Background
Intimate partner sexual aggression is defined as the use of psychological, verbal, or physical coercion to obtain or attempt to obtain sexual contact with an intimate partner who is unwilling or unable to consent [
1]. Intimate partner sexual aggression has received increasing attention over the past two decades. Specifically, an evolving body of research literature has shown that sexual aggression is not only a marker of severe physical violence in intimate relationships, it is also problematic in its own right and is associated with specific consequences [
2]. For example, compared with intimate partner physical violence, intimate partner sexual aggression has been found to be associated with a higher risk of homicide and more deleterious health outcomes [
3]. Intimate partner sexual aggression has also been identified as a significant predictor of post-traumatic stress disorder (PTSD), even after controlling for the severity of physical violence [
4,
5].
Sexual aggression in intimate relationships is not a single phenomenon. Rather, a spectrum of sexually aggressive acts has been documented [
2]. Some are unwanted sexual acts obtained through the use or threat of force [
2]. Such physically forced sexual acts are considered by some to qualify as rape [
6‐
8] and can be identified not only by the use or threat of force by the perpetrator, but also the lack of consent by the victim [
9]. Identifying acts of unwanted sex in intimate relationships where there is no report of forced sex or lack of consent, however, is more problematic. The term “sexual coercion” has been used to describe a woman’s acquiescence to her partner’s demands for sex [
8,
9], and the partner may not even know that the sex is unwanted [
9]. As such, non-physical sexual coercion is often subtle and requires careful assessment of how a woman gives in to sex without the partner using force or threat of force [
9]. It has been suggested that quantitative measures may not adequately reveal the context surrounding intimate partner sexual aggression in general [
10] and especially the subtle forms of non-physical sexual coercion [
9]. Supplementing quantitative self-report measures with in-depth interviews will more likely reveal the nuances of the complex phenomenon of intimate partner sexual aggression, particularly for identifying victims who are at greater risk of sexual aggression-specific outcomes [
2].
Eliciting information from women about their experiences of intimate partner sexual aggression, irrespective of whether force has been used, is further complicated by cultural factors. Specifically, in cultures such as the Chinese culture, where sex is a taboo subject [
11] and wives are socialized to believe that they should satisfy their husbands sexually [
12], extricating experiences of unwanted sex from the women requires special skills. Previously, we adopted the method of empathetic interviewing to help Chinese women recount their experiences of intimate partner violence, including sexual aggression [
13]. Among the narratives provided by the women reporting intimate partner physical violence victimization were accounts of how their partners also used various coercive acts, including the use of force, to make them have sex. The findings indicated that it was possible to elicit personal experiences of intimate partner sexual aggression from Chinese women, and that there was a need to further investigate the relative effects of physical violence and sexual aggression on these women’s health in light of the findings in the Western literature [
4,
14].
In addition, although the use of force or threat of force by an intimate partner to gain sexual access has long been recognized as a vicious and extremely damaging form of sexual aggression [
8,
15], less is known about the more subtle forms of unwanted sex where no force or threat of force is used [
9]. An exception is a study by Basile [
9], in which five types of acquiescence to unwanted sex in marital contexts were identified in a group of women recruited from a national telephone poll in the United States. The study uncovered the processes, including subtler processes, through which women gave in to unwanted sex in intimate relationships. Basile’s study also highlighted the need to recognize the subtler forms of sexual aggression, suggesting that these may be precursors to more severe forms. To date, information on the subtler forms of intimate partner sexual aggression is still limited, and even less is known about the differential impact on health made by physically forced sex and unwanted sex obtained by non-physical coercion. Such information is important for identifying those at risk so that tailored interventions may be provided for secondary and tertiary prevention.
For the purpose of this paper, we distinguish intimate partner sexual aggression based on whether force or threat of force was used in unwanted sex. Physically forced sex is defined as any unwanted sexual act (vaginal, anal, or oral penetration) that is obtained without consent through the use of force or threat of force [
2]. Non-physical coerced sex is defined as any unwanted sexual act (vaginal, anal, or oral penetration) with a partner that a woman gives in to as a result of being “coerced, tricked, pressured, and bullied into having sex” [
8], p.86. Non-physical coerced sex differs from physically forced sex in that no physical force or threat of force is used by the partner, and it does not involve the lack of consent and/or struggle by the woman [
9]. Although we distinguish between physically forced sex and non-physical coerced sex for the sake of clarity when making comparisons, we are not suggesting that they are two distinct phenomena. Rather, we acknowledge that they are different forms of sexual aggression existing on a continuum of severity, and that mildly coercive sexual acts can become more severe over time [
9], hence the need for a better understanding of the subtler forms of sexual aggression.
This article reports on sexual aggression in Chinese intimate relationships. Specifically, predictive factors of sexual aggression were identified, and the relative effects of physical violence and sexual aggression on mental health were examined. After distinguishing unwanted sex experienced by Chinese women based on whether physical force or threat of force was used by their partners, we then described the non-physical coercive tactics used to make the women give in to unwanted sex. The differential impact on the women’s mental health caused by physically forced sex and non-physical sexual coercion was also compared. The findings are useful for generating much-needed information about the different forms of unwanted sex in Chinese intimate relationships and about their impact on the women’s mental health. This information can help professionals to better identify the treatment needs of these often silent and under-served women and determine the most appropriate interventions to reduce further risks and promote recovery.
Discussion
This article focused on sexual aggression in Chinese intimate relationships. To the best of our knowledge, this is the first article to chronicle the nuances of Chinese women’s experiences of intimate partner sexual aggression based on quantitative findings enriched by qualitative accounts. It is also the first to report on the differential mental health effects between physically forced sex and non-physical sexual coercion among Chinese women.
We found that, after controlling for intimate partner physical violence, intimate partner sexual aggression significantly predicted PTSD and depressive symptoms. These results are consistent with those of prior studies involving non-Chinese participants, in which even in the context of ongoing physical violence, the experience of sexual aggression directly resulted in more severe PTSD or depressive symptoms [
3,
4]. Furthermore, we extended the existing literature by revealing that physically forced sex and non-physical sexual coercion had differential effects on Chinese women’s mental health. Specifically, those experiencing physically forced sex reported worse PTSD and depressive symptoms than did those experiencing non-physical sexual coercion. Our findings have clinical implications in that they underscore the importance for health and social service professionals to screen for sexual aggression when intimate partner physical violence is reported. Also, careful assessment should be made to ascertain whether forced sex has been used by the partner. Such information will assist clinicians to predict more accurately the severity of women’s post-trauma symptoms and provide interventions that are tailored for their specific needs.
From the women’s accounts, we uncovered a variety of non-physical coercive tactics used by the partners to make them give in to unwanted sex. The tactics varied in form and subtlety. Some of the types of tactics are analogous to the forms of coercion identified in the classic work of Finkelhor and Yllo [
8] on conceptualization of sexual coercion. For example, corresponding to Finkelhor and Yllo’s social type of coercion [
8], some women in our study reported feeling obliged to have sex with their partners even though it was unwanted because they were socialized to believe (and then reinforced by their partner) that it was their duty. Similarly, consistent with Finkelhor and Yllo’s interpersonal type of coercion [
8], some women in the present study may have given in to undesired sex as a result of the nonviolent threats made by their partners (e.g., withholding affection if sex was not given). Furthermore, the coercive tactics identified in our study also differed in subtlety. Some of the tactics were less subtle, as the women had learned from past experience that the consequence of not giving in to sex (e.g., retaliation by partners if sexual demands were not met) was far worse than succumbing to unwanted sex. Some of the tactics, however, such as compelling women to give in to unwanted sex out of obligation as a wife, appeared to be subtler. It has long been suggested that sexual coercion exists on a continuum [
6,
28,
29] and that mildly coercive sexual acts can become more dangerous and severely coercive over time [
9]. The findings in the present study indicating that women experienced different forms of sexually coercive tactics with different degrees of subtlety seem to align with the proposition of continuums of sexual coercion [
6]. Longitudinal research should be conducted to verify the possibility of a continuum but also to validate whether less severe coercion can, in fact, become more severe over time.
Despite the taboo and shameful nature of intimate partner sexual aggression in Chinese society [
30], the women in this study were prepared to share their personal experiences when interviewed in an empathetic manner. Moreover, their descriptions of how they negotiated and endured unwanted sex with their abusive partners revealed their resilience and resourcefulness, similar to their Western counterparts [
31]. We should also take note of the finding that the risk of being physically and sexually abused was 39% higher when the partner used a high level of controlling behavior in the intimate relationship. This finding lends support to the call to facilitate risk assessment and treatment planning by conducting a clinical assessment of the perpetrator’s intention and motivation when intimate partner sexual aggression is found [
2].
This study has several limitations. Sampling bias is one of the limitations. As the participants were recruited from organizations that provided services for abused women, they were essentially clinical samples. Thus, the high percentage of partner violence victimization reported would not be representative for the population of Chinese women in general. Furthermore, because self-reports were used to collect the information, recall errors may have led to important facts being unreported and social desirability may have introduced bias in favor of the prevailing social norms. Future research could consider using multiple data sources such as social reports, health records, and biophysiological measures to enhance the quality and accuracy of the data. The study design is another limitation. Because of the cross-sectional design of this study, even though an association was found between mental health problems and intimate partner sexual aggression, no causal inferences can be drawn. In future studies, a longitudinal design with data collected at different points over time would allow a better determination of the relationship between the presumed cause (i.e., sexual aggression) and the presumed effect (i.e., mental health problems).
Acknowledgements
We are extremely thankful to the Research Grant Council for granting the General Research Fund, to the Family and Child Protective Services Units (FCPSUs) under the Social Welfare Department of the HKSAR Government for assisting recruitment of participants, to Helena Yuk for allowing us to conduct surveys at the HKSKH Lady MacLehose Centre, to Kallie Law for collecting and analyzing the data, to Ruby Lo of Policy 21 for her helpful statistical assistance, and to all the women who took part in the study.
Funding
The study was funded by the General Research Fund from the Research Grant Council of Hong Kong (Project Number 753510).
Competing interests
The authors declare that they have no competing interests.
Authors’ contributions
Conceptualisation and design of the study: AT, EKLC, DYTF, ECWY, DHMT. Data collection and analysis: AT, GLLL. Preparing and reviewing the manuscript: AT, DC, GLLL, DYTF, EKLC, ECWY, DHMT. All authors read and approved the final manuscript.