Research Article

Violence Against Women

1–23
Women’s Behavioral Coping © The Author(s) 2023
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DOI: 10.1177/10778012231156149
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Posttraumatic Stress Disorder

Symptoms and the Moderating
Role of Alexithymia

Naomi Ennis1 , Alyssa Rheingold1,

Heidi M. Zinzow2, Martie P. Thompson2,
Amanda K. Gilmore3, Dean Kilpatrick1, and
Christine K. Hahn1

Abstract
We examined the associations between women’s behavioral coping responses during
sexual assault and posttraumatic stress disorder (PTSD) symptoms, and the moderat-
ing role of alexithymia in college women (N = 152). Immobilized responses (b = 0.52,
p < .001), childhood SA (b = 0.18, p = .01), and alexithymia (b = 0.34, p < .001) sig-
nificantly predicted PTSD. The interaction between immobilized responses and alex-
ithymia was significant (b = 0.39, p = .002), indicating a stronger association for those
higher in alexithymia. Immobilized responses are associated with PTSD, particularly
for those with difficulty identifying and labeling emotions.

Keywords
posttraumatic stress disorder, sexual assault, alexithymia, behavioral coping responses

1
Department of Psychiatry and Behavioral Sciences, National Crime Victims Research and Treatment
Center, Medical University of South Carolina, SC, USA
2
Department of Psychology, Clemson University, SC, USA
3
School of Public Health, Department of Health Policy and Behavioral Sciences, Mark Chaffin Center for
Healthy Development, Georgia State University, GA, USA
Corresponding Author:
Naomi Ennis, Carepoint Health, 2695 N Sheridan Way #120, Mississauga, ON L5 K 2N6, USA.
Email: ennisnaomi@gmail.com
2 Violence Against Women 0(0)

Sexual assault (SA; broadly defined as any form of nonconsensual sexual contact)
remains at epidemic levels on college campuses in the United States (Abbey et al.,
2005), with estimates showing that up to 75% of college women have experienced
SA (Abbey et al., 2005; Muehlenhard et al., 2017). SA is considered a potentially trau-
matic event strongly associated with posttraumatic stress disorder (PTSD; Kessler
et al., 2017). Individuals vary in their psychological responses to trauma, and not all
of those who experience SA go on to have PTSD (Kessler et al., 2017). Therefore,
understanding the characteristics of women’s responses to SA that incur risk for
PTSD is considered critical for targeting intervention for those who will experience
PTSD and for identifying factors to mitigate that maintain PTSD (Feldner et al.,
2007). Importantly, no matter the response, perpetrators are always to blame for SA
(Violence Against Women Reauthorization Act, 2013). There is a myriad of factors
that can influence how a woman behaviorally responds during a SA (e.g., being in
shock, relationship with the perpetrator, whether the perpetrator threatened violence
or had a weapon). None of these factors is the woman’s fault. This study aimed to iden-
tify aspects of behavioral responses during SA that may help to identify those at risk for
PTSD not to determine why women had different reactions or behavioral responses or
factors contributing to their engagement in these responses.
Two potential factors that might be associated with women’s psychological out-
comes following SA are their behavioral coping responses during SA (Cook &
Messman-Moore, 2018; Rizvi et al., 2008). and alexithymia (Frewen et al., 2008,
2012), defined as difficulty with identifying, labeling, and describing one’s emotions.
Peritraumatic reactions (i.e., emotional and behavioral reactions during a traumatic
event) such as peritraumatic dissociation (Thompson-Hollands et al., 2017) are impor-
tant predictors of subsequent PTSD among women who experienced SA (Massazza et
al., 2021; Ozer et al., 2003). However, the role of peritraumatic behaviors, particularly
women’s behavioral responses during SA (Norris et al., 2018), in PTSD has not been
widely studied. The behavioral responses one makes during an SA (e.g., dissociating,
fighting) may influence how they process the SA (e.g., develop thoughts such as “I
cannot protect myself”), that could in turn contribute to PTSD symptoms. Research
consistently finds an association between alexithymia and PTSD (Frewen et al.,
2008, 2012). Those with greater alexithymia may have difficulty processing why
they responded in certain ways during SA, rendering the relationship between behav-
ioral responses and PTSD stronger for those with alexithymia. This study examined
associations between behavioral responses and PTSD symptoms and the moderating
role of alexithymia.

Behavioral Coping Responses During Sexual Assault

Women’s behavioral responses during SA, also referred to as behavioral responses to
threat (Anderson & Cahill, 2015) encompass both verbal (e.g., screaming) and nonver-
bal (e.g., pulling away) responses, and can be planned (e.g., distracting the perpetrator),
unplanned (e.g., crying) and/or elicited involuntarily (e.g., freezing, dissociating,
waiting for help). Behavioral responses during SA may refer to a singular response
Ennis et al. 3

(e.g., kicking) or a series of responses (e.g., pleading, fighting, dissociating). Anderson

and Cahill (2015) assert that these behaviors are all responses elicited by a SA and may
be automatic and not be planned, or elicited by the women’s perception of the threat.
The literature on behavioral responses to SA is muddled by inconsistent terminol-
ogy and a lack of a comprehensive definition that encompasses the full range of poten-
tial behavioral responses to SA. Researchers agree that no measure or construct will
likely ever capture the full range of behavioral coping responses an individual may
have during SA. Some researchers have examined behavioral responses on the dimen-
sions of physicality (physical or nonphysical) and forcefulness (forceful or not forceful;
See Anderson & Cavill, 2015 for review). However, Anderson and Cahill (2015) argue
against such orthogonal perspectives on behavioral responses to threat and suggest a
continuous approach. Thus far, the Behavioral Response Questionnaire (BRQ; Macy
et al., 2006; Nurius et al., 2000) is considered the most commonly used measure of
behavioral coping responses to SA and to incorporate a substantial range of potential
responses (Anderson & Cavill, 2015). Factor analysis of the BRQ yielded three broad
categories of responses that researchers commonly use (Anderson & Cahill, 2015):
assertive, diplomatic, and immobilized (Nurius et al., 2000). As these categories
were derived through factor analysis, the BRQ is viewed as the most empirically sup-
ported measure of behavioral coping responses during SA. Importantly, these
responses are not mutually exclusive. For example, an individual may exhibit a mix
of assertive, immobilized, and diplomatic responses during SA.
Assertive responses, also referred to as forceful, direct, or active responses (Davis
et al., 2004; Testa et al., 2006), encompass verbal and physical responses such as
yelling, attacking the assailant, and running away. On the dimensions of physicality
and forcefulness, these responses are often categorized as forceful and can be phys-
ical (e.g., hitting) and/or verbal (e.g., yelling) behaviors. Assertive responses have
been associated with less severe SA (Clay-Warner, 2002; Ullman, 1997).
Diplomatic responses, also referred to as indirect, nonforceful, (Norris et al.,
2018), or polite (Davis et al., 2004), include responses that may attempt in a less
direct way (e.g., changing the subject, joking) to preserve the safety and protect
against the perpetrator while also avoiding emotionally or socially hurting or embar-
rassing the perpetrator in some way (e.g., telling the person politely you are not
interested). Individuals are thought to respond diplomatically in ambiguous situa-
tions when the degree of threat is unclear, to divert the assailant’s attention, or
diffuse the situation (Nathanson, 2010). Some researchers found diplomatic
responses are associated with a higher potential for more severe SA
(Clay-Warner, 2002) and consider this type of response to be “passive” (Norris
et al., 2018). Others found diplomatic responses protective against PTSD and
view them as “active” as they involve verbal or physical actions to mitigate harm
(Rizvi et al., 2008). Immobilized responses also referred to as passive or freezing
responses (Norris et al., 2018) are characterized by a lack of physical or verbal
attempts to stop the SA. Individuals often have immobilized responses when they
are in shock, too overwhelmed with fear to respond or trying to avoid injury
(Nurius & Norris, 1996).
4 Violence Against Women 0(0)

Women vary in their behavioral coping responses during SA (Kaysen et al., 2005)
and tend to engage in multiple behavioral responses during the same SA (Clay-Warner,
2002; Kaysen et al., 2005; Ullman, 2007). Approximately one-third of women reported
having assertive responses during SA, whereas a large proportion, particularly women
who have experienced rape, reported immobilized responses (Kaysen et al., 2005). The
Cognitive Mediation Model of Women’s Sexual Decision Making (Norris et al., 2004)
holds that cognitive processes and situational factors influence decision-making during
a potential sexual situation and decisions are guided hierarchically by a goal. For
example, a woman may engage in a diplomatic response (e.g., faking the arrival of
others) with the goal of maintaining the relationship and her appraisal that a more asser-
tive response (e.g., screaming) may interfere with that goal. Situational factors (e.g.,
presence of a weapon) may shift during the SA, causing appraisals (e.g., belief
about danger) and subsequent responses (e.g., use of force) to shift. For example, a
woman may initially respond diplomatically, then more assertively, and with increas-
ing violence or recognition that escape is not possible, have an immobilized response
(Ullman, 2007).

Behavioral Responses During SA and PTSD

PTSD includes intrusive (e.g., unwanted memories, nightmares), cognitive (e.g., self-
blame), emotional (e.g., shame), and behavioral (e.g., substance use, avoidance of
trauma reminders) symptoms as a result of a potentially traumatic event (American
Psychiatric Association, 2013). Social-cognitive (Brewin et al., 1996) and emotional
processing (Foa et al., 1989) theories of PTSD broadly hold that symptoms develop
and are maintained by disturbances in how the traumatic event is processed and the
meaning one makes from their traumatic experience. Maladaptive trauma processing
(e.g., distorted beliefs, fragmented memory, emotional avoidance) is thought to con-
tribute to the behavioral and emotional symptoms that characterize PTSD.
Meta-analyses on PTSD support these theories and identify several factors associated
with the disorder, including prior history of trauma such as childhood SA and whether
the SA was rape (Ozer et al., 2003). In their meta-analysis, Ozer et al. found peritrau-
matic (occurring at the time of trauma) such as peritraumatic dissociation, peritrau-
matic emotions, and perceived life threat during the trauma as among the strongest
predictors of PTSD. In line with social-cognitive theory, these findings suggest that
the way an individual behaviorally responds during an SA and their perceptions of
the impact of these responses can influence how they process the SA, contributing
to PTSD. For example, the negative appraisals women make of their behavioral
responses have been found to be significantly and positively associated with PTSD
severity, over and above the severity of the assault (Dunmore et al., 2001; Kline
et al., 2018). Behavioral responses may be associated with PTSD symptoms via the
meaning derived from the responses (e.g., “I have no control over my safety”) and
beliefs about the role of responses in the SA (e.g., “I could have done more to
prevent this”). Emotions that may be associated with responses (e.g., shame) and
behavioral reactions to the thoughts and emotions (e.g., avoidance) may also contribute
Ennis et al. 5

to and maintain PTSD symptoms. Although theory and research suggest behavioral
responses and PTSD symptoms are associated (e.g., Cook & Messman-Moore,
2018; Rizvi et al., 2008), the relationship requires further study.
Albeit limited, past research suggests that self-reported engagement in fewer asser-
tive responses and more immobilized responses are both associated with greater PTSD
symptoms. For example, Rizvi et al. (2008) examined behavioral responses among 296
women who experienced rape or physical assault no more than two months prior to
entering their study. They found that less assertive and more immobilized responses
during rape or physical assault significantly predicted greater PTSD symptoms.
Consistent with their findings, studies of behavioral responses during completed
rape suggest that those who reported assertive responses were less likely to experience
distress (Selkin, 1978), self-blame, and depression (Bart & O’Brien, 1985;
Janoff-Bulman, 1979; Meyer & Taylor, 1986). In an examination of the association
between voicing nonconsent during rape and PTSD, Cook and Messman-Moore
(2018) found that voicing nonconsent was associated with greater PTSD symptoms.
Interestingly, they also found that voicing nonconsent was associated with some
level of freezing (further highlighting that behavioral coping responses are not mutu-
ally exclusive). However, voicing nonconsent is only one type of assertive response.
Cook and Messman-Moore (2018) did not examine the association between other
assertive responses (e.g., physical resistance, yelling) and PTSD, limiting the conclu-
sions that can be drawn. Indeed, across each of the studies cited there are two important
limitations. None of the studies included women who had experienced attempted rape
or SA other than rape (e.g., nonconsensual sexual contact). Understanding the full
spectrum of SA with regard to the association between PTSD symptoms and behavio-
ral responses is important because with varying severity of SA (e.g., unwanted fon-
dling, rape with the use of physical force) women may have different behavioral
responses. Second, past studies have not examined the full spectrum of women’s
behavioral responses including diplomatic responses (e.g., distracting the perpetrator,
making excuses to avoid the situation). As most SA occurs by a known assailant
(Ullman, 2007) and diplomatic responses may be more common in acquaintance-
perpetrated SA (Macy et al., 2006), understanding the association between diplomatic
responses and PTSD symptoms is an important and clinically relevant research gap to
address. Understanding the relationship between how a woman responded during
attempted or completed SA can aid clinicians in both identifying women who may
be at greater risk for posttraumatic stress and may benefit from intervention, and
also asking relevant questions to women about their responses and how they make
meaning of those responses within the context of the SA and their emotional awareness
and experience at the time.
Research on related but distinct peritraumatic constructs also shed light on the asso-
ciation between immobilized responses and PTSD. Meta-analyses on retrospective
reports indicate that peritraumatic dissociation (Breh & Seidler, 2007; Ozer et al.,
2003) is associated with PTSD symptoms. Peritraumatic dissociation refers to a
range of complex reactions that disturb the integration of consciousness, memory,
emotion, body representation, behavior and motor control and include mild
6 Violence Against Women 0(0)

derealization, depersonalization, motor inhibition, and tonic immobility (Hatzimoysis,

2014). Tonic immobility, an unconditioned fear response displayed by humans and
animals in response to an inescapable life threat, is considered evolutionarily adaptive
and typically involves complete unresponsiveness and motor inhibition (Hatzimoysis,
2014). Peritraumatic dissociative reactions may render an individual less able to
actively respond and more likely to have immobile responses. Immobilized responses
may be one behavior displayed during peritraumatic dissociation, but an individual
may also have an immobile response without peritraumatic dissociation (e.g., when
incapacitated). Taken together, research suggests that immobilized responses may be
associated with greater PTSD symptoms, but further research is needed.
In contrast to assertive and immobilized responses, no known literature has exam-
ined the association between diplomatic responses and PTSD symptoms. The degree of
their association may be related to the subjective meaning made of these responses
(Dunmore et al., 2001; Kline et al., 2018). Assertive and immobilized responses can
more obviously represent active and nonactive responses, respectively (e.g., Norris
et al., 2018; Rizvi et al., 2008). There may be less ambiguity for women in how
they make meaning of the role of immobilized and assertive responses whereas the
role of diplomatic responses in protecting against SA may be less clear. Whether dip-
lomatic responses are associated with PTSD symptoms may depend on how the indi-
vidual processes their behavioral responses and the meaning they associated with them
(Dunmore et al., 2001; Kline et al., 2018). At present, there is limited literature to
inform a hypothesis regarding the association between diplomatic responses and
PTSD symptoms.

Alexithymia and PTSD

Considering that not all women who experience SA go on to experience PTSD, an
important question regarding the association between behavioral responses and
PTSD symptoms is for whom different behavioral coping responses predict PTSD
symptoms. Thus, the examination of moderators in the relationship between behavioral
responses during SA and PTSD symptoms is important. A potential moderator is alex-
ithymia (Bagby et al., 1994), conceptualized as a psychological trait that entails diffi-
culties describing and identifying emotions, challenges distinguishing emotions from
physical sensations, and an externally oriented thinking style. Externally oriented
thinking refers to an excessive focus on external stimuli rather than on internal emo-
tional experiences. Alexithymia is not a mental health diagnosis, but a trait considered
a risk factor for various psychopathological symptoms and poor adjustment (Pinna
et al., 2020). Alexithymia is associated with several mental health disorders, including
mood and anxiety disorders, autism, eating disorders, personality disorders, and trau-
matic stress-related disorders (Pinna et al., 2020). Meta-analyses consistently find that
alexithymia is significantly and positively associated with PTSD (Frewen et al., 2008,
2012) across survivors of SA (Cloitre et al., 2002; O’Brien et al., 2008). Alexithymia
may be related to PTSD through its effects on posttraumatic functioning (e.g., emo-
tional processing of trauma; Frewen et al., 2008). Difficulty with accessing emotions
Ennis et al. 7

during and following SA can render trauma processing difficult for individuals higher
in alexithymia and they may be more avoidant of trauma-related cues and dysregulated
when faced with reminders (Frewen et al., 2008). Individuals with alexithymia struggle
to describe their emotions and may have less opportunity for emotional disclosure
following the SA (Frewen et al., 2008), a predictor of trauma recovery
(Balderrama-Durbin et al., 2013) that helps individuals engage in adaptive processing.
Along these lines, individuals who report higher levels of alexithymia may struggle
to process why they had certain behavioral responses (e.g., processing that they reacted
the way they did during the SA because they were shocked) because they cannot access
their peritraumatic emotions. Those who had more immobilized responses or less
assertive responses may have difficulty understanding why they were unable to
respond actively (e.g., understanding they did not respond actively because they
were terrified). These individuals may be at greater risk for emotional dysregulation,
negative thoughts cognitions (e.g., Thompson-Hollands et al., 2017), and experiential
avoidance that characterize PTSD. Women with alexithymia may also have difficulty
accessing their feelings during the SA. Therefore, for those with greater alexithymia,
the association between greater immobilized responses, fewer assertive responses,
and PTSD may be stronger. Directional hypotheses regarding the moderating role of
alexithymia in the association between diplomatic responses and PTSD symptoms
are difficult due to the limited and mixed literature on diplomatic responses. As
described, diplomatic responses could be interpreted (by the survivor and members
of their social milieu) as adaptive and active or as maladaptive or ineffective.

Overview of Current Study

There is a dearth of literature examining the range of behavioral coping responses
women may employ during SA and their association with PTSD symptoms in
women who experience a range of SAs (e.g., nonconsensual sexual contact, attempted
SA). Moreover, no known studies have examined moderators within the association
between behavioral coping responses during SA and PTSD symptoms. To address
these gaps, this study aimed to examine the following hypotheses in a college
sample of women who experienced SA since age 18:
Hypothesis 1: Greater endorsement of assertive behavioral responses would be neg-
atively associated with PTSD and greater endorsement of immobilized responses and
alexithymia would be significantly positively associated with PTSD.
Hypothesis 2: For women who endorse greater alexithymia, the positive association
between immobilized responses and PTSD symptoms and the negative association
between assertive responses and PTSD symptoms would be stronger than for
women who endorse less alexithymia. No a priori hypotheses regarding the associa-
tions between diplomatic responses and PTSD symptoms and the interaction
between diplomatic responses and alexithymia were made. These analyses were
exploratory because of past mixed findings as to whether diplomatic responses are
“active” or “nonactive” responses. Rape (i.e., oral, vaginal, or anal penetration by inca-
pacitation, physical force, or threat of physical force) has been more strongly
8 Violence Against Women 0(0)

associated with PTSD than other types of adult SA (i.e., unwanted sexual touching;
Peter-Hagene & Ullman, 2015). Further, history of childhood SA has been associated
with PTSD (Peter-Hagene & Ullman, 2015; Ullman et al., 2009). Therefore, history of
adult rape and childhood SA were examined as covariates within study analyses.

Method
Participants
Participants were undergraduate students recruited from courses at a midsize university
in the southeastern United States. Participation was voluntary. This study was based on a
subsample of participants from a larger study on alcohol use, emotion regulation, bystander
behaviors, and SA. To be eligible for the parent study, participants had to be between 18
and 26 years old and students at the university. Of that sample, participants were included
in the current study who: (1) identified as female and (2) endorsed experiencing at least one
unwanted sexual experience since age 18 (attempted or completed) on the Sexual
Experiences Survey-Short Form Victimization (SES-SF; Koss et al., 2007).
The final sample in the current study included 152 participants who ranged in age
from 18 to 24 years old (M = 19.31, SD = 1.14). Nearly half (n = 67) were freshmen
(44.1%), 43 (28.3%) were sophomores, 30 were juniors (19.7%), and 12 were seniors
(7.9%) at the university. The majority of the sample identified as White (n = 130,
85.5%). Approximately 10% identified as Black or African American (n = 15),
5.3% Asian (n = 8), and 1% as Alaskan Native (n = 1). A minority (n = 11, 7.2%)
identified their ethnicity as Hispanic/Latino. With regard to current romantic relation-
ship status, 51 (33.6%) were in a steady relationship, 61 (40.1%) were not in any rela-
tionship, 24 (15.8%) were in a casual relationship with one person and 13 (8.6%) were
in casual relationships with multiple people.

Measures of Independent Variables

Behavioral coping responses during sexual assault. To assess behavioral coping responses,
participants completed a behavioral response scale developed by Macy et al. (2006)
based on prior work (Norris et al., 1996; Nurius et al., 2000). The measure includes
23 items that ask respondents to rate the degree to which they engaged in various
behavioral coping responses during the SA since age 18 that they identified through
the SES-SF. Respondents who endorsed having more than one SA since age 18
were asked to respond based on the most stressful SA. For each item, the respondent
indicates on a 5-point Likert scale how much their response was similar to the item
on the scale with anchors as follows: 1 (not at all like my response); 2 (a little like
my response); 3 ( fairly like my response); 4 (quite a bit like my response); and
5 (very much like my response). The measure yields Assertive, Diplomatic, and
Immobilized response scales. The Assertive response scale (e.g., “told him
clearly and directly that I wanted him to stop,” “Yelled or screamed loud enough for
someone to hear me,” “Raised my voice and used strong language”) consists of 11
Ennis et al. 9

items and demonstrated strong internal consistency in the current study (α = .87). The
Immobilized response scale includes four items (e.g., “I was so overwhelmed that I felt
almost paralyzed and was unresponsive to what the person was doing,” “Struggled at
first but stopped when I thought it was hopeless,” “Started tearing up or crying.”). The
Diplomatic scale includes eight items (e.g., “nicely or apologetically told him I didn’t
want to have sex,” “Tried to get the person to do things I was comfortable with like
kissing or hugging, but not sex,” “Made an excuse as to why I didn’t want to have
sex.”). The Immobilized (α = .79) and Diplomatic (α = .82) scales both demonstrated ade-
quate internal consistency. A mean score was calculated for each participant for each scale.
To determine how many participants engaged in each type of response, participants who
endorsed a 3 or greater on response were considered to have engaged in the response.

Alexithymia. The Toronto Alexithymia Scale (TAS-20; Bagby et al., 1994), a 20-item
self-report scale using a 5-point Likert Scale, is the most commonly used self-report
measure of alexithymia (Kooiman et al., 2002). Total scores are calculated by
summing responses to all items. Higher scores reflect more alexithymia (i.e., difficulty
identifying, labeling, and describing emotions). The TAS-20 has demonstrated conver-
gent and concurrent validity (Bagby et al., 1994) and test re-test reliability (r = .77 p <
.01; Kooiman et al., 2002) and good internal consistency in prior research (α = .91;
Bagby et al., 1994) and the current study (α = .84).

History of childhood sexual assault. The first three items of the Computer-Assisted
Maltreatment Inventory (CAMI; DiLillo et al., 2010) was used to assess for childhood
SA. Respondents were presented with a description of potential sexual experiences that
can occur during childhood and adolescence, including witnessing sexual activity,
unwanted touching, and attempted/completed sexual intercourse. Respondents were
then asked three yes/no questions to assess if before age 18 any of the sexual experi-
ences happened to them against their will or when they did not want it to happen, invol-
untarily with an immediate family member/relative, or involuntarily with anyone more
than five years older. Based on responses, a dichotomous variable was created to indi-
cate the presence of self-reported childhood SA.

History of sexual assault in adulthood. To assess for a history of attempted or completed

SA after age 18, participants completed the SES-SF (Koss et al., 2007). The SES-SF
uses behaviorally specific language to inquire if participants have experienced
attempted or completed sexual contact (e.g., fondling) or penetration (i.e., anal, oral,
vaginal) by use of different tactics. These include verbal coercion (e.g., telling lies,
verbal threats, or making false promises or using verbal pressure), incapacitation
(i.e., taking advantage when the participant was “too drunk or out of it” to stop
what was happening) or physical force (i.e., threatening physical force or use of phys-
ical force). Participants rate how many times they had each experience with each tactic
from 0 (never) to 3 (three or more times).
We first used the SES-SF to determine eligibility for participation from the larger
sample (i.e., endorsement of any SES-SF item with any tactic counted as SA and
10 Violence Against Women 0(0)

warranted inclusion). The SES-SF can be scored in various ways and recently,
researchers have examined the validity and consistency among different scoring
methods. Littleton and colleagues (2019) examined each tactic and SA experience sep-
arately and found fair to moderate agreement between responders’ endorsements on the
SES-SF over an approximately two-week period (Ks range from 0.33 to 0.69 depending
on tactic and SA experience), with the most consistency in endorsement of rape. In light
of these findings and research that suggests rape is most strongly associated with PTSD
symptoms (Peter-Hagene & Ullman, 2015), we scored the SES-SF to reflect whether the
participant had endorsed having experienced completed rape. Completed rape included
oral, vaginal, or anal penetration by incapacitation, physical force, or threat of physical
force. Participants who endorsed any type of adult SA were included in the current
sample, thus we included a dichotomous variable of adult rape based on the SES-SF
in our analyses to control for the history of adult rape (compared with other types of
adult SA) on outcomes.

Measures of Dependent Variable

Posttraumatic stress disorder. The past-month Posttraumatic Stress Disorder Checklist-5
(PCL-5; Weathers et al., 2013) is a self-report measure of PTSD symptoms according
to the DSM-5 (American Psychiatric Association, 2013). Respondents indicate how
much they were bothered by each symptom in the past 30 days from 0 (not at all)
to 4 (extremely). Participants responded based on their most stressful unwanted
sexual experience since age 18. A total score is produced by summing all 20 items.
Higher scores indicate greater severity. The PCL-5 demonstrated strong internal con-
sistency in the current (α = .96) and previous studies (α = .94; Weathers et al., 2013).
The PCL-5 has demonstrated strong test-retest reliability (r = .82), and convergent (rs
= .74 to .85) and discriminant (rs = .31 to .60) validity (Weathers et al., 2013).

Procedure
The study was approved by the university’s institutional review board. Participants were
recruited via courses that provided course credit through research study participation.
Participants completed an online survey through RedCap, a secure web application. A
waiver of written consent was used whereby participants were provided with a description
of the study and told that their responses to questions indicated agreement. Participants
were debriefed at the end of the study and provided with an opportunity to ask questions.

Data Analysis
Statistical analyses were conducted in SPSS Version 25.0 (IBM Corp., 2019). Prior to
testing study hypotheses, bivariate correlations were examined between all variables of
interest (Table 1). All assumptions of regression and moderation were tested and met.
To test hypotheses, a regression was conducted whereby all behavioral coping
Ennis et al. 11

response scales were entered with alexithymia, childhood SA and history of rape
during adulthood to predict PTSD. The behavioral response scales were included
in the same rather than in separate models to account for shared variance
between them and because they were correlated, indicating that participants
endorsed multiple responses. Next, the SPSS Macro PROCESS (Hayes, 2012)
was used to develop moderation models specifying linear interactions between
the behavioral response type and alexithymia. All predictors were mean-centered
to form the products when estimating the moderated path. For significant interac-
tion terms, PROCESS modeled conditional effects of the predictor (simple
slopes) at the mean, one below the mean (−1 SD), and one above the mean ( + 1
SD) for the moderator. Three regression models were developed to test for moder-
ation with all variables of interests and an interaction term including one of the
behavioral response types and alexithymia. A model with all three interaction
terms was not included due to limited power.

Results
According to the SES-SF, rape (n = 73, 48%) was the most common adult SA
reported by participants, followed by unwanted sexual contact (n = 29, 19.1%),
rape by coercion (n = 17, 11.2%), attempted rape by coercion (n = 17, 11.2%), and
attempted rape (n = 16, 10.5%). Of the behavioral coping responses endorsed, 101
(66.4%) participants reported at least one diplomatic response, 71 (46.7%) at least
one immobilized response, and 59 (38.8%) at least one assertive response.
Regarding engagement in multiple behavioral responses, 40 (26.3%) participants
reported at least one of each response, 25 (16.4%) reported engaging in diplomatic
and immobilized responses but no assertive responses, 16 (10.5%) reported engaging
in diplomatic and assertive responses and no immobilized responses, and 2 (1.3%)

Table 1. Correlations Between Posttraumatic Stress Symptoms, Behavioral Coping Responses,

and Alexithymia
Variable 1 2 3 4 5 6 7 M SD
1. PCL - .27** .59*** .21* .33** .32** .29** 15.84 16.50
2. Assertive - .35** .48*** −.04 .16 .14 1.53 .72
3. Immobilized - .29** −.09 .31** .25** 2.02 1.08
4. Diplomatic - −.01 .06 .07 2.34 .95
5. Alexithymia - .02 −.01 41.68 9.04
6. Rape - .14
7. Childhood SA -

Notes. Alexithymia = Toronto Alexithymia Scale; PCL = Posttraumatic Stress Disorder Checklist-5;
Rape = endorsed history of experiencing completed rape; SA = Sexual assault.
*p < .05 **p < .01 ***p < .001.
12 Violence Against Women 0(0)

reported engaging in immobilized and assertive responses but no diplomatic

responses. See Figure 1 for a Venn Diagram of the endorsement of multiple responses.
Fifty-two participants (34.2%) reported childhood SA. Bivariate correlations indicated
strong positive associations between PCL-5 scores and immobilized responses (r =
.59, p < .001) and moderate positive associations with alexithymia, history of child-
hood SA, assertive responses, and whether the SA in adulthood was rape (see Table 1).

Aim 1: Multivariate Model Testing Unique Effects

of Behavioral Coping Responses
The regression analysis with all three behavioral responses, alexithymia, history of
childhood SA, and whether the SA was rape was significant R2 = 0.49, F(6, 114) =
19.14, p < .001. Immobilized responses (b = 0.52, p < .001), alexithymia (b =
0.34, p < .001), and history of childhood SA (b = 0.18, p = .01) were significantly
positively associated with PTSD. The associations between Assertive (b = 0.001
p = .99) and Diplomatic (b = 0.05, p = .54) responses with PTSD were not
significant.

Figure 1. Venn diagram of participants’ endorsement of behavioral responses.

Ennis et al. 13

Aim 2: Moderation Analyses

Three multiple regressions were conducted each with childhood SA history, rape, all three
behavioral responses, alexithymia, and the interaction between alexithymia and one behav-
ioral response type. In the multiple regression that included the interaction between immo-
bilized responses and alexithymia, the interaction emerged as a significant predictor of
PTSD (b = 0.32, p = .002, SE = 0.10; See Table 2). Simple slopes (Figure 2a) indicated
that the association between immobilized responses and PTSD was stronger for those
higher versus those lower in alexithymia. In the multiple regression that included the inter-
action between diplomatic responses and alexithymia, the interaction was a significant pre-
dictor of PTSD (b = 0.39, p = .002, SE = 0.12; see Table 2). Simple slopes (Figure 2b)
indicated that the association between diplomatic response and PTSD was significant only
for those at the highest level of alexithymia. Finally, in the multiple regression that included

Table 2. Alexithymia as a Moderator in the Associations Between Behavioral Responses and

Posttraumatic Stress Disorder
95% Confidence Interval for
b
Predictor b SE(B) t P Lower bound Upper bound
Assertive
Assertive (centered) 0.24 1.69 0.14 .09 −12.96 0.91
Alexithymia (centered) 0.58 0.12 5.10 <.001 0.35 0.81
Assertive × Alexithymia 0.21 0.17 1.24 .22 −0.13 0.54
Rape 3.92 2.13 1.84 .07 −0.31 8.15
Childhood SA 5.91 2.14 2.77 .007 1.68 10.15
Immobilized 7.08 1.08 6.53 <.001 4.93 9.23
Diplomatic 0.91 1.23 0.74 .46 −1.53 3.35
Diplomatic
Diplomatic (centered) 0.70 1.18 0.59 .56 −1.64 3.03
Alexithymia (centered) 0.59 0.11 5.32 <.001 0.37 0.81
Diplomatic × Alexithymia 0.39 0.12 3.23 .002 0.15 0.64
Rape 3.59 2.05 1.75 .09 −0.48 7.65
Childhood SA 5.58 2.04 2.74 .007 1.54 9.64
Assertive 0.83 1.64 0.51 .61 −2.42 4.08
Immobilized 7.07 1.03 6.84 <.001 5.02 9.12
Immobilized
Immobilized (centered) 7.45 1.04 7.20 <.001 5.40 9.51
Alexithymia (centered) 0.54 0.11 4.80 <.001 0.31 0.76
Immobile × alexithymia 0.32 0.10 3.15 .002 0.12 0.53
Rape 4.16 2.06 2.02 .05 0.08 8.24
Childhood SA 5.60 2.05 2.74 .007 1.54 9.66
Assertive −0.31 1.63 −0.19 .85 −3.54 2.92
Diplomatic 0.72 1.18 0.61 .55 −1.62 3.06

Notes. Alexithymia = Toronto Alexithymia Scale; SA = Sexual Assault; Rape = endorsed history of
experiencing completed rape.
14 Violence Against Women 0(0)

Figure 2. (a) Interaction between immobilized responses and alexithymia predicting

posttraumatic stress disorder.
Note. Low alexithymia = −1 standard deviation; high alexithymia = +1 standard deviation.
(b) Interaction between diplomatic responses and alexithymia predicting posttraumatic stress
disorder. Note. Low alexithymia = −1 standard deviation; high alexithymia = +1 standard deviation.

the interaction between assertive responses and alexithymia, the interaction was not signif-
icant (b = 0.21, p = .22, SE = 0.17; see Table 2).

Discussion
This is the first study to examine the associations between college women’s behavioral
responses during SA and PTSD, and whether these associations were moderated by
Ennis et al. 15

alexithymia. As expected, when accounting for alexithymia, history of rape as an adult,

childhood SA history, and greater endorsement of immobilized responses significantly
predicted PTSD. This association was moderated by alexithymia such that at high
levels of alexithymia, the association between immobilized responses and PTSD
was stronger. Similarly, the interaction between diplomatic responses and alexithymia
was significant, indicating that there was a significant positive relationship between
diplomatic responses and PTSD but only for those with high levels of alexithymia.
In contrast to hypotheses, assertive responses were not significantly associated with
PTSD and the relationship was not moderated by alexithymia. Overall, findings indi-
cate that for individuals who have difficulty identifying and labeling emotions, the
association between immobilized and diplomatic responses and PTSD is especially
strong.
The result that immobilized responses were significantly and strongly positively
associated with PTSD provides important information on potential pathways to
PTSD (Rizvi et al., 2008). Immobilized responses may represent a link within the asso-
ciation between peritraumatic emotional distress, distorted cognitive appraisals, and
PTSD. Peritraumatic distress (e.g., panic or dissociation) may render someone
unable to respond “assertively” and more likely to become immobilized (e.g., Stoner
et al., 2007). In turn, individuals who endorsed immobilized responses may be more
likely to engage in distorted self-blame (Meyer & Taylor, 1986) and negative self-
views (Thompson-Hollands et al., 2017), which is found to predict the onset and main-
tenance of PTSD (e.g., Kline et al., 2018).
Beyond the intrapersonal processes that may contribute to PTSD, a trauma survi-
vor’s socio-interpersonal context also plays a role in PTSD (Maercker & Horn,
2013) and women’s behavioral responses may influence their interpersonal interac-
tions. Individuals who report immobilized responses during SA may experience
more negative reactions from others such as victim blaming (Davies et al., 2008),
and negative social reactions are consistently associated with PTSD (Wagner et al.,
2016). These intra- and interpersonal pathways likely influence each other (e.g., a
person who incurs blame from others may engage in more self-blame) and collectively
increase the risk for PTSD.
No a priori hypotheses were made on the associations between diplomatic responses
and PTSD because of the dearth of literature on diplomatic responses. Our study sug-
gests that diplomatic responses were only significantly associated with PTSD severity
at high levels of alexithymia. The result that at higher levels of alexithymia, there was
an association or stronger association between both immobilized and diplomatic
responses and PTSD makes sense in light of the potential that the meaning one ascribes
to behavioral responses may predict their posttraumatic psychopathology. Individuals
who struggle to identify, label, and express their emotions may have difficulty process-
ing the meaning of the SA as it is occurring and, following the SA, why they responded
in the ways that they did (e.g., Frewen et al., 2012), increasing their likelihood of expe-
riencing PTSD. As discussed, diplomatic responses may be particularly difficult to
interpret in that they may be considered “active” or “immobile/passive” attempts at
mitigating SA. Those with greater alexithymia may have more difficulty understanding
16 Violence Against Women 0(0)

why they engaged in diplomatic responses and may be more prone to view these
responses negatively. It is interesting that there was no significant association
between diplomatic responses and PTSD symptoms for those endorsing lower levels
of alexithymia. This suggests that for those who have a better ability to understand
and process feelings diplomatic responses may not be associated with traumatic
stress, perhaps because the individual has more understanding of the reasons why
they had diplomatic responses.
Findings are also interesting with regard to research on the association between
emotions and behavioral responses during SA. Research suggests anger may mobilize
women into action during SA whereas sadness may be associated with diplomatic
responses (Jouriles et al., 2014; Nurius et al., 2000). Individuals with greater alexithy-
mia may struggle to express anger, an emotion that could be associated with more
assertive responses by emboldening them to respond to the threat. Therefore, at
higher levels of alexithymia, diplomatic responses may be associated with PTSD via
a lack of anger response.
Findings have important clinical implications for psychotherapy and healthcare pro-
fessionals interacting with women following SA. Results suggest that those who report
more immobilized responses and exhibit more difficulty identifying, labeling, and
expressing emotion may be at increased risk for PTSD. Brief interventions that
provide psychoeducation and corrective information to normalize women’s responses
to SA, reduce self-blame, and facilitate the processing of emotions may be beneficial
following SA, particularly for women who endorsed immobilized responses, and high
alexithymia and diplomatic responses. Existing trauma-focused interventions that aim
to facilitate the processing of the traumatic event such as Prolonged Exposure and
Cognitive Processing Therapy both focus on accessing nuanced memories of the
assault and helping clients understand their role in the assault. These treatments may
benefit from fine-tuned emphasis on the individual’s perception of the responses
they engaged in during SA. Helping women identify and label their emotions, a
current feature in trauma-focused therapies, may be particularly helpful for women
who have greater alexithymia.
Findings from this study can also be used to inform educational interventions for
formal support (e.g., healthcare workers, law enforcement, college campus staff) and
informal supports (e.g., loved ones) of those who experience SA on ways to best
respond to disclosure of SA. Those who may be privy to SA disclosure should be edu-
cated on the range of behavioral responses that women engage in during SA. They
should inform women who disclose that they had an immobilized or diplomatic
response during SA that these responses are common, normal and do not indicate
that they are responsible for the SA.

Limitations and Future Directions

This study has several strengths, including the use of a sample exposed to SA. This is
also one of the first known studies to examine the associations between a range of
behavioral responses and PTSD, and examine alexithymia as a moderator of these
Ennis et al. 17

associations. Several limitations should be noted. This study relied on participants’ ret-
rospective reports and was correlational. Having PTSD may render individuals more
likely to report engaging in certain behavioral responses such as immobilized
responses and/or engaging in immobilized responses may increase the risk for
PTSD. The temporal sequencing of behavioral responses was also not collected.
Women’s engagement in multiple behavioral coping responses and the order in
which they responded in each way during the SA may have implications for PTSD
(Norris et al., 2018). In future research, measures should assess for the nuanced
sequencing of behavioral responses during the SA. Data on the participant’s relation-
ship with the perpetrator was also not collected. Past research identifies that women’s
relationships with their perpetrators can influence the behavioral coping responses used
during SA (Koss et al., 1988) and the likelihood of PTSD (Feinstein et al., 2011). Other
factors are known to be associated with behavioral coping responses and PTSD such as
fear of rejection, and alcohol consumption should be examined in future studies
(Ullman, 2007).
The study is also limited by some of the measures used. We used one variable based
on the SES-SF to capture whether the participants had experienced an adult rape or not,
which limits a more nuanced understanding of associations between different SAs and
behavioral responses. This scoring method was chosen to be parsimonious in the
number of variables included in our models in order to have sufficient power to
detect interactions. Future research with larger sample sizes should further investigate
the relationship between behavioral responses and SA by tactic and experience.
Similarly, data on childhood SA history was limited by the use of a brief self-report
measure that detected the presence of childhood SA, but did not collect detailed infor-
mation about childhood SA, such as type (e.g., unwanted sexual contact, rape), age of
onset, or frequency. Future researchers should use the full CAMI to include an assess-
ment of the severity of childhood SA. Although considered a valid and reliable
measure of PTSD, the PCL-5 may pick up on general distress rather than only
trauma-specific symptoms which may blur the interpretation of current findings. The
measure of behavioral responses used in this study captures a greater range of
responses than previous literature, however, there is poor data on the measure’s test
re-test reliability and it may still not capture the full spectrum of a woman’s potential
responses during SA (e.g., the measure does not explicitly assess tonic immobility).
Specifically, 44 participants endorsed a 1 or 2 on all scales, suggesting that they did
not engage in any response. This finding points to the possibility that certain responses
are not assessed with this measure and future research is needed to test this measure.
Although a strength of the study is that all participants had SA histories, constituting
a high-risk population for psychopathology and revictimization (de Haas et al., 2012),
the sample is limited to women who were enrolled at a university and were predomi-
nantly White. Data on participant sexual orientation, religion, and the gender of the
perpetrator was also not collected. These factors and their intersectionality can influ-
ence behavioral responses used during SA, alexithymia, and PTSD (Richardson &
Taylor, 2009). For example, Richardson and Taylor (2009) found that women of
color were more likely to experience discrimination based on gender and race
18 Violence Against Women 0(0)

simultaneously and to endorse concerns that responding actively could reinforce racial
stereotypes. Gender, sexual orientation, race, culture, and cultural beliefs about SA
should be considered in future research (Richardson & Taylor, 2009).
Results from the current study add to the literature on the role of peritraumatic
factors in PTSD by elucidating that women who endorsed immobilized responses
during SA may be at a greater likelihood of experiencing PTSD. For women who
exhibit greater alexithymia, the association between immobilized responses during
SA and PTSD was stronger and an association between diplomatic responses and
PTSD emerged. Women who experience SA victimization are never to blame for
the SA and perpetrators hold sole responsibility. The purpose of this study was not
to suggest one behavioral response is superior to another or blame individuals for
their behavioral responses. Rather, this study aimed to identify factors that can
inform intervention to support the psychological well-being and safety of women.
Clinically, these findings lend support to the importance of focusing on the identifica-
tion and expression of emotion in trauma-focused treatments, particularly emotions
related to behavioral responses used during the SA. Future research should examine
the directionality of associations between immobilized responses, alexithymia, and
PTSD and mechanisms within these associations such as cognitive distortions
(e.g., self-blame).

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship,
and/or publication of this article.

Funding
The author(s) disclosed receipt of the following financial support for the research, authorship,
and/or publication of this article. This work was supported by the Canadian Institutes
of Health Research, National Institute on Drug Abuse, National Institute on Alcohol Abuse
and Alcoholism (grant numbers 430549, 2U54DA016511-16, K23DA042935, and
1K23AA028055-01A1).

ORCID iD
Naomi Ennis https://orcid.org/0000-0003-2961-3153

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Author Biographies
Naomi Ennis, PhD, is the regional clinical and training lead for the Ontario Structured
Psychotherapy Program in the Mississauga, Halton, and Brampton regions of Ontario. She
was a Postdoctoral Fellow at the Medical University of South Carolina. Her research focuses
on interpersonal risk factors for posttraumatic stress disorder, and enhancing methods for access-
ing evidence-based trauma-focused treatment.

Alyssa A. Rheingold, PhD, is a licensed clinical psychologist and tenured Professor within the
National Crime Victim’s Research and Treatment Center (NCVC) Division at the Medical
University of South Carolina (MUSC). Dr. Rheingold’s overall research interests include exam-
ining the impact of victimization and trauma on a range of health outcomes and evaluating pre-
vention and intervention strategies to promote post-trauma resiliency.
Ennis et al. 23

Heidi M. Zinzow is a Professor and Licensed Clinical Psychologist at Clemson University. Her
research investigates risk factors associated with the development of psychological symptoms
among trauma victims, including posttraumatic stress disorder, depression, and substance use.
Her research also focuses on the development and evaluation of clinical interventions and pre-
vention programs for trauma, including sexual violence, interpersonal violence, combat, and
the loss of a loved one to homicide.

Martie P. Thompson, PhD, is a professor in the Department of Psychology at Clemson

University. Her research focuses on risk factors and consequences of violence, as well as risk
factors for suicidal behavior.

Amanda K. Gilmore, PhD, is an assistant professor in the Department of Health Policy and
Behavioral Sciences and the Mark Chaffin Center of Healthy Development in the School of
Public Health at Georgia State University. Her research focuses on the prevention of alcohol
use and sexual assault, as well as secondary prevention of substance use and mental health symp-
toms after sexual assault.

Dean Kilpatrick is a Distinguished University Professor and senior investigator within the
National Crime Victim’s Research and Treatment Center (NCVC) Division at the Medical
University of South Carolina (MUSC). His primary research interests include measuring the
prevalence of sexual violence, other violent crimes, mass violence, and other types of potentially
traumatic events, as well as assessing PTSD and other mental health impacts of such events.

Christine K. Hahn, PhD, is a Research Assistant Professor at the National Crime Victims
Research & Treatment Center (NCVRTC) at the Medical University of South Carolina. Dr.
Hahn conducts research focused on the treatment of substance use and traumatic stress following
recent exposure to interpersonal violence. She also investigates the role of emotional and behav-
ioral regulation on traumatic stress, sexual risk-taking, and substance use among people who
have experienced interpersonal violence. Finally, her interests include the intersection of trau-
matic stress and women’s reproductive health.