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Original Investigation
September 16, 2019

Association Between Forced Sexual Initiation and Health Outcomes Among US Women

Author Affiliations
  • 1Department of Medicine, Cambridge Health Alliance, Cambridge, Massachusetts
  • 2Harvard Medical School, Boston, Massachusetts
  • 3City University of New York, Hunter College, New York, New York
  • 4Division of Pulmonary and Critical Care Medicine, Cambridge Health Alliance, Cambridge, MA
JAMA Intern Med. 2019;179(11):1551-1558. doi:10.1001/jamainternmed.2019.3500
Key Points

Question  What is the prevalence of forced sexual initiation among women and girls in the United States and its association with reproductive, gynecologic, and general health outcomes?

Findings  In this cross-sectional, nationally representative study of 13 310 American women aged 18 to 44 years, 6.5% reported forced sexual initiation (mean age at forced sexual initiation, 15.6 years). Forced sexual initiation appeared to be associated with multiple adverse reproductive, gynecologic, and general health outcomes after adjustment for demographic confounders.

Meaning  These findings could help clinicians improve the medical care of women and girls and inform the development of public health policies aimed at reducing forced sexual initiation in the United States.


Importance  The #MeToo movement has highlighted how frequently women experience sexual violence. However, to date, no recent studies have assessed the prevalence of forced sex during girls' and women’s first sexual encounter or its health consequences.

Objective  To estimate the prevalence of forced sexual initiation among US women and its association with subsequent reproductive, gynecologic, and general health outcomes.

Design, Setting, and Participants  A cross-sectional analysis of the 2011-2017 National Survey of Family Growth was conducted, including a population-based sample of 13 310 US women. The study was conducted from September 2011 to September 2017.

Exposures  Self-reported forced vs voluntary first sexual intercourse.

Main Outcomes and Measures  Prevalence of forced sexual initiation, age of woman and partner/assailant at first sexual encounter, and odds ratios (ORs) (adjusted for sociodemographic characteristics) for having an unwanted first pregnancy or abortion, development of painful pelvic conditions, and other reproductive and general health measures.

Results  A total of 13 310 women between the ages of 18 and 44 years were included in the study. After survey weights were applied, 6.5% (95% CI, 5.9%-7.1%) of respondents reported experiencing forced sexual initiation, equivalent to 3 351 733 women in this age group nationwide. Age at forced sexual initiation averaged 15.6 (95% CI, 15.3-16.0) years vs 17.4 (95% CI, 17.3-17.5) years for voluntary sexual initiation (P < .001). The mean age of the partner/assailant at first sexual encounter was 6 years older for women with forced vs voluntary sexual initiation (27.0; 95% CI, 24.8-29.2 years vs 21.0; 95% CI, 20.6-21.3 years). Compared with women with voluntary sexual initiation, women with forced sexual initiation were more likely to experience an unwanted first pregnancy (30.1% vs 18.9%; adjusted OR [aOR], 1.9; 95% CI, 1.5-2.4) or an abortion (24.1% vs 17.3%; aOR, 1.5; 95% CI, 1.2-2.0), endometriosis (10.4% vs 6.5%; aOR, 1.6; 95% CI, 1.1-2.3), pelvic inflammatory disease (8.1% vs 3.4%; aOR, 2.2; 95% CI, 1.5-3.4), and problems with ovulation or menstruation (27.0% vs 17.1%; aOR, 1.8; 95% CI, 1.4-2.3). Survivors of forced sexual initiation more frequently reported illicit drug use (2.6% vs 0.7%; aOR, 3.6; 95% CI, 1.8-7.0), fair or poor health (15.5% vs 7.5%; aOR, 2.0; 95% CI, 1.5-2.7), and difficulty completing tasks owing to a physical or mental health condition (9.0% vs 3.2%; aOR, 2.8; 95% CI, 2.0-3.9).

Conclusions and Relevance  Forced sexual initiation in women appears to be common and associated with multiple adverse reproductive and general health outcomes. These findings highlight the possible need for public health measures and sociocultural changes to prevent sexual violence, particularly forced sexual initiation.

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    3 Comments for this article
    Selection and Terms
    Tanner Campbell |
    I'm curious about the selection process. Was the focus of the study known to the participants at the time of volunteering/selection? I'd also like to know the wording of the questions and whether or not terms like "forced" or "coerced" were defined or if the subjects were left to interpret them as they might.
    Terminology used
    Kristin Quenton, RN | consulting
    Really! Why not use the appropriate language? Forced and coerced sexual initiation is rape.
    "Really! Why not use the appropriate language?"
    Patti Rosenberg, B.A., M.A. | None
    Rape is a term that has a legal meaning that varies from state to state, depending on how legislation has defined it. In some states, it refers to only one specific act -- forced vaginal intercourse with a penis. Any other forced sexual act is defined by a different term.

    Maybe "forced or coerced sexual iniation" was used to make it clear that the study was looking at a more inclusive range of forced sexual contact.