The Relationship Between Alcohol Consumption and Sexual Victimization

Jeanette Norris

            Approximately 1 out of every 6 women in the United States has experienced attempted or completed rape (Tjaden & Thoennes, 2006). Fewer than one-fifth of these incidents are perpetrated by strangers, and at least half of all acquaintance sexual assaults involve alcohol consumption by the perpetrator, the victim, or, most commonly, both (Abbey, Zawacki, Buck, Clinton, & MacAuslan, 2004; Tjaden & Thoennes, 2006). The purpose of this paper is to provide a brief review and critique of research that examines the relationship between alcohol consumption and sexual victimization. The focus will be on victims' experiences, including resistance during and psychological effects subsequent to alcohol-involved sexual assault incidents. This does not in any way imply that women are responsible for sexual assaults perpetrated against them. Rather, the goal is to understand sexual assault from the victim's perspective so that women can be empowered to make informed decisions about alcohol use that may lower their risk. Consequently the paper will: 1) give a general overview of alcohol use in the United States; 2) define and discuss major types of alcohol effects; 3) provide information about the connection between alcohol consumption and sexual victimization; 4) discuss the relationship between alcohol consumption and sexual assault outcomes; 5) describe how a history of child sexual abuse may increase the risk for adult sexual assault; and 6) suggest ways in which this information can be used in risk reduction interventions and incorporated into work with sexual assault victims.

            Rape refers to vaginal, oral, or anal penetration obtained through force, threat of force, or the inability of the victim to provide consent. The term sexual assault is a more encompassing term and includes sexual acts ranging from non-consensual touching and kissing to attempted and completed rape. Alcohol-involved sexual assault is any sexual assault that occurs after the victim and/or the perpetrator has consumed alcohol and can be considered under its influence. A psychoactive drug is a drug that has effects on the brain and central nervous system. It can affect functions such as thinking, emotions, and motor control.

An Overview of Alcohol Use in the United States

            In the U.S. alcohol is one of the most commonly used psychoactive drugs, along with tobacco and caffeine. More than 80% of Americans report having drunk alcohol at some point in their lives with use as high as 90% among young adults, tapering off somewhat after age 35 (National Institute on Alcohol Abuse and Alcoholism [NIAAA], 2008). However, there is a great deal of variability in drinking practices across age, gender, and ethnic groups. In general fewer women than men drink, but women become more impaired after drinking the same amount as men. Women are also more vulnerable to some of alcohol's detrimental effects, such as organ damage, compared to men, and women who drink are more likely than those who do not to experience violent victimization (NIAAA, 1999).

            Regarding ethnicity, more Whites than Blacks or Hispanics drink (NIAAA, 2008), but published statistics on Native Americans are difficult to obtain. While drinking practices can vary greatly among tribes, it is widely acknowledged that high rates of drinking occur among Native Americans, as well as drinking-related problems (Center on Alcohol Marketing & Youth, 2006; Szlemko, Wood, & Thurman, 2006). Asian-Americans have historically reported the lowest rates of alcohol use in the US (Caetano, Clark, & Tam, 1998). However, there is considerable variation across particular Asian ethnic groups (Makimoto, 1998), and their alcohol consumption has increased in recent years. This is especially true among young Asian-Americans, possibly because of acculturation to mainstream U.S. drinking norms (NIAAA, 2002).

            Many individuals claim psychological benefits of drinking, such as relaxation, stress reduction, social facilitation, and sexual enhancement, but may also use drinking as an excuse for unacceptable behavior (Critchlow, 1986). Well-known, too, are the detrimental short- and long-term effects of excessive alcohol use, including, but not limited to, hangover and involvement in accidents, as well as addiction and its accompanying outcomes such as depression, medical problems, and job and family loss (NIAAA, 2004). Because alcohol is so commonly used, it is imperative that individuals understand its effects and make informed decisions about its use.

Types of Alcohol Effects

            Alcohol has both physiological and learned effects. As a person becomes more intoxicated, alcohol's physiological effects result in a decreased ability to process information and make judgments, impaired motor control, slurred speech, deterioration of reaction time, and ultimately loss of consciousness. In extreme cases of alcohol poisoning, death may occur (Hanson, Venturelli, & Fleckenstein, 2002). Of particular relevance to understanding the relationship between alcohol consumption and sexual victimization are alcohol's effects on cognitive abilities, such as decision-making and risk perception, and on stress reduction. As individuals become more intoxicated, they become less able to process a large amount of information. As a result, they focus on the most prominent cues in the environment, an effect known as ìalcohol myopiaî (Steele & Josephs, 1990). Frequently in social situations the most prominent cues are those associated with having fun, such as interacting with others, flirting, being sexually attracted to someone, or possibly developing a relationship. On the other hand, cues that might indicate risk, such as a man intentionally giving a woman strong drinks, are less likely to be noticed.

            Stress reduction that occurs after consuming alcohol can result in part from alcohol's physiological effects on thought processes. If someone does not perceive risk cues because of intoxication, feelings of anxiety or stress that might spur someone to avoid or leave a risky situation may not be generated. This effect is known as ìstress response dampeningî and is especially likely to occur if stress-producing cues are difficult to perceive, that is, when they are not very prominent (Sayette, 1993). For instance, if a woman were sober, she would be likely to notice that a man had given her a very strong drink as soon as she tasted it. This might lead her to think that he was deliberately trying to get her drunk and might make her nervous about his intentions. Therefore, she might try to avoid him. However, after having a couple of ìnormalî drinks, a woman might become somewhat intoxicated. In this state it can become more difficult to notice that a man has started putting extra alcohol in her drinks. Therefore, she would not feel alarmed, and it might not occur to her to get away from him. Both myopia and stress response dampening effects become more powerful as a person becomes more intoxicated.

            Culture, as well as personal experience, can influence an individual's beliefs about how alcohol will affect them (MacAndrew & Edgerton, 1969). These beliefs result from observing or talking with others and are called outcome expectancies. They can affect how much and when people drink (Goldman, Del Boca, & Darkes, 1999) and have also been tied to behaviors such as socializing and having sex (Dermen & Cooper, 1994). For instance, if someone believes that alcohol consumption will help her enjoy sex, she might drink in order to do so. Likewise, if a woman believes that alcohol consumption makes her feel vulnerable or powerless, she might not attempt to strongly resist a man's unwanted sexual advances after drinking. Expectancies can serve as a motivation for drinking and can set the stage for how individuals behave when they do drink. In general, when individuals drink it is likely that both expectancy and physiological effects occur simultaneously.

Alcohol Consumption and Risk for Sexual Victimization

            How does alcohol consumption raise a woman's risk of being sexually assaulted? The most obvious way concerns extreme intoxication: When a woman becomes severely debilitated from excessive drinking, she cannot effectively resist an assault. Some women have been raped when they are unconscious from alcohol consumption. Predatory men look for vulnerable women to rape, and drinking women are often viewed as sexually available (George, Cue, Lopez, Crowe, & Norris, 1995). Several studies have connected increased risk of being sexually assaulted with heavy drinking at the time (Mohler-Kuo, Dowdall, Koss, & Wechsler, 2004; Neal & Fromme, 2007; Parks & Fals-Stewart, 2004; Parks, Hsieh, Bradizza, & Romosz, 2008; Testa, VanZile-Tamsen, & Livingston, 2004). Not surprisingly, these women tend to be heavy drinkers in general (Krebs, Lindquist, Warner, Fisher, & Martin, 2007; Neal & Fromme, 2007; Parks, Romosz, Bradizza, & Hsieh, 2008), but women who are usually light drinkers may be particularly vulnerable to being sexually assaulted if they engage in heavy drinking on a particular occasion (Neal & Fromme, 2007). This may be because they do not have a high tolerance for alcohol and may experience its debilitating effects rather quickly. Often this is the case among young women who drank in high school and increase their alcohol consumption when they reach college and live away from home for the first time (Krebs et al., 2007; Mohler-Kuo et al., 2004; Parks et al., 2008).

            The social environment that someone spends time in can also come into play in these situations. Attending colleges that have reputations as ìparty schoolsî where heavy drinking is the norm and being associated with fraternities or sororities have been related to increased risk of alcohol-involved sexual assault (Krebs et al., 2007; Mohler-Kuo et al., 2004). Women are often sexually assaulted after drinking in bars or at parties, especially by men who are relatively unknown to the victim (Testa, Livingston, Vanzile-Tamsen, 2003). Settings that promote heavy drinking may encourage lack of restraint in other areas as well, including sexually. This may partially account for the connection between the number of sex partners a woman has had and an increased risk for being sexually assaulted when intoxicated (Parks et al., 2008), since intoxication may increase women's exposure to potential assailants. Frequency of drinking before sex has also been associated with alcohol-involved sexual assault (Abbey, Ross, MacDuffie, & MacAuslan, 1996; Krebs et al., 2007).

            There is a dearth of research on risk factors for alcohol-involved sexual assault across ethnic groups, or even to what extent there may be differences in prevalence rates. Some studies have found higher rates of rape among African-American women in general (Abbey et al., 1996; Scott, Lefley, & Hicks, 1993); however, others have found no differences in the prevalence of rape between African-Americans and other groups (Kalof, 2000; Tjaden & Thoennes, 2006). A nationally representative survey found the highest rates of rape reported by Native American women and the lowest among Asian-Americans (Tjaden & Thoennes, 2006). Abbey et al. (1996) found that African-American women were more likely than Caucasian women to report that neither they nor their assailants had consumed alcohol prior to the assault, yet predictors of alcohol-involved sexual assaults were the same for both groups. These included: women's frequency of drinking during a sexual assault, frequency of drinking during consensual sex, and number of dating partners.

            Many men believe that getting a woman drunk is just an easy way to increase their chances of having sex. The poet Ogden Nash's oft-quoted aphorism, ìCandy is dandy, but liquor is quickerî (Nash, 1995) indicates how deeply engrained this belief is. However, when a woman drinks to such an extent that she can no longer give consent, a man who continues to pursue having sex with her commits a sexual assault and should be adjudicated. Unfortunately this rarely occurs (Temkin & KrahÈ, 2008).

            Alcohol can also raise the risk of sexual assault at lower levels of consumption. A major complicating factor in the association between alcohol consumption and sexual assault is the frequent use of alcohol as a social lubricant. As noted earlier, many individuals expect alcohol to have beneficial effects and often drink to obtain them, especially in social situations. Although in most instances these associations are not problematic, some researchers have found stronger expectancies for tension reduction and sexual enhancement for victims of attempted and completed rape, including those who were intoxicated, than in non-victims (Corbin, Bernat, Calhoun, McNair, & Seals, 2001). Also indicative of the influence of expectancies, the victimized women reported more sexual activity after drinking in general. In another study that compared alcohol- and drug-involved sexual assault victims to non-victims and those who had not consumed any psychoactive substances prior to being sexually assaulted, the alcohol/drug victims were most likely to report greater alcohol effects on social and physical pleasure, aggression, social expression, impairment, and careless unconcern (Marx, Nichols-Anderson, Messman-Moore, Miranda, & Porter, 2000). In short, some women might drink to enhance their sociability, sexual enjoyment, or to ìlet looseî and have a good time. In doing so, these expectations could lead to excessive drinking: some women might think that if a little bit of alcohol helps, then a whole lot might be even better. As discussed above, excessive alcohol consumption substantially raises the risk for sexual assault. Thus, expectancies could indirectly increase some women's vulnerability to sexual assault.

            Abbey, McAuslan, Ross, and Zawacki (1999) developed a measure of alcohol expectancies related specifically to sex, aggression, and sexual vulnerability. They found that both women and men tended to endorse gender stereotypic expectancies when judging alcohol effects on others but not themselves. Intoxicated male targets were perceived as having higher sex drive and aggression than female targets whereas female targets were seen as more sexually vulnerable after drinking. The researchers point out that these expectancies mirror typical sexual assault scenarios and might result in victim blaming. After all, if a man cannot control his sex drive and a woman does not resist, then can it really be a sexual assault? Just as disturbing are findings that women who were the heaviest drinkers and held the highest alcohol expectancies related to sexual vulnerability for themselves also reported the most severe sexual victimization (Benson, Gohm, & Gross, 2007). Other researchers have similarly found that women with the strongest sexual vulnerability expectancies tend to also be the heaviest drinkers (Abbey et al., 1999; Benson et al., 2007; Marx et al., 2000). It is important to note that none of these studies can establish that women's alcohol expectancies cause their sexual assault. Do women who have been raped after drinking develop high sexual vulnerability expectancies because of their rape experience, or does having strong sexual vulnerability expectancies lead to less assertive resistance and a greater likelihood of being raped after drinking? While the answer to this question is not clear, it can be important for mental health providers to question alcohol-involved sexual assault victims about their alcohol beliefs in order to understand the experience from the woman's perspective and help her to work through it.

            Men and women commonly drink when socializing together (Norris, Nurius, & Dimeff, 1996) and most of these occasions do not result in sexual assault. However, alcohol-involved sexual assault is more likely to occur in the context of socializing with men who are not well-known than with intimate partners (Testa, VanZile-Tamsen, & Livingston, 2007). Thus, in such situations women are faced with having to process conflicting cues and other types of information from the setting, resulting in what has been termed ìwalking a cognitive tightropeî (Norris et al., 1996). On the one hand, traditional gender roles encourage women to be attractive to men by dressing and acting sexy, and yet to be the gatekeeper for any sexual activity, specifically to assume responsibility for their own safety. Thus, when a man responds positively to a woman, it is normally taken as a sign of mutual attraction and the couple's interaction might escalate into some amount of consensual sexual activity. Depending on how aggressive a man is and what his intentions are, their interaction might be completely satisfactory. But what if the man's actions and intentions are not completely clear? Many risk cues, such as being led to an isolated setting and consuming alcohol, can be ambiguous because they can also be a typical part of socializing and sexual flirtation (Norris, Nurius, & Graham, 1999). After drinking even a relatively small amount, it can be difficult to detect and feel uncomfortable with ambiguous risk cues (Davis, Stoner, Norris, George, & Masters, in press), especially when alcohol itself serves as a cue for consensual sex (George & Stoner, 2000). Moreover, after drinking, women may be more likely than when sober to anticipate benefits from and to engage in behaviors that might put them at higher risk for a sexual assault, such as letting a potentially risky man into their apartment, kissing him, and drinking with him (Testa, Livingston, & Collins, 2000). These effects likely occur because of alcohol's myopia and stress reduction effects. That is, the setting, her initial interactions with the man, and the association between alcohol and consensual sex lead a woman to see the situation in a positive light. Because of this focus on the pleasurable aspects of an interaction, an intoxicated woman may not recognize that a man has become sexually aggressive until his actions have become quite overt (Macy, Nurius, & Norris, 2006; Nurius, Norris, Macy, & Huang, 2004). Hence, fear that might otherwise motivate a woman to extract herself from a potentially dangerous situation is not evoked.

            Once a woman recognizes that a man has become sexually aggressive, alcohol may affect both the type and strength of resistance that she displays. Some studies have shown that alcohol consumption increases passive resistance or immobility, such as going along without wanting to or feeling paralyzed (Davis, George, & Norris, 2004; Testa, VanZile-Tamsen, Livingston, & Buddie, 2006), and ìpoliteî resistance, such as verbal negotiation or distraction, but decreases assertive resistance (Norris et al., 1996; Testa et al., 2006), such as yelling or hitting and kicking. As a woman becomes increasingly intoxicated, she may fail to respond more assertively as the man's aggression escalates whereas less intoxicated or sober women may increase their resistance concurrent with increased sexual aggression (Norris et al., 2006).

            Stress response dampening might play a role in the way in which alcohol lowers assertive sexual assault resistance. One study found that perceived severity of a sexual assault, as indicated by how fearful and helpless women felt, mediated the impact of alcohol consumption on victims' panic reactions during the assault, such as shortness of breath, increased heart rate, and sweating (Clum, Nishith, & Calhoun, 2002). That is, the more intoxicated a woman was during the attack, the less fearful and helpless she felt. The lower these feelings were, the less likely she was to feel panicked. In a similar vein, Testa and colleagues (2006) found that risk perception mediated the effect of alcohol on women's resistance intentions after reading a sexual assault scenario. The more intoxicated the women were, the less likely they perceived the situation as risky, which led to lower assertive resistance intentions. Thus, lowering fear reactions and perceived risk appears to be one mechanism by which alcohol can prevent women from assertively resisting a sexual assault.   

            Resistance responses may additionally be influenced by thoughts and feelings about the man and the situation. These thoughts and feelings have been labeled ìpsychological barriers to resistanceî (Norris et al., 1996). As a woman becomes more intoxicated, she may feel more conflict and uncertainty about what is happening in the situation, as well as embarrassment (Norris et al., 1996), which in turn can lead to unassertive resistance (Stoner et al., 2007). This can occur both because of cognitive impairment and the expectancy that alcohol is associated with consensual sex, thus causing confusion about the man's actions. On the other hand, in some situations alcohol consumption may result in less concern about harming the woman's relationship with the man or being injured, and she might feel less self-conscious about resisting (Macy et al., 2006). This might occur because intoxication has focused the woman on sexual aggression cues, thus potentially aiding her in mounting an assertive resistance. Drinking women may also recognize that alcohol consumption can serve as a barrier to resistance (Macy et al., 2006; Norris et al., 1996), which may serve as a self-fulfilling prophecy. That is, believing that she is too drunk to resist might actually lead the woman not to resist as assertively as she might when sober (Norris et al., 1996).

            A previous history of adult sexual assault (ASA) has also been related to lessened assertive resistance to later sexual assault experiences (Gidycz, Van Wynsberghe, & Edwards, 2008; Norris et al., 1996). ASA has also been associated with psychological barriers, such as embarrassment and the belief that alcohol impedes resistance, which in turn have been related to lessened resistance (Macy et al., 2006; Norris et al., 1996; Stoner et al., 2007). A study that developed separate profiles of sexual assault victims found that women who had had the highest level of alcohol consumption during a sexual assault, as well as the highest level of previous ASA, reported high powerlessness, recognized that alcohol made them vulnerable and impeded their resistance, and experienced the second highest level of completed rape, compared to others in the study. In contrast, women who were below average in both prior ASA and alcohol use at the time of the sexual assault noticed the man's controlling behavior, were above average in concern about injury and assertively resisting, and had experienced the lowest rate of completed rape (Macy, Nurius, & Norris, 2007 a,b).

            Ironically, when discussing alcohol's effects on resistance outside of an actual sexual assault situation, women are often overconfident that they can maintain control of a situation, even when drunk, and express the belief that other women are at greater risk than they are (Norris et al., 1996; Norris et al., 1999). However, heavy drinkers seem to recognize that they are at higher risk for being sexually assaulted than light or moderate drinkers. Gidycz et al. (2007) found that women who reported drinking at least once a week and typically were binge drinkers (drinking at least four drinks within a relatively short period of time) rated their risk of being sexually assaulted significantly higher than the other groups. This study also found that a previous history of sexual assault did not predict risk perception. Future research should address why heavy drinking women recognize their heightened risk for being sexually assaulted, yet do not moderate their drinking to lower their risk. Interventions should be developed to emphasize this connection and teach women how to stay in control while still having a good time.

The Relationship Between Alcohol and Sexual Assault Outcomes

            Sexual assault, regardless of whether the victim was drinking at the time, has been associated with negative consequences such as posttraumatic stress disorder (PTSD) and problem drinking (Ullman, Filipas, Townsend, & Starzynski, 2005, 2006). Sexual assault victims who experience both of these outcomes simultaneously have reported greater self-blame, belief that alcohol reduces tension, drinking to cope with negative affect, more negative reactions from others, and a history of other trauma, compared to sexual assault victims who have reported only PTSD symptoms (Ullman et al., 2006). Drinking to decrease negative feelings has been found to mediate the relationship between severity of sexual assault and general level of drinking (Miranda, Meyerson, Long, Marx, & Simpson, 2002). In other words, the positive relationship between sexual assault severity and drinking amount can at least in part be explained by using alcohol to decrease feelings such as anxiety and stress that may result from the assault.

            Relatively little research has specifically examined effects of being sexually assaulted while intoxicated. It appears that problematic drinking may serve as both a risk factor for being raped while intoxicated and a consequence of it (Kaysen, Lindgren, Lee, & Simpson, 2007; Kaysen, Neighbors, Martell, Fossos, & Larimer, 2006). That is, victims who had been raped after drinking had been heavier drinkers before the event, increased their drinking afterward, and experienced more negative consequences of drinking afterward than non-victims. Moreover, women's risk of future sexual victimization increases as level of previous sexual assault severity and drinking practices increase (Gidycz et al. , 2007). Women who have both a history of previous sexual assault and who are heavy drinkers may have a greater likelihood of being re-victimized than women with lower levels of either of these risk factors.

            Very little research has examined how ethnicity might play a role in women's experiences after being sexually assaulted. A study comparing Asian-American and Caucasian college women found that although Asian-American women who had not been raped while intoxicated had fewer drinking problems than Caucasian non-victims, Asian-Americans who had been raped after drinking reported more drinking problems than Caucasian women who were raped after drinking (Nguyen, Kaysen, Dillworth, Brajcich, & Larimer, 2008). Because these data were cross-sectional, it is not possible to determine whether the women who were raped after drinking were already problem drinkers beforehand. Another possibility is that the cultural stigma attached to both sexual assault and women's drinking in some Asian cultures might result in more severe consequences for Asian women compared to Caucasian women. Clearly more research in this area is needed.

            Being sexually assaulted after drinking has also been associated with heightened self-blame (Macy et al., 2006). Victims often feel that ìthey should have known betterî than to drink so much, or they should have been able to stay in control no matter how much alcohol they consumed. They end up feeling that they ìdeserved what they got.î Despite potentially feeling increased blame after an alcohol-involved sexual assault, Ullman (1996) found that sexual assault disclosure to anyone ñ family or friends, mental health providers, or law enforcement ñ did not differ for women who had been assaulted after drinking versus when sober. However, Krebs et al. (2007) reported that compared to women sexually assaulted through the perpetrator's use of force, women who had been incapacitated by alcohol or other drugs were less likely to report to either mental health providers or law enforcement officials, but there was no difference between the two groups in reporting to family or friends. Both of these studies found that sexual assault victims disclosed sooner if the perpetrator had used alcohol. This might occur because women are blamed least for a sexual assault when only the perpetrator has been drinking compared to when neither, both, or only the victim has been (Norris & Cubbins, 1992). Because it is only by disclosing sexual assault to others that a woman can receive help, future research should examine how to encourage women who have experienced alcohol-involved sexual assault to report it.

            Although lower alcohol consumption may reduce the risk of being sexually assaulted, a woman who is sexually assaulted when intoxicated should not be blamed for the assault. A man's sexual aggression is his responsibility and he should be held accountable for taking advantage of a vulnerable person and committing an act of violence. The ìpunishmentî for getting drunk should not be getting raped. Women need to know that they have a right to say no at any point during a sexual encounter with a man: A woman does not ìoweî a man anything in return for his attentions or for having engaged in some consensual sexual activity with him.

Childhood Sexual Abuse (CSA), Adult Sexual Assault (ASA), and Alcohol

      More than half of all rapes occur before the age of 18 (Tjaden & Thoennes, 2006), and having been sexually abused in childhood puts a woman at greater risk of adult sexual assault (Messman-Moore & Long, 2003). As noted earlier, adult sexual assault is associated with problem drinking and PTSD. A history of CSA might increase the likelihood of experiencing an adult sexual assault through its association with heavy or problematic drinking. CSA victims often try to cope with their psychological pain through alcohol consumption (Filipas & Ullman, 2006; Miranda et al., 2002), a phenomenon described as ìchemically induced dissociationî (Briere & Runtz, 1987). This in turn could lower the ability to perceive risk as intoxication level increases. Therefore, women sexually victimized in childhood and who are heavy drinkers might be especially vulnerable to not recognizing risk cues as adults, which in turn could lead to immobility or passive resistance (Gidycz et al., 2008; Stoner et al., 2007) and lower assertive resistance (Gidycz et al., 2008; Norris et al., 1996).

            Among a national sample of sexual assault victims who had experienced both childhood and adult sexual assault, the number of alcohol dependence and PTSD symptoms were positively associated with seeking help for mental health or substance problems (Ullman & Brecklin, 2003). Two studies have found that drinking to cope with emotional distress or to enhance mood mediates the effect of CSA on problem drinking (Grayson & Nolen-Hoeksema, 2005; Ullman et al., 2005), and a similar effect has been found for child abuse and neglect in general, including CSA (Schuck & Widom, 2001). PTSD has also been found to mediate the relationship between CSA and adult alcohol abuse (Epstein, Saunders, Kilpatrick, & Resnick, 1998). These studies indicate that women who have experienced child abuse, especially CSA, may be particularly vulnerable to drinking problems in adulthood and that these problems are often compounded by having experienced adult sexual assault and resulting PTSD. Recognizing that women often drink to cope with the effects of trauma pinpoints areas for clinical intervention. Understanding these dynamics can aid mental health and substance abuse treatment providers in exploring these underlying issues in women who present for alcohol abuse.

Summary and Recommendations

            Despite three decades of recognition and research, sexual assault remains a major public health problem and the percentage of sexual assaults that involve alcohol hovers around 50%. Alcohol consumption can raise the risk of sexual assault through both physiological and learned, or expectancy, effects. Alcohol myopia can focus attention on prominent social cues rather than ambiguous risk cues. Without the alarm that would normally arise from recognizing risk, a woman might not experience the anxiety or fear that would motivate her to leave a situation. Because of intoxication she might also experience a variety of psychological barriers that impede assertive resistance. Expectancies about alcohol effects might indirectly raise the risk of sexual assault through motivating a woman to drink excessively in order to experience anticipated beneficial effects of drinking or by increasing her belief that alcohol makes her more sexually vulnerable and therefore less able to resist.

            Alcohol can also play a role in the aftermath of sexual assault, whether or not the assault occurred after drinking. Drinking to cope with the trauma can lead to problem drinking and increase the risk of being re-victimized. If a woman feels somewhat responsible for a sexual assault because she was drinking at the time, she may be less willing to disclose the attack to others, thereby making it considerably less likely that she will receive needed help to deal with its effects. Because child sexual abuse can also result in drinking to cope as an adult, women with this history are at increased risk for being re-victimized and suffering PTSD and other negative consequences from problem drinking.

            A multi-pronged approach is needed to make both risk reduction and victim treatment efforts more effective. A brief review such as this can only highlight some of the many research needs and points of intervention that must be addressed in the association between alcohol consumption and sexual victimization. For instance, risk reduction and treatment efforts aimed at women need to convey how alcohol myopia can affect both risk perception and resistance. Role play and brainstorming are some of the techniques that can be used to teach women how to stay in control when drinking and develop strategies for identifying and avoiding potentially high-risk men. These techniques can be incorporated into anti-violence or drug and alcohol education programs as early as middle school and high school. The role of expectancies also needs to be addressed. Some programs have developed effective ways of challenging individuals' beliefs about alcohol effects in order to change drinking behavior (see, for instance, Lau-Barraco & Dunn, 2008). These efforts need to be increased and directed specifically toward sexual assault.

            Risk reduction and treatment efforts also need to recognize that some women may be more vulnerable than others. Programs that address substance abuse prevention, especially among young people, should include material that specifically deals with the relationship between alcohol and sexual assault. Women who have previously experienced sexual victimization as a child, adolescent, or adult should receive information about how alcohol consumption can increase their vulnerability to revictimization. Service providers need to be especially sensitive to the issue of self-blame, which is a particular concern for women who were sexually assaulted while intoxicated. Blaming oneself can be one way that rape victims gain a sense of control, and so therapists need to handle this issue with great care. In addition, service providers need to understand how phenomena such as dissociation and feelings of powerlessness resulting from earlier victimization might lead to drinking to cope and excessive alcohol consumption. This in turn can lead to lower assertive resistance during an assault and increase feelings of responsibility. Helping women to understand the underlying dynamics of their responses may aid their recovery.

            The extent to which there are differences across ethnic groups in the occurrence of sexual assault overall has not been well established, although one national study indicates that Native American women are at higher risk than other groups. Almost nothing is known about how cultural factors influence the experience of and responses to alcohol-involved sexual assault. This is a critical area for future research because mental health providers need to be especially sensitive to cultural issues in order to maximize the effectiveness of their therapeutic approaches.

            At the societal level, widespread blaming of the victim for being sexually assaulted while intoxicated needs increased attention. This practice affects the way the victim is treated by police or other professionals and is internalized by the victim, leading to reticence to report the crime to the police, as well as to seek medical help and counseling. As we as a society have made progress obtaining recognition that rape is not just seduction gone awry, so too do we need to make headway on further understanding that alcohol-involved sexual assault is a crime and should be treated as such. Concomitantly, blame needs to be placed squarely on those who commit these acts. Men and boys need to receive strong messages that using alcohol to obtain sex is not appropriate. Whether this occurs by urging women to drink, by providing extra-strong drinks, or by taking advantage of women who are too drunk to give consent, it is not acceptable and serious consequences will be imposed. Risk reduction programs need to be developed for boys and men to more effectively transmit these messages.

            Alcohol-involved sexual assault will not diminish without greater attention and effort at many levels. As members of our larger society, researchers and educators have a responsibility to double their efforts to change attitudes about women who are sexually victimized after drinking. At an individual level, it is important for those who work with victims to understand the phenomenon from their perspective. Just as no one who is about to go out in public is expected to prepare to be mugged at gunpoint, neither do women preparing for an evening of socializing think about which man might sexually assault them. Although insuring personal safety is an important consideration for all women, so too is being open to meeting and engaging with new acquaintances. It is important to acknowledge that this often occurs in the context of alcohol consumption. Helping women from an early age to maintain their balance while ìwalking the cognitive tightropeî should be a prime goal of sexual assault risk reduction endeavors.

Author of this document:
Jeanette Norris, Ph.D.
Senior Research Scientist
Alcohol and Drug Abuse Institute
norris@u.washington.edu

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