Personal and Situational Predictors of Sleep Problems in Sexual Assault Survivors
Article information
Abstract
Background and Objective
Sleep disturbances are common in survivors of sexual violence and may significantly hinder recovery. Identifying predictors of insomnia can provide insights into trauma response and clinical intervention. This study examined the prevalence of sleep disorders during the initial response phase and analyzed the influence of personal and situational trauma factors on insomnia severity.
Methods
This study included 365 women who survived rape and were registered at Sunflower Centers between 2015 and 2022, with a mean age of 27.64 years. Data were collected on participants’ demographic characteristics, incident-related variables, insomnia severity, and posttraumatic stress symptoms. Descriptive statistics, independent-samples t-tests, one-way analyses of variance, and multiple regression analyses were performed.
Results
The mean insomnia score among the participants was 15.51, approximately 50% experiencing clinically significant symptoms. The severity of insomnia was significantly associated with age, subjective health status, past psychiatric visits, physical violence, and loss of consciousness. Regarding the relative influence on insomnia severity, trauma symptoms emerged as the strongest predictor (β=0.568, p<0.001), followed by subjective health status reported as “very poor” (β=0.249, p=0.010), whereas survivors who experienced partial loss of consciousness during the incident reported lower insomnia scores than those who remained fully conscious (β=−0.101, p<0.030).
Conclusions
Insomnia severity after sexual violence was more strongly associated with subjective factors—such as trauma response and perceived health—than by objective characteristics of the assault. These findings highlight importance of early assessment of psychological responses in post-assault care.
INTRODUCTION
The survivors of sexual assault experience various posttraumatic symptoms, including sleep disturbances [1–3]. Posttraumatic sleep disturbances occur in many forms, including insomnia and nightmares [4]. Traumatic events, particularly sexual assault, cause hyperarousal, which disrupts normal sleep patterns leading to chronic insomnia [2,5,6]. Sleep is critical for recovery for trauma-related symptoms. Normal sleep helps regulate emotions, which play an important role in reducing trauma-related distress [7]. Adequate sleep after trauma promotes recovery, whereas sleep difficulties, such as arousal during this period, can exacerbate symptoms [8]. The severity of sexual assault is strongly associated with insomnia. More severe traumatic events, such as rape, are associated with high rates of sleep disturbance [9,10]. Individuals who survive sexual assaults are more likely to experience sleep problems, including insomnia. This increased risk is often due to exposure to environments that remind of the trauma, such as specific places or times (including bedtime) [11]. Therefore, it is important to recognize and intervene early for sleep disturbances among survivors of sexual assault. Early detection and intervention for insomnia symptoms can significantly influence recovery process [12]. A comprehensive assessment helps to create a tailored treatment plan that improves the prognosis and overall well-being of survivors. Therefore, this study aimed to investigate the presence of sleep disorder symptoms in survivors of sexual assault and to identify their associations with demographic and case characteristics.
Studies have primarily examined sleep problems experienced by survivors of sexual assault, most often using recall-based approaches, conducted for a significant amount of time after the event. This approach has limitations in clarifying whether sleep disturbances are a specific response to sexual trauma or a nonspecific response that commonly accompanies trauma. In this study, the participants’ age, nationality, disability status, subjective health status, insomnia severity, past sexual assault experience, past psychiatric visits, referral route to the center, and motivation for reporting were defined as “personal characteristics.” Situational characteristics included the duration of the assault, timing of reporting, whether the survivor or perpetrator was intoxicated, presence of physical or verbal violence, and occurrence of loss of consciousness.
This study aimed to 1) analyze survivors’ sleep patterns during the acute post assault period and 2) identify associations between the sexual assault characteristics and sleep disturbance symptoms at the time of the initial visit. We analyzed the data collected from sexual violence reports and clinical assessments at the Sunflower Women’s and Children’s Violence Victim Support Center.
METHODS
Participants
The participants included 365 women who had experienced rape and subsequently received outpatient care at university hospitals in the metropolitan area of South Korea between January 2015 and February 2022. The study population was limited to patients who were referred to the Sunflower Center through various individual pathways and subsequently received psychiatric care. The inclusion criteria required that participants be adult women who had experienced rape. Experience of other forms of sexual violence was excluded to control for potential confounding variables. This study was approved by the Institutional Ethics Committee of Ajou University Hospital (AJOUIRB-MDB-2019-166).
Procedure
All participants were rape survivors who received obstetric and gynecological care at the Sunflower Center, a government-funded crisis intervention facility in the metropolitan area of South Korea. The Sunflower Center provides free medical, legal, psychological, and counseling services to women and children who have experienced sexual assault, domestic violence, and prostitution. The center operates in partnership with contracted hospitals and provides access to medical services after a visit. Data were collected as part of routine clinical assessments during the initial visit. Trained social workers conducted interviews, lasting less than 30 minutes, in private counseling rooms. Information on survivors and traumatic events was recorded using the Sunflower Center’s electronic registry system. Standardized measures, including the Trauma Symptom Checklist and Insomnia Severity Index (ISI), were administered on average within two weeks of the initial visit, but the timing varied depending on the individual’s situation.
Measures
Demographic information
The demographic information (e.g., age, nationality, disability status, referral source, reporting timing, and relationship with the perpetrator) was collected through interviews with survivors and their caregivers, as well as case information provided by external agencies. All information was recorded in the Survivor Registry System, managed by the Sunflower Center. As the intake information and self-report questionnaires were completed at the initial visit, some variables included missing item-level data.
ISI
The ISI, developed by Bastien et al. [13], published in Korean by Bae and Cho [14], and revised in 2014 [15], was used to assess the severity and impact of insomnia symptoms. The ISI consists of seven items that measure the intensity of sleep disturbance, satisfaction with current sleep, interference with daily functioning, impact on quality of life, and distress due to sleep problems. Each item is rated on a five-point Likert scale from zero (not at all) to four (very much), with the total score ranging from zero to 28. Higher scores indicated greater insomnia severity. In this study, the internal consistency of the scale was acceptable (Cronbach’s α=0.89).
PTSD Symptom Scale–Self-Report
The PTSD Symptom Scale–Self-Report (PSS-SR) was used to assess the severity of posttraumatic stress symptoms [16]. This scale consists of 17 items that correspond to the posttraumatic stress disorder (PTSD) symptom criteria from the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, specifically Criteria B through D. Each item is rated on a four-point Likert scale ranging from zero (not at all) to three (extremely). The total score was calculated by summing all the items. High scores indicated greater severity of PTSD symptoms. The Korean version of the PSS-SR, modified and used in a previous study, was used in the present study. The internal consistency of the scale in this study was acceptable (Cronbach’s α=0.81).
Data Analysis
All statistical analyses were performed using SPSS (version 27.0; IBM Corp.). Descriptive statistics, including frequencies, means, and standard deviations (SDs), were calculated for all major variables. Independent-sample t-tests and one-way analyses of variance were conducted to compare insomnia severity across groups defined by participant and assault characteristics. Given the number of group comparisons, there is a possibility of Type I error, potentially leading to significant results by chance. To control for this, Tukey’s post hoc test was used, applying a stricter significance level of p<0.01. Multivariate regression analyses were performed to examine predictors of insomnia severity. Predictor variables were selected based on those that showed significant associations with insomnia scores in preliminary univariate analyses. The final regression model included PTSD symptom severity (PSS-SR total score), current subjective health status, history of psychiatric visits, physical violence, loss of consciousness, and age. Model assumptions, including multicollinearity, were evaluated using variance inflation factor diagnostics, and no indications of multicollinearity were observed. Adjusted R2 and F-statistics were used to describe the overall model fit.
RESULTS
General Characteristics of Participants
A total of 365 adult women participated in this study with a mean age of 27.64 years (SD=9.47). The participants were predominantly in their 20s, and most were Korean nationals (Table 1). Additional demographic and incident-related characteristics, including disability status, referral source, voluntary reporting, reporting timing, and relationship with the perpetrator, are summarized in Table 1. The mean ISI score was 15.51 (SD=6.75), and the mean PSS-SR score was 28.68 (SD=13.09).
Personal characteristics of the participants
Association between Personal Characteristics and Insomnia
Analysis of the association between personal characteristics and insomnia severity revealed significant differences in age, subjective health status, and history of psychiatric treatment (Table 2). Participants in their 30s (M=17.81, SD=6.65 years) reported significantly higher insomnia scores than those in their teens (M=12.37, SD=5.86 years; F=3.038; p=0.018). Participants reporting “Extremely bad” (M=20.77, SD=6.32) or “Bad” (M= 18.56, SD=5.57) health had significantly higher insomnia scores than those reporting “Normal” (M=13.13, SD=5.93), “Good” (M=9.95, SD=6.07), or “Extremely good” (M=7.00, SD=8.08; F=26.649, p<0.001) health. In addition, participants with a history of psychiatric visits (M=16.92, SD=6.29) reported significantly higher insomnia scores than those without such a history (M= 14.93, SD=6.85; t=−2.419, p=0.016). In contrast, alcohol use, frequency and amount of drinking, and prior experience of sexual violence were not significantly associated with insomnia scores (p>0.05).
Association between personal characteristics of the victim and insomnia
Association between Event Characteristics and Insomnia Severity
Analysis of the association between event-related characteristics and insomnia severity indicated significant differences, with respect to physical violence and loss of consciousness (Table 3). The participants who experienced physical violence (M=17.07, SD=5.94) reported significantly higher insomnia scores than those who did not (M=15.14, SD=6.88; t=−2.011, p=0.045). With respect to loss of consciousness, participants who were “Not conscious” (M=16.42, SD=6.68) or had “Partial loss of consciousness” (M=14.31, SD=6.42) differed significantly from those who remained “Conscious” (M=14.23, SD=6.91), with an overall group effect (F=4.036, p=0.019). In contrast, the duration of trauma, timing of reporting, survivors’ alcohol use, perpetrators’ alcohol use, and verbal violence were not significantly associated with insomnia severity (p>0.05).
Association between situational variables of the assault and insomnia
Factors Influencing Insomnia Severity
Multivariate regression analysis was conducted with variables that showed significance in the group comparison analyses to evaluate their relative explanatory power for insomnia severity (n=301) (Table 4). The analyses conducted were cross-sectional wherein the term “predictor” refers to statistical prediction in the regression model rather than causal influence. In the univariate analyses, PSS-SR, current subjective health status, history of psychiatric visits, physical violence, and loss of consciousness were significant predictors.
Impact of personal and situational variables on insomnia severity
In the multivariate model, PTSD symptom score was the strongest predictor of insomnia severity (β=0.291, standardized β=0.568, p<0.001). A poorer current subjective health status, particularly “Extremely bad” (β=6.095, standardized β=0.249, p=0.010), was also significantly associated with high insomnia scores. Additionally, partial loss of consciousness was associated with lower insomnia scores than complete loss (β=−1.577, standardized β=−0.101, p=0.030). The model explained 49% of the variance in insomnia severity (adjusted R2=0.47), and the F-statistic was significant (F=27.99, p<0.001).
DISCUSSION
This study used reports and symptom data collected from a one-stop support center for survivors of sexual violence in Korea to analyze the individual and situational factors associated with insomnia severity during the initial visit period following sexual violence. This study aimed to identify groups at high risk for sleep disturbance at an early stage and provide baseline data for clinical intervention.
The results showed that half of the participants exhibited clinically significant levels of insomnia. This suggests that sleep disturbance is a common problem after sexual violence requiring immediate intervention efforts. Significant differences in insomnia severity were also observed based on individual factors, such as age, subjective health status, presence of physical violence, and loss of consciousness.
Multiple regression analysis revealed that severity of posttraumatic symptoms was the strongest predictor of insomnia. These predictors reflect statistical associations rather than causal effects. This finding is consistent with those of previous studies demonstrating a close association between PTSD symptoms and sleep disturbance. Additionally, participants who rated their current health as “Extremely bad” experienced significantly higher levels of insomnia, indicating that self-perception of health is a key indicator of sleep problems [17]. Kim et al. [18] reported that low sleep quality was associated with high self-reported stress and poor health perception consistent with the prior finding. These findings suggest that health perceptions extend beyond subjective judgment and significantly influence overall well-being.
Interestingly, participants who experienced a partial loss of consciousness during the assault reported lower levels of insomnia than those who remained fully conscious. This finding suggests that the level of cognitive arousal experienced during a traumatic event may influence the manifestation of sleep problems. According to the Dual Representation Theory, traumatic experiences are stored as both verbally accessible memory and sensory-based automatic memory (SAM) [19]. When trauma is experienced in full consciousness, the event may be processed more explicitly at the cognitive and emotional levels, leading to sustained hyperarousal and a high likelihood of posttraumatic symptoms, including insomnia [20]. Although no prior studies have directly examined partial loss of consciousness in this context, it is possible that reduced initial cognitive activation associated with partial consciousness attenuates the short-term severity of insomnia symptoms. Research on patients with traumatic brain injury [21] has reported an association between changes in consciousness and sleep disturbances supportive of the interpretation above. Collectively, these findings suggest that experiencing trauma in full consciousness may increase the vulnerability to emotional instability, whereas partial loss of consciousness may mitigate this burden.
In the regression model, age, psychiatric visits, and physical violence were not significantly associated with insomnia. This indicates that subjective experiences and response characteristics—such as the intensity of psychological reactions to trauma, self-perception, and arousal levels during trauma—have a greater influence on sleep disturbance than objective characteristics of trauma, including the externally observable presence of physical violence [22].
In clinical practice, the findings suggest that during the initial visit to sexual violence support centers, assessment of survivors’ sleep status is crucial along with the evaluation of subjective psychological distress. In addition, the ways in which they perceive and encode the traumatic event (including their level of consciousness at the time of the event and memory processing) are equally important. The cognitive and emotional burdens involved in processing traumatic memories play a critical role in sleep problems, underscoring the need for careful assessment of survivors’ psychological experiences and memory processing during early intervention [23,24].
Furthermore, this study is significant because it analyzed the relative influence of personal and situational factors on insomnia severity following sexual violence by distinguishing between these factors. This approach provides foundational data for understanding whether sleep disturbances are specific to sexual trauma or reflect general responses to trauma. Future research should verify the specificity and universality of the event characteristics through comparative analyses between groups experiencing different types of trauma beyond rape.
Generally, posttraumatic sleep is recognized as a protective factor that not only promotes physiological recovery but also enhances psychological stability. Sleep deprivation immediately after trauma may serve as an adaptive function by delaying the integration of contextual fear and emotional memories. Thereby attenuating negative responses to traumatic stimuli. Comparative studies between PTSD and non-PTSD groups have shown significant differences in subjective reports of sleep quality, whereas objective indicators such as polysomnography revealed no group differences. This suggests that although sleep architecture itself may remain unchanged, subjective deterioration in sleep quality, associated with hyperarousal and the re-experiencing of traumatic memories, can present significant clinical challenges. Collectively, these findings indicate that sleep disturbances immediately after trauma do not necessarily reflect pathological outcomes. Instead, they may temporarily play a protective role in the initial adaptation process, which is closely tied to subjective trauma responses. Therefore, it is essential to thoroughly assess the survivors’ subjective sleep experiences and reports during their initial visits.
This study has several limitations. First, owing to its cross-sectional design, causal correlations could not be clearly established, and all data were collected through self-report methods, presenting the possibility of response bias. The PSS-SR includes one sleep-related item, which may have led to an overinterpretation of the association between PTSD symptoms and insomnia severity. Therefore, this study may have partially increased the variance owing to the inclusion of overlapping items. Second, the participants were limited to women who received treatment at government-supported crisis intervention centers, making it difficult to generalize the results to other populations or medical environments. Future studies should adopt a longitudinal design to examine how sleep disorders may become chronic over time or develop into PTSD-related sleep problems.
In conclusion, this study emphasizes that initial trauma symptoms and health perceptions play crucial roles in understanding sleep problems among survivors of sexual violence during their initial visits. These findings can serve as foundational data for developing clinical guidelines tailored to this population and establishing early interventions.
Notes
Availability of Data and Material
The datasets generated or analyzed during the study are available from the corresponding author on reasonable request.
Author Contributions
Conceptualization: Sora Han, Sam Sik Choi. Data curation: Kyoungah Choi. Formal analysis: Sora Han. Investigation: Sora Han, Kyoungah Choi. Methodology: Sora Han, Sam Sik Choi. Supervision: Sam Sik Choi, Hyoung Yoon Chang. Writing—original draft: Sora Han. Writing—review & editing: Hyoung Yoon Chang.
Conflicts of Interest
The authors have no potential conflicts of interest to disclose.
Funding Statement
None
Acknowledgements
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