non-survivors. Sexual violence was associated with a lower condom use frequency, a lower sexual assertiveness regarding condom use and unprotected sex (through a lower sexual assertiveness and depression symptoms) and sexual and drug risk behavior

Trevillion et al. (2012)
44.8% of survivors is be diagnosed with PTSD No significant difference was found in the prevalence of depression and personality disorders among survivors and non-survivors.

Ullman (2004)
Survivors report more (past year) suicidal ideation, suicide attempts and feelings of hopelessness An increased risk of a lifetime suicide attempt among survivors compared to non-survivors However, the association between sexual violence and suicidal behavior is not found in all studies

Ulloa et al. (2016)
20-50% of survivors report little to great change in the positive direction, 30% of survivors report become involved in social and political action/became an advocate Survivors may report post-traumatic growth, increased spirituality, increased sense of wellbeing, PTSD, depression, distress, appreciation of life, spiritual change, personal strength, stronger sense of self and new possibilities Survivors may report changes such as an increased relationship with their mother, relationship with others, more empathy towards others

van Berlo et al. (2000)
A 2.5 times higher likelihood to experience sexual dysfunctions (i.e., arousal dysfunction, desire dysfunction, vaginismus, dyspareunia, anorgasmia, organismic disorder, fear of sex, aversion towards sex, sexual noncommunication, sexual feelings, feelings of sensuality), 30% of survivors report sexual problems, 22-33% decreased sexual satisfaction, 32% decreased frequency of having sex, 29-38% avoiding sex for at least 6 months, 50% flashbacks during sex, 14-34% finding sensual contact less pleasurable, 30% having PTSD symptoms and 4% depression symptoms. Survivors report a decrease in orgasms Survivors are less sensual compared to controls Some studies found no differences between victimized and non-victimized respondents regarding the frequency of oral sex, sexual intercourse, anal intercourse, masturbation, orgasms, sexual avoidance, sexual noncommunication, vaginismus, affectional experiences and autoerotic experiences

Vitek et al. (2021)
Having experienced sexual violence is associated with experiencing physical violence in intimate relationships, decreased relationship satisfaction, poorer communication

Psychological changes
Social changes (however, inconsistent), poorer emotional intimacy (but not sexual intimacy). No association is found with hostility

Wadsworth, et al. (2013)
A higher likelihood of experiencing depression and anxiety symptoms (b = 1.37; 2.96 < OR < 5.32), PTSD symptoms (3.05 < OR < 7.15; R = .40) and somatic symptoms (OR = 3.65) compared to non-survivors. One study stated that recent sexual violence is not associated with anxiety symptoms and another study stated that there was no association with suicidal ideation. Sexual violence is associated with more substance use, illicit drug use, alcohol abuse, inconsistent condom use, unprotected vaginal, anal or oral sex, number of partners, practicing monogamy and trading sex compared to non-survivors.

Walker et al. (2017)
A mean prevalence rate of revictimization of 47% following sexual violence among adolescents

Zarchev et al. (2021)
5.3% of men with a mental illness has experienced past-year sexual violence whereas 14.1% of men with a mental illness has experienced adulthood sexual violence Note. PTSD = Post-traumatic stress syndrome, STD = Sexually transmitted disease