Greater time in military service correlated with higher resilience for women but had little correlation for men; might be due to relative reduction in resilience for those goal-oriented women trained at West Point who leave the service

Psychological Resilience in West Point Graduates: Results From a Nationally Representative Study. Melissa M. Thomas et al. Chronic Stress, Nov 5 2021. https://journals.sagepub.com/doi/10.1177/24705470211053850

Abstract

Background: The purpose of this study was to examine factors associated with psychological resilience in a nationally representative sample of West Point graduates.

Aims: The aims of this study were to (a) employ a dimensional approach to operationalizing psychological resilience in a trauma-exposed population that had been highly trained and educated in persisting in the face of stress, was previously unstudied, and in which we could examine correlates of resilience, (b) identify key psychosocial factors, character traits, health variables, military experiences, and coping strategies as potential correlates of psychological resilience; and (c) examine whether reported gender moderated any of these associations in this population.

Methods: A nationally representative sample of 1342 West Point graduates after gender integration from classes 1980 to 2011 were surveyed. Psychological resilience was operationalized using a discrepancy-based approach in which a measure of composite psychological distress (current posttraumatic stress disorder, generalized anxiety and depression symptoms) was regressed on measures of cumulative trauma burden. A multivariable linear regression model was then employed to identify factors that were independently associated with psychological resilience scores.

Results: Purpose in life (29.8% of relative variance explained [RVE]), fewer perceived negative experiences in the military (20.6% RVE), social support (9.6% RVE), and grit (9.5% RVE) were the strongest correlates of psychological resilience scores for both women and men. Time in service was positively associated with resilience in women only.

Conclusion: This study identifies key correlates of psychological resilience in West Point graduates, individuals who are highly trained to persevere in the face of stress and then were trauma-exposed. Most of these factors are modifiable and can be targeted in stress prevention and treatment interventions, especially for high-stress professions such as the military, frontline health care providers, and first responders.

Popular version: What West Point Graduates Can Teach Us About Stress and Resilience. Jan 2 2022. https://medicine.yale.edu/news-article/what-west-point-graduates-can-teach-us-about-stress-and-resilience/

Discussion

To our knowledge, this study is the first to examine factors associated with psychological resilience in a nationally representative sample of West Point graduates. A notable strength of this investigation was access to and study of a sample of individuals extensively trained to be resilient who have high risk of exposure to stressful events. The assessment of psychological resilience used a discrepancy-based approach that computes each participant’s individual level of distress in relation to what is expected at the population level. This approach generates a measure of psychological resilience that spans the full-dimensional spectrum from high vulnerability to high resilience. Given previous criticisms that operationalizations of psychological resilience should not be limited to PTSD symptoms, we chose to employ a more comprehensive assessment of psychological distress that included PTSD, anxiety, and depressive symptoms. In addition, a wide range of psychosocial factors, character traits, health variables, military experiences, as well as coping strategies that could be linked to psychological resilience were measured and assessed.

Results revealed that purpose in life, social support, and grit were most strongly associated with resilience. Report of fewer negative experiences in the military was also associated with resilience and, for women, greater time in service was correlated with resilience. Results of the current study suggest multiple factors contribute to the capacity to weather adversity. Importantly, these factors are modifiable and thus use of multimodal prevention and treatment efforts may be effective in maintaining and building psychological resilience for both men and women.

Purpose in life was most strongly associated with psychological resilience. Potential behavioral mechanisms underlying this association include a positive relationship between purpose in life and physical activity, internal locus of control, better sleep quality, better emotion regulation, and use of preventive health care services.^37–39 Interventions that may help enhance purpose in life for high-risk populations exposed to stress and trauma include using meaning-based therapies, such as logotherapy, and integration of meaning- and purpose-centered activities in other established psychotherapies, such as cognitive-behavioral therapy.^40–43 Development of purpose in life also might lead to an increase in other protective factors, such as motivation to engage in social interactions.³⁷

Military service provides both subjective positive and negative experiences that influence veterans’ mental health later in life.⁴⁴ For example, veterans who report more negative military experiences may be more likely to develop PTSD symptoms later in life and have increased odds of current suicidal ideation and current mental health disorders.^45,46 Results of our study extend this work to suggest that reports of drinking problems, witnessing death and destruction, and worsening physical health may be linked to reduced psychological resilience. Although witnessing death and destruction as a negative consequence of military service may appear to be embedded in our trauma exposure calculation, the trauma exposure measure is based on whether exposure to an event occurred, not whether it is perceived as having a negative consequence in one's life. It is the perception of the event being negative that we found to be related to lower psychological resilience. Given the cross-sectional design of our study, however, we are unable to ascertain whether negative perceptions of reported events are influenced by current mental health difficulties, or if the endorsement of more negative effects drives risk for psychological distress and general maladaptive perceptions of one's life (eg relationships, finances, health).⁴⁶ Nevertheless, this finding underscores the importance of addressing negative mental and physical health consequences of perceived trauma, as well as screening for and treating current risky drinking behaviors and poor health in efforts to help promote resilience.

Social support was also strongly associated with psychological resilience. Greater perceptions of social support may help increase psychological resilience by promoting self-esteem, active coping strategies, a sense of control, evaluation of potentially stressful events as less threatening, and motivation to adopt healthfully and reduce risky behaviors.¹ Encouraging involvement in one's community, as well as community policies and programs that support and enhance connection by promoting safe neighborhoods, affordable housing, and public spaces for assembly and exercise are all methods of promoting and improving social support.⁴⁷ Of note, positive social support has been shown to activate the parasympathetic nervous system and brain regions implicated in the processing of safety cues and stimulate the release of oxytocin, which is known to have anxiolytic effects.^48,49

Grit has 2 main components, perseverance of efforts and consistency of interest.^21,50–52 The first component, perseverance of efforts is thought to overlap with the construct of resilience since it refers to maintaining goals even when obstacles are encountered. Some studies show grit is associated with a reduced tendency for suicide ideation and decreased burnout in doctors and surgical residents.^53–55 In studying West Point cadets, Duckworth and colleagues found that those who had higher grit at the entry to the academy were less likely to drop out of the first basic training summer than less gritty peers, even after controlling for SAT scores, high school class rank, and conscientiousness.⁵² Recently, Duckworth et al.⁵⁶ also found that grit and physical ability in a cohort of West Point cadets were better predictors of 4-year graduation from the Academy than cognitive ability. Additionally, grit has been associated with resilience itself but, to our knowledge, this is only based on self-reported resilience scales, such as the Connor–Davidson Resilience Scale©.^57,58 Our study adds to this literature by identifying a relationship between grit and psychological resilience using a resilience score measured on a continuum. This is an important identified relationship since grit is also a modifiable factor. Therapeutic interventions to promote a growth mindset and work on goal-setting and discovering one's passions may help increase grit.^59,60

Results did not indicate gender differences in factors associated with resilience except for the greater time in service, which was associated with greater resilience in women only.^61-63 This is perhaps a result of women who stay in the military longer being those who have accommodated to the military environment and learned to cope and survive in a male-dominated hierarchical environment.⁶⁴ It is also possible that there are psychological vulnerabilities from leaving military service that are inherent to women only. One reason women are more likely to leave the service than men are due to family obligations, such as having children. Driven, gritty women who obtain training and education by attending West Point then no longer work or fill the role of a military officer may become more vulnerable to mental health issues later in life. This is perhaps due to a loss of purpose in life or career goals, whereas men who leave the military are more often pursuing a different career. For those who opt to leave the military and pursue a different career, female veterans often seek careers in similarly male-dominated fields and have reported difficulty integrating into the civilian workforce due to differences in dress, behavior (posture, assertiveness), identity issues, and disconnection from their civilian female counterparts.^64,65 Efforts to support a smooth transition for women into civilian careers may alleviate these experiences, particularly regarding the unique challenges they may face.

Limitations of this study include the use of self-report measures, which may be subject to recall bias, although this is a similar possibility with clinician-administered scales. The response rate of the survey was also a limitation. However, with our sampling strategy of overrepresenting women, we achieved statistically significant results for gender comparisons; and, through age, class year, racial, and branch demographics for the population, we were able to achieve a representative sample of the targeted population. Although social support and grit appear to play a role in psychological resilience, the amount of variance explained by each was relatively low. Finally, given the cross-sectional design, we cannot establish temporal or causal associations. Consequently, it is unclear if the greater purpose in life, social support, and grit give rise to greater resilience or vice versa, or if these associations are bidirectionally linked over time. To date, all of the known studies that have employed a discrepancy based psychological resilience approach to operationalizing resilience have done so using cross-sectional data.^9,10 Longitudinal studies employing prospective designs are needed to evaluate the application of a discrepancy-based approach and evaluate the role of flexible self-regulation and other time-varying factors in contributing to resilience.⁶⁶

Both men and women evaluate a man as more creative and socially skilled when he is attractive, and women regard him as having higher mate value when his female friends are attractive... but these and related effects are quite nuanced

Mr. Popular: Effects of implicit and explicit social endorsement. Ryan C. Anderson & Beatriz Escobar. Current Psychology, Jan 5 2022. https://link.springer.com/article/10.1007/s12144-021-02679-3

Abstract: Humans are a social species with a high degree of information sharing. Character information is transferred between individuals frequently. Making a decision about who to mate with is one of the most consequential choices an individual makes, hence it pays to attend to any cheaply available mate-relevant information on offer. Building on previous research reporting a mating advantage for men romantically associated with women, here we present 3 studies examining the effects of being popular with the opposite sex. In all three studies men and women were presented with (and asked to evaluate) visual profiles of individuals of the opposite sex. Study 1 (N = 294) found that both men and women evaluate a man as more creative and socially skilled when he is attractive, and that women regard him as having higher mate value when his female friends are attractive. Study 2 (N = 233) found that men, but not women, considered profiles that were highly popular with the opposite sex to be more desirable. Study 3 (N = 765) found that neither men’s nor women’s desirability ratings of opposite-sex others were influenced by how popular that individual was with members of the opposite sex. It was concluded that while both men and women can be influenced by social information implicitly offered by others, this phenomenon is quite nuanced. Several possible theoretical and methodological explanations are considered, adding valuable knowledge to the existing body of research about mate copying propensity.

Analyses revealed direct and indirect associations between frequent pornography consumption and greater sexual functioning through greater sexual flexibility in women, but not in men

Associations Between Pornography Consumption, Sexual Flexibility, and Sexual Functioning Among Austrian Adults. Nikola Komlenac & Margarethe Hochleitner. Archives of Sexual Behavior, Jan 4 2022. https://link.springer.com/article/10.1007/s10508-021-02201-7

Abstract: To date, only a few studies have examined the associations between pornography consumption and sexual functioning. The Acquisition, Activation, Application Model (3AM) indicates that the frequency of pornography consumption and the perceived realism of pornography may influence whether sexual scripts are acquired from viewed pornography. Having sexual scripts that are alternative to their preferred sexual behaviors may help people switch to alternative sexual behavior when sexual problems arise. The current study analyzed whether frequent pornography consumption was associated with greater sexual flexibility and greater sexual functioning. Additionally, the perceived realism of pornography consumption was tested as a moderator of those associations. At an Austrian medical university, an online cross-sectional questionnaire study was conducted among 644 medical students (54% women and 46% men; Mage = 24.1 years, SD = 3.8). The participants were asked about their pornography consumption, partnered sexual activity, sexual flexibility, perceived realism of pornography, and sexual functioning. Manifest path analyses revealed direct and indirect associations between frequent pornography consumption and greater sexual functioning through greater sexual flexibility in women but not in men. Perceived realism did not moderate those associations. In conclusion, our study was in line with previous studies that found no significant associations between men’s pornography consumption and sexual functioning in men. However, some women may expand their sexual scripts and learn new sexual behaviors from pornography consumption, which may help with their sexual functioning.

Discussion

The current study found a direct association between frequent pornography consumption and greater sexual functioning in women but not in men (H1). Additionally, an indirect link between frequent pornography consumption and greater sexual functioning through the mediator of sexual flexibility was found in women (H2). The perceived realism of pornographic material did not moderate the found associations (H3).

Frequent Pornography Consumption and Greater Sexual Functioning in Women

Our study supports previous findings that revealed no associations between men’s pornography consumption and sexual functioning (Landripet & Štulhofer, 2015; Prause & Pfaus, 2015). Moreover, our study adds to the literature by providing findings on such associations for women. In contrast to other studies that have analyzed this link (Berger et al., 2019; Wright et al., 2021), we found an association between women’s frequent pornography consumption and greater sexual functioning (Bőthe et al., 2021).

The majority of pornographic content depicts two actors who engage in genital stimulation, oral stimulation, or vaginal intercourse (Gorman et al., 2010; Vannier et al., 2014). Such pornographic material may help women expand their sexual scripts, learn new rewarding sexual behaviors, and thereby increase their sexual flexibility. For example, learning about oral-genital activity has been most frequently cited in this regard (Weinberg et al., 2010). This finding is supported by additional findings showing that women who consume pornography more frequently have oral sexual activity than do women who do not consume pornography (Brown & L'Engle, 2009).

The current finding of associations between frequent pornography consumption and greater sexual functioning is further supported by studies that report consumers’ self-perceived effects of their pornography consumption. Such studies report that people self-perceive positive effects of pornography consumption on their sexuality rather than negative consequences (Daneback et al., 2009; Hald & Malamuth, 2008; Weinberg et al., 2010).

The current study’s findings, as well as the findings of past studies, may encourage some clinical practitioners to use pornography in psychosexual therapy to instruct or show clients new or alternative sexual behaviors (Brewster & Wylie, 2008). Such material may, for example, include portrayals of adult solo and mutual masturbation and oral, vaginal, and anal sexual activity. Such material may encourage clients to explore alternative sexual activities when problems occur during preferred sexual behaviors. Furthermore, such material may help with the understanding and acceptance of certain sexual behaviors (Watson & Smith, 2012). However, one must also bear ethical implications in mind when using pornography in psychosexual therapy. Some clients might find the use of pornographic material challenging and distressing because of their attitudes or past experiences (Rhoades, 2007). Therefore, clinicians must evaluate a client’s readiness to view pornographic material. Additionally, some other sexual health concerns, such as relationship problems, may contraindicate the use of pornographic material (Miller et al., 2019; Wright et al., 2017).

Alternative Explanations

Our hypothesis that the link between pornography consumption and sexual functioning is stronger for people who perceive pornography as realistic than for people who do not perceive such content to be realistic was not supported by our findings. As is the main problem with most cross-sectional studies, the current cross-sectional study does not permit any conclusions about the directionality or causality of the found associations. The associations found between pornography consumption and sexual flexibility could mean that women who are already open and flexible in their approach to sexuality are more likely to consume pornography than are women who are limited in regard to their sexual flexibility. In such a case, one’s perceived realism of pornography is unlikely to influence the association.

The Antecedents-Context-Effects Model (Campbell & Kohut, 2017) exemplifies the problem that most of the studies about pornography do not consider the factors or traits that make a person more likely to consume pornography. Thus, many studies do not consider the so-called antecedents of pornography consumption. In some cases, those antecedents and not pornography consumption may be a better explanation for the found links between pornography consumption and components of sexual health (Campbell & Kohut, 2017). This also applies to our study and the hypothesized associations between sexual flexibility, sexual functioning and pornography consumption. Future studies of the links between pornography consumption and sexual health should consider potential factors that may explain pornography consumption and assumed effects of pornography consumption. Additionally, future longitudinal studies or experimental studies are needed to shed light on the directionality of the found associations.

Even though pornography consumption was seen to be indirectly associated with sexual functioning through sexual flexibility, sexual flexibility could not fully explain the association between pornography consumption and sexual functioning. The considerable direct effect between pornography consumption and sexual functioning indicates that further studies need to include additional mediators to explain the found associations. For example, women who consume pornography may be more likely to know their own sexual interests and desires and in turn be willing and able to communicate their preferences during partnered sexual activity (Weinberg et al., 2010). The ability to communicate sexual preferences has been reported to be associated with greater sexual satisfaction in women (Blunt-Vinti et al., 2019; Herbenick et al., 2019).

Gender Differences

The current study replicated the previously known finding that men consume pornography more frequently than women (Landripet & Štulhofer, 2015; Miller et al., 2019; Sun et al., 2016). Additional gender differences became evident, as hypothesized associations between pornography consumption, sexual flexibility, and sexual functioning were supported only in women but not in men.

Notably, an association was observed between frequent pornography consumption and greater sexual flexibility in men. However, sexual flexibility, in turn, was not linked to sexual functioning. One explanation for the different findings in women and men may be explained by the methods used to assess sexual functioning in women and men. For women, we used the FSFI-6, which includes many domains of sexual functioning. The erectile functioning scale of the IIEF, in contrast, contains questions only about erectile functioning. Thus, associations between men’s frequency of pornography consumption and other components of sexual functioning may have been missed because this scale was used. There is evidence that pornography consumption may be positively associated with men’s sexual desire (Prause & Pfaus, 2015). Future studies should use more sophisticated questionnaires that assess each component of sexual functioning with multiple items. Furthermore, future studies may also include questions about the distress a sexual problem causes because sexual problems that cause considerable distress may be clinically relevant. Prevalence rates and estimates of sexual problems change significantly when distress is considered (Hendrickx et al., 2016; Komlenac et al., 2019; Mitchell et al., 2016).

The purpose of pornography consumption may also differ between women and men. Compared to women, men are more likely to use pornography to achieve sexual arousal during solitary sexual activity. Women are more likely than men to report using pornography together with a partner to enhance sexual stimulation during partnered sexual activity (Albright, 2008; Bridges & Morokoff, 2011; Solano et al., 2020). Additionally, gender differences have been reported in regard to preferences for specific pornographic content (Hald & Štulhofer, 2016), for pornographic material (e.g., pictures, films, videos or text) accessed, or for the motivation behind or the purpose of pornography consumption (Solano et al., 2020). All these factors may influence the effects of pornography consumption (Wright, 2011) and may explain the gender differences in the found associations between pornography consumption and components of sexual health, including sexual functioning. Therefore, we agree with recommendations that future studies should extend their measures of pornography consumption to include questions on frequency, content, medium, and motivation (Hald & Štulhofer, 2016; Solano et al., 2020).

Limitations

The current study is not without its limitations. First, the study is based on participants’ self-reports. This approach entails known problems. For instance, participants may not correctly remember all occasions of their sexual activity or pornography consumption. Additionally, participants may have felt that it is socially desirable to withhold or reveal certain information (Choi & Pak, 2005).

Second, the found associations are only small or moderate (Cohen, 1988). Therefore, the found associations between sexual functioning, sexual flexibility, and pornography consumption should be interpreted with caution.

Third, we modified the questions on the IIEF (Rosen et al., 1997) from asking about sexual functioning in the previous 4 weeks to asking about sexual functioning over the last 6 months to be more in accordance with classification time frames for sexual dysfunctions (American Psychiatric Association, 2013). However, a technical error caused us to not apply the same changes to the FSFI-6 (Isidori et al., 2010). Future studies should include a 6-month time frame for women and men.

Last, even though the study used a relatively large sample, this sample has limitations. The current study’s results are based on a convenience sample of university students. Many other studies of pornography consumption have used such samples (Short et al., 2012). However, such a sample may significantly differ from other populations (Henrich et al., 2010). In general, studies with university students as participants find associations with larger effect sizes than those of studies with more general samples. Additionally, it has been shown that the directionality of an association may be in the opposite direction in studies with university students and in studies with nonstudent samples. This is why conclusions based on studies with only university students as participants may differ from studies that base their findings on a less homogeneous and more general sample (Peterson, 2001). Another limitation of the sample is that sexual minority groups remained relatively underrepresented. Found associations between sexual orientation and pornography consumption indicate that acceptance and habits of pornography consumption may differ between people of different sexual orientations. These limitations indicate the need for future studies with more diverse samples to replicate and extend current findings.

Diversity in religiosity in a society poses a threat to conventional personal morality of social conservatives (religiously devout or socially traditional), due to variegated attitudes on abortion, divorce, euthanasia, suicide, prostitution

Diversity in Religiosity Undermines Conventional Personal Morality Across the Globe: Evidence From 90 Nations, 300,000+ Individuals. M.D.R. Evans, Jonathan Kelley. Journal for the Scientific Study of Religion, December 14 2021. https://doi.org/10.1111/jssr.12756

Abstract: In societies where the populace exhibits a wide range of religiosity, social conservatives (religiously devout or socially traditional) feel their beliefs and way of life threatened, even where others in their society (secular, or socially liberal) have no desire to threaten them, or to discriminate against them, or even to proselytize. Examples include devout English Pilgrims in liberal 16th century Holland and devout Muslims in liberal 21st century Western Europe. We suggest that this is because diversity in religiosity itself poses a threat to conventional personal morality (attitudes on abortion, divorce, euthanasia, suicide, prostitution). The consequences of societal diversity in religiosity (the centrality of religion to one's life) for individuals’ endorsement of conventional personal morality have been neglected in prior research. This paper shows that diversity in religiosity at the national level undermines individuals’ endorsement of conventional personal morality, net of an individual's own religiosity, net of the average levels of religiosity and socioeconomic development in the individual's society, and net of key individual-level controls. Data are pooled from the World Values Surveys/European Values Surveys, 1981–2008, with 90 countries, 200+ surveys, and 300,000+ individual respondents. Analysis is by multilevel methods (variance components models with fixed effects and random intercepts, estimated by generalized least squares [GLS]).

Overall, as has been the case for previous media such as video games, concerns about screen time and mental health are not based in reliable data

Ferguson, C. J., Kaye, L. K., Branley-Bell, D., Markey, P., Ivory, J. D., Klisanin, D., Elson, M., Smyth, M., Hogg, J. L., McDonnell, D., Nichols, D., Siddiqui, S., Gregerson, M., & Wilson, J. (2021). Like this meta-analysis: Screen media and mental health. Professional Psychology: Research and Practice, Jan 2022. https://doi.org/10.1037/pro0000426

Abstract: The question of whether screen time, particularly time spent with social media and smartphones, influences mental health outcomes remains a topic of considerable debate among policy makers, the public, and scholars. Some scholars have argued passionately that screen media may be contributing to an increase in poor psychosocial functioning and risk of suicide, particularly among teens. Other scholars contend that the evidence is not yet sufficient to support such a dramatic conclusion. The current meta-analysis included 37 effect sizes from 33 separate studies. To consider the most recent research, all studies analyzed were published between 2015 and 2019. Across studies, evidence suggests that screen media plays little role in mental health concerns. In particular, there was no evidence that screen media contribute to suicidal ideation or other mental health outcomes. This result was also true when investigating smartphones or social media specifically. Overall, as has been the case for previous media such as video games, concerns about screen time and mental health are not based in reliable data.

Check also A neural circuit for spirituality and religiosity derived from patients with brain lesions: There is a common brain circuit in a region previously implicated in fear conditioning, pain modulation, and altruistic behavior:

A neural circuit for spirituality and religiosity derived from patients with brain lesions. Michael A. Ferguson et al. Biological Psychiatry, June 29 2021. https://www.bipartisanalliance.com/2021/06/a-neural-circuit-for-spirituality-and.html

Men were far more likely to expect a negative reaction from the receiver of an unsolicited nude or sexual image, and more likely to show a flirty or positive reaction when they were the receiver

Expectations vs. reality: Expected and actual affective reactions to unsolicited sexual images. V. Karasavva, J. Swanek, A. Smodis, A. Forth. Computers in Human Behavior, January 4 2022, 107181. https://doi.org/10.1016/j.chb.2022.107181

Highlights

•Most participants reported negative or ambivalent reactions to being cyberflashed.

• The majority of cyberflashers endorsed expecting a flirty reaction.

• Women were more likely expect flirty or positive and men negative reactions.

• Women were more likely typically have ambivalent/negative reactions when cyberflashed.

• Flirty and positive expectations were predictive of cyberflashing.

Abstract: Most of the research on cyberflashing (i.e., using technology to send someone a nude or sexual image without their consent) has focused on cisgender men sharing pictures of their genitals (i.e., “dick pics”). Within this, what is known about the expectations and reactions to cyberflashing is also limited. Here, we examine the cyberflashing practices, expectations, and reactions of both men and women. Participants in our study (n = 810, 41.8% cyberflashers; 68.0% had been cyberflashed) reported how they expected those receiving their unsolicited sexual images would feel and how they feel when they receive such an image. Women cyberflashers were more likely to endorse expecting a flirty or positive reaction from the receiver and were more likely to report having an ambivalent or negative reaction when cyberflashed. Conversely, men cyberflashers were more likely to expect a negative reaction from the receiver but reported having a flirty or positive reaction when cyberflashed. Finally, we found that expecting a flirty or positive reaction and not expecting a negative reaction were predictive of cyberflashing. Findings highlight the mismatch between the expectations and actual reactions of cyberflashing and underscore the importance of consent education for online sexual interactions.

Keywords: CyberflashingSextingDick picsImage-based sexual abuseTechnology-facilitated sexual violence

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