JOURNAL OF AMERICAN COLLEGE HEALTH, VOL. 57, NO.

College Womens Experiences with Physically Forced, Alcohol- or Other Drug-Enabled, and Drug-Facilitated Sexual Assault Before and Since Entering College
Christopher P. Krebs, PhD; Christine H. Lindquist, PhD; Tara D. Warner, MA; Bonnie S. Fisher, PhD; Sandra L. Martin, PhD

Abstract. Objective: Research has shown associations between college womens alcohol and/or drug consumption and the risk of sexual assault, but few studies have measured the various means by which sexual assault is achieved. Participants: The authors Campus Sexual Assault Study obtained self-report data from a random sample of undergraduate women (N = 5,446). Methods: The authors collected data on sexual assault victimization by using a cross-sectional, Web-based survey, and they conducted analyses assessing the role of substance use. The authors also compared victimizations before and during college, and across years of study. Results: Findings indicate that almost 20% of undergraduate women experienced some type of completed sexual assault since entering college. Most sexual assaults occurred after women voluntarily consumed alcohol, whereas few occurred after women had been given a drug without their knowledge or consent. Conclusions: The authors discuss implications for campus sexual assault prevention programs, including the need for integrated substance use and sexual victimization prevention programming. Keywords: alcohol, drug facilitation, incapacitation, rape, sexual assault, sexual battery

here is mounting evidence that sexual assault is a common and reoccurring problem among college women.15 Men are also sexually assaulted, but the prevalence among women is believed to be considerably higher and is the focus of this study. Researchers have reported that between one-fifth to one-quarter of college women are raped during the course of their college careers.2,3 Moreover, during an academic year, approximately 23% of college women experience forcible rape.2,4
Drs Krebs and Lindquist are with RTI International in Research Triangle Park, NC. Ms Warner is with Bowling Green State University. Dr Fisher is with the University of Cincinnati, OH. Dr Martin is with the University of North Carolina, Chapel Hill. Copyright 2009 Heldref Publications 639

Some perpetrators physically force women, or threaten them with physical force, to engage in sexual activity. This type of assault is often termed physically forced sexual assault. The term incapacitated sexual assault has been used to refer to incidents in which victims are unable to legally consent to sexual acts because of incapacitation. Situations in which women are sexually assaulted when they are incapacitated because of their voluntary and/or excessive use of alcohol and/or drugs are referred to in the present article as alcohol and/or other drug (AOD)-enabled sexual assault. In another type of sexual assault, the perpetrator surreptitiously gives the victim a substance without her knowledge or consent to incapacitate her; this type of assault is often termed drug-facilitated sexual assault (DFSA). The substances commonly reported in association with DFSA (often called date rape drugs) include Rohypnol (flunitrazepam), gamma hydroxybutyrate (GHB), Ketamine (a general anesthetic), MDMA (ecstasy), and Soma (carisoprodol).6,7 Alcohol may also be administered without a victims knowledge or consent, but this type of incapacitation was neither measured in the present study nor included in the definition of DFSA. There is growing evidence of links between victims substance use and sexual assault.1,8 Data from the nationally administered 2005 Core Alcohol and Drug Survey showed that 82% of students who experienced unwanted sexual intercourse during the current academic year were under the influence of AOD when they were victimized.9 The College Alcohol Study (CAS) found that from 19972001, approximately 3.4% of college women reported having been raped when they were so intoxicated that [they] were unable to consent4 since the beginning of the school year (p. 42). These studies are somewhat limited in that they did not distinguish the means by which women became intoxicated before being raped. That is, they did not distin-

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guish between women who voluntarily consumed AOD and women who were administered a substance without their knowledge or consent. Stories about college women who were purposively drugged and then sexually assaulted (ie, cases of DFSA) have led some people to believe or fear that heinous acts such as these are commonplace during the college years.10 It is therefore important to learn more about how women become incapacitated prior to being sexually assaulted, paying particular attention to the prevalence of DFSA, as this information can inform the development of sexual assault prevention programs. A study by Testa, Livingston, et al8 was among the first of few investigations that have identified the means by which women became incapacitated and were subsequently raped. They surveyed a community sample of 1,014 women in the vicinity of Buffalo, New York, using a modified version of the Sexual Experiences Survey (which was validated in a follow-up study by Testa, VanZile-Tamsen, Livingston, and Koss11) that distinguished between incapacitated and drugfacilitated rapes. Results indicated that 9.8% of the women had experienced physically forcible rape (ie, forced sexual intercourse). Fewer women, 8.4%, experienced a rape when they were incapacitated due to alcohol or drugs, and 3.1% of the sample experienced alcohol or drug-facilitated rape, which was defined by an affirmative response to a question about experiencing sexual intercourse when you didnt want to because a man made you intoxicated by giving you alcohol or drugs without your knowledge or consent. Testa and her colleagues research added much needed information to the scientific literature; however, the experiences of this community sample of women may not be similar to those of undergraduate college women. For example, the average age of the women in their sample was 24 years; undergraduate women are typically younger, and as the National Crime Victimization Survey (NCVS) has consistently shown, being younger places them at increased risk of sexual victimization.12 Also noteworthy is the evidence from 1 campus to suggest that the risk of rape is greater among women who recently entered college (eg, freshmen) and that this risk decreases over the college tenure.5 Moreover, the college culture and its associated lifestyle, with many students frequenting parties and/or bars and consuming AOD, may place college women at greater risk of sexual assault compared with women in the general population. Given the serious consequences experienced by victims of rape (ie, oral, anal, or vaginal penetration), it is not surprising that it has received much more attention by researchers than has sexual battery (ie, sexual assault that involves no more than touching), even though some studies suggest college women are more likely to experience sexual battery than rape.13,14 For example, the National Sexual Victimization of College Women study that surveyed 4,446 college women found that almost 9% of the women experienced unwanted sexual contact within an academic year, whereas nearly 3% experienced rape.2 Even though less research has focused on sexual battery than rape, the little research that has been done on
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this topic has found that the perpetrators of this type of sexual assault also may use alcohol or drugs to incapacitate women and assault them sexually. For example, in a sample of undergraduate women from 1 university, Banyard and colleagues14 found that 9% of unwanted sexual contact victims reported that the perpetrator used force, whereas 8% reported that the perpetrator got them intoxicated by giving them alcohol and/or drugs. To the best of our knowledge, no previous studies have examined whether college women who experience sexual battery while incapacitated were in this state because of their voluntary use of substances or because of someone giving them an intoxicating substance without their knowledge or consent. Seldom has a study simultaneously examined the prevalence of each of these types of sexual assault within a large sample of college women. The present study, the Campus Sexual Assault (CSA) study, analyzed results from a Webbased survey administered to a probability-based sample of 5,446 undergraduate women enrolled at 2 large public, 4-year universities. The CSA study builds on past research in an effort to further the understanding of the prevalence of different types of sexual assault experienced by college women. Notable aspects of the CSA methodology are that it examined both attempted and completed rape and sexual battery, with attention paid to whether the assault occurred through means of physical or threatened force or incapacitation of the victim, including AOD-enabled sexual assault and drug-facilitated sexual assault. Further, the CSA study gathered data on sexual assaults that happened before entering college and those that occurred since entering college. We first present data on the different types of sexual assault experienced by the college women studied, with attention paid to the prevalence of various types of completed sexual assault experienced before entering college and the prevalence of various types of completed sexual assault since entering college. In addition, to understand when most undergraduate women experience sexual assault, the prevalence data on the types of completed sexual assault experienced since entering college were stratified by year of study (eg, sophomore, junior). We discuss the implications of these results for informing college-based prevention efforts that target specific types of sexual assault. METHODS Recruitment of the Study Sample Undergraduate students from 2 large public, 4-year universities1 located in the southern United States and the other in the Midwestparticipated in the CSA study. The Institutional Review Board (IRB) at the leading institution, a nonprofit research organization, and the IRBs at both participating universities reviewed and approved the CSA study protocol. Registrars at both universities provided demographic information on all undergraduates enrolled in the 2005 fall term. The sampling frame was limited to traditional undergraduate students (ie, those between the ages of 18 and 25 who were enrolled at least three-quarters time). A
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total of 26,764 students met these criteria. From these students, we randomly sampled a total of 7,200 women from university 1 and 5,646 women from university 2, inviting them to participate in the survey. Sampled students were sent an initial recruitment e-mail that described the study and were provided with a unique CSA study identification number and a hyperlink to the CSA study Web site. However, it is important to note that because the survey was anonymous, students did not enter their identification number on the study Web site. The identification number was only used to receive the incentive for study participation (a gift code for an online store worth $10), which was provided after the students entered the CSA study identification number with a computer-generated survey completion code supplied after the last survey question was answered. Two weeks after the initial e-mailing, students who had not completed the survey were sent a follow-up e-mail encouraging them to participate; after 3 weeks, nonrespondents were mailed a hard-copy recruitment letter. Two weeks after the mailing, nonrespondents were sent a final recruitment e-mail. The overall response rates for survey completion for the undergraduate women sampled at the 2 universities were 42.2% and 42.8%, respectively. A nonresponse bias analysis was conducted to create sample weights. We compared respondents and nonrespondents on the administrative data elements provided by the universities, which included age, university, race/ethnicity, and year of study. Cohens effect size was used as a measure of the magnitude of the bias. The results indicated that a minimal amount of bias existed, and the bias that was present was in the race/ethnicity category. Nonwhite students (ie, those identified as black, Hispanic, or other) were less likely to respond to the survey than were their white counterparts. Weights adjusting for

nonresponse were developed using a generalized exponential model15 to reduce nonresponse bias and increase sample representativeness so that the sample would better resemble the university populations. Once weights were added for university, gender, year of study, and race/ethnicity, the observable bias indicated by Cohens effect size was reduced to negligible levels. All prevalence estimates and multivariate models were computed using weighted data. Assessment The CSA Web-based survey was cross-sectional in nature and collected a wide range of information from the students, including data on demographics (eg, race/ethnicity, age, year of study), school involvement, substance use, and dating and sexual activity. Through separate series of questions, students were asked whether they had experienced physically forced sexual assault (with attempted but not completed incidents, and completed incidents recorded separately) and sexual assault when they were incapacitated and unable to provide consent (see the Figure 1 for definitions and survey questions). Sexual assault involved unwanted sexual contact that could include touching of a sexual nature, oral sex, sexual intercourse, anal sex, or sexual penetration with a finger or object. Several questions focused on the students experiences with attempted (but not completed) and completed sexual assault before entering college. The survey also gathered data in greater detail on students experiences with sexual assault since entering college. For both physically forced and incapacitated sexual assaults, data were gathered about the nature of the sexual contact that occurred, enabling us to classify the sexual assault as rape or sexual battery. Those who experienced an incapacitated sexual assault since entering college were asked several questions about

Undergraduate women respondents (n = 5,446) 1. Attempted or completed SA before entering college (n = 819, 15.9%) 2. Attempted SA (n = 514, 10.1%) 4. Physically forced SA (n = 322, 6.4%) 3. Completed SA (n = 590, 11.3%) 6. Attempted or completed SA since entering college (n = 1,073, 19%) 7. Attempted SA (n = 682, 12.6%) 8. Completed SA (n = 782, 13.7%) 12. Incapacitated SA (n = 651, 11.1%) 14. Rape (n = 507, 8.5%)

5. Incapacitated SA (n = 377, 7.0%) 10. Sexual battery only (n = 75, 1.4%)

9. Physically forced SA (n = 256, 4.7%) 11. Rape (n = 181, 3.4%)

13. Sexual battery only (n = 144, 2.6%)

15. AOD-enabled SA (n = 466, 7.8%)

16. Certain drugfacilitated SA (n = 31, 0.6%)

17. Suspected 18. Other drug-facilitated SA incapacitated SA (n = 103, 1.7%) (n = 48, 1.0%)

Figure 1. The prevalence of different types of sexual assault (SA) before and since entering college (unweighted frequencies, weighted percentages).

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the means by which they became incapacitated. Specifically, victims were asked whether they had been drinking alcohol or voluntarily using drugs other than alcohol prior to the incident and whether they think they had been given a drug other than alcohol without their knowledge or consent. Depending on the means by which they became incapacitated, sexual assault victims were classified into the following sexual assault groups: (1) drug-facilitated (women who indicated they had been given a drug other than alcohol without their consent prior to being assaulted), (2) suspected drug-facilitated (women who were not certain whether or not they had been given a drug without their consent prior to the assault), (3) AOD-enabled (women who had been voluntarily consuming alcohol and/or drugs prior to being assaulted), and (4) other incapacitated (women who indicated they were victims of a sexual assault while incapacitated but did not respond in a way that enabled us to determine how they became incapacitated). RESULTS Description of the Sample The majority (66.9%) of the women were white, although a sizeable proportion of them were black (16.2%) or in the other category (14.0%), which included Asians, Native Hawaiians/Other Pacific Islanders, American Indians/Alaska Natives, and respondents of multiple races. Only 3.0% of the sample were Hispanic. The majority of the sample (63%) was 1820 years of age. There were larger percentages of freshman (29.9%) and seniors (26.6%) than of sophomores (22.8%) and juniors (20.7%). This distribution reflected the distribution at the participating universities because the data were weighted for year of study. Prevalence Estimates of Sexual Assault Before and Since Entering College Of the 5,446 women, 28.5% reported having experienced an attempted or completed sexual assault either before or since entering college. Figure 1 presents the estimates for the various types of sexual assault experienced by the women. Nearly 16% of the 5,446 women experienced attempted or completed sexual assault before entering college (see Figure 1, box 1). Almost equal percentages experienced attempted sexual assault before college (10.1%; Figure 1, box 2) and completed sexual assault before college (11.3%; Figure 1, box 3). Some women (5.5%) experienced both attempted and completed sexual assault before entering college (ie, the women represented in boxes 2 and 3 are not mutually exclusive). Similar percentages of women experienced completed physically forced assault (6.4%; Figure 1, box 4) and incapacitated sexual assault (7.0%; Figure 1, box 5) before entering college. It should be noted that 2.1% of the women in our study experienced both physically forced and incapacitated sexual assault before entering college (ie, the women represented in boxes 4 and 5 are not mutually exclusive). Nineteen percent of the women reported experiencing completed or attempted sexual assault since entering col642

lege (Figure 1, box 6), a slightly larger percentage than those experiencing such incidents before entering college (Figure 1, box 1). Since entering college, slightly more women experienced completed sexual assault (13.7%; Figure 1, box 8) than attempted sexual assault (12.6%; Figure 1, box 7), with 7.2% of the women experiencing both completed sexual assault and attempted sexual assault during college (ie, the women represented in boxes 7 and 8 are not mutually exclusive). Nearly 5% of the total sample were forcibly sexually assaulted since college entry (4.7%; Figure 1, box 9). More than 3% of the women (3.4%) experienced forced rape since entering college (Figure 1, box 11) and 1.4% experienced forced sexual battery since entering college (Figure 1, box 10). Approximately 11% of the women experienced sexual assault while incapacitated since entering college (Figure 1, box 12), with a higher percentage of women being victims of incapacitated rape than incapacitated sexual battery since entering college (8.5%; Figure 1, box 14, compared with 2.6%; Figure 1, box 13, respectively). It is important to note that AOD-enabled sexual assault was experienced by 7.8% of the women since entering college (Figure 1, box 15). In contrast, smaller percentages of women experienced drug-facilitated sexual assault that they were certain happened (0.6%; Figure 1, box 16), that they suspected happened (1.7%; Figure 1, box 17), or some other type of incapacitated sexual assault (1.0%; Figure 1, box 18). Comparison of the Risk of Completed Sexual Assault Before and Since Entering College Figure 2 shows changes in the prevalence of completed forced sexual assault and completed incapacitated sexual assault before and since entering college. Similar percentages of women experienced completed incapacitated sexual assault (7.0%) and completed physically forced sexual assault (6.4%) before entering college, McNemar 2(1, N = 5,466) = 1.698, p = .1925; however, the percentages of victims of completed incapacitated sexual assault (11.1%) and completed forced sexual assault (4.7%) differ greatly for the since entering college time period, 2(1, N = 5,446) = 194.477, p < .0001. This is in part because during college, the prevalence of completed incapacitated sexual assault is considerably higher than for the prior to college time period (7.0% before college compared with 11.1% during college, 2(1, N = 5,446) = 72.780, p < .0001). One hundred and forty women (2.5%) were victims of completed incapacitated sexual assault both before and since entering college, whereas 68 women (1.4%) were victims of completed physically forced sexual assault both before and since entering college. Prevalence of Completed Sexual Assault During College by the Womens Year of Study It is important to recognize that the window of time or risk period during which undergraduate women can be sexually assaulted varies by their year of study (eg, freshman in the study had experienced less than 1 year of college, hence
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College Women and Sexual Assault

Forced sexual assault

Incapacitated sexual assault

12.0% 12 10.0% 10 8.0% 8.0 6.0% 6.0

%

11.1%

7.0% 6.4% 4.7%

Percentage 4.0 4.0%

2.0 2.0% 0.0 0.0%

Before Entering College

Before entering college

Figure 2. The prevalence of physically forced and incapacitated sexual assault before and since entering college. Forced Sexual Assault Incapacitated Sexual Assault

Time Period

Time Period

After Entering College

After entering college

they had less than 1 year at risk; sophomores experienced more than 1 year but less than 2 years of college, hence they had less than 2 years of risk). Table 1 presents prevalence estimates of the types of completed sexual assault since entering college, first examining the prevalence estimates over the womens entire college tenure (so women in different years of study have different periods of risk) and then examining the prevalence estimates for the past 12 months. Table 1 shows that women surveyed in their senior year of college (those having the longest risk period for sexual assault since entering college) had the greatest cumulative prevalence of each type of completed sexual assault. Almost 20% of the seniors experienced some type of sexual assault since entering college, with 6.9% experiencing physically forced sexual assault and 16.0% experiencing incapacitated sexual assault. It is noteworthy that most of the incapacitated sexual assaults (10.8%) were AOD-enabled. As expected, a smaller percentage of freshman women experienced each type of completed sexual assault since entering college because of their reduced time at risk during college. Table 1 also shows that when the womens risk period for sexual assault during college was taken into account (by restricting the risk period to the past 12 months for sophomores, juniors, and seniors), women who were sophomores during the time of the survey had significantly higher past 12-month prevalence estimates of all types of completed sexual assault (except for drug-facilitated sexual assault) compared with women who were juniors or seniors. Freshmen were excluded from this analysis because they had not experienced at least 12 months of college. Just over 9% of women surveyed in their sophomore year experienced some type of completed sexual assault during the past 12 months, compared with 7.2% of surveyed juniors and 6% of surveyed seniors. In particular, womens annual risk
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of incapacitated sexual assault decreased the longer they were in college, with this pattern being primarily due to the decrease in the annual prevalence of AOD-enabled sexual assault with increasing years of college experience (5.9% of sophomores, 3.6% of juniors, and 3.6% of seniors). Our findings appear to support literature5 suggesting that women are at the greatest risk of experiencing sexual assault early in their college careers. COMMENT Echoing the findings of past national studies,2,3 the CSA Study found that many undergraduate women were victims of sexual assault during college, with almost 20% of the women experiencing some type of completed sexual assault by winter of their senior years. The CSA study is also consistent with past research in finding positive associations between womens use of substances and their likelihood of experiencing sexual assault.1,4,8,16 It is extremely important to keep in mind, however, that even though many sexual assaults involve substance use by the victim, this does not imply that women are in any way responsible for their sexual assault. Victimization is committed by the perpetrator, and prevention programs targeting university men should strongly emphasize that an intoxicated or incapacitated person cannot legally or otherwise consent to sexual contact. Supportive of White and Smiths work,5 the CSA Study found that women new to the college experience such as freshmen and sophomores appeared to be at a particularly high risk for sexual assault compared with women who had more college experience (ie, juniors and seniors). The CSA study extended prior research by clarifying the means by which college women became incapacitated and subsequently experienced sexual assault. The CSA study results demonstrated that the majority of completed sexual
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644 Freshman (n = 1,297) Sophomore (n = 1,354) Junior (n = 1,390) Senior (n = 1,402) All women (N = 5,466) pb 7.5 2.0 6.1 4.6 0.3 0.8 0.4 9.3 3.1 7.6 5.9 0.2 0.9 0.7 7.2 2.8 5.4 3.6 0.5 0.8 0.5 12.6 4.6 10.3 7.6 0.3 1.5 0.7 15.8 6.1 13.0 8.7 0.8 2.0 1.4 19.8 6.9 16.0 10.8 0.9 2.6 1.6 6.0 1.9 4.9 3.6 0.3 0.7 0.3 13.7 4.7 11.1 7.8 0.6 1.7 1.0 7.5 2.5 6.0 4.3 0.3 0.8 0.5 < .001 < .001 < .001 < .001 .0463 .0008 .0011 .0026 .1365 .0048 .0032 .3464 .8266 .4250

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TABLE 1. Prevalence of Completed Sexual Assault Since Entering College and Prevalence of Completed Sexual Assault During the Past 12 Months, Stratified by Womens Year of Study During the Survey (Weighted Percentages)a

Variable

Types of completed sexual assaults experienced since entering college Any completed sexual assault Physically forced sexual assult Incapacitated sexual assault AOD-enabled sexual assault DFSA SDFSA Otherwise incapacitated sexual assault Types of completed sexual assaults experienced during the past 12 monthsc Any completed sexual assault Physically forced sexual assult Incapacitated sexual assault AOD-enabled sexual assault DFSA SDFSA Otherwise incapacitated sexual assault

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Note. AOD = alcohol or drug; DFSA = drug-facilitated sexual assault; SDFSA = suspected drug-facilitated sexual assault. a Three women were missing college classification; they are excluded from this analyses. b Values based on the F test from analysis of variance. c Freshmen were not included in the presentation of past 12 months prevalence because they had not experienced 12 months of college at the time of the interview. The 12-month reference period included their senior year in high school.

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assaults of college women occurred while the victim was incapacitated, with this incapacitation typically being due to the womens voluntary use of alcohol. The CSA findings have implications for campus-based sexual assault prevention policies and programs. Currently, the Clery Act mandates that colleges and universities participating in Federal student aid programs state their policy regarding [their] campus sexual assault program to prevent sexual offenses that must include a description of educational programs to promote the awareness of sexual violence.17 A review of these programs has found that they seldom emphasize the important link between womens use of substances (in particular, womens voluntary alcohol or drug use) and becoming a victim of sexual assault.18 Neglecting to include this important information in college sexual assault prevention programs is especially problematic given that the college environment is often characterized as one in which it is common to experiment with, and sometimes excessively use, alcohol and illicit drugs. Researchers have consistently reported that individuals who consume alcohol to excess are less able to resist or prevent victimization and are, therefore, more vulnerable to victimization, including sexual assault.8 In light of the CSA study findings and those of other researchers demonstrating this strong link between alcohol use and sexual assault, we encourage the development, implementation, and evaluation of campus-based sexual violence prevention programs that include a component educating students about the link between substance use and sexual victimization. Furthermore, such programs should teach students to use various cognitive, behavioral, and social strategies to monitor the amount of alcohol and/or drugs they consume and to recognize when they, or their peers, are cognitively and/or physically impaired (and therefore at increased risk of sexual assault victimization). It is important to promote the message that not drinking to excess (limiting intake) and not taking drugs are important sexual assault self-protection strategies, especially within the context of the campus social situations. When delivering this message, one must be careful not to blame the victim because of substance use, while clarifying that such substance use increases ones risk for sexual victimization. Such programs should be delivered when women first enter college and throughout the early college years because it appears that freshmen and sophomore women are at the greatest risk of experiencing sexual assault. In addition, programs should be developed, implemented, and evaluated that teach both women and men how they can help protect their peers from sexual assault. For example, male peer support programs that encourage men to get proactively involved in efforts to reduce sexual assault (eg, being involved in education programs and/or support groups for abusive men) and intervene (eg, shaming men who make sexist comments or engage in sexual abuse) need to be expanded, enhanced, and evaluated.19 In addition, teaching college students how they might intervene to help a peer who is obviously cognitively and/or physically
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impaired because of AOD use and in a situation in which an assault could easily occur may be helpful; this has been suggested by the social guardianship work of Spano and Nagy,20 whose findings imply that supportive peers can serve as a protective factor against violent victimization. Limitations Caution is urged in interpreting the CSA study findings because of the methodological limitations of this research. First, because this study only examined the sexual assault experiences of women from 2 large public, 4-year universities, it may be that the experiences of these women are not representative of those of all college women, which limits the generalizability of study findings. Another threat to the representativeness of the sample is that this study had a relatively modest response rate (approximately 42.5% of all eligible women responded to the survey), even though this level of response is viewed as reasonable/acceptable for Web-administered surveys.21 In addition, weighting the data to the true distribution of students in the study population likely enhanced the representativeness of the sample responses. In addition, the findings from the nonresponse bias analyses were encouraging. A final limitation concerns the types of incapacitated sexual assault measured in the CSA study. Because we did not ask victims of incapacitated sexual assault whether they had been given alcohol specifically (the question about the surreptitious administration of substances was limited to drugs other than alcohol) without their knowledge or consent, we are unable to estimate the prevalence of this type of incapacitated sexual assault. In closing, the CSA study findings brings researchers one step closer to understanding the strong association between college womens substance use and their experiences with sexual assault victimization. The findings provide insight into the prevalence of different types of sexual assault and clearly demonstrate that many women are incapacitated (and thus unable to provide consent) at the time of their sexual assault. It is important to note that this study shows that the majority of this incapacitation is due to womens voluntary use of AOD, and that few women were sexually assaulted after being given a drug (eg, GHB or Rohypnol) without their knowledge or consent. Taken together, these findings suggest the need for campus sexual assault prevention programs that educate students not only about the risks of forcible rape, which is less common, but also about this well-established link between womens voluntary substance use and their risk for being a victim of incapacitated sexual assault. Campus safety advocates and sexual assault prevention providers should work with Congress to amend the Clery Act requirements to mandate such content in all campus sexual assault prevention programs.
ACKNOWLEDGMENTS

RTI International is an independent organization dedicated to conducting innovative, multidisciplinary research that improves the human condition.
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This project was supported by Grant Number 2004-WGBX-0010, awarded by the National Institute of Justice, Office of Justice Programs, US Department of Justice. Points of view are those of the authors and do not necessarily represent the official position or policies of the US Department of Justice.
NOTE

For comments and further information, address correspondence to Dr Christopher P. Krebs, RTI International, 3040 Cornwallis Rd., Research Triangle Park, NC 277092194, USA (e-mail: krebs@rti.org).
REFERENCES 1. Abbey A. Alcohol-related sexual assault: a common problem among college students. J Stud Alcohol. 2002;14:118128. 2. Fisher BS, Cullen FT, Turner MG. The Sexual Victimization of College Women. Washington, DC: US Department of Justice, Office of Justice Programs; 2000. 3. Koss MP, Gidycz CA, Wisniewski N. The scope of rape: incidence and prevalence of sexual aggression and victimization in a national sample of higher education students. J Consult Clin Psychol. 1987;55:162170. 4. Mohler-Kuo M, Dowdall GW, Koss MP, Wechsler H. Correlates of rape while intoxicated in a national sample of college women. J Stud Alcohol. 2004;65:3745. 5. White JW, Smith PH. A Longitudinal Perspective on Physical and Sexual Intimate Partner Violence Against Women. Washington, DC: National Institute of Justice; 2004. NCJ 199708. 6. US Department of Justice, National Drug Intelligence Center. Drug Facilitated Sexual Assault Resource Guide. Washington, DC: US Department of Justice, National Drug Intelligence Center; 2003. 7. LeBeau M, Andollo W, Hearn W, et al. Recommendations for toxicological investigations of drug-facilitated sexual assaults. J Forensic Sci. 1999;44:227230. 8. Testa M, Livingston J, Vanzile-Tamsen C, Frone MR. The role of womens substance use in vulnerability to forcible and incapacitated rape. J Stud Alcohol. 2003;64:756764. 9. Dowdall GW. The role of alcohol abuse in college student victimization. In: Fisher B, Sloan JJ, eds. Campus Crime. 2nd ed.

Springfield, IL: Thomas; 2007:167187. 10. Zorza J. Drug-faciliated rape. In: Ottens AJ, Hotelling K, eds. Sexual Violence on Campus: Policies, Programs and Perspectives. New York, NY: Springer Publishing; 2001:5375. 11. Testa M, Vanzile-Tamsen C, Livingston J, Koss MP. Assessing womens experiences of sexual aggression using the sexual experiences survey: evidence for validity and implications for research. Psychol Women Q. 2004;28:256265. 12. Catalano SM. National Crime Victimization Survey: Criminal Victimization, 2005. Washington, DC: US Department of Justice, Office of Justice Programs, Bureau of Justice Statistics; 2006. NCJ 214644. 13. Adams-Curtis LE, Forbes GB. College womens experiences of sexual coercion. Trauma, Violence Abuse. 2004;5:91122. 14. Banyard V, Ward S, Cohn ES, Plante EG, Moorhead C, Walsh W. Unwanted sexual contact on campus: a comparison of womens and mens experiences. Violence Vict. 2007;22:5270. 15. Folsom RE, Singh AC. The generalized exponential model for sampling weight calibration for extreme values, non-response, and post-stratification. Paper presented at: American Statistical Association Meeting, Proceedings of the Section on Survey Research Methods of the American Statistical Association; August 13-17, 2000; Indianapolis, IN. 16. Testa M, Vanzile-Tamsen C, Livingston J. The role of victim and perpetrator intoxication on sexual assault outcomes. J Stud Alcohol. 2004;65:320329. 17. Security on Campus Inc. Web site. http://www.securityoncampus.org. Accessed May 2, 2008. 18. Bachar K, Koss MP. From prevalence to prevention: closing the gap between what we know about rape and what we do. In: Renzetti C, Edleson J, Bergen RK, eds. Sourcebook on Violence Against Women. Thousand Oaks, CA: Sage Publications; 2001:117142. 19. Dekeseredy WS, Schwartz MD, Alvi S. The role of profeminist men in dealing with women abuse on the Canadian campus. Violence Against Women. 2000;6:918935. 20. Spano R, Nagy S. Social guardianship and social isolation: an application and extension of lifestyle/routine activities theory to rural adolescents. Rural Sociol. 2005;70:414437. 21. Cook C, Heath F, Thompson R. A meta-analysis of response rates in web- or internet-based surveys. Educ Psychol Meas. 2000;60:821836.

APPENDIX Definitions of Sexual Assault Used in the Campus Sexual Assault (CSA) Study The CSA Web-based survey collected a wide range of information from students. The survey included questions concerning the characteristics of the respondents (eg, age, race, years in college), their substance use, dating experiences, and many aspects of their experiences with sexual assault prior to and since entering college. The sexual assault experiences portion of the CSA survey was prefaced with the following information:
This section of the interview asks about nonconsensual or unwanted sexual contact you may have experienced. When you are asked about whether something happened since you began college, please think about what has happened since you entered any college or university. The person with whom you had the unwanted sexual contact could have been a stranger or someone you know, such as a family member or someone you were dating or going out with. These questions ask about 5 types of unwanted sexual contact: Forced touching of a sexual nature (forced kissing, touching of private parts, grabbing, fondling, rubbing up against you in a sexual way, even if it is over your clothes) Oral sex (someones mouth or tongue making contact with your genitals or your mouth or tongue making contact with someone elses genitals) Sexual intercourse (someones penis being put in your vagina) Anal sex (someones penis being put in your anus) Sexual penetration with a finger or object (someone putting their finger or an object like a bottle or a candle in your vagina or anus) (appendix continues)

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College Women and Sexual Assault APPENDIX (continued) Respondents were then asked about the following 2 general types of sexual assault: (a) physically forced sexual assault and (b) sexual assault when they were incapacitated and unable to provide consent. Each type was described with introductory text. The following is an example:
The questions below ask about unwanted sexual contact that involved force or threats of force against you. Force could include someone holding you down with his or her body weight, pinning your arms, hitting or kicking you, or using or threatening to use a weapon against you.

Respondents were then asked the following:

Since you entered college, has anyone had sexual contact with you by using physical force or threatening to physically harm you?

To capture instances in which physically forced sexual assault was attempted but not completed, women were asked the following:
Has anyone attempted but not succeeded in having sexual contact with you by using or threatening to use physical force against you?

The same 2 questions were asked about victimizations occurring before entering college. The following text prefaced questions about sexual assault when the victim was incapacitated and unable to provide consent:
The next set of questions asks about your experiences with unwanted sexual contact while you were unable to provide consent or stop what was happening because you were passed out, drugged, drunk, incapacitated, or asleep. These situations might include times that you voluntarily consumed alcohol or drugs and times that you were given drugs without your knowledge or consent.

Respondents were then asked the following:

Since you entered college, has someone had sexual contact with you when you were unable to provide consent or stop what was happening because you were passed out, drugged, drunk, incapacitated, or asleep? This question asks about incidents that you are certain happened.

Women were also asked about sexual assaults that they suspected had happened while they were incapacitated. These 2 questions were also asked about incapacitated sexual assaults occurring before entering college. Please note that because a primary focus of this paper was completed sexual assaults, women classified as victims of suspected drug-facilitated sexual assault (Figure 1, box 17) were those who experienced a completed assault (an incident they were certain had happened) but were uncertain whether they had been given a drug without their consent prior to the assault. Separate survey modules then asked contextual questions about each type of sexual assault and responses were used to further classify sexual assault types and victims. Regarding any of their physically forced or incapacitated sexual assault victimizations, women were asked which of the following happened: (a) forced touching of a sexual nature, (b) oral sex, (c) sexual intercourse, (d) anal sex, or (e) sexual penetration with a finger or object. Respondents were allowed to check off all behaviors that applied. Women were classified as victims of rape if they selected any of the following: oral sex, sexual intercourse, anal sex, or sexual penetration with a finger or object. Those who selected forced touching but no other behavior were coded as victims of sexual battery. To further an understanding of incapacitated sexual assault, the type of incapacitation was used to classify victims of incapacitated sexual assaults. Women who experienced sexual assault when they were incapacitated and unable to provide consent were asked the following:
1. Just prior to the incident/any of the incidents had you been drinking alcohol? 2. Just prior to the incident/any of the incidents had you been given a drug without your knowledge or consent?

On the basis of their responses, we classified the victims into the following four mutually exclusive categories: (a) victims of drugfacilitated sexual assault (DFSA; victims who were sexually assaulted when they were incapacitated after they had been given a drug without their knowledge), (b) victims of suspected drug-facilitated sexual assault (SDFSA; victims who were sexually assaulted while incapacitated but were uncertain whether they had been given a drug without their knowledge), (c) victims of alcohol and/or other drugenabled sexual assault (AOD; victims who were sexually assaulted when they were incapacitated after voluntarily consuming drugs or alcohol), and (d) victims who were sexually assaulted when they were otherwise incapacitated (victims who were asleep or unconscious when they were assaulted but who were not incapacitated due to voluntary or involuntary drug or alcohol consumption).

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The Journal of American College Health provides information related to health in institutions of higher education. The journal publishes articles encompassing many areas of this broad field, including clinical and preventive medicine, environmental and community health and safety, health promotion and education, management and administration, mental health, nursing, pharmacy, and sports medicine. The Journal of American College Health is intended for college health professionals: administrators, health educators, nurses, nurse practitioners, physicians, physician assistants, professors, psychologists, student affairs personnel, and students as peer educators, consumers, and preprofessionals. The journal publishes (1) scientific or research articles presenting significant new data, insights, or analyses; (2) state-of-theart reviews; (3) clinical and program notes that describe successful and innovative procedures; and (4) brief reports, viewpoints, book reviews, and letters to the editor.

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References
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