write your opinion for each article and post 2 questions pertaining to articles
Are Traumatic Events Necessary to Elicit Symptoms
of Posttraumatic Stress?
Jordan S. Robinson and Christine Larson
University of Wisconsin—Milwaukee
A diagnosis of posttraumatic stress disorder (PTSD) has been conceptualized as being precipitated by a
particularly traumatic stressor (e.g., combat exposure, rape, and violent assault). Recent research suggests
that common stressful events (e.g., relational problems, divorce, and expected death of a loved one) may
also be capable of eliciting posttraumatic symptomatology. The current study replicated and extended
these previous findings, examining three groups of event exposure: those who reported experiencing only
traumatic events in the past year, those who reported experiencing only significant stressful life events
in the last year, and those who experienced both types of events. Consistent with previous findings, we
found that all three groups of event exposure, including those experiencing only stressful life events,
experienced similar amounts of PTSD symptomatology across symptom clusters. These data add to the
growing literature that suggests that the type of events that cause symptoms of PTSD may be broader than
the current diagnostic criteria indicate, and as such calls for more rigorous research in this area to better
understand the diagnostic implications of these findings.
Keywords: PTSD, life events, PCL, life stress, posttraumatic stress
Since the formal inclusion of posttraumatic stress disorder
(PTSD) into the Diagnostic and Statistical Manual of Mental
Disorders (3rd ed.; DSM–III; American Psychiatric Association
[APA], 1980), controversy has arisen with the diagnosis, much of
it centered on Criterion A1 (the “stressor criterion”). In DSM–III,
this event criterion held that an individual had to experience an
“event that is outside the range of usual human experience and that
would be markedly distressing to almost anyone” (APA, 1980).
One of the first critiques of PTSD came from Breslau and Davis
(1987), who claimed that the connection between this stressor
criterion and the symptom constellation of the PTSD diagnosis had
not been adequately tested in an empirical manner. An additional
criticism of this early criterion concerned the definition of a
traumatic event as one that occurred rarely in the population.
Epidemiological studies have shown that traumatic stressors are
relatively common, with most people experiencing at least one
traumatic event within their lifetime (Breslau, Davis, Andreski, &
Peterson, 1991). In addition to these early criticisms of PTSD as a
construct, several research studies have documented that events
not necessarily considered traumatic elicit the symptom constella-
tion thought to be associated with PTSD, raising questions con-
cerning the disorder’s symptom specificity.
A study conducted by Joseph, Mynard, and Mayall (2000) on
English adolescents found a relationship between high scores on
measures of posttraumatic stress symptoms and stressful life
events that normally would not be classified as traumatic by the
current PTSD inclusion criteria (e.g., parental separation, trouble
with the police, and family member with a drug or alcohol prob-
lem). Additionally, Mol and colleagues (2005) used a general
population sample to examine whether stressful events could gen-
erate symptoms of PTSD and found that those who identified a
stressful life event as their worst subjective experience endorsed
higher levels of PTSD symptoms than did those whose worst
experience was a traumatic event. Similarly, Gold, Marx, Soler-
Baillo, and Sloan (2005) divided college undergraduate partici-
pants into two groups: those who endorsed a traumatic event
consistent with the A1 criterion of PTSD and those who experi-
enced a negative life event not consistent with that criterion.
Consistent with previous research, individuals who reported expe-
riencing negative life events not consistent with the traumatic
nature of the A1 criterion showed equal, if not more, posttraumatic
symptomatology than did those who indicated the experience of a
traumatic event in their life. A more recent study using structured
clinical interviews found similar results in a sample of people
seeking treatment for major depression (Bodkin, Pope, Detke, &
Hudson, 2007). These recent findings underscore a perceived
problem with the construct of PTSD and the stressor criterion that
has received increased attention as we move closer to the release
of DSM (5th ed.). These studies also highlight the importance of
additional research in this area to further explore the A1 criterion
of PTSD and the stressors that can lead to a posttraumatic stress
symptom constellation.
Current Study
The current study sought to replicate and extend the findings
that posttraumatic symptomatology may also be present among
individuals who have experienced stressful life events (Bodkin et
al., 2007; Gold et al., 2005;Mol et al., 2005). The large sample of
Jordan S. Robinson and Christine Larson, Department of Psychology,
University of Wisconsin—Milwaukee.
The data for this study were collected at Michigan State University.
Correspondence concerning this article should be addressed to Christine
L. Larson, Department of Psychology, University of Wisconsin—
Milwaukee, 2441 East Hartford Avenue, Garland 210, Milwaukee, WI
53211. E-mail: larsoncl@uwm.edu
Psychological Trauma: Theory, Research, Practice, and Policy © 2010 American Psychological Association
2010, Vol. 2, No. 2,
71
–76 1942-9681/10/$12.00 DOI: 10.1037/a0018954
71
college undergraduates obtained in the current study allowed us to
clearly delineate three groups of event exposure: those who re-
ported experiencing a traumatic event and no significant stressful
events in the past year, those who reported experiencing only
significant stressful life events in the past year without the expe-
rience of a traumatic event, and those who experienced both types
of events in the past year. This enables us to build on methods used
in previous research, in that it allows for assessment of PTSD
symptoms in groups with more specific exposure to traumatic or
stressful life events as well as examination of the cumulative
effects of exposure to both types of stressful life experiences.
Specifically, we predict results consistent with previous literature,
that traumatic events not consistent with the A1 criterion of PTSD
will elicit symptoms of posttraumatic stress on self-report mea-
sures, even after controlling for differential exposure to both
traumatic and stressful events in the past year. This will be ad-
dressed by predicting symptom severity on the PTSD Checklist—
Civilian version (PCL–C) as a function of type of event experi-
enced. Additionally, we compared severity of PTSD symptoms
between groups exposed to different types of events (traumatic
only, stressful only, and both types).
Method
Participants
The participants in this study were 1190 adults, ages 18 –26
years, recruited through the Michigan State University Human
Participant in Research (HPR) subject pool website. Participants
were volunteers enrolled in undergraduate psychology courses
who received course credit or extra credit for their participation.
Participants in the study read a description of the study procedures
and gave informed consent before participation. Men accounted
for 52.5% of the sample. Participants were predominantly Cauca-
sian (84.5%), along with 5.6% identifying themselves as African
American, 4.1% as Hispanic, and the remaining participants as
“other.” Fifty-one participants were lost because of technical prob-
lems with the HPR database. Those having experienced at least
one traumatic event within the past year accounted for 22.9% of
participants. Traumatic event prevalence for men was 19.5% and
was 26.8% for women within the past year. After selecting those
who reported events in the past year, the final sample consisted of
362 participants (178 men and 184 women). This final sample
consisted of (a) those individuals experiencing only traumatic
events in the last year without the experience of a negative stress-
ful event (trauma only group, n � 64), (b) individuals experiencing
only a negative stressful life event with no experience of a trau-
matic event within their life (stressful event group, n � 149), and
(c) those having experienced both types of events in the past year
(both groups, n � 149). The prevalence of exposure to different
types of events is reported in Table 1.
Procedure and Materials
After providing written informed consent, participants com-
pleted a series of questionnaires assessing life event exposure and
posttraumatic stress symptoms anonymously through the HPR
website.
Trauma and stressful life events scales. The Traumatic
Events Screening Inventory (TESI; Ribbe, 1996) was used to
assess the occurrence of events that would be considered traumatic
by DSM (4th ed., text rev.; DSM–IV–TR; American Psychiatric
Association [APA], 2000) standards. This questionnaire inquires
about a variety of traumatic stressors that may be encountered
throughout an individual’s life (e.g., death of a loved one, witness-
ing an assault, and sexual assault). In addition to measuring oc-
currence of events, this scale inquires as to the severity of the
stressor as experienced by the individual in terms of a subjective
rating on a 7-point Likert scale. Participants were also asked to
indicate whether or not each event endorsed had been experienced
in the past year.
The Life Events Survey (LES; Sarason, Johnson, & Siegel,
1978) was used to assess stressful life events. The LES is a 49-item
self-report measure that yields an occurrence rate and individual-
ized weightings of the impact of life events for each individual.
The questions ask about common life stressors (e.g., “Major
change in financial status”; “Serious injury or illness of close
friend”; and “Marriage”) and asks individuals to indicate which
events have occurred over the past year and rate the severity of
those events on a 7-point scale from �3 (extremely negative) to
�3 (extremely positive). A summed score for positive and negative
events is obtained along with an overall event score. Positive life
events were included because of previous research suggesting that
positive events can be stressful and possibly lead to exacerbation
of symptomatology when other vulnerability or stress factors are
present (e.g., Brown & McGill, 1989).
Posttraumatic stress measures. The PCL–C (Weathers &
Ford, 1996) is a 17-item inventory that assesses the 17 symptoms
of PTSD as is outlined in the DSM–IV–TR. Subscales for each type
of symptom (reexperiencing, avoidance, and hyperarousal) are
calculated along with an overall score for PTSD symptomatology.
Participants are asked to rate how much they have been bothered
by a particular symptom (e.g., “Feeling jumpy or easily startled” or
“Feeling as if your future will somehow be cut short”). Participants
were asked to rate each symptom on the basis of what they felt
their most stressful life experience was. The event that each
Table 1
Frequency of Traumatic and Stressful Event Exposure in the
Past Year by Gender
Event type
Male (%)
(n � 178)
Female (%)
(n � 184)
Traumatic events
Life-threatening accident 51 (28.7) 55 (29.9)
Physical assault 20 (11.2) 11 (6.0)
Sexual assault 9 (5.1) 34 (18.5)
Witness life-threatening accident 51 (28.7) 51 (27.7)
Experience domestic violence 10 (5.6) 21 (11.4)
Witness violence (nonfamily) 50 (28.1) 29 (15.8)
Unexpected death of loved one 38 (21.3) 65 (35.3)
Stressful events
Expected death of a loved one 71 (39.9) 81 (44)
Relational stress 86 (48.3) 97 (52.7)
Problems with school/work 62 (34.8) 73 (39.7)
Serious illness in the family 36 (20.2) 40 (21.7)
Legal problems 55 (30.9) 35 (19)
72 ROBINSON AND LARSON
participant indicated for these ratings is consistent with how they
were assigned for analysis. The PCL–C shows adequate reliability
in the current sample (� � .92, M � 14.63, SD � 11.36).
Results
Individuals in the traumatic event only group reported a mean
number of 2.05 traumatic events (SD � 1.26, maximum � 6).
Those in the stressful life event only group reported a mean number
of 2.75 stressful events (SD � 2.22, maximum � 14). Last,
individuals experiencing both types of events endorsed a mean
number of 2.39 traumatic events (SD � 1.30, maximum � 7) and
3.71 stressful events (SD � 2.42, maximum � 12). Individuals in
the both events group did experience significantly more stressful
life events than did those individuals who had endorsed only a
stressful life event in the past year (t � 3.57, p � .05). There was
no difference in the incidence of traumatic events between the
traumatic event only group and the both events group (t � 1.77,
p � .05).
The analyses conducted attempted to replicate previous findings
(Bodkin et al., 2007; Gold et al., 2005; Mol et al., 2005) suggesting
that stressful life events can precipitate posttraumatic symptom-
atology and extended this work by using groups with more clearly
defined exposure to traumatic and nontraumatic stressful events.
To assess the level of posttrauma symptoms as a function of
exposure to different types of life events, we used two approaches:
regressions predicting posttrauma symptoms as a function of per-
ceived severity of different types of stressful events and a com-
parison of mean levels of PTSD symptoms among groups’ expe-
rience exposure to different types of life events.
The multiple regression analyses were calculated using PCL–C
scores as the outcome variable and perceived severity of life events
as the predictor. Separate regression analyses were conducted for
three groups, defined on the basis of exposure to different types of
life events, including individuals who had reported experiencing
no traumatic events in the past year but had experienced at least
one negative event and possibly one or more positive life events in
the past year (n � 149), individuals who reported the experience
of at least one traumatic event without the experience of significant
stressful life events in the past year (n � 64), and individuals who
had experienced both traumatic and stressful life events (n � 149).
This grouping extends previous work in two ways: first, by allow-
ing a comparison not only between those who have and have not
experienced a significant traumatic event, but also allowing a
comparison group of individuals experiencing both types of life
events; and second, by removing the possible confound of includ-
ing individuals who experienced both types of events in the same
analysis. Those who reported experiencing solely stressful life
events did not have a traumatic event severity predictor variable in
the regression. The regression results for each of these three groups
are presented in Table 2.
Among those who endorsed traumatic event exposure with no
negative stressful events in the past year, traumatic event severity
accounted for 16.3% unique variance in posttraumatic stress symp-
tomatology and positive event severity accounted for 3.9% of the
remaining variance. The zero-order correlation between TESI trau-
matic event severity and PCL–C scores was r � 0.37 ( p � .001).
For those endorsing only stressful life events, negative event
severity accounted for 8.6% of the unique variance in posttrau-
matic stress symptomatology, and positive event severity ac-
counted for another 2.2% of variance in the equation. Last, within
the group for which both types of events were endorsed, negative
stressful life event severity accounted for 6.2% of unique variance,
traumatic event severity accounted for 4.5%, and positive life
event severity accounted for a nonsignificant 0.2% of variance for
posttraumatic stress symptomatology. These results indicate that
although the effect sizes are small, the experience of negative
stressful life events may contribute as much, or slightly more, to
the experience of symptoms of posttraumatic stress.
It is possible that different types of stressors led to different
types of symptoms. To examine this possibility, the PCL–C was
broken down into its constituent symptom clusters of Reexperi-
encing, Avoidance, and Hyperarousal. With this distinction made,
mean levels of PTSD symptoms for each cluster were compared
among the three groups (traumatic event only, stressful event only,
and both). The means and standard deviations of these clusters
across these groups are listed in Table 3. A Symptom Cluster �
Group analysis of variance (ANOVA) did not reveal any interac-
Table 2
Results of Simultaneous Regression Predicting PCL–C Scores by Type of Event Experienced
Trauma type Predictor variable
Unstandardized
coefficient (b)
Standard
error
Standardized
coefficient (�) Significance ( p) Effect size
Traumatic only Constant 27.135 2.249 �.001
TESI 1.010 .293 .394 .001 .163
LES pos �.706 .310 �.260 .026 .078
Stressful events only Constant 28.731 1.479 �.001
LES pos �.288 .151 �.149 .058 .022
LES neg .725 .193 .293 �.001 .086
Both events Constant 28.305 1.978 �.001
TESI .428 .164 .217 .010 .045
LES pos �.101 .181 �.043 .577 .002
LES neg .674 .218 .257 .002 .062
Note. PCL–C � Posttraumatic Stress Disorder Checklist—Civilian version; TESI � subjective current severity of distress from traumatic event; LES
pos � subjective rating of current positive life events; LES neg � subjective rating of current stressful life events. Traumatic events only n � 64;
stressful events only n � 149; both events n � 149.
73ELICITATION OF POSTTRAUMATIC STRESS SYMPTOMS
tion effects as a function of symptom type and event exposure type
( p � .71) and thus is not reported further here.1
For each symptom cluster (Reexperiencing, Avoidance, and
Hyperarousal) as well as overall symptom count (PCL–C compos-
ite), we calculated a one-way ANOVA with group as the lone
factor (traumatic event only, stressful event only, and both events).
ANOVAs for all four symptom severity variables indicated a
significant main effect for group as follows: PCL–C composite
score, F(2, 359) � 5.68, p � .004; Reexperiencing symptoms, F(2,
359) � 7.63, p � .001; Avoidance symptoms, F(2, 359) � 3.14,
p � .044; and Hyperarousal symptoms, F(2, 359) � 3.85, p �
.022. When the means were compared for each group (using a
Games–Howell test for multiple comparisons with unequal sample
sizes), the both events group showed significantly greater symp-
tom severity for the Reexperiencing and Hyperarousal clusters of
symptoms, as well as total PCL–C scores, than did the stressful life
event only group ( ps �.02). The both events group showed higher
values than did the trauma only group, but these results only
trended toward significance ( ps � .073–.118). The stressful life
event only group and the traumatic event only group did not differ
significantly in their mean scores.
To determine whether these effects were due to the inclusion of
those with relatively low levels of PTSD symptomatology, we ran
the same one-way ANOVAs for each symptom cluster on individ-
uals who endorsed PCL–C scores greater than 45. A cut score of
45 was chosen because previous research suggests that this score
displays adequate sensitivity and specificity in civilian populations
exposed to traumatic events (Blanchard, Jones-Alexander, Buck-
ley, & Forneris, 1996). These results are presented in Table 4.
None of the main effects were significant in any of the four
ANOVAs (PCL–C total score, Reexperiencing, Avoidance, or
Hyperarousal), indicating that among those with more severe
PTSD symptoms, PCL–C scores did not vary as a function of the
type of event that they deemed most stressful or traumatic.
Discussion
Supporting previous findings, results from the present study
indicated that traditionally stressful negative live events not in-
cluded in the A1 criterion of PTSD—such as loss of job, problems
with school or work, or change in financial status—may be capable
of eliciting symptoms of posttraumatic stress. In addition, the
current study attempted to resolve one possible methodological
issue from previous studies in which PTSD symptoms were as-
sessed as a function of participants’ self-designated “worst event”
experienced in their lives. As a result of this procedure, it is
possible that although an individual reported that a stressful life
event was the “worst” event that they had experienced, they may
have experienced a significant traumatic event in their life that
would contribute to the experience of posttraumatic stress. The
current study accounted for this potential problem by comparing
rates of PTSD symptoms in participants who reported experienc-
ing only a traumatic event, experiencing only a stressful negative
life event, and those who reported experiencing both types of
events.
Comparisons of these three groups indicated similar levels of
posttrauma symptom severity for all three symptom clusters
among people who had endorsed the experience of only a trau-
matic type event and people who had reported the experience of
only stressful negative life events. However, participants who
reported experiencing both traumatic and stressful life events had
higher, albeit nonsignificant, symptoms for all clusters, with the
Reexperiencing cluster significantly differing from the stressful
events only group. This finding suggests that although both tradi-
tional traumatic events and negative life events generally not
considered traumatic can cause similar levels of posttraumatic
symptomatology, the additive effect of experiencing both types of
events within a relatively short period of time may lead to a
significantly higher level of symptom severity across most clus-
ters. It should be noted, however, that for the individuals who
endorsed both types of events, they could have anchored their
posttraumatic stress symptoms to either type of event, a method-
ological issue that should be addressed in future studies. Addition-
ally, there is a possibility that the increased levels of posttraumatic
symptomatology are due to the fact that the individuals in the both
events experienced group experienced slightly more stressful life
events when compared with the stressful event only group.
While the findings that both traumatic and stressful events are
capable of eliciting posttraumatic stress may call for more rigorous
study regarding symptoms of posttraumatic stress following these
events, it is also important to recognize that outcomes regarding
clinically significant distress experienced may be different for the
two types of events. Exploration of this possibility is beyond the
scope of the current study; however, the finding of Mol and
colleagues (2005)—that posttrauma symptoms persist longer
among those experiencing traumatic events—suggests that further
study of the effects of different types of events is warranted. Our
data do, however, suggest that therapists should consider the
posttraumatic stress symptom constellation in response to a
1 It should be noted that we also examined the three event groups at the
item level of posttraumatic stress symptoms. These results did not offer any
new information beyond those obtained in the symptom cluster analysis.
Table 3
Group Means and Standard Deviations in Posttraumatic Symptomatology
Group Total PCL–C (SD) Reexperiencing (SD) Avoidance (SD) Arousal (SD)
Trauma only 30.29 (12.28) 9.00 (4.19) 11.82 (4.79) 9.43 (4.04)
Stress only 30.13 (10.08)a 8.64 (3.64)a 12.06 (4.63) 9.36 (3.39)a
Both events 34.27 (12.16)a 10.39 (4.22)a 13.29 (5.13) 10.52 (4.18)a
Note. PCL–C � Posttraumatic Stress Disorder Checklist—Civilian version. Stress only refers to the stressful life event group. Traumatic events only n �
64; stressful events only n � 149; both events n � 149.
a Significantly different at p � .05.
74 ROBINSON AND LARSON
broader range of negative life events rather than exclusively fol-
lowing traditionally traumatic events. This is not to say that clini-
cians should necessarily consider diagnosing PTSD arising from
these stressful life events, rather that they should be aware that
these events may elicit a similar symptom constellation. Tradition-
ally, these individuals would most likely be given a diagnosis of
adjustment disorder. Taking into consideration the current study
and previous research, it may be worthwhile to examine whether or
not treatments effective in treating PTSD could not be easily
modified to treat individuals suffering from similar symptoms
arising from more common stressful life events that do not meet
the A1 criterion for PTSD.
PTSD is one of the only disorders in the DSM–IV–TR for which
an etiological factor (in this case a precipitating traumatic event) is
included in the criteria. It is now evident that a traumatic event
consistent with the A1 criterion may not be a necessary etiological
factor in eliciting the cascade of symptoms associated with the
diagnosis of PTSD. However, we need to be careful in the early
interpretation of this research, because some authors argue that
broadening the definition of what constitutes a trauma consistent
with the A1 criterion of PTSD may cause the “significance of the
traumatic experience to diminish” (Gold et al., 2005, p. 695). This
caution echoes earlier sentiment in trauma research pertaining to
the A1 criterion of PTSD. For example, in a recent critique,
Spitzer, First, and Wakefield (2007) called for a tightening of the
definition of what constitutes an event that qualifies for the A1
criterion. They argue that the A1 diagnostic criteria should be
restricted to an event in which “the person directly experienced or
witnessed an event or events” (Spitzer et al., 2007, p. 235) rather
than merely being confronted with such an event, as is stated in
earlier definitions of the criterion. The authors state that this
clarification of terminology will serve to assist clinicians and
researchers in the area of trauma distinction between PTSD-
producing events and other stressors that may produce a similar
symptom cluster. Having this distinction more clearly demarcated
may assist future research in more fully understanding the etiology
of PTSD and how different stressors contribute to the experience
of posttraumatic stress and similar symptom constellations.
After reviewing the evolution of the A1 criterion through its
various incarnations, Weathers and Keane (2007) offered an alter-
native perspective. In contrast to Spitzer et al. (2007), they viewed
the current A1 criterion of PTSD as an adequate definition of what
constitutes a traumatic event capable of eliciting posttraumatic
stress. Though they are satisfied with this definition, they argued
against studies that have suggested broadening the criteria to
include such events as sexual harassment (Avina & O’Donohue,
2002) or extramarital affairs (Dattilio, 2004). Weathers and Keane
(2007) argued that a further broadening of the definition of trauma
within current PTSD guidelines would lead to an “excessively
broad definition of trauma” (p. 115) and possibly lead to problems
with the A1 criterion that were present in DSM–III (APA, 1980).
The research and critiques surrounding the A1 criterion high-
light the need for further study using more rigorous methods. To
date, most of the research in this area, with the exception of the
Bodkin et al. (2007) study, relied on self-report methods to assess
symptoms of posttraumatic stress. Unfortunately, people may in-
terpret the items on trauma symptom questionnaires in a way that
is not consistent with the intent of the clinical criteria. For exam-
ple, one reexperiencing symptom of PTSD requires that an indi-
vidual have recurrent and intrusive distressing recollections of the
event, including images, thoughts, or perceptions. Someone expe-
riencing a negative life event not consistent with the A1 criterion
(e.g., failing an important exam) may be ruminating about the
event and construe that as fulfilling the reexperiencing requirement
when filling out a self-report measure. In addition to the lack of
clinical judgment in the form of clinical interviews, research in this
area has also failed to examine the extent to which symptoms
arising from stressful life events may cause significant distress and
functional impairment, important factors to consider when diag-
nosing psychopathology.
Another limitation of this study was the absence of A2 criterion
measurement. The A2 criterion states that an individual must have
a subjective emotional response that involves “intense fear, help-
lessness, or horror” (APA, 2000, p. 467) in order to meet diag-
nostic criteria for PTSD. Although obtaining a direct measurement
of this criterion would be ideal, inferences can be made in its
absence. In a recent article, Bedard-Gilligan and Zoellner (2008)
found that across three samples (two undergraduate and one com-
munity), the A2 criterion lacked specificity in its ability to diag-
nose PTSD. In other words, the A2 criterion did not predict very
well who would develop the disorder by its presence. This finding
has also been observed in other studies, suggesting that the A2
criterion does not improve predictive accuracy of diagnosis above
and beyond the A1 criterion alone (Kilpatrick et al., 1998; Schnurr,
Spiro, Vielhauer, Findler, & Hamblen, 2002).
Additionally, recent research has examined the effect that order
of measure presentation has on filling out stressful and traumatic
event questionnaires and how it relates to PTSD symptom endorse-
ment (Long, Elhai, Schweinle, Gray, & Frueh, 2008). Participants
in the Long et al. (2008) study filled out a stressful life event and
traumatic life event screener but were counterbalanced on what
order they completed these measures in. After each of these, they
completed a posttraumatic symptom measure anchored to their
worst event on each measure. Long and colleagues found that
those who completed the stressful life events measure and accom-
panying PTSD symptom measure displayed higher rates of PTSD
Table 4
Group Means and Standard Deviations in Posttraumatic Symptomatology: PCL–C Greater Than 45
Group Total PCL–C (SD) Reexperiencing (SD) Avoidance (SD) Arousal (SD)
Trauma only 50.14 (5.01) 15.33 (2.31) 18.91 (2.61) 15.75 (2.34)
Stress only 50.79 (4.09) 14.56 (3.24) 21.56 (2.87) 14.56 (2.47)
Both events 53.40 (6.42) 16.25 (3.91) 20.71 (3.41) 16.28 (2.70)
Note. PCL–C � Posttraumatic Stress Disorder Checklist—Civilian version. Stress only refers to the stressful life event group. The main effect for group
was not significant for the analysis of variance for any of the four scales. Traumatic events only n � 12; stressful events only n � 16; both events n � 32.
75ELICITATION OF POSTTRAUMATIC STRESS SYMPTOMS
and symptomatology in response to non-Criterion A1 events
(stressful life events) than they did to Criterion A1-consistent
events, suggesting that there may be some sort of priming effect at
work when individuals are asked about different types of events.
Although we did not anchor PTSD symptom measures to both
types of events simultaneously as did this study, its results support
the notion that there is a need for more rigorous research in the
area of posttraumatic stress symptom constellations in response to
a variety of life events.
Thus, research considering a broader range of life events is
warranted to better understand the specific aspects of stressful life
events that can lead to reexperiencing, avoidance, and hyper-
arousal symptoms. Future research in this area needs to examine
the extent to which these different types of traumatic and stressful
events cause clinically significant markers of psychopathology
(e.g., symptom constellation, distress, and impairment in function-
ing). This research would need to address the limitations found
within the larger body of previous work. Namely, more method-
ologically rigorous studies need to replicate these findings with
structured clinical interviews and better accounting of events ex-
perienced (i.e., chronicity, frequency, and severity). Such research
would also more definitively establish whether these traditionally
stressful events are indeed capable of causing posttraumatic psy-
chopathology or whether their inclusion in the A1 criterion of
PTSD would constitute what has been considered a “bracket
creep” (McNally, 2003, p. 231) by artificially expanding this
conceptualization of what constitutes trauma. In addition, if the
definition of what constitutes a traumatic event is widened, PTSD
may “shift from an anxiety disorder resulting from a traumatic
experience to more of an adjustment disorder related to difficult
life experiences” (Gold et al., 2005, p. 695).
In conclusion, the data from this and other recent studies suggest
that a wide variety of life events are capable of eliciting some form
of posttraumatic stress. Future research should further examine
whether or not symptoms of PTSD are consistent with reactions to
a variety of life stressors or whether the definition of what con-
stitutes a “traumatic event” in the mental health field needs to be
broadened. The clinical ramifications of this finding are potentially
important and serve as a call to assess posttrauma symptoms
following a broad range of stressful life events. It is beyond the
scope of this study to determine and unclear in the literature as to
the extent to which these symptoms of posttraumatic stress arising
from traditionally stressful events cause impairment in functioning
(interpersonal, occupational/academic, and emotional) to the indi-
viduals who experience them. Further research is warranted in this
area to illustrate the clinical impact that these stressful negative life
events have and how best to treat symptoms of possible differing
severities and composition.
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Received December 1, 2008
Revision received August 31, 2009
Accepted December 9, 2009 �
76 ROBINSON AND LARSON
699
Violence Against Women
Volume 15 Number 6
June 2009 699-719
© 2009 Sage Publications
10.1177/1077801209332182
http://vaw.sagepub.com
hosted at
http://online.sagepub.com
Trauma Victim: Yes or No?
Why It May Be Difficult to Answer
Questions Regarding Violence,
Sexual Abuse, and Other
Traumatic Events
Siri Thoresen
Carolina Øverlien
Norwegian Centre for Violence and Traumatic Stress Studies
The aim of this study is to explore the reasons why it may be difficult to answer questions
regarding violence, sexual abuse, and other potentially traumatic events (PTes). Qualitative
and quantitative methods are used with a nonrepresentative community sample of 628
women who respond to a Web survey. altogether, 65% do not find it difficult to answer any
PTe questions. Difficulties in answering occur more frequently with violence and sexual
abuse items and are associated with exposure. Reasons for difficulties in answering include
“event fit” (severity, frequency, force), “me as a victim” (responsibility, reactions, protec-
tion, memory), and “you as abuser” (intention, protection).
Keywords: measurement; potentially traumatic events; sexual abuse; violence
a large body of research has documented negative social and psychological con-sequences of experiencing violence, sexual abuse, and other potentially trau-
matic events (PTes; Dube et al., 2005; graham-Bermann & Seng, 2005; Jarvis,
gordon, & Novaco, 2005; Kessler, Sonnega, Bromet, & Nelson, 1995). It is of great
importance to society to identify the prevalence of traumatic events in different
populations and reveal their causes and effects. However, exposure to PTes may be
hard to measure, and we know little about how informants comprehend our ques-
tions and what kinds of events informants perceive to qualify for a “yes” response.
The aim of this study was to investigate why it may be difficult to answer questions
regarding violence, sexual abuse, and other PTes.
A Wide Range of PTEs
When investigating the relationship between exposure to traumatic events and sub-
sequent social and mental health problems, much research has focused on specific
trauma populations, such as victims of sexual assault, victims of violence, combat
veterans, or terror and disaster victims.1 However, there are several well-documented
Article
700 Violence against Women
reasons for the necessity of measuring lifetime exposure to a variety of traumatic
events. For example, the number of exposures seems to have a cumulative effect and
experiencing more than one traumatic event seems to be quite common (Follette,
Polusny, Bechtle, & Naugle, 1996; Frans, Rimmo, aberg, & Fredrikson, 2005; green
et. al., 2000; Resnick, Kilpatrick, Dansky, Saunders, & Best, 1993). In large population
studies, there is often a requirement that screening instruments for PTes be brief. Several
brief measures of lifetime exposure to traumatic events, including violence and sexual
assault, have been developed (for a review, see Norris & Hamblen, 2004).
Traumas Are Gendered
PTes are not evenly distributed in the population, but follow specific gender and
age patterns. Women and girls are more exposed to sexual abuse than men and boys;
men are more exposed to nondomestic violence and combat, and women are more
exposed to domestic violence (Nemeroff et al., 2006; Norris, 1992). On a general
level, women and girls are more often victims of intrafamilial violence, and men and
boys are more often victims of extrafamilial violence. These gender patterns are
related to other gender-specific behavior patterns in societies. Interpersonal traumas,
especially rape and sexual molestation, are thought to have more devastating effects
on social and mental functions than other PTes, for both men and women (Creamer,
Burgess, & McFarlane, 2001; Dube et al., 2005; green et al., 2000).
Stigma and Taboo: Can We Ask
These Questions and How?
Violence and sexual abuse are issues that are loaded with taboos, social stigma,
and moral preconceptions. Hence, researchers may be reluctant to include PTe
measures and wonder if it is acceptable for informants to be asked such questions,
or whether informants will react negatively, be unwilling to answer, be bothered by
reminders, be put in physical danger because their violent partner is bothered by
such questions, or drop out of the study altogether. Because of such concerns, PTe
measures may be omitted from large epidemiological studies, resulting in a loss of
important information. In a recent article, Becker-Blease and Freyd (2006) argued
that most such objections are not supported by research. empirical investigations seem
to contradict the hypothetical unwillingness to respond to PTe questions. For exam-
ple, it has been found that violence questions are well accepted, and that nonresponses
to single items occurred much more frequently with income questions than with
sexual abuse questions (Black, Kresnow, Simon, arias, & Shelley, 2006). Research on
childhood victimization has been found to be well tolerated by participating women,
Thoresen, Øverlien / Trauma Victim: Yes or No? 701
adverse reactions are less common than usually expected (Newman, Walker, &
gefland, 1999), and most individuals make favorable cost–benefit appraisals regard-
ing their participation (Newman & Kaloupek, 2004).
One of the most important causes of measurement error in this research area is
underreporting of violence and sexual abuse, while false positives are probably rare
(Fergusson, Horwood, & Woodward, 2000; Hardt & Rutter, 2004). Willingness to
disclose (give a “yes” answer) seems to be dependent on how the questions have
been formulated, in the sense that the use of “labeling” terms, such as “rape,” will
reduce the number of respondents who answer yes, while using behaviorally specific
questions (such as asking directly about forced vaginal, oral, or anal penetration)
will increase disclosure (Harned, 2004; Resnick et al., 1993). Two recent studies
using both types of question formulations supported this hypothesis (Harned, 2004;
Thombs et al., 2006).
Are Informants Consistent in Their
Answers to PTE Questions?
Several studies have empirically investigated consistency in responses to trau-
matic event screening questionnaires. Two studies found the number of reported
events to increase (Roemer, Litz, Orsillo, ehlich, & Friedman, 1998; Southwick,
Morgan, Nicolaou, & Charney, 1997), whereas another study found the number of
reported events to remain unchanged 1 year later (Bramsen, Dirkzwager, van esch,
& van der Ploeg, 2001). Research indicates that it is common (>80%) to change at
least one response at follow-up (Bramsen et al., 2001; Spinhoven, Bean, &
eurelings-Bontekoe, 2006). The overall frequency of inconsistent reporting of PTes
in a study with a 6-year follow-up was 64% (Hepp et al., 2006). Reports of child-
hood sexual abuse and physical punishment have also been found to be relatively
unstable over time (Fergusson et al., 2000).
Inconsistencies in self-reports are not unique to traumatic stress studies and have
been reported in other research areas as well. Skog (1992) found large inconsisten-
cies between self-reported drug use over time; of those reporting lifetime drug use,
approximately 50% reported lifetime drug use when they were asked again a year
later. Similarly, major inconsistencies in self-reported age of first alcohol use and
first smoking were reported by engels, Knibbe, and Drop (1997). Hence, the incon-
sistencies in traumatic stress studies may be no larger than those in other research
areas of the human and social sciences.
Inconsistencies in reporting PTes may have serious implications for estimated
prevalence rates and for evaluating the consequences of violence, sexual assault, and
other PTes. How can such inconsistencies be explained? Some studies have tried to
investigate predictors of inconsistencies in self-reports of traumatic events. These include
702 Violence against Women
gender, level of posttraumatic stress symptoms and dissociation, substance abuse,
memory functions, compensation seeking, initial underreporting, and embarrassment
owing to stigma and shame (e.g., Della Femina, Yeager, & Lewis, 1990; Frueh,
Hamner, Cahill, & gold, 2000; goodman, Corcoran, Turner, Yuan, & green, 1998;
Hepp et al., 2006; Krinsley, gallagher, Weathers, Kutter, & Kaloupek, 2003; Ouimette,
Read, & Brown, 2005). However, little is known about how informants respond to
PTe questions, if they find PTe questions difficult to answer, and what active choices
informants make in the decision-making process when they choose between a “yes”
and a “no” answer.
This study was undertaken to investigate the acceptability and comprehensibility
of a brief screening instrument for PTes, including violence and sexual abuse in
women. The research questions in this study were as follows:
1. Do women find it acceptable to be asked questions regarding violence, sexual
abuse, and other PTes?
2. Do women find it difficult to answer yes or no to such questions?
3. For those women who find it difficult to answer yes or no, why is it difficult?
To answer these questions, a combination of quantitative and qualitative research
methods was used.
Method
Procedure and Participants
The research was designed as a pilot study for a large, prospective epidemiologi-
cal study of women and children in Norway. The pilot questions were intended to be
included at the time point when the children would be 6 to 8 years of age. as the mean
age of giving birth in Norway was 27 years in 2000, we can estimate that the mean
age of the women in our study population was approximately 34 years. Twenty-five
percent of 34-year-old women in Oslo are immigrants (those who either were not
born in Norway or whose parents were not born in Norway; M. T. Dzamarija,
Statistics Norway, personal communication, March 17, 2008). Seventy-nine percent
of them work either part-time or full-time (B. Olsen, Statistics Norway, personal
communication, March 18, 2008). Hence, the study population in the current study
consisted mostly of working women living in Oslo who were mothers of 6- to
8-year-old children, with a predominantly Norwegian background. The study was
anonymous and did not record any personal data.
The Board of education in the Municipality of Oslo approved the study and for-
warded a letter to all schools in Oslo, asking them to distribute the letter to mothers
of children in the first, second, and third grades. The letter described the purpose of
the study, asking the women to assist the researchers in constructing clear questions
regarding “negative life events, such as violence, sexual assault, and other traumatic
Thoresen, Øverlien / Trauma Victim: Yes or No? 703
events.” To do this, the women had to enter a Web site and answer a Web questionnaire.
This procedure was considered sufficient for the purpose of the pilot study, although
it was obvious that a rather large proportion of the population would not be able to
participate, such as women with no easy access to the Internet and women not suf-
ficiently fluent in the Norwegian language (approximately 10% of the Oslo popula-
tion have a language other than Norwegian as their first language). The response rate
was low in this study but could not be calculated exactly. altogether, 99 schools
were asked by the Board of education to distribute the letter. We contacted all
schools and found that 55 schools, attended by approximately 8,831 children, had
actually asked their teachers to distribute the letter. However, school administrators
had not recorded how many of their teachers actually distributed the letter to their
pupils. In addition, in the case of siblings, efforts were made not to distribute to more
than one child of the same mother. However, the proportion of siblings was not
known. altogether, 628 women responded to the Web survey, forming a nonrepre-
sentative and probably highly self-selected sample of the population in question.
Results of this study should not be taken as representative of any larger group, but
rather be considered as examples from a potential range of considerations individu-
als may have when answering traumatic event questionnaires.
Measures
PTEs. The purpose of the pilot study was to evaluate the appropriateness of the
PTe questions to be included in a large questionnaire study of women (and their
children). From several available instruments, we chose the Stressful Life events
Screening Questionnaire (SLeSQ; goodman et al., 1998), a 13-item questionnaire
that includes behaviorally formulated items, focuses more than other instruments on
interpersonal trauma, and has been carefully researched for psychometric properties
(Norris & Hamblen, 2004) and cross-cultural validity (green, Chung, Daroowalla,
Kaltman, & DeBenedictis, 2006). The SLeSQ was adapted for our purposes in
several steps, including translation to Norwegian, restriction of certain items, and
simplification of response alternatives, including two items that could be especially
relevant for women, and some changes of wording as a result of pilot interviews
with 29 women exposed to violence and/or sexual abuse (see appendix). Changes
made in the SLeSQ-adapted were carefully recorded and are available from the
authors on request. The SLeSQ-adapted consists of 13 questions regarding serious
accident; stillbirth or spontaneous abortion; loss of a child; loss of a family mem-
ber in an accident, murder, or suicide; rape; sexual assault; other unwanted sexual
experiences; violence in childhood; violence in adulthood; emotional violence;
witnessing assault; being a victim of criminal acts; and other life-threatening events.
Back-translation of the SLeSQ-adapted was performed by an independent agency.
Acceptability. Respondents were asked to report the degree to which they would
respond with the following reactions if they were asked such PTe questions in a
704 Violence against Women
comprehensive survey: (a) I would be upset or uneasy, (b) I would react negatively
to being asked such questions, (c) I would react negatively to not being asked about
something I have experienced, (d) I would react positively to being asked such ques-
tions, (e) It would be dangerous for me to answer such questions, and (f) If I was
asked such questions, I would have a need to talk to somebody professional, or get
other forms of support. all items were rated on a 5-point Likert-type scale ranging
from not at all to to a very high degree.
Difficulties in deciding how to answer PTE questions. The respondents were asked if
they had difficulties deciding whether to answer yes or no to any of the PTe questions
and, if yes, to specify to which of the questions these difficulties applied. The respond-
ents were then asked to describe why it was difficult to decide how to answer.
Analyses and Statistical Procedures
Statistical analyses. Differences between groups were analyzed using chi-square
tests (for categorical data) and Pearson’s r (for continuous data). all analyses were
performed in SPSS-14.
Qualitative analyses. The qualitative data consisted of an elicited text, that is,
a text written in response to the researchers’ request. Using a grounded theory
approach to analyzing our data (glaser & Strauss, 1967; Strauss & Corbin, 1990),
we first asked the pivotal question, “What is happening here?” (glaser, 1978). To
answer this question, the two authors separately performed a line-by-line coding
followed by a focused coding in which the most frequent earlier codes were
grouped together in categories (Charmaz, 2006). When comparing the categories
from the two different analyses, nine categories emerged, which were later organ-
ized into three metacategories.
Results
Acceptability of PTE Questions
as shown in Table 1, informants in this sample reported a high overall acceptance
of PTe questions. Only 3% reported that they would react negatively to being asked
such questions. acceptance was equally high for those who had been and those who
had not been exposed to violence and/or sexual abuse.
Difficulties in Deciding How to Answer PTE Questions
Table 2 shows the proportion of respondents who confirmed having experienced
the different PTes, and the proportion of respondents who reported that they found it
Thoresen, Øverlien / Trauma Victim: Yes or No? 705
difficult to decide how to answer the questions. For 10 of the 13 items, the “exposed”
group reported difficulties in deciding how to answer significantly more often than
the “not exposed” group.
Of the 628 informants, 65% (n = 410) reported no difficulties in answering any of the PTe
items, 16% (n = 98) reported difficulty on only one item, 10% (n = 65) reported difficulties
on two items, and 9% (n = 55) reported difficulties on three to six of the items.
Difficulties in answering PTe items occurred more frequently on the sexual
assault and violence items (29% reported difficulties on at least one of Items 5 to 10)
compared with the other items (15% reported difficulties on at least one of Items 1
to 4 or 6 to 13) (p < .001).
Having difficulties answering the questions was reported much more frequently
by those who reported any trauma (43%) compared with those who reported no
trauma (14%) (p < .001). Of the women who reported being exposed to sexual
assault or violence, 50% had difficulties answering at least one item. In addition,
the number of traumas reported was significantly associated with the number of
items that respondents had difficulties answering (Pearson’s r = .34, p < .001).
Why It Was Difficult to Answer
PTE Questions: Qualitative Analysis
Of the 218 women who reported that they had difficulties choosing between a
“yes” and a “no” answer to at least one of the questions, 174 (80%) described why
Table 1
Reported Reactions to PTE Questions in Those Exposed
and Not Exposed to Violence and/or Sexual Abuse
Reactions (to a High or
Very High Degree)a exposed, % (n) Not exposed, % (n) χ2,a
I would be upset or uneasy 5 (16) 3 (8) 1.54
I would react negatively 3 (9) 3 (8) 0.01
to being asked such questions
I would react negatively to not 8 (28) 5 (15) 2.18
being asked about something
I have experienced
I would react positively to being 73 (250) 68 (194) 2.46
asked such questions
It would be dangerous for me to 0.9 (3) 0.3 (1) 0.70
answer such questions
I would have a need to talk to 8 (26) 7 (20) 0.10
somebody professional,
or get other forms of support
Note: PTe = potentially traumatic event.
a. None of the differences was significant at the .05 level.
706 Violence against Women
this was difficult for them. In this section, we present the results of an analysis of
these descriptions. We focused on the six violence and sexual assault questions, as
difficulties occurred more often on these items (Items 5-10). The nine categories
that emerged from our qualitative analysis of “reasons for difficulties” were sever-
ity, frequency, force, responsibility, reactions, intent of abuser, memory, protecting
oneself, and protecting others. Categories representing the most frequent descrip-
tions are presented first.
Severity: When does punishment become violence? Informants who found it
difficult to answer yes or no to the question regarding violence in childhood
reported difficulties in deciding if their experience would be considered serious
enough to fit the intention of the question. Four examples are provided below, but a
series of similar descriptions were given.
Table 2
Proportion of Respondents Exposed to Potentially Traumatic Events
and Proportion of Respondents Reporting Difficulties Answering
Proportion Reporting Difficulties answering
Potentially Traumatic Proportion Reporting Total Sample, exposed, Not exposed,
event exposure, % (n) % (n) % (n) % (n) χ2,a
1. Serious accident 14 (89) 4 (27) 14 (12) 3 (15) 21.14*
2. Stillbirth or spontaneous 12 (76) 2 (10) 1 (1) 2 (9) 0.04
abortion
3. Loss of a child 2 (12) 1 (7) 8 (1) 1 (6) 5.77
4. Loss of a family member 8 (51) 3 (20) 8 (4) 3 (16) 3.89
in accident, murder,
or suicide
5. Rape 16 (100) 7 (44) 26 (26) 3 (18) 65.55*
6. Sexual assault 23 (142) 11 (70) 28 (40) 6 (30) 53.52*
7. Other unwanted sexual 15 (95) 9 (55) 24 (23) 6 (32) 33.35*
experiences
8. Violence in childhood 21 (129) 9 (56) 23 (29) 5 (27) 36.66*
9. Violence in adulthood 20 (124) 3 (18) 10 (12) 1 (6) 25.68*
10. emotional violence 21 (130) 10 (62) 27 (35) 5 (27) 53.26*
11. Witnessing violence 12 (73) 3 (20) 12 (9) 2 (11) 22.35*
or sexual assault
12. Victim of criminal 11 (71) 3 (19) 10 (7) 2 (12) 12.71*
offense
13. Other life-threatening 11 (71) 4 (23) 18 (13) 2 (10) 48.57*
events
a. χ2 for the difference between exposed and not exposed.
*p < .01.
Thoresen, Øverlien / Trauma Victim: Yes or No? 707
Because it was a part of child raising, and it wasn’t perceived or intended as
maltreatment.
My father punished me, slapped my back when I did something wrong.
How much is “injured”? Is a burning chin enough?
I experienced “controlled” spanking as a child, but cannot remember that I perceived
this as abuse.
The informants seemed to struggle with the borderline between child maltreatment
and physical punishment, which they perceived to be part of child raising.2
Contrary to the questions regarding violence in childhood, only a few informants
reported difficulties in answering the question regarding violence in adulthood. The
few comments from informants related to the degree of severity of the violent act
and the degree of injuries.
In relation to sexual abuse, some informants found it difficult to decide if their expe-
riences were severe enough to qualify for a “yes” answer. In addition, informants strug-
gled to determine whether the act involved could be termed “sex”; whether the parts of
the body touched, or the parts of the body they had to touch, qualified as “private parts”;
and if “touching” was a correct term if their clothes were on. For example,
I don’t think it was serious enough.
Because the rape was not completed.
I’m not sure if that . . . could be called intercourse.
Because it was outdoors, with my clothes on.
I was forced to touch parts other than the private parts.
Frequency: What if it happened only once? Informants reported problems in
deciding if what they experienced occurred sufficiently often, or for a sufficiently
long period, to qualify for a “yes” answer. Such considerations related to violence in
childhood, psychological violence, and sexual abuse. For instance,
It happened only once; I got away from it.
Violence is a strong word. Is one single blow violence?3
Pressured to intercourse, but only one single episode.
. . . it wasn’t systematic. Only once in a while . . .
Force: Hard to define. Similarly, informants reported it difficult to decide the
degree of force or pressure that had been used against them. However, this related
only to sexual abuse.
What if you are afraid of what will happen if you don’t give in?
Force, but not power.
How much threat . . . it’s hard to say.
It’s hard to evaluate how much force . . . in hindsight—yes, but back then I didn’t think
of it like that.
708 Violence against Women
To what extent did the abuser induce fear, use physical or psychological threat, or
use physical force? as can be seen from the examples, these terms were not perceived
as categorical phenomena, which made it difficult to answer yes or no to the questions.
as indicated below, the force or pressure used by the abuser was perceived to occur
in an interaction with the participant, and many informants consequently questioned
their (in)ability to stop the event from occurring.
Responsibility: Perhaps it was my own fault? In this study, considerations regard-
ing responsibility occurred frequently in association with sexual assault questions,
but were otherwise almost nonexistent. Considerations regarding responsibility
ranged from giving in because of fear of the consequences of saying no, changing
states of desire and fear, a reported inability to protest (e.g., because of being under-
age), an inability to fight back, unspoken threats, and taking responsibility for
“building up to something.” For example,
Because I was partly willing.
. . . was it something I chose to put myself through . . . or was it force . . .?
I sort of built up to it myself . . . flirting, kissing . . . hadn’t thought it would go so far
as to having sex. Locked the car doors, touched me, and I protested.
Now I know I just wasn’t tough enough to say no . . .
Because I didn’t fight back.
Because my reasons to refuse were moral, not due to lack of desire . . . but no doubt
there was pressure . . . was physically held down in spite of loud protests.
Parallel to the perception of force not being a categorical phenomenon, desire,
doing something against one’s will, saying no, and resistance were perceived as
states and actions that could be present to varying degrees. Informants expressed
difficulties in deciding if it was the abuser who used force or pressure, or if it was
the informant who allowed it to happen. For the informant, her own actions in
the situation leading up to the event seemed to be of pivotal importance for how
she understood and conceptualized the event that followed, and hence, how she
responded to questions about sexual abuse.
Reactions: When it doesn’t bother you, does it count? another aspect of the
women’s decision-making process was connected to their reactions as victims.
I . . . have not carried it with me to any great extent.
Have not seen the events as being categorized as traumatizing.
I don’t have any problems attached to this, and it happened a long time ago.
When you are not particularly bothered by it afterwards, then does it count?
I remember being hit by my mother, but this is not something I have a bad feeling about
today.
Thoresen, Øverlien / Trauma Victim: Yes or No? 709
This category of answers has nothing to do with the abuser or the situation itself,
but relates to the victim. absence of negative emotional reactions seemed to influence
the informant toward a “no” answer. For a situation of coerced sex to be defined as
abuse, for example, there seemed to be a preconceived notion that the victim would not
only have strong negative reactions but that these reactions should be long lasting.
The intention of the abuser: What if he didn’t do it on purpose? Our informants
seemed to take into account the purpose or intentions of the abuser.
What about when it is done with the best intentions?
I don’t think my mother did it because she is evil.
Not systematic, and against his intelligence, thereby not planned.
The behavior was a part of him and not directed only at me.
If the respondent understood the intention of the abuser to be good, spontaneous, or
as against his or her better knowledge, the respondent may have been inclined to
answer no to the questions of abuse and violence.
Memory: What if I can’t remember it properly? Problems with recollection of
specific events were mentioned by a few, although this topic did not dominate the
women’s descriptions. “Memory considerations” ranged from very vague and gen-
eral to a more confident perception that “something” happened but that recollections
of this event were not adequately precise. Reasons for memory problems were attrib-
uted to the long period of time that had passed since the event, repression, and
problems in separating recollections of several different events. For instance,
Think you forget things that you don’t want to remember.
Sometimes I get the feeling that something happened when I was a child—an uncle and
a basement. I’m so unsure. . . . Did anything happen, did I repress it, or do I just
imagine?
I experienced something when I was a child.
Things get repressed, especially when there are several things . . . not sure.
It’s a long time ago. I buried these things far back in my brain.
These examples relate to both violence and sexual assault items. Several of the
women with “memory considerations” reported having difficulties choosing between
“yes” and “no” on several items.
Protecting oneself: Me, a victim? a few of our respondents did not have the
energy or strength to answer our questions, or found it hard to be reminded of an
incident that belonged in their past. Others pondered whether a positive answer
defined them in a way they did not want to be defined.
710 Violence against Women
Don’t have the strength.
I don’t like to dwell on things that have been difficult.
Feels a bit like I’m exposing myself.
Because it’s embarrassing to tell that both as a child and as an adult you have been a
victim of . . . humiliations.
Hard to admit to oneself.
I don’t see myself as a victim.
answering no to the survey question can be understood as a way of protecting
oneself from painful memories and from putting a label on oneself that may feel
negative and not in accordance with the respondent’s self-image. What does it do for
a person to answer yes to a question that defines her or him as a victim? What con-
sequences does the check mark in the “yes” box have for the person’s identity?
Protect others: If I tell, he will look bad. The last category found among our
respondents has to do with wanting to protect others. Defining someone as an abuser
also labels the person in a way the respondent may not wish to do.
gives a negative impression of him.
By marking “yes” . . . [it] feels like involving the family.
I don’t define it as violence but as my mother’s helplessness.
I told my mother, and she said I should be careful not to say such things.
Comments such as these give the impression that the respondent wants, or is told
by others, to protect the abuser from being put in a bad light. By answering yes to
the survey question, the respondent not only defines the person as an abuser, an
offender, or a person committing a crime (i.e., as a “bad” person) but also as a person
with “bad” intentions. By redefining violence into helplessness, the mother cannot
be defined as an abuser, but rather as a victim who needs protection herself. What
consequences does a “yes” have for not only me but also the person who did this to
me and the image I have of him or her?
Three Metacategories
We grouped the nine categories described above into three metacategories, relating
to “event fit,” “me (victim?),” and “you (abuser?).” “event fit” relates to the different
aspects of deciding whether the individual experience belongs to the population of
events intended in questions, such as “severity” (e.g., how hard was the blow, how
much injury was there), “force” (e.g., how much physical force was used, did what he
said qualify as a threat), and “frequency” (e.g., it happened only once, it was not typi-
cal). “event fit” was by far the most frequent reason given for difficulties in deciding
how to answer violence and sexual abuse questions. “Me (victim?)” relates to aspects
Thoresen, Øverlien / Trauma Victim: Yes or No? 711
of the informant, such as “responsibility” (e.g., communication of unwillingness to
participate), “reactions” (e.g., using the current absence of stress reactions to define the
event as not qualifying for a “yes” answer), “protection” (e.g., protecting against the
self-perception of being a victim and against stressful reminders), and “memory”
(e.g., lack of precise recollections). The last metacategory, “you (abuser?),” concerns
the abuser and the informant’s relationship to him or her, such as the “intention” (e.g.,
informants seemed reluctant to give a “yes” answer for behaviors that were perceived
as unintentional or explained by other factors, such as helplessness), and “protection”
(e.g., wanting to protect the abuser from looking bad). Certain aspects of these meta-
categories overlapped to some extent. For example, for some, the issue of frequency
was related to the evaluation of severity, and responsibility for the event was related
both to the use of force and to the victim’s inability to stop the event from happening.
although informants reported more difficulties with violence and sexual abuse
questions, there were also several comments on the other PTe items. Most related to
different aspects of “event fit,” such as, what is to be considered a “serious” acci-
dent; what is to be considered “an injury”; what happens when you witness sexual
acts, but you don’t know if they were abusive or not; what if you knew your girl-
friend was abused by her dad, but you never actually saw it; how are you to evaluate
if a threat was serious or not; and in a natural disaster, such as an earthquake, how
do you know if your life is threatened or not.
Discussion
The aim of this study was to investigate whether questions regarding violence,
sexual abuse, and other PTes were acceptable, if such questions were difficult to
answer, and if so, why they were difficult.
Was it acceptable to be asked such questions? The vast majority of informants in
the current study reported positive attitudes to being asked questions regarding vio-
lence, sexual abuse, and other PTes. This is in line with previous research that shows
that questions regarding disaster experiences (galea et al., 2005) and childhood
victimization (Newman et al., 1999) are well tolerated, and that most informants
judge their participation favorably (Newman & Kaloupek, 2004). acceptance was
equally high in those exposed to violence and/or sexual abuse and those not exposed,
which has also been previously reported (Black et al., 2006). It does not seem likely,
then, that the reported difficulties in answering the PTe questions in this study could
be explained by lack of acceptance.
Was it difficult to answer these questions? The majority of women in this study
(65%) did not find it difficult to answer any of the PTe questions. However, sig-
nificantly more informants reported difficulties in choosing between “yes” and “no”
when answering violence and sexual abuse questions compared with other PTe
items. In addition, having difficulties answering was related to trauma; difficulties
712 Violence against Women
were reported significantly more often in informants who had experienced violence
or sexual assault, and the number of traumatic events was associated with the
number of items that were difficult to answer.
Why was it difficult to answer? When analyzing the comments made by the
women about why the questions were difficult to answer, nine different—but also
clearly linked—categories were found, out of which three metacategories emerged:
(a) “event (fit?)” (severity, frequency, force); (b) “Me (victim?)” (responsibility,
protecting oneself, memory, reactions), and (c) “You (abuser?)” (protecting the
abuser, intention of the abuser). The first was by far the most dominant category.
The majority of reasons given for why it was difficult to answer concerned the
question of whether the personal experience would qualify for a “yes” answer: Was
the experience “serious” enough; was the physical contact sufficiently hard; did it
last long enough or occur with sufficient frequency; was enough force or threat
used? Informants in this study seemed to possess a more multidimensional view of
potentially traumatic experiences than a brief screening instrument could encom-
pass; several dimensional phenomena (e.g., “serious,” “life threat,” “force”) were
summarized into a qualitative (dichotomous) question demanding a “yes” or “no”
answer. Confronted with this rather difficult task, it is possible that only prototype
events will elicit a straightforward “yes” answer. Other, less prototypical events may
leave the informant with a need to interpret and evaluate several aspects of the event.
These results are in line with a previous study that showed that reporting of abuse
depends, among other factors, on the severity and frequency of the abusive acts
(Katerndahl, Burge, & Kellogg, 2006).
Responsibility issues were uniquely related to sexual abuse questions. Informants
gave descriptions of a variety of situations in which their own behavior may have
been related to the event occurring. These comments seemed to range from a bal-
anced retrospective analysis of responsibility to self-blame. Victims who take
responsibility for the violence and blame themselves have been discussed by Loseke
(2001) and Leisenring (2006), among others. These issues are similar to the “issues
of consent” described by Harned (2005) as one important aspect of women labeling
unwanted sex as abuse and may well be one reason for getting a “no” response to
events in which the researcher would have expected a “yes” answer. However, less
attention has been given to the dimensional aspects of consent that were discussed
by informants in this study. Lack of negative emotional long-term reactions was used
by some informants to retrospectively conceptualize the event as “not qualifying”
for a “yes” answer. If this reasoning is widespread in research participants, it may be
a serious threat to the validity of the association between traumatic exposure and
subsequent mental health or social problems. Problems with recollection of specific
events were mentioned by some informants in this study, although much less fre-
quently than we expected considering the extensive literature on memory and
trauma.
Only a few informants commented that they did not have the strength to answer,
or that answering would activate reminders. More frequently, questions regarding
Thoresen, Øverlien / Trauma Victim: Yes or No? 713
violence and sexual abuse seemed to touch on the informants’ self-perception and
identity: Who am I to be abused? Some informants seemed to perceive answering
the Web-based questionnaire as interactive, and felt that selecting “yes” would affect
the way they perceived themselves and were perceived by others (in this case, the
researchers). The informants were not only hesitant to answer yes because they did
not wish to expose themselves to a possible negative emotional memory, but also
because they did not wish to identify themselves as victims. We understand this as
protection against the negative attitudes and values of being a victim of violence and
sexual abuse in society as a whole. as Leisenring (2006) argues, there are strong
cultural discourses that depict abused women as blameworthy and powerless. Berns
and Schweingruber (2007) found that informants who have not been victimized
describe victims of abuse as weak and lacking personal qualities that could have
prevented the abuse. Consequently, victims are stigmatized (goffman, 1968).
Claiming a victim identity is thereby risky business.
The relationship between the abuser and the abused is of great importance in
understanding the decision-making process of the women (e.g., Theran, Sullivan,
Bogat, & Sutherland, 2006). Several of our informants gave explicit comments that
they felt reluctant to answer yes because this might give a negative impression of the
person who did this to them. In addition, the presumed intention of the “abuser” was
taken into account when answering the questions. Can you be an abuser without
having the intention to abuse? Similar findings were reported by Sedlak (1988). In
her examination of the labeling of violence, she found that the decision-making
process was influenced by the victim’s attributions of the abuser’s intelligence and
motivation. as researchers, we would prefer our informants report their experiences
with violence and abuse without considering how the abuser may be perceived by
the researchers and without speculations as to the intention of the abuser. However,
this and previous studies indicate that some informants do take these factors into
consideration.
Implications
Several previous studies have focused on issues regarding the informant to
explore reasons for inconsistent reporting of PTes, including memory and mental
health symptoms (e.g., Della Femina et al., 1990; Ouimette et al., 2005). In our
opinion, the results of this study may contribute to a move away from the informant
and toward the way PTe screening instruments are designed. The “yes” or “no”
response categories consistently used in screening instruments when referring to
dimensional phenomena may leave the informant with a less-than-optimal under-
standing of how to answer the questions. This may be one explanatory factor for the
observed inconsistency in PTe reporting.
The main implication of this study is an increased awareness of the complexity
of such phenomena and a call for caution in how epidemiological results in this field
may be interpreted. Previous research has shown that behaviorally specific questions,
714 Violence against Women
compared to labeling questions, are more likely to result in a “yes” response (Harned,
2004; Thombs et al., 2006). In the present study, labeling terms such as “rape” were
avoided, and efforts were made to include behaviorally specific questions. However,
a possible way to further reduce ambiguity in the questions may be to operationally
define important concepts such as “force” and “pressure” (O’Sullivan, Byers, &
Finkelman, 1998). One important issue for this research field may be the balance
between brevity and precision. On one hand, we strive to keep screening instruments
brief and the questions short and easy to read. On the other hand, we strive to
achieve precise measurement, which implies that at the least, the informants clearly
understand if their experiences fall into or outside of the category covered by the
question. The “ease” of answering such questions and the balance between brevity
and precision could be considered an empirical question that has not been suffi-
ciently investigated and one that could be further researched using both qualitative
(e.g., green et al., 2006) and quantitative (e.g., Thombs et al., 2006) methods. The
difficulty of informants’ using their own emotional reactions to the event and their
interpretation of abuser intent as guides for whether to answer yes to a PTe question
may possibly be overcome by specific instructions to the informant not to consider
such factors. However, such a proposal needs to be investigated empirically.
Limitations
The current study was not designed to be representative of any specific group. The
reported acceptance, proportions exposed to different PTes, and proportion who found
it difficult to answer the questions are all results that may be highly affected by the
selected population (women with children of a certain age), response bias, research
method, time period, and culture.
The aim of this study was to shed light on the decision-making process of
women informants and the reasons why they found it difficult to answer PTe ques-
tions. Results should be considered examples from a potential range of considera-
tions that individuals may have when answering traumatic event questionnaires.
The considerations described in this study may well have relevance for informants
of another gender or age, in another setting, or responding to somewhat differently
formulated questions. However, improved clarity of the questions might have been
achieved through defining concepts such as “pressure” and “force.” although
violence and sexual abuse of women is a worldwide social problem, it is also a
temporally and culturally dependent phenomenon. Issues regarding violence and
sexual abuse have been understood differently in different time periods, and are
understood differently in different cultures. The population in the current study
comprised mostly working women in a certain age group, with minor children, and
a predominantly Norwegian background. The willingness to respond to these sen-
sitive issues might be regarded as highly culture or sample dependent. However,
we consider it less likely that the difficulties answering survey questions regarding
these sensitive taboo issues would be restricted to Norwegian women and would
Thoresen, Øverlien / Trauma Victim: Yes or No? 715
expect similar difficulties to be found among respondents living in other areas of
europe or North america. This expectation requires empirical investigations with
other informant groups.
The qualitative data were restricted to the rather short descriptions given by the
informants, without the possibility of further exploration or reflection, which could
have been given in an interview setting. However, anonymous written comments,
such as those made by the informants in this study, may foster frank disclosures that
would not emerge during an interview, especially if the topic is sensitive and could
result in the informant feeling shame or disgrace (Charmaz, 2006).
Other strengths of this study include the rather large sample size, the large propor-
tion of women who reportedly found it difficult to answer the questions and actually
added a description of why this was difficult, the large spectrum of descriptions given by
the informants, and the fact that to our knowledge this is the first study of its kind.
Concluding Thoughts
Our intention with this article is by no means to suggest that informants have
misunderstood the survey questions or have a confused understanding of the phe-
nomena. Finding it difficult to choose between “yes” and “no” is not the same as
giving “incorrect” answers. On the contrary, we consider the informants’ comments
to be important contributions to the ongoing discussion of defining and measuring
violence and sexual abuse.
Appendix
SLESQ-Adapted
1. Were you ever in a serious car accident or other accident in which you were seri-
ously injured or your life was in danger?
2. Did you ever experience stillbirth or missed abortion after week 12 of pregnancy?
3. Have you ever lost a child (from death)? (biological child, foster child, adopted
child, step child or partner’s child that you have lived together with)?
4. Has an immediate family member or romantic partner died because of accident,
homicide, or suicide?
5. Has anyone (parent, other family member, romantic partner, stranger, or someone
else) ever forced you to have intercourse, or to have oral or anal sex against your
wishes? (either by physically forcing you, by threatening you, or by taking advan-
tage of a situation in which you could not defend yourself, e.g. because you were
asleep or unconscious/intoxicated, or that you were underage.)
6. Other than experiences mentioned in earlier questions: Has anyone ever touched
private parts of your body or made you touch private parts of their body against
your wishes?
(continued)
716 Violence against Women
7 Other than experiences mentioned in earlier questions: Have you ever been pres-
sured to engage in other sexual situations or acts against your wishes?
8. Before age 16: Did a parent, caregiver, or other adult person ever kick you, hit you,
or otherwise attack or harm you?
9. after age 16: Have you ever been kicked, beaten, slapped around, or otherwise
physically harmed by a romantic partner, date, family member, stranger, or some-
one else?
10. Has a parent or a romantic partner systematically ridiculed you, put you down, or
told you you were no good?
11. Have you ever witnessed another person being killed, seriously injured, or sexually
or physically assaulted?
12. Other than the experiences mentioned in earlier questions: Were you ever exposed to a
criminal act in which you could have been seriously injured or your life was in danger
(robbed, taken hostage, kidnapped, or attacked or threatened with a weapon)?
13. Other than the experiences mentioned in earlier questions: Have you ever been in
any other situation where you could have been seriously injured or your life was in
danger (e.g. experienced war, natural disaster, fire)?
all questions had the response categories “yes” or “no, never.” If a “yes” answer was
given, the respondent was asked to specify in which time period the event occurred:
Before age 16, after age 16, and past 12 months (the specification of time period was
omitted for Item 8 (violence in childhood), and the time period “before age 16” was
omitted for Item 9 (violence in adulthood). Item 5 (rape) and Item 9 (violence in adult-
hood) asked in addition for frequency (“Please specify how many times this happened to
you”: 1, 2-4, 5-10, more than 10 times). Item 9 (violence in adulthood) asked in addition
for the identity of the perpetrator (“stranger, family or relative, other known person”).
Notes
1. The use of the word victim in this article may seem counterproductive, as our aim is by no means
to further emphasize the status of women as victims. Furthermore, the Web survey did not use the word
victim. However, our analysis shows that the women relate to the question of being a victim when decid-
ing if they should answer yes or no to the survey questions. The choice of the word victim in the title of
the article, for example, is thereby part of our analytical work.
2. Spanking, and other physical punishment of children, is forbidden by Norwegian law.
3. The word violence was not used in the question.
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Thoresen, Øverlien / Trauma Victim: Yes or No? 719
Siri Thoresen is a researcher at the Norwegian Centre for Violence and Traumatic Stress Studies. She
was trained as a clinical psychologist and received her PhD from the University of Oslo, Norway. Her
research interests include traumatic stress, gender, suicide, social psychology, and public health.
Carolina Øverlien is a researcher at the Norwegian Centre for Violence and Traumatic Stress Studies.
She has a PhD in Child Studies from Linköping University, Sweden. Her research interests include chil-
dren and adolescents exposed to domestic violence, physical violence and sexual abuse, qualitative
methods, and feminist theory.
