The Community Response to Rape: Victims' Experiences with the Legal, Medical, and Mental Health Systems1

American Journal of Community Psychology, Vol. 26, No. 3, 1998

Rebecca Campbell2 University of Illinois at Chicago

This research examined how the legal, medical, and mental health systems respond to the needs of rape victims. A national random sample of rape victim advocates (N = 168) participated in a phone interview that assessed the resources available to victims in their communities. as well as the specific experiences of the most recent rape victim with which they had completed work. Results from hierarchical and iterative cluster analysis revealed three patterns in victims' experiences with the legal, medical, and mental health systems. One group of victims had relatively positive experiences with all three systems, a second group had beneficial outcomes with only the medical systems, and the final group had difficult encounters with all three systems. Multinominal logistic regression was then used to evaluate an ecological model predicting cluster membership. Community-level factors as well as features of the assault and characteristics of the victims predicted unique variance in victims' outcomes with the legal, medical, and mental health systems. These findings provide empirical support for a basic tenet of ecological theory: environmental structures and practices influence individual outcomes. Implications for ecological theory and interventions to improve the community response to rape victims' needs are discussed. KEY WORDS: rape victims; community response; rape victim advocates.

1The author thanks Ana Mari Cauce, Bill Davidson, Chris Keys, Deborah Salem, and Sarah Ullman for their helpful comments on this paper; the members of the Community Response to Rape Project for their assistance in data collection; and the rape victim advocates who participated in this study for their time, expertise, and feedback on this manuscript. This research was the first-place recipient of the Society for Community Research and Action (Division 27 of the American Psychological Association) 1997 Dissertation Award, William S. Davidson, II, Chair. 2A1I correspondence should be addressed to Rebecca Campbell, Department of Psychology, University of Illinois at Chicago, 1007 West Harrison, Chicago, Illinois 60607-7137.

When women go public with their stories of rape, they place a great deal of trust in our social systems as they risk disbelief, scorn, shame, punishment, and refusals of help (Madigan & Gamble, 1991). How these interactions with system personnel unfold can have profound implications for victims' recovery (Kerstetter, 1990). If women receive the services they need, and are treated in an empathic and supportive manner, then our social systems can work as effective catalysts for healing (Estrich, 1987: Fairstein, 1993; Golding, Siegel, Sorenson, Burnman, & Stein, 1989; Madi- gan & Gamble, 1991; Parrot, 1991; Russell, 1990; Warshaw, 1988; Wyatt, Notgrass & Newcomb, 1990). Conversely, if victims do not receive the services they want and are treated in an insensitive manner, then interactions with community personnel can magnify feelings of powerlessness, shame, and guilt for rape victims (Feldman-Summers & Palmer, 1980; Madigan & Gamble, 1991). These negative experiences have been termed "the second rape" or "secondary victimization" (Madigan & Gamble, 1991). Analysis of these interactions between victims and social systems may uncover ways to promote a community response to rape that is psychologically beneficial to victimized women. Community resources for rape victims are often piecemeal and unco- ordinated as different systems perform different functions. For example, victims go to the hospital for the rape exam and evidence collection; to the police station to meet with a detective; to the state's attorney to discuss prosecution; to the rape crisis center for information and crisis counseling; and to many other agencies as well. Not surprisingly. research in this area is likewise diffused across disciplines and methodologies. Typically, each system—legal, medical, mental health—is studied in isolation. From the perspective of the victims, however, these lines of demarcation may not be as distinct, meaningful, or useful. This flurry of activity is about one event in their lives, one trauma that is then parceled out among many for attention. Focusing on how the legal, medical, and mental health systems respond to victims' needs increases our understanding of victims' experiences with community systems. By taking this more holistic view of how communities respond, we can begin to see what victims experience and evaluate how well our social services are responding to their needs. A primary obstacle in the development of this holistic view of victims' experiences has been the recruitment of survivors who have sought community services. Rape victims are often difficult to identify and the emo- tional trauma of sexual assault often leaves them reluctant to discuss their experiences with researchers. An alternative sample to consider is rape victim advocates. Most communities in the United State have a rape crisis center with staff members who work as community-based advocates, helping victims negotiate the process of interacting with each community system Community Response to Rape 357

(Webster, 1989). Advocates explain the services that are available to victims, determine what victims want from each system, and then work to bring about outcomes consistent with their needs. Through this process, rape victim advocates become privy to a great deal of information about both rape victims' needs and how service systems respond to victims. In this research, a national random sample of rape victim advocates was recruited to address two issues. First, this study sought to identify patterns of victims' experiences across multiple community systems. Advocates were asked to describe the most recent sexual assault case they had completed, and what actions were taken in that case by the legal, medical, and mental health systems. In describing these interactions, three dimensions were considered: (a) What services were provided to victims by each system?; (b) Did those outcomes fit with victims' needs (i.e., did the system respond in a manner that was consistent with victims' wishes)?; (c) How readily available were those services? This information was used to develop clusters profiling different patterns of community response to sexual assault. The second goal is to determine what factors predict different experiences: Which victims receive which services? A multi-level model predicting cluster membership was evaluated. Presented first is an overview of existing literature on rape victims experiences' with social systems that examines research on service delivery in each major community system. Then, extending this work, an ecological model predicting victims' experiences with the legal, medical, and mental health systems is described and evaluated.

RAPE VICTIMS' EXPERIENCES WITH COMMUNITY SYSTEMS

The Legal Processing of Rape Cases

Prosecuting a rape is a complicated process, which starts with reporting the assault to the police. This initial report may be given to a detective for a more detailed investigation. In some jurisdictions, this report/investigation is automatically forwarded to the prosecutor, but in others, the police decide whether to forward the report. The prosecutor then chooses whether to authorize an arrest and press charges—either for the original charge of sexual assault or a lesser offense (e.g., simple assault, reckless endangerment). These charges may be dropped later, but if not, the accused rapist has the choice of pleading guilty to the charged offense, or, if a bargain has been struck, to a lesser offense, or going to trial. If he is convicted at the trial, the judge may choose either probation or jail as punishment. With a system this complex, it is to be expected that some cases will slip through the cracks, and indeed over half of reported rapes are filtered out 358 Campbell

of the criminal justice system (Galvin & Polk, 1983; LaFree, 1980). Which cases proceed, and which are filtered out, is influenced by multiple factors. At the community level, the resources allocated to address sexual assault and the coordination of those services increase prosecution efforts (Fairstein, 1993; U.S. Department of Justice, 1994). The type of rape is also significant, as several studies have found that stranger rapes are investigated more thor- oughly and are less likely to be filtered out of the system than nonstranger- rape cases (Fairstein, 1993; Finkelhor & Yllo, 1985; Kerstetter, 1990; Madigan & Gamble, 1991; McCahill, Meyer, & Fischman, 1979: Russell, 1990). Assaults that involve the use of a weapon and result in physical injuries to the victim are more likely to be pursued (LaFree, 1981: Kerstetter, 1990; Rose & Randall, 1980). Characteristics of the victim also influence case dis- position. Victims who are perceived as less credible are more likely to have their cases rejected for prosecution (Rose & Randall 1989). In a similar vein, Madigan and Gamble (1991) suggested that system workers distinguish between "good victims" and "bad victims." "Good victims" show visible, expressive signs of trauma (e.g., crying) and are receptive to help from system personnel. Consequently, they may receive more help than victims who do not show as much visible distress.

Medical Care for Rape Victims

There are four reasons why victims may need medical attention following a rape. First, forensic evidence can be collected (e.g., semen, blood, and/or hair/fiber/skin samples). Second, a medical examination is helpful to detect and treat physical injuries from the assault. Third, victims often want information and testing for sexually transmitted diseases (STDs), and some hospitals administer of a preventative dose of antibiotics to treat any STDs that might have been contracted in the assault. Finally, although pregnancy from rape is rare (5% of the time, Beebe, 1991: Koss, Woodruff, & Koss, 1991), it is a concern for many victims, and some hospitals administer the morning-after pill to prevent pregnancy (i.e., ethinyl estradiol- norgestrel [Ovral]). There has been very little research examining whether hospitals offer these services to victims. The National Victim Center's (1992) survey of female survivors of sexual assault indicated that 60% of victims were not ad- vised about pregnancy testing or how to prevent pregnancy. Although 43% of the women were concerned about contacting HIV from the assault, 73% were not given information about testing for exposure to HIV Another 40% were not given information about the risk of contracting other STDs. Camp- bell and Bybee (1997) found that emergency room personnel rarely provide rape victims with the morning-after pill to prevent pregnancy (38% of the Community Response to Rape 359 time). These findings suggest that there is some inconsistency in what information and services are offered to victims during the medical exam.

Mental Health Services for Rape Victims

Mental health workers may be called upon to help both victims and those close to them who are also traumatized by the rape, including her family, friends, and/or husband (significant other). This assistance could be limited to providing information about rape and its effects, or could extend to short-term or long-term counseling or support groups. Most research on psychological services for rape victims has sought to identify effective forms of therapy (e.g, Foa, Rothbaum, Riggs, & Murdock, 1991; Frank & Stewart, 1984; Frank, Stewart, Dancu, Hughes, & West, 1988; Koss & Harvey, 1991; Resick, Jordan, Girelli, Hutter, & Marhoefer-Dvorak, 1989; Resick & Schnicke, 1992) and assess the prevalence of posttraumatic stress disorder (PTSD) in rape victim populations (e.g., Foa, Steketee, & Olasov. 1989; Norris, 1992; Rothbaum, Foa, Riggs, Murdock, & Walsh, 1992), rather than documenting whether these services are provided to victims and their families. Some light was shed on this issue by Forman and Wadsworth's (1983) study of community mental health centers (CMHC), which found that over 75% of CMHCs in their sample offer these services to victims and their families. Other work by Campbell, Baker, and Mazurek (1998), Gornick, Burt, and Pittman (1985), and Harvey (1982a, 1982b, 1985) revealed that rape crisis centers have begun to offer these mental health services. King and Webb's (1981) survey of 24 rape crisis centers found that all victims who requested counseling received it, and 62% of the victims had at least one follow-up contact with center staff.

AN ECOLOGICAL MODEL PREDICTING RAPE VICTIMS' EXPERIENCES WITH COMMUNITY SYSTEMS

The existing literature on service delivery for sexual assault victims sug- gests that multiple factors influence the response of the legal system, but less is know about the response of the medical and mental health systems. In effort to understand multiple community systems and the multiple influ- ences impacting system response, a multilevel model was evaluated in this research. Ecological theory with its attention to person-environment fit and ecological settings can provide one framework through which to theorize and research victim-system interaction that spans individual and systemic factors (Kelly, 1966, 1968, 1971; Trickett, Kelly, & Vincent, 1985). Thus, the focus of this research was on the fit between victims' needs and system response, and how environmental factors impact this fit. 360 Campbell

The proposed ecological model expands previous rape research in two areas. First, as noted previously, much of the existing research has focused on the legal response to sexual assault, and in order to further a more holistic picture of victims' experiences, the aim of this study was to predict outcomes in all three systems simultaneously (legal, medical, and mental health). Whereas there are multiple ways to define victims' outcomes, this model fo- cuses on the ecological conception of person-environment fit: Did the system respond in a manner consistent with victims' needs? A "good" outcome for one victim may be different from another as their needs vary. Focusing on the concept of fit defines good outcomes as those consistent with individual victims' needs. Second, several community-level, rape-related, and individual- level factors have been demonstrated to affect the legal system response. This study expands this literature by considering the impact of such variables across all three community systems (legal, medical, and mental health), as well as examining the effects of untested variables, such as victims' use of alcohol and demeanor when interacting with social system personnel.

Community-Level Factors

Two community-level factors are explored in this model. First, Kelly (1966, 1968, 1971) and other ecological theorists have suggested that the quantity and quality of resources available to address a social problem (e.g., staffing resources, financial support) will affect service delivery. Second, in- terorganizational coordination has been suggested to improve service delivery (Agranoff & Pattakos, 1979; Baker & O'Brien, 1971; Tausig, 1987: Turner & TenHoor, 1978). For instance, some communities have a coordinated response to sexual assault that brings multiple service providers together to assist victims (e.g., Sexual Assault Response Teams). How a system responds to victims may be a function not only of what resources are available, but also how embedded that system is within a network of social agencies.

Rape-Related Factors

Several characteristics of the assault itself may influence how social systems respond to victims. Four features of the rape itself are considered in this model: (a) type of rape (stranger or nonstranger); (b) use of a weapon; (c) presence of physical injuries; and (d) whether the rape oc- curred while the victim was under the influence of alcohol. There has been growing interest in the role of alcohol in rape (e.g., Abbey, Ross, McDuffie, & McAuslan, 1996: Richardson & Hammock, 1991), and as such, this variable is included in the model along with previously established predictors. Community Response to Rape 361

Individual-Level Factors

Whereas there are numerous characteristics of victims that may influence system response, three broad-based characteristics are considered: race/ethnicity, social class, and victims' demeanor when interacting with system personnel. Several studies in the victimology literature (as well as research on other social problems) suggest that members of disadvantaged or stigmatized groups (i.e., non-White, lower socioeconomic status) receive differentially worse treatment by social systems (Davis & Proctor, 1989: Gordon-Bradshaw, 1988: Mama, 1989: Pinderhughes, 1989: Wyatt, et al., 1990). Furthermore, Madigan and Gamble (1991) suggested that some women are perceived by system personnel as "good victims" (i.e., they are visibly distressed and receptive to help), and hypothesized that women who behaved in this manner may receive more help than those who do not. This assumption is explicitly tested in this model.

METHOD

Participants

A two-step process was used to select the national random sample of rape victim advocates. First, using a national directory of services for sexual assault victims (Webster, 1989), 759 agencies that provide advocacy services to rape victims were identified: 390 free-standing rape crisis centers and 369 combined rape crisis-domestic violence programs. An a priori power analysis indicated that 165 participants would be needed to have power = .80 (a = .05), assuming a medium effect size (f2 [standardized effect size] = .15, equivalent to a multivariate R2 = .40 and multiple-R2 = .13) (Cohen, 1988). A random sample was selected, stratifying for agency type. In the second step, the directors of the randomly selected agencies were contacted by telephone. They were asked if they had paid or volunteer staff who provide community-based advocacy services to adult rape victims, and if so, to provide the name of the advocate who provides the most direct-advocacy work at that agency. If the director stated that no one provided these services, the agency was removed from the list of target agencies and a randomly selected replacement from the same type of agency was drawn. A total of 213 agencies were screened for participation in this study, and 177 were eligible.3

3Of the 36 centers that were not eligible for the study, 8 were no longer in existence, 19 have changed their services since the publication of the directory and now provided only therapy for victims, 2 had not had a sexual assault case in the past 3 years, 5 now worked only with domestic violence victims, and 1 now worked only with victims of child sexual abuse. 362 Campbell

From this pool of eligible centers, 168 advocates participated in the interview (95% response rate). The advocates were on average 37.25 years old (range 22-65). The majority of the sample was White (88%) (5% African American, 4% Lat- ina, 2% Native American Indian, 1% Asian American, and 1% Arabic American). Most of the advocates had at least a bachelors degree (74%). The advocates had been working in their current position at the rape crisis centers for an average of 5.28 years (range 5 months-20 years). As mentioned previously, the advocates were asked to describe the most recent adult sexual assault case they had completed. The victims were, on average, almost 10 years younger than the advocates (M age 28.35 years, range 17-78). Most of the victims were White (71%) (14% African Ameri- can, 9% Latina, 4% Native American Indian, and 2% Asian American). Most of the victims had at least a high school degree (60%). Over one third of the victims were described by the advocates as working class (35%), with 25% described as lower class and 26% as middle class. Only 14% were described as above middle class. Consistent with previous research, most of the rape survivors in this sample were assaulted by someone they knew (acquaintance, date, partner) (76%), and most were raped by a single assailant (90%). Whereas almost all of the women were subjected to forced vaginal penetration (95%), some experienced anal rape (20%), oral rape (23%). and/or rape by a physical object (14%). Some women, therefore, experienced multiple forms of rape. In this sample of victims, women were raped on average 1.89 times by the assailant in the assault with a range of 1-20 times. Forty-one percent experienced no physical injuries from the attack, but 48% experienced some bruising, 23% were cut during the assault, and 19% experienced some type of head injury, such as a blow to the head and/or broken blood vessels in the eyes and face from being choked. Most of the women did not have a weapon used against them in the assault (71%), and most were not under the influence of alcohol (66%).

Procedure

Interviews with advocates were conducted by phone with a mean du- ration of 1.34 hours (SD = 27 minutes, range 40 minutes-3.25 hours). The interviews were conducted by the author and 10 undergraduate research assistants, who received course credit for their participation in the project. To assess test-retest reliability, 25% of the completed interviews were randomly selected and the advocates were recontacted by a different interviewer to repeat only the questions assessing rape victims' experiences with the medical system. Test-retest reliability was .95. To assess interrater reli- Community Response to Rape 363

ability, a random selection of 25% of the phone interviews were listened to by a second interviewer to code the entire interview. Interrater agreement for the entire questionnaire was 95%, which was corrected for chance agreement (K = .86).

Measures

Independent Variables in the Model

The measures to assess the constructs in the proposed model were created for this study by the author with input from two focus groups of rape victim advocates (10 advocates in each group). For the community-level factors, two scales were created to measure resources available for rape victims and the coordination of those services. The rape-related and individual-level factors were assessed with single items in the interview protocol. Community-Level Variables. To assess the resources within each community, the advocates were asked what services were available in their communities (15 total): police sex crimes unit, police rape protocol, prosecutor sex crimes unit, prosecutor victim-witness program, prosecutor court ac- companiment program. information provided at the hospitals on pregnancy, information provided on STDs, morning-after pill. STD preventive treatment, scheduling follow-up medical visit, crisis intervention therapy, short- term rape-related therapy, long-term rape-related therapy, rape-related counseling services for women with special needs (e.g., women with dis- abilities), and support groups.4 The Community Resources scale was created by summing number of services available (a = .63). The Community Coordination of services scale summed the number of programs in a community that brought together the various agencies serving rape victims to streamline their services (e.g., Sexual Assault Response Teams). The internal consistency for this 10-item scale was .64. (The Community Resources scale and the Community Coordination scale were based on items that were dichotomously coded, so it is to be expected that their alphas will be somewhat low.) Rape-Related Variables. The rape-related variables in the model were assessed with individual items from the interview protocol. For the analyses, Type of Rape was coded to distinguish stranger rape and nonstranger rape (acquaintance, date, and marital). Use of a Weapon and Physical Injuries were coded to reflect presence/absence of a weapon and the presence/ab-

4Another item, rape exam and evidence collection, was asked, but dropped from the scale due to lack of variance as all communities offered this service. 364 Campbell sence of physical injuries to the victim. Finally, Victims' Use of Alcohol at the time of assault was coded to reflect use of alcohol/no use of alcohol. Individual-Level Variables. The individual-level variables in the model were also assessed with single items in the interview protocol. For the analyses, Victims' Race and Assailants' Race were coded to reflect persons who were described as White/Caucasian and those that were described as people of Color. Match in Race was coded to distinguish inter- and intraracial rapes. Victims' SES was similarly coded to distinguish between those described as lower class from those described as working, middle, or upper class. Assessment of Victims' Demeanor was operationalized using a defi- nition of "good victim" behavior suggested by Madigan and Gamble (1991). The advocates were asked if the victim was crying or showing some other obvious, expressive signs of distress, and was receptive to help and sugges- tions from system personnel. This variable was dichotomously coded for the analyses.

Dependent Variable in the Model (Victims' Experiences)

To describe the responses of the legal, medical, and mental health systems to victims' needs, three dimensions of information were collected: (a) what actions were taken by each system; (b) did those actions taken (or those actions not taken) fit with what the victim wanted from the system (i.e., did the system respond in a manner consistent with victims' needs); and (c) how readily available services were. Thus, for each action that could have been taken by each community system, three pieces of information were gathered: Was the action taken? (scale: 1 = yes; 0 = no); Did that outcome fit with what the victim wanted? (scale: 1 = yes; 0 = no); How much, if any, advocacy was needed to bring about that outcome (scale: 0 = none; 1 = a little; 2 = some; 3 = quite a bit; 4 = a great deal). For each system (legal, medical, and mental health), three scales were con- structed: System Action, System Fit, and System Advocacy. To create the scale scores, the number of "Actions," "Fits," and "Advocacies" were summed within each system. Higher scale scores reflect more actions taken, higher consistency with victims' wishes, and higher levels of intervention employed to bring about each outcome. Internal consistencies (a) for these scales were Legal Action =.77, Legal Fit = .76. Legal Advocacy = .73, Medical Action =.68, Medical Fit =.57. Medical Advocacy =.65. Mental Health Action = .75, Mental Health Fit = .38. Mental Health Advocacy = .61. The intercorrelations among these nine scales was generally quite low except between the Mental Health Action and Mental Health Advocacy scales (r =.72, p < .01). To address this potential problem of multicol- linearity, the Mental Health Advocacy Scale was dropped for the analyses Community Response to Rape 365 and only the Mental Health Action and Mental Health Fit scales were used. This high correlation suggested that to receive mental health services, some advocacy was necessary. Complete psychometric information for all scales can be obtained from the author.

RESULTS

Two issues were examined in this research. First, rape victims' experiences with the legal, medical, and mental health systems were explored, focusing not only on services offered but also on whether those outcomes fit their needs and the intervention required by the advocates. A combi- nation of hierarchical and iterative cluster analyses was used to identify patterns of system responses that summarize these experiences. The second question was whether these patterns of experiences could be successfully predicted by the proposed ecological model.

Rape Victims' Experiences With Community Systems

Cluster analysis was performed in two stages on the eight remaining scales assessing victims' experiences with community systems: Legal Action, Legal Fit, Legal Advocacy, Medical Action, Medical Fit, Medical Advocacy, Mental Health Action, and Mental Health Fit. The scale scores were standardized prior to clustering to account for their differing variances (Alden- derfer & Blashfield, 1984; Rapkin & Luke, 1993). First, initial groupings were derived through hierarchical clustering using Ward's Method and squared Euclidean distances as the measure of proximity. Second, the centroids of these initial clusters were submitted to an iterative clustering procedure (K-means) to refine final cluster membership and reduce the incidence of cluster misassigment that is common with agglomerative methods (Blashfield & Aldenderfer. 1988; Mowbray, Bybee, & Cohen, 1993). The iterative procedure used the initial centroids to maximize within-group similarity and between-group difference. From this two-step procedure, a three-cluster solution emerged. The reliability/stability of this solution was examined using a split-half test (Luke, Rappaport, & Seidman, 1991). Half of the victims' data were randomly selected and the cluster procedures described above were employed. The same three-cluster solution emerged from this split-half test, suggesting that the clusters represented a stable organization of the data. Figure 1 presents the profile of scores found in the first cluster. To aid in interpretation, each cluster was given a short name to summarize its pattern of victims' experiences. Cluster 1 ("Approaching Justice") contained 53 (32%) women, and was characterized by a high number of actions, high 366 Campbell

Fig. 1. Cluster 1 profile: Approaching Justice.

fit, but with low advocacy across all three systems. These victims received a relatively large number of services, which was what they wanted, and the advocates did not need to intervene to bring about those outcomes. For example, most of the cases in this cluster progressed all the way through the criminal justice system. In 89% of the cases in this cluster, the prosecutor issued some type of charge against the assailant, and 39% of the cases ended in a plea bargain and 28% were convicted at trial. The outcomes of the trials and plea bargains were not always desirable (only 66% of the time was the outcome consistent with the victims' wishes), but the assailants in this cluster were most likely to receive some jail time for their crime (53%). In the medical system, these women also received many of the services they wanted. Most victims received information about pregnancy and STDs (86 and 92%, respectively), and 54% were able to obtain the morning-after pill. Almost all of them received a preventive dose of antibiotics to treat any STDs that might have been contracted in the assault (94%). The women in this cluster also received many of the counseling services they wanted for themselves and those close to them. Over half received either short-term or long-term counseling (89 and 65%, respectively), and almost half of the victims' family or friends received counseling (40%). It is important to note that many women in this cluster still had difficult interactions with system personnel, and had outcomes that were inconsistent with their needs. But this first cluster described the best outcomes victims received in this study. The second cluster contained the largest portion of the sample with n = 65 (39% of the sample). Figure 2 shows the profiles in this cluster, Community Response to Rape 367

Fig. 2. Cluster 2 profile: One Saving Grace. which was named "One Saving Grace." The women in this group did not have uniform experiences across all three systems. First, their legal involvement was characterized by low actions, low fit, and fairly low advocacy. In other words, these cases did not progress very far in the legal system, but the victim did want to pursue prosecution. There was a marked misfit between what the system did and what the victim wanted. Most often, these cases were filtered out in the early stages of processing, usually by the police deciding not to forward their reports to the prosecutors. For example, only 43% of the police reports were forwarded to the prosecutor (with only 43% of the women reporting that this outcome was consistent with their wishes) and only 8% of the cases in this cluster were charged by the prosecutors. None of the rapists in this cluster received jail time. The advocates usually did not intervene to try to push these cases forward. One advocate summarized an explanation for this lack of intervention that was similar to one voiced by many advocates: You could tell it (the case) was going to go no where and nothing I could do would change that. The police were adamant. I would have had better luck banging my head against a brick wall. Besides, you have to think of the next victim you'll be working with. You don't want to anger the police so badly on one case that it may hurt the next victim who comes through. By contrast, the victims in this second cluster had better experiences with the medical system. Although they received fewer services than the women in the first cluster, what they received was what they wanted. The advocates did not feel they had to intervene to see that the victims' needs were being met. For example, most of the women received information 368 Campbell

Fig. 3. Cluster 3 profile: Exercises in Futility.

about pregnancy and STDs (73 and 73%, respectively), but only 39% were able to obtain the morning-after pill. Most of them received a preventive dose of antibiotics to treat any STDs that might have been contracted in the assault (77%). The response of the mental health system was mixed in this second group. Most women did not receive short-term or long-term counseling (which was somewhat consistent with what they wanted), but their family or friends often did not receive information about rape and its effects (which was inconsistent with what victims wanted; 32% received information, which only 25% of the victims stated was consistent with what they wanted). Finally, the third cluster was characterized by very high yet ultimately unsuccessful levels of advocacy (see Fig. 3 for profiles of this cluster), and was named "Exercises in Futility" (n = 50, 29%). For these women, their involvement with the legal system was characterized by fairly high action, fairly high fit, and very high advocacy. These cases progressed quite far in the criminal justice system (i.e., they were not dismissed immediately as in the second cluster). But, these cases did not go as far, or as well, as the cases in the first cluster. At every step along the way, the advocates had to intervene to keep these cases progressing. But, in the final stages of court processing, many cases unexpectedly fell apart—as one advocate described it, it was an "llth-hour catastrophe." For example, 70% of these cases were charged by the prosecutor, but only 39% of the women reported that the outcome of that charge was consistent with what they wanted. The cases were proceeding (with the encouragement of the advocates), but in the final stages, something went wrong: A case was dismissed a few days Community Response to Rape 369 or hours before trial, a plea was struck that reduced the charges to mis- demeanors such as simple assault, reckless endangerment, or "terroristic tendencies." Thirty-four percent of the assailants pled guilty (28% were to a reduced charge), 12% were convicted of the original charge, and 34% received jail time. The advocates were unable to prevent or reverse these negative outcomes. A somewhat similar pattern of results was found in the medical system: very low number of services, even lower fit, and very high advocacy. These women wanted far more services than they received, and the advocates were largely unsuccessful in obtaining these services for the victims. Only 48% of the women received information about pregnancy, and 34% received information about STDs. Most of the women were not able to obtain the, morning after pill (11%), and only 34% of the women stated that this was consistent with what they wanted. Over half of the women, however, did receive preventive antibiotic treatment for STDs (66%). In the mental health system, many of these women received some counseling (84% short-term; 37% long-term), but only about half of the time did their family or friends receive desired information about rape and its effects (51%). It appeared that for the women in this cluster, their families and friends wanted to learn more about rape, but this assistance was largely unavailable.

An Ecological Model Predicting Victims' Experiences

The second question explored in this research was whether rape victims' experiences with community systems could be successfully predicted by the proposed ecological model. Given that the dependent variable was cluster membership, a categorical variable with three levels, multinominal logistic regression was used to evaluate the model (Hosmer & Lemshow, 1989). Table I presents the intercorrelations among the predictor variables.5 To evaluate this model, four sets of analyses are needed. First, the overall fit of the model must be considered with the likelihood ratio (LR) statistic. Second, the significance of the individual predictors to differenti-

5In the first set of analyses where all predictor variables were entered into the model, two problems became apparent. First, several variables were not significant: victims' race, assailants' race, and victims' SES. Second, a suppressor effect emerged because of a moderate correlation between type of rape and use of a weapon. As a result, Hosmer and Lemshow's (1989) recommendations were followed: Drop variables that have no predictive value and rerun a smaller, better fitting model. Retaining the variables that make no significant con- tribution to the outcome variable can artificially inflate the goodness-of-fit indices. To address the suppressor effect, three dummy-coded variables were created to capture four relationships that could exist between type of rape (stranger or nonstranger) and weapon use (weapon or no weapon). 370 Campbell Community Response to Rape 371 ate cluster membership must be considered using odds ratios and Wald tests. Third, the prediction success index and the percentage correctly classified address the degree to which the model successfully classified the cases into their correct cluster. Finally, because this is a multilevel model (community-level, rape-related, and individual-level predictors), the utility of each level must be examined (i.e., are all three levels necessary to predict cluster membership). A series of LR statistics testing for the significant effect of each level to predict unique variance in the outcome variable must be computed. The LR test for goodness-of-fit for the overall model was significant, indicating that the model provided a good fit of the data: LR x2 (18, N = 168) = 71.03, p < .001. Table II presents the results of the odds ratio and Wald tests. For an outcome variable with three levels, two sets of contrasts are performed, as well an overall test for each predictor (Wald). In the first contrast, the women who had the best possible outcomes (Cluster 1: Approaching Justice) were compared to the women who had a positive outcome with only the medical system (Cluster 2: One Saving Grace). The results of the odds ratio tests indicated that women who were raped by a stranger without the use of a weapon were 15 times more likely than those raped by strangers with a weapon to be in the One Saving Grace cluster, which was the group whose cases were dropped out early in the stages of legal processing. Similarly, women who were raped by someone they knew without the use of a weapon were approximately 6 times more likely to be in the One Saving Grace cluster. Taken together, these odds ratios suggest that being raped by a nonstranger and/or the absence of a weapon placed victims in the cluster where cases were dropped by the legal system. Fur- thermore, victims who were drinking at the time of the assault were also 4 times more likely to be in the One Saving Grace cluster where their involvement with the legal system was cut short. This contrast between Cluster 1 and 2 (Approaching Justice and One Saving Grace) also indicated that women who lived in communities with more resources for addressing sexual assault, and those who lived in communities where there was more coordination of such services had relatively positive experiences across all three systems (Approaching Justice). Women who were injured in the assault were also somewhat more likely to be in this positive experiences cluster. Finally, women who exhibited "good victim" behavior (i.e., showed visible distress) were also more likely to be in the Approaching Justice cluster. In the second contrast, Cluster 1 (Approaching Justice) and Cluster 3 (Exercises in Futility) were compared. Fewer variables differentiated these two clusters. Women in the Exercises in Futility cluster were 4 times more likely to have been raped by a someone known to them without the use 372 Campbell Community Response to Rape 373 of a weapon. Again, nonstranger rape without the use of a weapon was associated with a negative response from the legal system. A trend emerged for match in race: Infraracial rapes were somewhat more likely to be in the cluster Approaching Justice, and interracial rapes in the cluster Exer- cises in Futility. Specifically, women of Color who were raped by White men were somewhat more likely to have been in the Exercises in Futility cluster. The Wald test provides an overall test of the predictive value of each variable in the equation by averaging across these contrasts. So, as expected, variables significant in the individual contrasts remained significant, but the trends in the contrasts were not. Overall effects were found for community resources, community coordination, stranger rape without a weapon, nonstranger rape without a weapon, alcohol use by victim, and whether the victim exhibited "good victim" behavior. The prediction success indices revealed that this model could successfully classify 54% of the cases, which was significantly better than chance (34%): 53% for Cluster 1 (Approaching Justice), 62% for Cluster 2 (One Saving Grace), and 46% for Cluster 3 (Exercises in Futility). The prediction success index, which measures the gain the model exhibits in the number it correctly predicts versus a purely random model. was .21 for Cluster 1, .23 for Cluster 2, and .16 for Cluster 3. The larger the success index, the better the model did in successfully classifying cases. This index can be negative if the classification was worse than chance. Both the percentage correctly classified and the prediction success index for Cluster 3 (Exercises in Futility) were somewhat low, but given that fewer variables distinguished the third cluster, it is not surprising that these values pulled down the overall rate for the model. In the final set of analyses, the utility of each level in the proposed model was considered. It has been argued that the advantage of an ecological perspective is that it can help us understand phenomena from a multiple-level perspective. At issue for this final set of analyses is whether all three levels of ecological theory predict unique variance in cluster membership. Do we really need information about the community, about the rape, and about the victim to predict outcome? A series of LR tests were performed to examine the unique variance explained by each level. In this test, the LR for the full model is compared to the LR for a model with a block of variables removed. The full model is compared to this nested model. The LR from the nested model is subtracted from the LR of the full model. This difference is a chi-square statistic that is then evaluated for significance (with the difference degrees of freedom). This chi-square statistic should be significant, indicating that the model with this block is significantly different from a model without this block of variables. (The 374 Campbell

logic of these procedures was suggested by Darlington, 1968, for ordinary least squares regression, and is adapted here for logistic regression.) With the variance accounted for by the rape-related and individual- level factors already established, the community-level factors explained additional unique variance (difference LR x2 = 6.17, p < .05). Moreover, after taking into account the effects of the community and individual level factors, the rape-related factors could still explain unique variance (difference LR x2 = 38.70, p < .001). Finally, the variance accounted for by the community level and rape-related variables still left unexplained variance that could be successfully predicted by the individual level factors (difference LR x2 = 10.84, p < .05). Thus, each level specified by ecological theory explained unique variance in victims' experiences with community systems. These results suggest that all three levels of variables specified by ecological theory were necessary to predict victims' experiences with the legal, medical, and mental health systems.

DISCUSSION

This study provides national-level data that describe rape victims' experiences with the legal, medical, and mental health systems, and explains how multilevel factors impact service delivery. Cluster analysis was used to describe victims' experiences with these systems. A three-cluster solution was supported. The first cluster (Approaching Justice) was characterized by relatively high services, high fit, and low advocacy across all three systems. These women were able to obtain most of the services they wanted with little intervention. They also lived in communities where there were more resources for victimized women, and there were more programs in place to coordinate those resources to streamline service delivery. Stranger assaults with the use of a weapon were more common in this cluster, and these victims were slightly more like to have been injured in the assault. These findings are consistent with previous research by Estrich (1987), Ker- stetter (1990), LaFree (1981), Madigan and Gamble (1991), McCahill et al. (1979), and Rose and Randall (1982), which indicated that the legal system responds differentially when weapons and injuries are involved. These are perceived as "real" crimes and as such are more likely to be prosecuted. The medical and mental health systems were also quite responsive under these circumstances. Furthermore, Madigan and Gamble (1991) described from their clinical work with rape victims the "good victim" phe- nomenon: Women who are clearly distressed and receptive to help may be treated preferentially. The results of this quantitative, larger scale study indicate that such demeanor was associated with the most favorable out- Community Response to Rape 375 comes. For many of the cases in this cluster, several of the key ingredients that appear to prompt social systems to respond were present. In the second cluster (One Saving Grace), women did not have uniform experiences across these three systems. Most of these cases were not forwarded for criminal prosecution, which was not consistent with what the victims wanted. In the mental health system, victims in this cluster received only some of the services they wanted. By contrast, the medical system was more responsive to these women's needs—their "saving grace." The victims second cluster were more likely to have been raped by someone they knew without the use of a weapon and were more likely to have been drinking at the time of the assault. These findings provide some quantitative support to qualitative narratives collected by Finkelhor and Yllo (1985), Russell (1990), and Warshaw (1988), which indicated that rapes between known parties are often met with skepticism Very little research has examined how alcohol affects service delivery, and these findings support attitudinal research that suggested that alcohol use "negates" the rape (Richardson & Hammock, 1991). This profile of findings is consistent with what is often thought of as the typical date rape—rape between known parties, under the influence of alcohol. These results imply that although the medical system may not respond differentially to these cases, the legal and mental health systems may have implicit rules for service delivery in date rapes. The third cluster (Exercises in Futility) was characterized by negative experiences across all three systems. Due to the advocates' efforts, many cases did proceed through the initial steps of criminal prosecution, but were irrevocably stalled in the final stages. In the medical and mental health systems, this pattern of frustration repeated itself. The victims wanted far more services than they were able to receive, despite the efforts of the advocates. Only two of the variables in the ecological model differentiated this third cluster rape by a nonstranger without the use of a weapon, and a mismatch between the victims' and assailants' races (trend). In some re- spects, it appears that this cluster was defined as much by what it lacked as what it included. These cases did not involve strangers; they did not involve weapons; they did not involve injuries; they did not involve alcohol use; they did not have victims who exhibited "good victim" behavior. In other words, these cases lacked many of the factors that our social systems may use to decide how to respond. What these cases did involve was rape between known parties, and for some of the women of Color in this cluster, a rape committed by a White man. The findings from this research suggest that for rape victims to receive desired services their cases may need to fit a rather constricted mold. When certain characteristics of the victim, the assault, and the community are in careful alignment, the likelihood of an outcome that is consistent with vic- 376 Campbell tims' needs is most probable. As these factors start to deviate from this narrow path, the number of services may drop off, the fit with victims' wishes may be compromised, and the advocacy needed to bring about beneficial outcomes may rise. Furthermore, it appears that the legal system may be the least forgiving of such "deviations." Cases that do not conform were often filtered out of the system The medical system may not work under such stringent implicit rules. In cases of date rape, for example the doctors and nurses in this study often responded in a manner consistent with victims' needs. The implicit rules of mental health system, however, did not emerge as clearly. Many women received the short-term help they desired, but longer-term help was not as readily available, creating relatively negative experiences for women in two of three the clusters. This research also provides an empirical examination of ecological theory. In this study, community-level, rape-related, and individual-level factors explained unique variance in the outcome variable (cluster membership/victims' experiences). Whereas the individual predictors in this model may or may not have been successful predictors, the levels appear to be instrumental. In other words, drawing on information from the environment the rape itself, and some characteristics of the victims were necessary to predict victims' outcomes. For instance. race and victims' demeanor explain only part of the pattern. With additional information about the type of rape, the use of a weapon, injuries sustained, and alcohol use at the time of the assault, more variance can be accounted for. Furthermore, an even more distant variable, such as the coordination of the services available to victims in these communities, had an effect. The programs and policies in a community that work to streamline services to victims may trickle down to affect the specific experiences of individual victims. These findings provide some empirical support for Kelly's (1966,1968,1971) theoretical arguments that environmental structures and practices may impact individual outcomes. The individual level is a necessary but not sufficient approach to understand victim-system interactions such as these. Two methodological limitations temper the conclusions of this study First, collecting data from rape victim advocates raises issues of the reliability and validity of these reports. The reliability of the data may have been influenced by the advocates' ability to recall the details of the assault and system response. To address this issue, the advocates were asked to review their case notes prior to conducting the interview, and we assessed test-retest reliability (r = .95). To provide some insight into the validity of the advocate reports, complete validating information from the advocates, victims, hospital staff, police, and prosecutors was obtained for only ten cases (randomly selected from the sample). In these ten cases, there was consistent agreement from all parties as to what services were provided to Community Response to Rape 377 the victim. But due to the fact that validity was not assessed for the entire sample, it is possible that the advocates may have had a different perspective than that of the victims and social system personnel. Second, because this study did not include a comparison group of victims who did not work with advocates, we do not know what effect the mere presence of the advocate may have had on service delivery. If this presence was beneficial, then these data may overreport the frequency with which victims are receiving help. Given that many women still did not receive all of the help they desired, and had an advocate, then we may have reason to be quite concerned for victims who do not have such assistance. In conclusion, this study provides a view into rape victims' experiences with the legal, medical, and mental health systems. When women go public with their stories of rape, they do not all have negative experiences, nor do they all have positive outcomes. When we consider victims involvement with multiple community systems, we can begin to see the uniqueness of each system, as well as the totality of victims' experiences. The response from these social systems appears to be function of several variables. Char- acteristics of the victim affect these interactions as do features of the rape itself. Even more distant variables, such as the community coordination of resources for victims, can have tangible effects on victims' experiences. These findings present some initial ideas as to how our social systems can be reorganized to create settings that are more receptive to victims' needs. Improving victims' experiences with the legal, medical, and mental health systems may require both individual and structural changes.

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