Mental Health| Volume 33, ISSUE 1, P105-112, January 2023

Gynecological Health Complaints Among College Women With Sexual Victimization Histories: Examination of Depression and Anxiety as Potential Mediators



      The study's purpose was to examine the relation between sexual victimization history and gynecological health complaints among college women. A further aim was to explore whether anxiety and depression are mediators of this relation, as well as to examine the size of these indirect relations among individuals with different types of victimization histories (childhood sexual abuse, adolescent/adult sexual assault, combined childhood sexual abuse/adolescent/adult sexual assault).


      A sample of 1,759 undergraduate cisgender women attending a large Southeastern U.S. university completed online measures of lifetime sexual victimization history, current anxiety and depression, and current gynecological health complaints (dysmenorrhea, dyspareunia, vaginal discharge, pain during urination, and pelvic pain). Mediation analyses with bootstrapping were conducted to explore the relations among study variables.


      College women with a history of sexual victimization were significantly more likely to report experiencing the gynecological health complaints in the past month than women with no sexual victimization history (all ps < .05). There was a significant indirect path from sexual victimization to gynecological health complaints through both anxiety and depression for all three victimization types (βs = 0.12–0.26). The indirect paths were stronger for women with combined childhood sexual abuse/adolescent/adult sexual assault histories as compared with the other two types of victimization history.


      Health care providers working with college women should implement a trauma-informed approach to addressing gynecological health complaints that recognizes that sexual victimization survivors are at an increased risk for these issues. Further, anxiety and depression represent possible mechanisms of risk for gynecological health complaints among survivors.
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Women's Health Issues
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Abdi H.
        • Williams L.J.
        Tukey’s honestly significant difference (HSD) test.
        in: Salkind N. Encyclopedia of research design. Sage, Newbury Park, CA2010
        • Bonvanie I.J.
        • van Gils A.
        • Janssens K.A.M.
        • Rosmalen J.G.M.
        Sexual abuse predicts functional somatic symptoms: An adolescent population study.
        Child Abuse & Neglect. 2015; 46: 1-7
        • Bouvier P.
        • Halpérin D.
        • Rey H.
        • Jaffé P.D.
        • Laederach J.
        • Mounoud R.-L.
        • Pawlak C.
        Typology and correlates of sexual abuse in children and youth: Multivariate analyses in a prevalence study in Geneva.
        Child Abuse & Neglect. 1999; 23: 779-790
        • Campbell R.
        • Lichty L.F.
        • Sturza M.
        • Raja S.
        Gynecological health impact of sexual assault.
        Research in Nursing & Health. 2006; 29: 399-413
        • Conoscenti L.M.
        • McNally R.J.
        Health complaints in acknowledged and unacknowledged rape victims.
        Journal of Anxiety Disorders. 2006; 20: 372-379
        • Cougle J.R.
        • Resnick H.
        • Kilpatrick D.G.
        Does prior exposure to interpersonal violence increase risk of PTSD following subsequent exposure?.
        Behaviour Research and Therapy. 2009; 47: 1012-1017
        • Craner J.R.
        • Martinson A.A.
        • Sigmon S.T.
        • McGillicuddy M.L.
        Prevalence of sexual trauma history using behaviorally specific methods of assessment in first year college students.
        Journal of Child Sexual Abuse. 2015; 24: 484-505
        • Crawford J.R.
        • Henry J.D.
        The Depression Anxiety Stress Scales (DASS): Normative data and latent structure in a large non-clinical sample.
        British Journal of Clinical Psychology. 2003; 42: 111-131
        • Decker M.
        • Littleton H.L.
        Sexual revictimization among college women: A review through an ecological lens.
        Victims & Offenders. 2018; 13: 558-588
        • Dougall A.
        • Fiske J.
        Surviving child sexual abuse: The relevance to dental practice.
        Dental Update. 2009; 36: 294-304
        • Dworkin E.R.
        Risk for mental disorders associated with sexual assault: A meta-analysis.
        Trauma, Violence & Abuse. 2020; 21: 1011-1028
        • Dworkin E.R.
        • DeCou C.R.
        • Fitzpatrick S.
        Associations between sexual assault and suicidal thoughts and behavior: A meta-analysis.
        Psychological Trauma: Theory, Research, Practice and Policy, Advance online publication. 2020;
        • Edwards J.R.
        • Lambert L.S.
        Methods for integrating moderation and mediation: A general analytical framework using moderated path analysis.
        Psychological Methods. 2007; 12: 1-22
        • Hassam T.
        • Kelso E.
        • Chowdary P.
        • Yisma E.
        • Mol B.W.
        • Han A.
        Sexual assault as a risk factor for gynaecological morbidity: An exploratory systematic review and meta-analysis.
        European Journal of Obstetrics & Gynecology and Reproductive Biology. 2020; 255: 222-230
        • Hayes A.F.
        • Preacher K.J.
        Statistical mediation analysis with a multicategorical independent variable.
        British Journal of Mathematical and Statistical Psychology. 2014; 67: 451-470
        • International Society for Traumatic Stress Studies (ISTSS)
        International Society for Traumatic Stress Studies Sexual Violence Briefing Paper Work Group. Sexual assault, sexual abuse, and harassment: Understanding the mental health impact and providing care for survivors.
        Date: 2018
        Date accessed: January 7, 2021
        • Jamieson D.J.
        • Steege J.F.
        The association of sexual abuse with pelvic pain complaints in a primary care population.
        American Journal of Obstetrics & Gynecology. 1997; 177: 1408-1412
        • Kelly R.H.
        • Russo J.
        • Katon W.
        Somatic complaints among pregnant women cared for in obstetrics: Normal pregnancy or depressive and anxiety symptom amplification revisited?.
        General Hospital Psychiatry. 2001; 23: 107-113
        • Koss M.P.
        • Abbey A.
        • Campbell R.
        • Cook S.
        • Norris J.
        • Testa M.
        • White J.
        Revising the SES: A collaborative process to improve assessment of sexual aggression and victimization.
        Psychology of Women Quarterly. 2007; 31: 357-370
        • Krebs C.P.
        • Lindquist C.H.
        • Warner T.D.
        • Fisher B.S.
        • Martin S.L.
        College women’s experiences with physically forced, alcohol- or other drug-enabled, and drug-facilitated sexual assault before and since entering college.
        Journal of American College Health. 2009; 57: 639-647
        • Kroenke K.
        • Spitzer R.L.
        • Williams J.B.
        The PHQ-15: Validity of a new measure for evaluating the severity of somatic symptoms.
        Psychosomatic Medicine. 2002; 64: 258-266
        • Lee J.
        • Lee E.H.
        • Moon S.H.
        Systematic review of the measurement properties of the Depression Anxiety Stress Scales-21 by applying updated COSMIN methodology.
        Quality of Life Research. 2019; 28: 2325-2339
        • Littleton H.L.
        • Grills A.E.
        • Drum K.B.
        Predicting risky sexual behavior in emerging adulthood: Examination of a moderated mediation model among child sexual abuse and adult sexual assault victims.
        Violence and Victims. 2014; 29: 981-998
        • Lovibond S.H.
        • Lovibond P.F.
        Manual for the Depression Anxiety Stress Scales.
        Psychology Foundation of Australia, Sydney1995
        • Lovibond P.F.
        • Lovibond S.H.
        The structure of negative emotional states: Comparison of the Depression Anxiety Stress Scales (DASS) with the Beck Depression and Anxiety Inventories.
        Behaviour Research and Therapy. 1995; 33: 335-343
        • McCall-Hosenfeld J.S.
        • Weisman C.S.
        • Perry A.N.
        • Hillemeier M.M.
        • Chuang C.H.
        “I just keep my antennae out”: How rural primary care physicians respond to intimate partner violence.
        Journal of Interpersonal Violence. 2014; 29: 2670-2694
        • MacKinnon D.P.
        • Lockwood C.M.
        • Hoffman J.M.
        • West S.G.
        • Sheets V.
        A comparison of methods to test mediation and other intervening variable effects.
        Psychological Methods. 2002; 7: 83-104
        • Miron L.R.
        • Orcutt H.K.
        Pathways from childhood abuse to prospective revictimization: Depression, sex to reduce negative affect, and forecasted sexual behavior.
        Child Abuse & Neglect. 2014; 38: 1848-1859
        • Muthén L.K.
        • Muthén B.O.
        Mplus user’s guide, 8th ed.
        Date: 1998–2017
        Date accessed: January 7, 2021
        • Nelson S.
        • Baldwin N.
        • Taylor J.
        Mental health problems and medically unexplained physical symptoms in adult survivors of childhood sexual abuse: An integrative literature review.
        Journal of Psychiatric and Mental Health Nursing. 2012; 19: 211-220
        • Nelson E.C.
        • Norries J.
        • Bryan A.E.B.
        • Stappenbeck C.A.
        Sexual assault severity and depressive symptoms as longitudinal predictors of the quality of women's sexual experiences.
        Sex & Marital Therapy. 2017; 43: 463-478
        • Osman A.
        • Wong J.L.
        • Bagge C.L.
        • Freedenthal S.
        • Gutierrez P.M.
        • Lozano G.
        The Depression Anxiety Stress Scales-21 (DASS-21): Further examination of dimensions, scale reliability, and correlates.
        Journal of Clinical Psychology. 2012; 68: 1322-1338
        • Owens L.
        • Terrell S.
        • Low L.K.
        • Loder C.
        • Rhizal D.
        • Scheiman L.
        • Seng J.
        Universal precautions: The case for consistently trauma-informed reproductive healthcare.
        American Journal of Obstetrics & Gynecology. 2021; 226: 671-677
        • Preacher K.J.
        • Hayes A.F.
        SPSS and SAS procedures for estimating indirect effects in simple mediation models.
        Behavior Research Methods, Instruments, & Computers. 2004; 36: 717-731
        • Pulverman C.S.
        • Kilmnik C.D.
        • Meston C.M.
        The impact of childhood sexual abuse on women’s sexual health: A comprehensive review.
        Sexual Medicine Reviews. 2018; 6: 188-200
        • Roberts S.J.
        • Chandler G.E.
        • Kalmakis K.
        A model for trauma-informed primary care.
        Journal of the American Association of Nurse Practitioners. 2019; 31: 139-144
        • Sadler A.G.
        • Mengeling M.A.
        • Fraley S.S.
        • Torner J.C.
        • Booth B.M.
        Correlates of sexual functioning in women veterans: Mental health, gynecologic health, health status, and sexual assault history.
        International Journal of Sexual Health. 2012; 24: 60-77
        • Shrout P.E.
        • Bolger N.
        Mediation in experimental and nonexperimental studies: New procedures and recommendations.
        Psychological Methods. 2002; 7: 422-445
        • Staples J.M.
        • Eakins D.
        • Neilson E.C.
        • George W.H.
        • Cue Davis K.
        • Norris J.
        Sexual assault disclosure and sexual functioning: The role of trauma symptomatology.
        Journal of Sexual Medicine. 2016; 13: 1562-1569
        • Svavarsdottir E.K.
        • Orlygsdottir B.
        Identifying abuse among women: Use of clinical guidelines by nurses and midwives.
        Journal of Advanced Nursing. 2009; 65: 779-788
        • Sutherland M.A.
        • Hutchinson M.K.
        Organizational influences on the intimate partner violence and sexual violence screening practices of college health care providers.
        Research in Nursing & Health. 2019; 42: 284-295
        • Williams C.
        • Larsen U.
        • McCloskey L.A.
        The impact of child sexual abuse and intimate partner violence on sexually transmitted infections.
        Violence and Victims. 2010; 25: 787-798
        • Williams L.M.
        • Siegel J.A.
        • Pomeroy J.J.
        Validity of women’s self-reports of documented child sexual abuse.
        in: Stone A.A. Turkkan J.S. Bachrach C.A. Jobe J.B. Kurtzman H.S. The science of self-report: Implications for research and practice. Lawrence Erlbaum, Mahwah, NJ2000: 211-226
        • Woods A.B.
        • Page G.G.
        • Campo P.
        • Pugh L.C.
        • Ford D.
        • Campbell J.C.
        The mediation effect of posttraumatic stress disorder symptoms on the relationship of intimate partner violence and IFN-gamma levels.
        American Journal of Community Psychology. 2005; 36: 159-175
        • Zilkens R.R.
        • Smith D.A.
        • Phillips M.A.
        • Mukhtar S.A.
        • Semmens J.B.
        • Kelly M.C.
        Genital and anal injuries: A cross-sectional Australian study of 1266 women alleging recent sexual assault.
        Forensic Science International. 2017; 275: 195-202


      Heather Littleton, PhD, is Director of Research Operations and Associate Professor at the Lyda Hill Institute for Human Resilience at the University of Colorado Colorado Springs. Her research focuses on risk factors for sexual violence and factors that affect violence recovery.


      LaNika Wright, PhD, WHNP-BC, is the Director of Student Health at East Carolina University. Her research interests include the acute and long-term care of patients with a sexual assault history.


      Julia C. Dodd, PhD, is an Assistant Professor in the Department of Psychology at East Tennessee State University. Her research interests include sexual and reproductive health and the pathways via which traumatic experiences create and heighten health disparities.


      Molly Higgins, BA, is a doctoral student in the Trauma Psychology track of the Clinical Psychology program at the University of Colorado Colorado Springs. Her research interests include the role of physical activity in natural recovery following sexual violence.