Background Sexual assault is a risk factor for poor mental health, yet its relationship to cardiovascular disease risk is not understood. We tested whether women with a sexual assault history had greater carotid atherosclerosis levels and progression over midlife. Methods and Results A total of 169 non-smoking, cardiovascular disease-free women aged 40 to 60 years were assessed twice over 5 years. At each point, women completed questionnaires, physical measures, phlebotomy, and carotid ultrasounds. Associations between sexual assault and carotid plaque level (score 0, 1, ≥2) and progression (score change) were assessed in multinomial logistic and linear regression models, adjusted for age, race/ethnicity, education, body mass index, blood pressure, lipids, insulin resistance, and additionally depression/post-traumatic stress symptoms; 28% of the women reported a sexual assault history. Relative to non-exposed women, women with a sexual assault history had an over 4-fold odds of a plaque score of ≥2 at baseline (≥2, odds ratio [OR] [95% CI]=4.35 [1.48-12.79], P=0.008; 1, OR [95% CI]=0.49 [0.12-1.97], P=0.32, versus no plaque; multivariable); and an over 3-fold odds of plaque ≥2 at follow-up (≥2, OR [95% CI]=3.65 [1.40-9.51], P=0.008; 1, OR [95% CI]=1.52 [0.46-4.99], P=0.49, versus no plaque; multivariable). Women with a sexual assault history also had an over 3-folds greater odds of a plaque score progression of ≥2 (OR [95% CI]=3.48[1.11-10.93], P=0.033, multivariable). Neither depression nor post-traumatic symptoms were related to plaque. Conclusions Sexual assault is associated with greater carotid atherosclerosis level and progression over midlife. Associations were not explained by standard cardiovascular disease risk factors. Future work should consider whether sexual assault prevention reduces women's cardiovascular disease risk.