IJG-08013; No of Pages 6

International Journal of Gynecology and Obstetrics xxx (2014) xxx–xxx

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International Journal of Gynecology and Obstetrics

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

CLINICAL ARTICLE

Psychiatric evaluation of women who were assisted at a university

referral center in Campinas, Brazil, following an experience of
sexual violence
Cláudia O. Facuri a,⁎, Arlete M.S. Fernandes b, Renata C.S. Azevedo a
a
Department of Medical Psychology and Psychiatry, School of Medical Sciences, University of Campinas, Campinas, Brazil
b
Gynecological Division, Department of Obstetrics and Gynecology, School of Medical Sciences, University of Campinas, Campinas, Brazil

a r t i c l e i n f o a b s t r a c t

Article history: Objective: To present the sociodemographic characteristics and psychiatric symptoms of women who have been
Received 8 August 2013 raped. Methods: Between 2006 and 2010, a retrospective study was conducted of 468 women who underwent psy-
Received in revised form 16 April 2014 chiatric evaluation at a university referral center in Brazil after an experience of sexual violence. Results: The
Accepted 18 June 2014 women had a mean age of 24.1 years; were predominantly white, unmarried, childless, and employed; had
9–11 years of education; and had a religion. Rape was the first sexual intercourse for 124 (26.8%) of 462 for
Keywords:
whom data were available; 53 (13.6%) of 389 had a personal history of sexual violence and 29 (8.0%) of 361 had
Mental disorders
Psychiatric symptoms
a family history. No psychiatric symptoms were reported in 146 (32.9%) of 444 women, mild/short-term symp-
Psychiatry toms were reported in 107 (24.1%), and a psychiatric diagnosis was made for 191 (43.0%). Psychiatric comorbidity
Rape was seen in 59 (12.6%) women, and 174 (38.0%) received pharmacologic treatment. All follow-up consultations
Sexual violence were attended by 215 (45.9%) of 468 women; 166 (35.5%) attended some, and 87 (18.6%) attended only one dur-
Violence against women ing the 6-month follow-up period. Conclusion: The frequency and severity of psychiatric symptoms and mental dis-
orders among women who have been raped highlights the importance of mental health monitoring.
© 2014 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.

1. Introduction The consequences of rape do not only compromise interpersonal re-

Violence has been recognized since 1993 as a leading worldwide pub-
lic health problem, and 20 years later, it is still an ongoing issue [1,2]. Sex-
ual violence is defined by WHO as “any sexual act, attempt to obtain a
sexual act, unwanted sexual comments or advances…against a person’s
sexuality using coercion, by any person regardless of their relationship
to the victim, in any setting, including but not limited to home and
work”[1]. Globally, the prevalence of sexual violence by an intimate part-
ner is 30%, whereas the prevalence of sexual violence by a nonpartner is
7.2%, but the latter may reach more than 15% in some regions [2,3].
A US survey [4] found that nine of 10 people who experience sexual
violence are women, and a Brazilian study [5] confirmed that it is mainly
women who experience domestic and sexual violence, from childhood
to old age. The Brazilian Penal Code [6] defines rape as follows: “to con-
strain someone by violence or serious threat, to have sexual intercourse
or to practice or allow the practice of other lewd acts with him/her.” In
Brazil, a total of 43 227 rapes were reported from 2001 to 2003 [7].
⁎ Corresponding author at: Rua Tessália Vieira de Camargo, 126 CidadeUniversitária
“ZeferinoVaz”, 13083–887, Campinas, SP, Brazil. Tel.: + 55 19 3521 7206, + 55 19
96111530; fax: +55 19 32531639.
E-mail addresses: claudiafacuri@yahoo.com.br, psiquiatra@claudiafacuri.com.br
(C.O. Facuri).
lationships but also professional aspects of the life of the person who has
been assaulted. Physical and mental health is affected in the short- and
long-term [1,2,8,9]. Unwanted pregnancy, abortion, sexually transmit-
ted infections (STIs), sexual dysfunction, infertility, and urinary and
genital lesions are some of the physical short-term outcomes [2,9,10].
People who have been raped are at increased risk of suicide, abuse of al-
cohol and other substances, and other mental disorders [1–3].
The most profound long-term consequence of rape might be the im-
pact on a person’s mental health [2,8,9,11]. The psychological sequelae
of rape include not only recognized psychiatric diagnoses but also a
range of mental health symptoms [8]. Burgess and Holmstrom [12] de-
scribed a range of psychological, cognitive, emotional, and behavioral
responses to rape (the “rape trauma syndrome”), suggesting that
there is an acute phase marked by disorganization of the person’s life-
style with the presence of physical and mental symptoms, followed by
a long-term reorganization process. Whether the adaptation responses
are better or worse depends on the age and lifestyle of the affected per-
son, the circumstances of the rape, personality characteristics, and the
person’s support network [10].
Rape survivors have a greater risk of being diagnosed with a psychi-
atric illness and of experiencing trauma-induced symptoms such as
nightmares, inability to concentrate, sleep and appetite disturbances,
and feelings of anger, humiliation, and self-blame [11,12]. One-third of

http://dx.doi.org/10.1016/j.ijgo.2014.04.020
0020-7292/© 2014 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.

Please cite this article as: Facuri CO, et al, Psychiatric evaluation of women who were assisted at a university referral center in Campinas, Brazil,
following an experience of sexual violence, Int J Gynecol Obstet (2014), http://dx.doi.org/10.1016/j.ijgo.2014.04.020
2 C.O. Facuri et al. / International Journal of Gynecology and Obstetrics xxx (2014) xxx–xxx
people who have been raped develop post-traumatic stress disorder
(PTSD); in fact, rape survivors constitute the largest single group of
people with PTSD and they are more likely to have persistent symptoms
than are people who have experienced another type of trauma [11–13].
Another third experience at least one depressive episode in the first year
after the assault, and these people have a 13-fold increased risk of
attempting suicide [14]. People who have experienced child abuse are
at greater risk for depression, drug misuse, PTSD, and suicide in adult-
hood [15]. Rape survivors with a personal history of physical, psycho-
logical, or social problems tend to develop additional symptoms of
depression, display psychotic and suicidal behaviors, use psychoactive
substances, and experience sexual changes [9,12].
The aim of the present study was to evaluate the psychiatric
health of women who have experienced sexual violence and to
assess the relationship between psychiatric symptoms after the trau-
ma and sociodemographic characteristics.
2. Materials and methods
The present study was a retrospective, descriptive, and quantitative
study that involved evaluation of the medical records of women who
had experienced sexual violence and who were subsequently assessed
at the referral center for sexual violence at Dr. José Aristodemo Pinotti
Women's Hospital, State University of Campinas, Campinas, Brazil. The
study protocol was reviewed and approved by the local institutional
ethics committee. Informed consent was not needed because the data
were extracted from medical records.
At the study hospital, emergency and outpatient health care related
to sexual violence has been provided by a multidisciplinary team of gy-
necologists, nurses, psychologists, and social workers since 1994. The
aims are: to promote women’s physical, psychological, and social recov-
ery; to prevent pregnancy and STIs; and, if needed, to provide assistance
for rape-related pregnancy in accordance with the guidance provided
by the Ministry of Health [16].
Emergency care procedures for women who have experienced sex-
ual violence follow an organized routine and the women are then re-
ferred within 7–10 days to outpatient care for 6 months [17]. Mental
health support (psychological and psychiatric assessment and treat-
ment) is available to every rape survivor during the outpatient follow-
up, which is composed of a monthly psychiatric appointment and
weekly psychological appointments. After that period, if mental health
treatment is still needed, patients may be referred to a primary care
unit in their home town.
It is unique to Brazil that the multidisciplinary team responsible
for the assessment of female rape survivors includes a psychiatrist.
Psychiatric evaluation was established in June 2006 and has since
been performed by psychiatrists and by psychiatry residents under
supervision using a semi-structured interview. The interviews are
used to capture reports on sexual violence, actively investigate phys-
ical and psychiatric symptoms, and establish whether the woman
has a personal and family history of mental health problems. If
psychiatric symptoms are identified, these are matched to the
criteria for psychiatric disorders from the International Classification
of Diseases, 10th revision [18]. If a woman meets the criteria for a
psychiatric diagnosis, medication may be prescribed. All women
are offered psychotherapy.
The present study included all women aged 12 years or older who
sought care for sexual violence between June 1, 2006, and December
31, 2010, and underwent psychiatric evaluation at least once at the out-
patient clinic. Patients younger than 12 years were referred to a child
and adolescent outpatient service at the same university and were ex-
cluded from the present study, as were women whose assault was not
of a sexual nature (according to the emergency evaluation) and those
who did not attend the outpatient clinic.
Data for the study were collected from the evaluation records of the
multidisciplinary team responsible for emergency and outpatient care
Please cite this article as: Facuri CO, et al, Psychiatric evaluation of women who were assisted at a university referral center in Campinas, Brazil,
following an experience of sexual violence, Int J Gynecol Obstet (2014), http://dx.doi.org/10.1016/j.ijgo.2014.04.020
and from the patient charts. A data collection form was used that had
been specifically designed for the present study; a previous version of
this form had been tested on the medical records of 50 women to verify
its applicability. The assessed variables included sociodemographic
characteristics, initiation of sexual intercourse prior to the assault, and
personal and family history of sexual violence. In addition, information
was obtained on the personal and family history of psychiatric illness,
current psychiatric diagnoses among the study participants or their
family members, current psychiatric or psychological treatments, and
drug classes in current use.
Based on the psychiatric evaluation, the mental and somatic symp-
toms were grouped into four clusters: suicidal behavior (suicidal idea-
tion or planning and suicide attempt); social response to trauma
(shame and self-blame); avoidance behaviors (social withdrawal, social
restriction, and routine changes); and apprehension response to trauma
(fear of contracting an STI, fear of rape-related pregnancy, and fear of a
repeat experience). Women were deemed to have no psychiatric symp-
toms related to trauma, mild/short-lasting symptoms, or symptoms
meeting the criteria for a psychiatric diagnosis. Comorbid diagnoses
were categorized as affective/mood disorders, disorders related to the
use of psychoactive substances, intellectual disability, psychotic disor-
ders, anxiety disorders, appetite disorders, personality disorders, and
others.
Prescribed psychiatric medications were classified by drug class
(antidepressants, anxiolytics, mood stabilizers/anticonvulsants, anti-
psychotics, and other drugs). Adherence to the outpatient appoint-
ments during the 6-month follow-up period was classified as full
attendance of consultations, partial attendance of consultations, and
attendance of a single consultation only.
The data were analyzed with SPSS version 11.5 (SPSS Inc, Chicago, IL,
USA) and SAS version 9.2 (SAS Institute, Cary, NC, USA). Descriptive data
were presented as frequencies (categorical variables) and measures of
dispersion and position (numerical variables). Assessment of associa-
tions and comparisons of proportions were performed using the χ2 or
Fisher exact test, as appropriate. The Mann-Whitney U test was used
for the comparison of numerical data. P b 0.05 was considered statisti-
cally significant.
3. Results
During the assigned period, 745 women sought emergency care
because of sexual violence and 468 patients underwent psychiatric
evaluation (Fig. 1). The women had a mean age of 24.1 years; were
predominantly white, unmarried, childless, and employed; had
9–11 years of education; and had a religion (Table 1). Half the
women were Catholic, and three-quarters practiced their religion
(Table 1).
Of 462 women for whom data were available, 338 (73.2%) women
had initiated sexual intercourse prior to the assault (Table 1). Fifty-
three (13.6%) of 389 women had a personal history of sexual violence
and 29 (8.0%) of 361 reported a family history of sexual violence; the
mothers and sisters of these 29 women were predominantly affected
(Table 1). Data concerning the mental health history of the women
are presented in Table 2.
The mean elapsed time between the assault and the psychiatric
evaluation was 37.2 days (median, 17 days; mode, 13 days; range,
0–1825 days). Problems related to the episode were identified in the
majority of the women and mainly comprised sleep disturbances,
depressive symptoms, and anxiety symptoms (Table 3). Many women
developed social responses to the assault and avoidance behavior, near-
ly one-fifth displayed suicidal ideation, and apprehension responses
affected up to one-quarter (Table 3).
Approximately one-third of the women did not develop any
trauma-related symptoms, and approximately one-quarter had mild/
short-lasting symptoms (Table 3). Psychiatric diagnoses were made
in 191 (43.1%) of 444 women (Table 3). Psychiatric comorbidities
 C.O. Facuri et al. / International Journal of Gynecology and Obstetrics xxx (2014) xxx–xxx 3

Assessed for eligibility (n=745)

Excluded (n=277)
Did not meet inclusion criteria (n=226)
Aged <12 years (n=24)
Did not experience SV (n=34)
Did not aend outpaent service (n=168)
Declined to parcipate (n=51)

Evaluated by psychiatrist (n=468)

Excluded (n=24)
Missing data

Psychiatric symptoms developed aer SV (n=444)

No symptoms (n=146)
Mild/short lasng symptoms (n=107)
Severe symptoms/ICD 10 psychiatric disorder
(n=191)
Adjustment disorder (n=98)
Post traumac stress disorder (n=55)
Major depressive episode (n=38)

Fig. 1. Flow diagram of the participants. Abbreviations: SV, sexual violence; ICD-10, International Classification of Diseases, 10th revision.

(intellectual disability, psychoactive-substance-related disorders,
affective/mood disorders, anxiety disorders, personality disorders, and
psychotic disorders) were present in 59 (12.6%) women. Psychiatric
medication was prescribed for almost 40% of the evaluated women
(Table 3). All evaluated women were referred for psychological
counseling at the outpatient clinic.
The four clusters of symptoms (social responses, suicidal behavior,
avoidance behavior, and apprehension responses) were positively asso-
ciated with the development of sleep and appetite disturbances, fatigue,
flashbacks, anxiety, and depressive symptoms (Table 4). Having chil-
dren was associated with the development of social responses to sexual
violence, avoidance behavior, and suicidal behavior.
Social responses to the assault were also associated with marital status,
having been raped vaginally, number of offenders, and intimidation
(Table 4). Women with social responses were likely to experience gastro-
intestinal or genitourinary disturbances and fear of rape-related pregnancy.
Avoidance behavior was associated with marital status, having been
intimidated or forced into oral coitus, fear of a rape-related pregnancy
or of being raped again, and moving to a different address (Table 4).
Women displaying avoidance behavior were likely to have no personal
history of psychiatric illness (Table 4).
Suicidal behavior was correlated with employment status, having a
personal history of sexual violence, having been raped by a single of-
fender, vaginal or anal penetration, having gastrointestinal or genitouri-
nary disturbances, and changes in routine (Table 4).
Apprehension responses were associated with assault by a stranger,
intimidation, attack with a fire weapon, vaginal penetration, and routine
changes (Table 4).
Women who developed social responses and avoidance behaviors
were more likely to be offered psychiatric medication after the psychiat-
ric evaluation (P b 0.05) (Table 4).
All follow-up consultations were attended by 215 (45.9%) of 468
women; 166 (35.5%) attended some of the consultations, and 87
(18.6%) attended only a single consultation at the outpatient clinic.
4. Discussion
Rape is one of the most severe of all traumas, causing multiple short-
and long-term negative outcomes [1,8,9]. The development of psychiat-
ric symptoms in particular causes great distress among survivors [1,2,9].
The present research provides data from Brazil on the psychiatric symp-
toms and diagnoses seen in an outpatient referral center for sexual
violence.
The characteristics of the study population were similar to those
described in the national [19] and international literature [1–3,10].
However, it is important to emphasize that there is no typical rape
survivor. Forced sexual initiation is a particular concern because past ex-
periences of violence increase the risk of a subsequent sexual assault
[15,19,20].
Approximately one-third of the women in the sample had a family
history of psychiatric illness and one-quarter had a personal history.
One in six women received ongoing psychiatric treatment with medica-
tion at the time of the aggression and only a few women had previously
received psychological treatment. In the general female population
worldwide, 35.2%–46.3% have any psychiatric illness, 21%–24.5% have
mood disorders, 15.6%–30.5% have anxiety disorders, and 7.4%–23%

Please cite this article as: Facuri CO, et al, Psychiatric evaluation of women who were assisted at a university referral center in Campinas, Brazil,
following an experience of sexual violence, Int J Gynecol Obstet (2014), http://dx.doi.org/10.1016/j.ijgo.2014.04.020
4 C.O. Facuri et al. / International Journal of Gynecology and Obstetrics xxx (2014) xxx–xxx

Table 1 Table 3
Sociodemographic characteristics of women who underwent psychiatric evaluation.a Distribution of symptoms related to sexual violence, psychiatric diagnoses, and proposed
treatment.a
Variable Value
Variable Value
Age (n = 468)
12–19 years 221 (47.2) Problems, reactions, or changes related to sexual violence (n = 463) 411 (88.7)
≥20 years 247 (52.8) Sleep disturbances (n = 466) 254 (54.5)
Race (n = 468) Depressive symptoms (n = 466) 243 (52.1)
White 348 (74.3) Anxiety symptoms (n = 467) 227 (48.6)
Other 119 (25.4) Appetite disturbances (n = 468) 157 (33.5)
Marital status (n = 459) Fatigue (n = 466) 116 (24.8)
Single 343 (74.7) Flashbacks (n = 462) 94 (20.1)
Married 78 (17.0) Gastrointestinal disturbances (n = 468) 64 (13.6)
Divorced/separated 31 (6.8) Fear of rejection (n = 466) 27 (5.7)
Widowed 7 (1.5) Genitourinary disturbances (n = 467) 16 (3.4)
Offspring (n = 453) Moved to a different address (n = 464) 13 (2.8)
No children 307 (67.7) Suicidal behavior (n = 466)
Have children 146 (32.3) Suicidal ideation 87 (18.6)
Schooling (n = 461) Suicide planning 30 (6.4)
Illiterate 6 (1.3) Suicide attempt 8 (1.7)
≤8 years 183 (39.7) Social response to the trauma (n = 462)
9–11 years 204 (44.3) Shame 214 (46.5)
≥12 years 57 (12.4) Self-blame 96 (20.8)
Special teaching and support schools 11 (2.4) Avoidance behaviors (n = 468)
Employment status (n = 462) Social withdrawal 165 (35.2)
Employed 206 (44.6) Social restriction 157 (33.5)
Unemployed 30 (6.5) Routine changes 135 (28.8)
Sickleave 7 (1.5) Apprehension response to the trauma (n = 466)
Homemaker 30 (6.5) Fear of repeat assault 121 (25.9)
Student 178 (38.5) Fear of contracting STI 114 (24.4)
Other 11 (2.4) Fear of pregnancy 52 (11.1)
Had a religion (n = 453) 393 (86.6) Psychiatric symptoms related to the trauma (n = 444)
Religion (n = 391) No symptoms 146 (32.9)
Catholic 206 (52.7) Mild/short-lasting symptoms 107 (24.1)
Evangelical 160 (40.9) Adjustment disorder 98 (22.1)
Spiritualist 10 (2.6) Post-traumatic stress disorder 55 (12.4)
Other 15 (3.8) Major depressive episode 38 (8.6)
Practiced their religion (n = 307) 230 (74.9) Presence of comorbid diagnosis (n = 468) 59 (12.6)
Sexual intercourse prior to violence (n = 462) 338 (73.2) Comorbid diagnosis (n = 59)
Chronic illness (n = 423) 85 (20.0) Intellectual disability 21 (35.6)
Personal history of sexual violence (n = 389) 53 (13.6) Psychoactive drug usedisorder 13 (22.0)
Family history of sexual violence (n = 361) 29 (8.0) Affective/mood disorder 8 (13.6)
Mother affected 9 (2.5) Anxiety disorder 7 (11.9)
Sister affected 9 (2.5) Personality disorder 4 (6.8)
Other family member affected 11 (3.1) Psychotic disorder 3 (5.1)
a Prescription of psychiatric medication after the initial evaluation (n = 458) 174 (38.0)
Values are given as number (percentage).
Prescribed drug class (n = 458)
Antidepressants 129 (28.2)
Anxiolytics 122 (26.6)
Mood stabilizer/anticonvulsants 12 (2.6)
Table 2 Antipsychotics 12 (2.6)
Personal and family psychiatric history of women who had experienced sexual violence.a Abbreviation: STI, sexually transmitted infection.
a
Values are given as number (percentage).
Variable Value

Personal history of psychiatric diagnosis (n = 445) 112 (25.2)

Affective/mood disorder 47 (10.6)
have psychoactive substance misuse/dependence [21]. The prevalence
Intellectual disability 19 (4.3)
Psychoactive drugs related disorder 15 (3.4) of psychiatric disorders overall was 43% in the present study sample, al-
Anxiety disorder 7 (1.6) though the prevalence rates of some specific diagnoses identified in the
Psychotic disorder 5 (1.1) study population were higher (e.g. adjustment disorders and PTSD). The
Eating disorder 3 (0.7)
presence of a psychiatric illness increases a woman’s vulnerability to
Mental disorder attributable to a medical condition 1 (0.2)
Learning disability 1 (0.2)
sexual assault, is positively related to the development of postassault
Current psychiatric treatment with medication (n = 457) 70 (15.3) mental health sequelae (including anxiety and depressive symptoms),
Drug classes in current use (n = 70) and affects the recovery process [22,23]. It is important that referral ser-
Antidepressants 42 (60) vices for rape survivors closely evaluate these women to identify any
Anxiolytics 41 (58.6)
pre-existing psychiatric illness, investigate the impact of the trauma
Mood stabilizer/anticonvulsants 25 (35.7)
Antipsychotics 18 (25.7) on their psychopathologic presentation, and promote adherence to
Others 7 (10) follow-up.
Current psychological treatment (n = 456) 36 (7.9) Most women in the study population displayed a range of reactions
Family history of psychiatric diagnosis (n = 441) 151 (34.2) that have also been identified by other researchers [2,9,12,24] and that
Affective/mood disorder 65 (14.7)
Psychoactive drugs related disorder 54 (12.2)
are related to a decrease in the survivors’ quality of life. The majority of
Intellectual disability 10 (2.3) rape survivors experience symptoms that meet the criteria for PTSD,
Psychotic disorder 7 (1.6) major depression disorder, or anxiety disorders [13–15]. The present
Anxiety disorder 1 (0.2) study focused not only on formal psychiatric diagnoses but also on indi-
Pervasive developmental disorder 1 (0.2)
vidual symptoms, given their impact on the survivor’s mental health;
a
Values are given as number (percentage). the symptoms were grouped into clusters. The resulting prevalence

Please cite this article as: Facuri CO, et al, Psychiatric evaluation of women who were assisted at a university referral center in Campinas, Brazil,
following an experience of sexual violence, Int J Gynecol Obstet (2014), http://dx.doi.org/10.1016/j.ijgo.2014.04.020
following an experience of sexual violence, Int J Gynecol Obstet (2014), http://dx.doi.org/10.1016/j.ijgo.2014.04.020
Please cite this article as: Facuri CO, et al, Psychiatric evaluation of women who were assisted at a university referral center in Campinas, Brazil,

Table 4
Sociodemographic characteristics, type of violence, and clinical psychiatric evaluation of women who had experienced sexual violence by psychiatric symptom cluster.a,b

Variable Social responses Avoidance behavior Suicidal behavior Apprehension responses

No Yes P value No Yes P value No Yes P value No Yes P value

Having children 58 (39.7) 88 (60.2) 0.043c 53 (36.3) 93(63.7) 0.002c 102 (69.8) 44 (30.1) b0.001c 84 (57.5) 62 (42.4) 0.367c
Marital status 0.003d 0.008d 0.385c 0.029d
Single 176 (51.3) 167 (48.6) 176 (51.1) 168 (48.8) 284 (82.8) 59 (17.2) 220 (64.3) 122 (35.6)
Married 24 (30.7) 54 (69.2) 29 (37.1) 49 (62.8) 63 (79.7) 16 (20.2) 38 (48.7) 40 (51.2)
Divorced/separated 11 (35.4) 20 (64.5) 8 (25.8) 23 (74.1) 21 (67.7) 10 (32.2) 16 (51.6) 15 (48.3)
Widowed 2 (28.5) 5 (71.4) 4 (57.1) 3 (42.8) 3 (50.0) 3 (50.0) 5 (83.3) 1 (16.6)
Employment status 0.139c 0.019c 0.024c 0.024c
Employed 93 (45.1) 113 (54.8) 82 (39.8) 124 (60.1) 166 (80.5) 40 (19.4) 110 (53.6) 95 (46.3)
Unemployed 9 (30.0) 21 (70.0) 14 (46.6) 16 (53.3) 22 (73.3) 8 (26.6) 16 (53.3) 14 (46.6)
Sick leave 2 (28.5) 5 (71.4) 2 (28.5) 5 (71.4) 3 (42.8) 4 (57.1) 4 (57.1) 3 (42.8)

C.O. Facuri et al. / International Journal of Gynecology and Obstetrics xxx (2014) xxx–xxx
Homemaker 11 (36.6) 19 (63.3) 12 (40.0) 18 (60.0) 22 (73.3) 8 (26.6) 17 (56.6) 13 (43.3)
Student 91 (51.1) 87 (48.8) 102 (57.3) 76 (42.7) 153 (86.4) 24 (13.5) 120 (68.1) 56 (31.8)
Other 7 (63.6) 4 (36.3) 5 (45.4) 6 (54.5) 8 (72.7) 3 (27.2) 8 (72.7) 3 (27.2)
Offender 0.637c 0.102c 0.480c 0.004c
Acquaintance 53 (44.5) 66 (55.4) 64 (53.3) 56 (46.6) 94 (78.3) 26 (21.6) 85 (70.8) 35 (29.1)
Stranger 159 (47.0) 179 (52.9) 151 (44.6) 187 (55.3) 274 (81.3) 63 (18.6) 187 (55.8) 148 (44.1)
Number of offenders 0.046c 0.799c 0.013c 0.241c
Multiple 30 (58.8) 21 (41.1) 23 (45.1) 28 (54.9) 35 (67.3) 17 (32.6) 27 (51.9) 25 (48.0)
One 175 (44.0) 222 (55.9) 187 (46.9) 211 (53.0) 324 (81.8) 72 (18.1) 238 (60.4) 156 (39.5)
Intimidation 184 (43.9) 235 (56.0) 0.021c 183 (43.6) 236 (56.3) 0.006c 335 (79.9) 84 (20.0) 0.288c 238 (56.9) 180 (43.0) 0.001c
Fire weapon 51 (44.7) 63 (55.2) 0.830c 43 (37.7) 71 (62.2) 0.056c 88 (77.1) 26 (22.8) 0.260c 51 (45.1) 62 (54.8) 0.001c
Type of sexual violence
Vaginal 146 (42.4) 198 (57.5) 0.002c 148 (43.0) 196 (56.9) 0.111c 268 (78.1) 75 (21.8) 0.045c 190 (55.5) 152 (44.4) 0.043c
Oral 63 (45.9) 74 (54.0) 0.840c 49 (35.7) 88 (64.2) 0.010c 108 (78.8) 29 (21.1) 0.713c 72 (52.5) 65 (47.4) 0.142c
Anal 40 (42.1) 55 (57.8) 0.473c 42 (44.2) 53 (55.7) 0.942c 68 (70.8) 28 (29.1) 0.011c 55 (57.2) 41 (42.7) 0.953c
Personal history of sexual violence 21 (39.6) 32 (60.3) 0.334c 24 (44.4) 30 (55.5) 0.945c 34 (62.9) 20 (37.0) b0.001c 38 (70.3) 16 (29.6) 0.108c
No personal history of psychiatric diagnosis 148 (43.7) 190 (56.2) 0.102c 150 (44.3) 188 (55.6) 0.023c 281 (83.3) 56 (16.6) 0.148c 201 (59.8) 135 (40.1) 0.588c
Disclosure to husband 34 (39.0) 53 (60.9) 0.586c 29 (33.3) 58 (66.6) 0.009c 72 (81.8) 16 (18.1) 0.363c 46 (52.8) 41 (47.1) 0.724c
Symptoms
Sleep 96 (37.8) 158 (62.2) b0.001c 88 (34.6) 166 (65.3) b0.001c 185 (72.8) 69 (27.1) b0.001c 130 (51.3) 123 (48.6) b0.001c
Appetite 52 (33.1) 105 (66.8) b0.001c 52 (33.1) 105 (66.8) b0.001c 107 (67.7) 51 (32.2) b0.001c 84 (53.1) 74 (46.8) 0.024c
Gastrointestinal 19 (29.6) 45 (70.3) 0.004c 27 (42.1) 37 (57.8) 0.374c 43 (68.2) 20 (31.7) 0.006c 30 (49.1) 31 (50.8) 0.056c
Genitourinary 2 (12.5) 14 (87.5) 0.005c 5 (31.2) 11 (68.7) 0.187c 8 (50.0) 8 (50.0) 0.004c 7 (43.7) 9 (56.2) 0.170c
Fatigue 40 (34.4) 76 (65.2) 0.003c 32 (27.5) 84 (72.4) b0.001c 72 (62.0) 44 (37.9) b0.001c 53 (46.0) 62 (53.9) 0.001c
Anxiety 85 (37.4) 142 (62.5) b0.001c 77 (33.9) 150 (66.0) b0.001c 173 (76.2) 54 (23.7) 0.015c 120 (53.3) 105 (46.6) 0.003c
Depressive 88 (36.2) 155 (63.7) b0.001c 86 (35.3) 157 (64.6) b0.001c 164 (67.4) 79 (32.5) b0.001c 130 (53.7) 112 (46.2) 0.002c
Suicidal ideation 27 (31.0) 60 (68.9) 0.001c 25 (28.7) 62 (71.2) b0.001c NA NA NA 44 (50.5) 43 (49.4) 0.039c
Flashbacks 30 (31.9) 64 (68.0) 0.002c 34 (36.1) 60 (63.8) 0.015c 64 (67.3) 31 (32.6) b0.001c 46 (48.4) 49 (51.5) 0.008c
Fear of STI 33 (28.9) 81 (71.0) b0.001c 30 (26.3) 84 (73.6) b0.001c 84 (73.0) 31 (26.9) 0.013c NA NA NA
Fear of pregnancy (n = 52) 15 (28.8) 37 (71.1) b0.001c 14 (26.9) 38 (73.0) 0.001c 39 (75.0) 13 (25.0) 0.427c NA NA NA
Fear of repeating 51 (42.1) 70 (57.8) 0.306c 33 (27.2) 88 (72.7) b0.001c 91 (75.2) 30 (24.7) 0.062c NA NA NA
Shame NA NA NA 86 (39.6) 131 (60.3) 0.001c 164 (75.5) 53 (24.4) 0.006c 113 (52.3) 103 (47.6) b0.001c
Self-blame (n = 98) NA NA NA 36 (36.7) 62 (63.2) 0.018c 68 (69.3) 30 (30.6) 0.001c 47 (47.9) 51 (52.0) 0.004c
Moved address (n = 13) 8 (61.5) 5 (38.4) 0.264c 2 (15.3) 11 (84.6) 0.018c 10 (76.9) 3 (23.0) 0.717d 7 (53.8) 6 (46.1) 0.617c
Routine changes 57 (42.2) 78 (57.7) 0.252c NA NA NA 89 (65.9) 46 (34.0) b0.001c 59 (44.0) 75 (55.9) b0.001c
Social withdrawal 61 (36.9) 104 (63.0) 0.002d NA NA NA 114 (69.5) 50 (30.4) b0.001c 82 (50.3) 81 (49.6) b0.001c
Social restriction 59 (37.5) 98 (62.4) 0.006c NA NA NA 111 (71.1) 45 (28.8) b0.001c 72 (46.4) 83 (53.5) b0.001c
Prescription of medication 71 (40.5) 104 (59.4) 0.045c 56 (32.0) 119 (68.0) b0.001c 106 (60.5) 69 (39.4) b0.001c 91 (52.3) 83 (47.7) 0.004c

Abbreviations: STI, sexually transmitted infection; NA, not applicable.

a
Values are given as number (percentage).
b
Percentages calculated with the total number of women for whom data were available for each variable and symptom cluster.
c
χ2 test.
d
Fisher exact test.

5
6 C.O. Facuri et al. / International Journal of Gynecology and Obstetrics xxx (2014) xxx–xxx
data highlight the need to give due attention to the issue of mental
health.
The deleterious aftermaths of suicidal behavior, social responses,
PTSD-related avoidance behaviors, and apprehension responses to
rape have been shown in various international studies [1,9,11,15,16],
but national literature on the topic is sparse. Effective mental health in-
terventions may improve coping strategies, diminish the duration and
negative perception of the symptoms, and result in appropriate treat-
ment for survivors. The delivery of mental health services at referral
centers may facilitate the timely evaluation and treatment of these
patients and promote faster and sustained recovery. The frequency
and severity of psychiatric symptoms and mental disorders found
in women who have been raped points to the importance of mental
health care.
Some women in the sample did not develop any symptoms after
rape. This finding could be explained by resilience or a delayed onset
of symptoms [25]. Future prospective studies may help to understand
this phenomenon and to identify factors related to the development of
psychiatric symptoms.
The present study is limited by missing data (because of incomplete
medical records) and the fact that the history of mental disorders was
not obtained by structured diagnostic interview or the use of specific/
validated scales. One strength is its large sample size, allowing the anal-
ysis of correlations of clinical interest and encouraging recognition of
the problem. It is hoped that this will stimulate further research and
improvements in care for affected women.
In conclusion, women who have experienced sexual violence de-
velop a wide range of psychiatric symptoms that must be recognized.
The clustering of symptoms into suicidal behavior, avoidance behav-
ior, apprehension responses, and social responses to aggression is
not only useful because it helps to call attention to individual symp-
toms, but it also provides a symptom pattern that will facilitate the
identification of people who have experienced sexual violence. The
frequency and severity of psychiatric symptoms and mental disor-
ders found in women who have been raped points to the importance
of mental health monitoring.
Conflict of interest
The authors have no conflicts of interest.
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