Association of Sexual Harassment and Sexual Assault With Midlife Women’s Mental and Physical Health Association of Sexual Harassment and Sexual Assault With Midlife Women’s Mental and Physical Health Rebecca C. Thurston, PhD; Yuefang Chang, PhD; Karen A. Matthews, PhD; Roland von Känel, MD; Karestan Koenen, PhD IMPORTANCE Sexual harassment and sexual assault are prevalent experiences among women. However, their association with health indices is less well understood. OBJECTIVE To investigate the association of history of sexual harassment and sexual assault with blood pressure, mood, anxiety, and sleep among midlife women. DESIGN, SETTING, AND PARTICIPANTS Nonsmoking women without cardiovascular disease were recruited from the community to undergo physical measurements (blood pressure, height, weight), medical history, and questionnaire psychosocial assessments (workplace sexual harassment, sexual assault, depression, anxiety, sleep). EXPOSURES Sexual harassment and sexual assault. MAIN OUTCOMES AND MEASURES Blood pressure, depressive symptoms, anxiety, and sleep characteristics. RESULTS Among the 304 nonsmoking women aged 40 to 60 years who participated in the study, all were free of clinical cardiovascular disease, and the mean (SD) age was 54.05 (3.99) years. A total of 19% reported a history of workplace sexual harassment (n = 58), and 22% reported a history of sexual assault (n = 67). Sexual harassment was related to significantly greater odds of stage 1 or 2 hypertension among women not taking antihypertensives (odds ratio [OR], 2.36; 95% CI, 1.10-5.06; P = .03) as well as clinically poor sleep (OR, 1.89; 95% CI, 1.05-3.42; P = .03), after adjusting for covariates. Sexual assault was associated with significantly greater odds of clinically elevated depressive symptoms (OR, 2.86; 95% CI, 1.42-5.77; multivariable P = .003), clinically relevant anxiety (OR, 2.26; 95% CI, 1.26-4.06; P = .006), and clinically poor sleep (OR, 2.15; 95% CI, 1.23-3.77; multivariable P = .007), after adjusting for covariates. CONCLUSIONS AND RELEVANCE Sexual harassment and sexual assault are prevalent experiences among midlife women. Sexual harassment was associated with higher blood pressure and poorer sleep. Sexual assault was associated with poorer mental health and sleep. Efforts to improve women’s health should target sexual harassment and assault prevention. JAMA Intern Med. 2019;179(1):48-53. doi:10.1001/jamainternmed.2018.4886 Published online October 3, 2018. Corrected on November 5, 2018. Related article page 108 Author Affiliations: Author affiliations are listed at the end of this article. Corresponding Author: Rebecca C. Thurston, PhD, Department of Psychiatry, University of Pittsburgh, 3811 O’Hara St, Pittsburgh, PA 15213 (thurstonrc@upmc.edu). Research JAMA Internal Medicine | Original Investigation 48 (Reprinted) jamainternalmedicine.com © 2018 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ by a Carnegie Mellon University User on 04/05/2021 https://jama.jamanetwork.com/article.aspx?doi=10.1001/jamainternmed.2018.4886&utm_campaign=articlePDF%26utm_medium=articlePDFlink%26utm_source=articlePDF%26utm_content=jamainternmed.2018.4886 https://jama.jamanetwork.com/article.aspx?doi=10.1001/jamainternmed.2018.4859&utm_campaign=articlePDF%26utm_medium=articlePDFlink%26utm_source=articlePDF%26utm_content=jamainternmed.2018.4886 mailto:thurstonrc@upmc.edu http://www.jamainternalmedicine.com/?utm_campaign=articlePDF%26utm_medium=articlePDFlink%26utm_source=articlePDF%26utm_content=jamainternmed.2018.4886 S exual harassment and sexual assault are common ex-periences among women. In the United States, an esti-mated 40% to 75% of women have experienced work- place sexual harassment,1 and over 1 in 3 women (36%) have experienced sexual assault.2 With recent popular move- ments (eg, MeToo, #TimesUp), there is rising public aware- ness of sexual harassment and assault and their implications for women’s health. Both sexual harassment and sexual assault have been linked to poorer self-reported physical and mental health outcomes.3-8 While these studies suggest that harassment and assault are associated with adverse outcomes broadly, these findings are limited by several issues. Survey studies, particu- larly of sexual harassment, largely assess physical health via self-report. These reports can be biased by mood, memory, and reporting of physical symptoms9 and by awareness of health conditions, which can vary by socioeconomic status, health care access, and health literacy.10 Another limitation is incom- plete consideration of critical confounding factors, such as socioeconomic position, adiposity, and medication use. Fur- thermore, self-reported outcomes are often assessed using single-question items rather than full validated measures. Re- search on sexual harassment and assault using measured health indices, full multidimensional scales, and comprehensive con- sideration of confounders is warranted. Among a well-characterized sample of 304 midlife women, we investigated the association of a history of sexual harass- ment and sexual assault with blood pressure (BP), depressed mood, anxiety, and sleep, important health issues affecting midlife women. Elevated BP is a major risk factor for cardio- vascular disease (CVD), the leading cause of death in women,11 and an important indicator of risk among midlife women who typically develop clinical CVD later in life.12 Depression and anxiety show a doubling in rates in women relative to men,13 and up to half of midlife women report problems with sleep.14,15 We hypothesized that sexual harassment and assault would be associated with higher BP, more depressed mood and anxi- ety, and poorer sleep after accounting for key confounders. Methods Study Participants A total of 304 nonsmoking women aged 40 to 60 years were recruited from the community (Pittsburgh, Pennsylva- nia) via advertisements, mailings, and online message boards. The cohort was originally selected for a study designed to ex- amine the association of menopausal hot flashes and subclini- cal atherosclerosis as assessed by carotid ultrasonography.16 Per the original study design, half of the women reported menopausal hot flashes, and half reported no hot flashes.16 Of the 1929 women who underwent telephone screening, 304 were eligible and enrolled. Exclusions, selected based on their impact on menopausal symptoms and cardiovascular health, included premenopausal status; hysterectomy or oophorec- tomy; reported history of CVD, arrhythmia, kidney failure, gy- necological cancer; current pregnancy; or having used key medications in the past 3 months: oral/transdermal estrogen or progesterone, selective estrogen receptor modulators, se- lective serotonin reuptake inhibitors, serotonin norepineph- rine reuptake inhibitors, gabapentin, insulin, β-blockers, calcium channel blockers, and α-2 adrenergic agonists. Pro- cedures were approved by the University of Pittsburgh insti- tutional review board, and all participants provided written informed consent. Main Outcomes and Measures Procedures included physical measurements, interviews, and questionnaires. Sexual harassment and assault were as- sessed from Brief Trauma Questionnaire items developed for the Nurses’ Health Study II17 adapted from the Brief Trauma Interview.18,19 Items assessed workplace sexual harassment (“Have you ever experienced sexual harassment at work that was either physical or verbal?”) and sexual assault (“Have you ever been made or pressured into having some type of un- wanted sexual contact? [By sexual contact we mean any con- tact between someone else and your private parts or between you and someone else’s private parts])?” Response options were yes/no. This measure has high interrater reliability relative to the Diagnostic and Statistical Manual of Mental Disorders (fourth edition) for presence of Criterion A1 trauma exposure (κ = 0.70).17 Seated BP was measured via a Dinamap device after a 10-minute rest. Height and weight were measured via a sta- diometer and balance beam scale. Body mass index (BMI) was calculated as weight in kilograms divided by height in meters squared. Depressive symptoms were assessed by the Center for Epidemiologic Studies Depression (CESD) scale,20 trait anxi- ety via the Spielberger State-Trait Anxiety Inventory (STAI),21 and sleep quality via the Pittsburgh Sleep Quality Index (PSQI)22 considered continuously and via clinical cut points (CESD ≥1620; PSQI >522; and STAI ≥4023 and upper quartile of nor- mative samples21). Demographics and medical history were as- sessed via structured interview. Women reported current medi- c ation use (eg, for BP: angiotensin converting enzyme inhibitors, angiotensin receptor blockers, diuretics; for sleep: melatonin, GABA-α agents (γ-aminobutyric acid-α); for anxi- ety: benzodiazepines; and for depression: bupropion, tricy- clic agents). Physical activity was assessed via the Interna- Key Points Question Do women with a history of sexual harassment or sexual assault have higher blood pressure, greater depression and anxiety, and poorer sleep than women without this history? Findings Among 304 nonsmoking midlife women recruited from the community to undergo assessment and complete questionnaires for this prospective cohort study, those with a history of workplace sexual harassment had significantly higher odds of hypertension and clinically poor sleep than women without this history, after adjusting for covariates. Women with a history of sexual assault had significantly higher odds of clinically significant depressive symptoms, anxiety, and poor sleep than women without this history, after adjusting for covariates. Meaning Sexual harassment and sexual assault have implications for women’s health. Association of Sexual Harassment and Sexual Assault With Midlife Women’s Health Original Investigation Research jamainternalmedicine.com (Reprinted) JAMA Internal Medicine January 2019 Volume 179, Number 1 49 © 2018 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ by a Carnegie Mellon University User on 04/05/2021 http://www.jamainternalmedicine.com/?utm_campaign=articlePDF%26utm_medium=articlePDFlink%26utm_source=articlePDF%26utm_content=jamainternmed.2018.4886 tional Physical Activity Questionnaire24 and snoring via the Berlin Questionnaire.25 Data Analyses All PSQI values were natural log–transformed for analysis. Dif- ferences between participants by harassment or assault history were tested using linear regression, Wilcoxon rank sum, and χ2 tests. Associations between exposures and outcomes were tested in regression models. Covariates were factors associated with the outcome at P < .15, with select variables selected a priori for in- clusion (medications and for sleep models snoring and nightshift work). Residual analysis and diagnostic plots were conducted to verify model assumptions. Analyses were performed with SAS software, version 9.4 (SAS Institute Inc). Models were 2 sided, α = .05. Results Participants were on average 54 years old (Table 1). Nineteen percent of women (n = 58) reported a history of workplace sexual harassment, and 22% reported a history of sexual as- sault (n = 67). Ten percent of women reported both sexual ha- rassment and assault (n = 30). Women with a history of sexual harassment had higher education yet more financial strain. No characteristics varied by sexual assault. Women with a history of sexual harassment had signifi- cantly higher systolic BP (SBP), marginally higher diastolic BP (DBP), and significantly poorer sleep quality than women with- out a history of harassment, after adjusting for covariates (all supporting data provided in Table 2). When considering clini- cal cut points, harassment was associated with significantly higher likelihood of stage 1 or 2 hypertension among women not taking antihypertensive medications (SBP ≥130 or DBP ≥80 mm Hg; odds ratio [OR], 2.36; 95% CI, 1.10-5.06; multivari- able P = .03) and of poor sleep consistent with clinical insom- nia (OR, 1.89; 95% CI, 1.05-3.42; multivariable P = .03) (Figure 1). Women with a history of sexual assault had higher depres- sive symptoms, anxiety, and poorer sleep quality than women without a history of sexual assault (Table 2). Assault was as- sociated with significantly higher odds of clinically elevated depressive symptoms (OR, 2.86; 95% CI, 1.42-5.77; multivari- able P = .003), anxiety (OR, 2.26; 95% CI, 1.26-4.06; multi- variable P = .006), and poor sleep (OR, 2.15; 95% CI, 1.23- 3.77; multivariable P = .007) (Figure 2). Table 1. Study Participant Characteristics Characteristic Participants, No. (%) (n = 304) Workplace Sexual Harassment Sexual Assault Yes (n = 58 [19%]) No (n = 246 [81%]) Yes (n = 67 [22%]) No (n = 237 [78%]) Age, mean (SD), y 53.93 (3.53) 54.08 (4.09) 53.73 (4.06) 54.14 (3.97) Race/ethnicity White 45 (77.59) 175 (71.14) 50 (74.63) 170 (71.73) Nonwhitea 13 (22.41) 71 (28.86) 17 (25.37) 67 (28.27) Educationb