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Table 1.  
Sociodemographic Characteristics of US Women Aged 18 to 44 Years According to Forced vs Voluntary Sexual Initiation
Sociodemographic Characteristics of US Women Aged 18 to 44 Years According to Forced vs Voluntary Sexual Initiation
Table 2.  
Type of Coercion Used by Assailant to Force Sex Among Women Who Experienced Forced Sexual Initiationa
Type of Coercion Used by Assailant to Force Sex Among Women Who Experienced Forced Sexual Initiationa
Table 3.  
Association Between Forced Sexual Initiation and Reproductive, Gynecologic, and General Health Outcomes
Association Between Forced Sexual Initiation and Reproductive, Gynecologic, and General Health Outcomes
1.
National Institute of Justice. Rape and sexual violence. https://www.nij.gov/topics/crime/rape-sexual-violence/Pages/welcome.aspx. Published March 21, 2017. Accessed June 7, 2019.
2.
Breiding  MJ, Smith  SG, Basile  KC, Walters  ML, Chen  J, Merrick  MT.  Prevalence and characteristics of sexual violence, stalking, and intimate partner violence victimization: National Intimate Partner and Sexual Violence Survey, United States, 2011.  MMWR Surveill Summ. 2014;63(8):1-18.PubMedGoogle Scholar
3.
Ruggiero  KJ, McLeer  SV, Dixon  JF.  Sexual abuse characteristics associated with survivor psychopathology.  Child Abuse Negl. 2000;24(7):951-964. doi:10.1016/S0145-2134(00)00144-7PubMedGoogle ScholarCrossref
4.
Lange  A, de Beurs  E, Dolan  C, Lachnit  T, Sjollema  S, Hanewald  G.  Long-term effects of childhood sexual abuse: objective and subjective characteristics of the abuse and psychopathology in later life.  J Nerv Ment Dis. 1999;187(3):150-158. doi:10.1097/00005053-199903000-00004PubMedGoogle ScholarCrossref
5.
Schoedl  AF, Costa  MCP, Mari  JJ,  et al.  The clinical correlates of reported childhood sexual abuse: an association between age at trauma onset and severity of depression and PTSD in adults.  J Child Sex Abus. 2010;19(2):156-170. doi:10.1080/10538711003615038PubMedGoogle ScholarCrossref
6.
McFarlane  J, Malecha  A, Watson  K,  et al.  Intimate partner sexual assault against women: frequency, health consequences, and treatment outcomes.  Obstet Gynecol. 2005;105(1):99-108. doi:10.1097/01.AOG.0000146641.98665.b6PubMedGoogle ScholarCrossref
7.
Byrne  CA, Resnick  HS, Kilpatrick  DG, Best  CL, Saunders  BE.  The socioeconomic impact of interpersonal violence on women.  J Consult Clin Psychol. 1999;67(3):362-366. doi:10.1037/0022-006X.67.3.362PubMedGoogle ScholarCrossref
8.
 Understanding and Addressing Violence Against Women: Sexual Violence. Geneva, Switzerland: World Health Organization; 2012.
9.
McCarthy-Jones  S, Bulfin  A, Nixon  E, O’Keane  V, Bacik  I, McElvaney  R.  Associations between forced and “persuaded” first intercourse and later health outcomes in women.  Violence Against Women. 2019;25(5):528-548. doi:10.1177/1077801218793223PubMedGoogle ScholarCrossref
10.
Moore  AM, Awusabo-Asare  K, Madise  N, John-Langba  J, Kumi-Kyereme  A.  Coerced first sex among adolescent girls in sub-Saharan Africa: prevalence and context.  Afr J Reprod Health. 2007;11(3):62-82. doi:10.2307/25549732PubMedGoogle ScholarCrossref
11.
Shamu  S, Munjanja  S, Zarowsky  C, Shamu  P, Temmerman  M, Abrahams  N.  Intimate partner violence, forced first sex and adverse pregnancy outcomes in a sample of Zimbabwean women accessing maternal and child health care.  BMC Public Health. 2018;18(1):595. doi:10.1186/s12889-018-5464-zPubMedGoogle ScholarCrossref
12.
Stockman  JK, Lucea  MB, Campbell  JC.  Forced sexual initiation, sexual intimate partner violence and HIV risk in women: a global review of the literature.  AIDS Behav. 2013;17(3):832-847. doi:10.1007/s10461-012-0361-4PubMedGoogle ScholarCrossref
13.
Sano  Y, Sedziafa  AP, Tenkorang  EY.  Correlates of forced first sexual intercourse among women in the Philippines.  Sex Cult. 2016;20(3):717-730. doi:10.1007/s12119-016-9356-zGoogle ScholarCrossref
14.
Koenig  MA, Lutalo  T, Zhao  F,  et al.  Coercive sex in rural Uganda: prevalence and associated risk factors.  Soc Sci Med. 2004;58(4):787-798. doi:10.1016/S0277-9536(03)00244-2PubMedGoogle ScholarCrossref
15.
Koenig  MA, Zablotska  I, Lutalo  T, Nalugoda  F, Wagman  J, Gray  R.  Coerced first intercourse and reproductive health among adolescent women in Rakai, Uganda.  Int Fam Plan Perspect. 2004;30(4):156-163. doi:10.1363/ifpp.30.156.04PubMedGoogle Scholar
16.
Maharaj  P, Munthree  C.  Coerced first sexual intercourse and selected reproductive health outcomes among young women in KwaZulu-Natal, South Africa.  J Biosoc Sci. 2007;39(2):231-244. doi:10.1017/S0021932006001325PubMedGoogle ScholarCrossref
17.
Stockman  JK, Campbell  JC, Celentano  DD.  Sexual violence and HIV risk behaviors among a nationally representative sample of heterosexual American women: the importance of sexual coercion.  J Acquir Immune Defic Syndr. 2010;53(1):136-143. doi:10.1097/QAI.0b013e3181b3a8ccPubMedGoogle ScholarCrossref
18.
Williams  CM, Clear  ER, Coker  AL.  Sexual coercion and sexual violence at first intercourse associated with sexually transmitted infections.  Sex Transm Dis. 2013;40(10):771-775. doi:10.1097/OLQ.0000000000000011PubMedGoogle ScholarCrossref
19.
Brookmeyer  KA, Beltran  O, Abad  N.  Understanding the effects of forced sex on sexually transmitted disease acquisition and sexually transmitted disease care: findings from the National Survey of Family Growth (2011-2013).  Sex Transm Dis. 2017;44(10):613-618. doi:10.1097/OLQ.0000000000000651PubMedGoogle ScholarCrossref
20.
Abma  J, Driscoll  A, Moore  K.  Young women’s degree of control over first intercourse: an exploratory analysis.  Fam Plann Perspect. 1998;30(1):12-18. doi:10.2307/2991518PubMedGoogle ScholarCrossref
21.
Centers for Disease Control and Prevention. National Survey of Family Growth. https://www.cdc.gov/nchs/nsfg/index.htm. Updated June 26, 2019. Accessed June 7, 2019.
22.
Centers for Disease Control and Prevention. About the National Survey of Family Growth. https://www.cdc.gov/nchs/nsfg/about_nsfg.htm. Updated January 24, 2019. Accessed Feb 24, 2019.
23.
Centers for Disease Control and Prevention. 2011-2015 NSFG: selected data and documentation. https://www.cdc.gov/nchs/nsfg/nsfg_2011_2015_puf.htm. Updated November 14, 2017. Accessed June 7, 2019.
24.
Latthe  P, Mignini  L, Gray  R, Hills  R, Khan  K.  Factors predisposing women to chronic pelvic pain: systematic review.  BMJ. 2006;332(7544):749-755. doi:10.1136/bmj.38748.697465.55PubMedGoogle ScholarCrossref
25.
Mellins  CA, Walsh  K, Sarvet  AL,  et al.  Sexual assault incidents among college undergraduates: prevalence and factors associated with risk.  PLoS One. 2017;12(11):e0186471. doi:10.1371/journal.pone.0186471PubMedGoogle ScholarCrossref
26.
Ullman  SE, Brecklin  LR.  Sexual assault history and health-related outcomes in a national sample of women.  Psychol Women Q. 2003;27(1):46-57. doi:10.1111/1471-6402.t01-2-00006Google ScholarCrossref
27.
Sandfort  TG, Orr  M, Hirsch  JS, Santelli  J.  Long-term health correlates of timing of sexual debut: results from a national US study.  Am J Public Health. 2008;98(1):155-161. doi:10.2105/AJPH.2006.097444PubMedGoogle ScholarCrossref
28.
Salsberry  PJ, Reagan  PB, Fang  MZ.  Disparities in women’s health across a generation: a mother-daughter comparison.  J Womens Health (Larchmt). 2013;22(7):617-624. doi:10.1089/jwh.2012.4143PubMedGoogle ScholarCrossref
29.
Mandoki  CA, Burkhart  BR.  Sexual victimization: is there a vicious cycle?  Violence Vict. 1989;4(3):179-190. doi:10.1891/0886-6708.4.3.179PubMedGoogle ScholarCrossref
30.
Agency for Healthcare Research and Quality. Trauma-informed care. https://www.ahrq.gov/professionals/prevention-chronic-care/healthier-pregnancy/preventive/trauma.html. Updated April 2016. Accessed June 7, 2019.
31.
American College of Obstetricians and Gynecologists; Committee on Health Care for Underserved Women.  Committee opinion no. 498: adult manifestations of childhood sexual abuse.  Obstet Gynecol. 2011;118(2, pt 1):392-395.PubMedGoogle ScholarCrossref
32.
Substance Abuse and Mental Health Services Administration.  SAMHSA’s concept of trauma and guidance for a trauma-informed approach. Rockville, MD: Substance Abuse and Mental Health Services Administration; 2014. HHS Publication No. (SMA) 14-4884.
33.
Ravi  A, Little  V.  Providing trauma-informed care.  Am Fam Physician. 2017;95(10):655-657.PubMedGoogle Scholar
34.
Basile  KC, DeGue  S, Jones  K,  et al. STOP SV: a technical package to prevent sexual violence. https://www.cdc.gov/violenceprevention/pdf/sv-prevention-technical-package.pdf. Published 2016. Accessed February 25, 2019.
35.
van Wormer  K.  Restorative justice as social justice for victims of gendered violence: a standpoint feminist perspective.  Soc Work. 2009;54(2):107-116. doi:10.1093/sw/54.2.107PubMedGoogle ScholarCrossref
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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.
    CONFLICT OF INTEREST: None Reported
    Terminology used
    Kristin Quenton, RN | consulting
    Really! Why not use the appropriate language? Forced and coerced sexual initiation is rape.
    CONFLICT OF INTEREST: None Reported
    "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.
    CONFLICT OF INTEREST: None Reported
    Views 11,679
    Citations 0
    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.

    Abstract

    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.

    Introduction

    Numerous recent high-profile allegations of sexual violence and the social movements that gained momentum in response to those events (eg, #MeToo, #TIMESUP) have increased public awareness of the high frequency of sexual violence against girls and women in the United States. Sexual violence is defined by the National Institute of Justice as a constellation of crimes including sexual harassment, nonpenetrative sexual assault, and rape.1 More than 40% of women have experienced some form of sexual violence in their lifetime, of whom half have been raped.2 Exposure to sexual violence has been associated with a wide range of adverse health outcomes.3-7

    The World Health Organization has recognized forced sexual initiation—an unwanted first sexual intercourse that is physically forced or coerced—as a distinct form of sexual violence.8 Forced sexual initiation is a worldwide problem whose reported prevalence varies widely from 0.8%9 to 38%.10 Studies conducted predominantly outside the United States suggest that experiencing forced sexual initiation, which occurs at a time of heightened physical and psychological vulnerability, may place girls and women at unique risks for adverse reproductive health outcomes, such as increased sexual risk behaviors, increased rates of HIV and other sexually transmitted infections, and unwanted first pregnancies.9-16 Several US studies have examined the association between forced sexual initiation and health outcomes, but most focused narrowly on elevated rates of sexually transmitted diseases,17-19 are outdated,17-20 or used measures that combined forced sexual initiation with subsequent experiences of forced sex.19

    To our knowledge, no recent data are available on the prevalence of forced sexual initiation, the sociodemographic characteristics of women who experience it, or the association between forced sexual initiation and reproductive, gynecologic, and general health outcomes among American women. We analyzed data from a nationally representative US survey to address these questions.

    Methods
    Data Source and Study Population

    We analyzed data on 13 310 adult (age, 18-44 years) women respondents to the 2011-2017 National Survey of Family Growth. The National Survey of Family Growth is a cross-sectional, multistage, household-based nationally representative survey conducted by the Centers for Disease Control and Prevention that collects data on family life, marriage and divorce, pregnancy, infertility, use of contraception, and general and reproductive health.21 The Cambridge Health Alliance Institutional Review Board, Cambridge, Massachusetts, deemed this study exempt from review because the data are deidentified and publicly available.

    Surveys were conducted during in-person interviews, with sensitive questions, including those about forced sex, asked using Audio Computer-Assisted Self-Interviewing.22 Our data included the 3 most recent 2-year waves of the female respondent survey (September 2011-September 2013; September 2013-September 2015; and September 2015-September 2017). Detailed information on survey design and sampling procedures is available elsewhere.23 Response rates ranged from 67% to 73% for the included years. We excluded women with no history of vaginal intercourse, as well as respondents younger than 18 years at the time of survey completion, who were not asked questions about sexual history.

    Study Variables
    Forced Sexual Initiation and Method of Coercion

    We categorized women as having experienced forced sexual initiation if they responded “not voluntary” to the question, “Would you say that this first vaginal intercourse [with a male] was voluntary or not voluntary, that is, did you choose to have sex of your own free will or not?” We categorized women responding “voluntary” to this question as having experienced voluntary sexual initiation.

    All respondents who reported that their first sexual encounter was not voluntary were then asked the following questions regarding the method of sexual coercion. “Were you given alcohol or drugs?” “Did you do what he said because he was bigger than you or a grown-up, and you were young?” “Were you told that the relationship would end if you didn’t have sex?” “Were you pressured into it by his words or actions, but without threat of harm?” “Were you threatened with physical harm or injury?” “Were you physically hurt or injured?” “Were you physically held down?” Participants could report more than 1 type of coercion.

    Reproductive, Gynecologic, and General Health Outcomes

    Reproductive outcomes included the number of pregnancies, age at first pregnancy, number of lifetime sexual partners, abortion, unwanted first pregnancy, never using birth control, or using fertility services. Gynecologic outcomes included having undergone routine cervical cancer screening (for women aged ≥21 years) or not ever having an HIV test or having received a diagnosis of fibroids, pelvic inflammatory disease, endometriosis, or problems with ovulation or menstruation. General health outcomes included having a diagnosis of diabetes, obesity (defined as body mass index >30 [calculated as weight in kilograms divided by height in meters squared]), current smoking, binge drinking (defined as consuming ≥4 alcoholic beverages on ≥1 occasion in the past month), illicit drug use (defined as self-reported use of cocaine, crack, methamphetamine, or injectable drugs in the past 12 months), self-reported health (fair or poor vs good, very good, or excellent), and difficulty completing tasks outside of the home owing to a physical or mental condition.

    All outcomes were prospectively selected based on past studies of the health sequelae of sexual violence. The gynecologic health outcomes (uterine fibroids, pelvic inflammatory disease, endometriosis, and problems with ovulation and menstruation) were selected because these conditions may be diagnosed in the workup of pelvic pain, which has been associated with sexual violence.7,24 Although no mental health diagnoses were available in the survey data, we included responses to the question, “In the past month, have you experienced difficulty completing tasks outside the home due to a physical or mental condition?” as an outcome that may reflect mental health problems.

    Sociodemographic Variables

    Sociodemographic characteristics included the respondent’s age at the time of interview, race/ethnicity (white, black, or other), current poverty status (at/below federal poverty level vs above), and whether the respondent was born outside the United States (yes/no).

    Statistical Analysis

    We estimated the number and proportion of women in the United States aged 18 to 44 years who reported experiencing forced sexual initiation. We then compared the sociodemographic characteristics of respondents who experienced forced and voluntary sexual initiation using a 2-tailed, unpaired t test for continuous variables and χ2 test for categorical variables. For women who experienced forced sexual initiation, we tabulated the proportions of those reporting each type of coercion during sexual initiation.

    We then examined the association between having experienced forced vs voluntary sexual initiation and reproductive, gynecologic, and general health outcomes in unadjusted and adjusted analyses. For the adjusted analyses of the 3 continuous outcomes, we estimated the mean adjusted difference between women who experienced forced vs voluntary sexual initiation using multivariable linear regression models that controlled for age, race/ethnicity, poverty level, and place of birth, similar to other studies assessing outcomes of sexual assault.25-27 For categorical outcomes, we estimated adjusted odds ratios (aORs) using multivariable logistic regression models that included the same set of control variables. We included 1 negative control variable—ever diagnosis of cancer (excluding cervical cancer)—to test for unmeasured confounders.

    All analyses were conducted with Stata, version 15.1 (StataCorp LLC), using the complex survey design command procedures that account for the National Survey of Family Growth’s sampling strategy and weights provided by the Centers for Disease Control and Prevention that allow extrapolation to the US population as a whole.

    We performed subsidiary analyses to explore whether characteristics associated with forced sexual initiation, such as early sexual initiation or multiple sexual assaults, might account for our findings of adverse outcomes associated with forced sexual initiation. First, we repeated our analyses of the association between forced sexual initiation and adverse outcomes stratified by age at first intercourse (<18 or ≥18 years). Second, we identified women who experienced forced sexual initiation and no other forced vaginal intercourse. We then repeated the analysis assessing associations between forced sexual initiation and adverse outcomes using only women reporting forced sexual initiation and no other forced intercourse.

    We performed additional subsidiary analyses to investigate whether potential confounding covariates not included in the main analyses would affect our findings. First, because the interval since sexual initiation might affect the likelihood of experiencing adverse outcomes, we conducted the main analyses with the additional covariate time since first sexual encounter. The covariate current age was removed from this model because it was colinear with time since first sexual encounter. Second, we added a covariate that captures the respondent's mother's level of education, which reflects childhood socioeconomic conditions that may be associated with health outcomes.28 Third, to control for assaults subsequent to sexual initiation, we added a covariate in the main model for later sexual assault. Findings were considered significant at an α level of .05.

    Results

    The total unweighted sample included 13 310 women aged 18 to 44 years with a history of vaginal intercourse. After applying survey weights, 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.

    The mean age at first intercourse for women with forced sexual initiation was almost 2 years younger than for those with voluntary sexual initiation (15.6 years; 95% CI, 15.3-16.0 years vs 17.4 years; 95% CI, 17.3-17.5 years) (Table 1). The mean age discrepancy between study participants and their male partners/assailants at the time of sexual initiation was 6 years greater among those for whom sexual initiation was forced (27.0 years; 95% CI, 24.8-29.2 years vs 21.0 years; 95% CI, 20.6-21.3 years). Nearly three-fourths (74.7%) of women who experienced forced sexual initiation were younger than 18 years at the time of sexual initiation vs 60.5% of women with voluntary sexual initiation (P < .001); 6.8% of women reporting forced sexual initiation were aged 10 years or younger vs 0.1% of women with voluntary sexual initiation (P < .001).

    Compared with women with voluntary sexual initiation, women with forced sexual initiation were less likely to be white (65.3% vs 74.7%; P < .001). Women who experienced forced sexual initiation were somewhat more likely to be born outside the United States (21.5% vs 16.1%; P = .01) and have incomes below the poverty level (35.1% vs 24.9%; P < .001) and less likely to be college educated (23.9% vs 31.7%; P = .002); however, as presented in these data, all demographic groups reported substantial rates of forced sexual initiation.

    Type of Coercion Used by Assailant

    Among women who reported forced sexual initiation, 50% (n = 1 670 892) reported coercion by a partner who was larger or older, 56.4% described experiencing verbal pressure, and 46.3% were held down (Table 2). Women with forced sexual initiation also commonly reported being given a drug (22.0%) and experiencing a physical threat (26.5%) or physical harm (25.1%).

    Association of Forced Sexual Initiation With Health Outcomes

    Women who experienced forced sexual initiation were more likely to have experienced an unwanted first pregnancy (30.1% vs 18.9%; aOR, 1.9; 95% CI, 1.5-2.4), ever had an abortion (24.1% vs 17.3%; aOR, 1.5; 95% CI, 1.2-2.0), and to not have used birth control in their lifetime (2.6% vs 0.9%; aOR, 2.6; 95% CI, 1.6-4.4). Women with forced sexual initiation were not more likely to have used fertility services (10.5% vs 9.5%; aOR, 1.0; 95% CI, 0.7-1.4 (Table 3).

    Forced sexual initiation appeared to be associated with having received a diagnosis of pelvic inflammatory disease (8.1% vs 3.4%; aOR, 2.2; 95% CI, 1.5-3.4), endometriosis (10.4% vs 6.5%; aOR, 1.6; 95% CI, 1.1-2.3), and problems with ovulation or menstruation (27.0% vs 17.1%; aOR, 1.8; 95% CI, 1.4-2.3). There was no association between forced sexual initiation and reporting recent cervical cancer screening (27.4% vs 25.4%; aOR, 95% CI, 1.1 [0.9-1.4]) or never undergoing HIV testing (16.0% vs 18.6%; aOR, 0.9; 95% CI, 0.7-1.2) (Table 3).

    Women who reported forced sexual initiation more frequently reported being in fair or poor health rather than in good, very good, or excellent health (15.5% vs 7.5%; aOR, 2.0; 95% CI, 1.5-2.7), having difficulty completing tasks outside the home owing to a physical or mental condition (9.0% vs 3.2%; aOR, 2.8; 95% CI, 2.0-3.9), and, although rates for this outcome were low in both groups, having past-year illicit drug use (2.6% vs 0.7%; aOR, 3.6; 95% CI, 1.8-7.0) (Table 3). The negative control analysis found no association between forced sexual initiation and ever diagnosis of cancer (aOR, 1.1; 95% CI, 0.6- 2.2).

    Subsidiary Analyses

    In the subsidiary analysis assessing the association between forced vs voluntary sexual initiation and health outcomes after stratification by age at first intercourse, all outcomes remained significantly associated with forced sexual initiation among those who reported first sexual intercourse when younger than 18 years except for ever had an abortion. Among women whose reported first sexual intercourse occurred at age 18 years or older, forced sexual initiation was significantly associated with 4 adverse outcomes: ever having an abortion (aOR, 4.6; 95% CI, 2.5-8.7), pelvic inflammatory disease (aOR, 3.8; 95% CI, 1.5-10.1), problems with ovulation or menstruation (aOR, 1.8; 95% CI 1.0-2.9), and difficulty completing tasks outside the home (aOR, 3.5; 95% CI, 1.2-9.9). All other outcomes showed similar nonsignificant trends with wide 95% CIs, suggesting lack of power. eTable 1 in the Supplement displays the details of the findings.

    In the subsidiary analysis that compared women reporting forced sexual initiation but no subsequent sexual assault with women with voluntary sexual initiation, forced sexual initiation was significantly associated with 4 adverse outcomes: first pregnancy unwanted (aOR, 1.8; 95% CI, 1.3-2.4), never using birth control (aOR, 2.2; 95% CI, 1.2-3.8), pelvic inflammatory disease (aOR, 1.8; 95% CI, 1.1-2.8), and problems with ovulation or menstruation (aOR, 1.7; 95% CI, 1.2-2.3). Similar trends and wide 95% CIs were noted for all other adverse outcomes (eTable 2 in the Supplement). The subsidiary analyses evaluating additional potential confounders, including time since sexual initiation, respondent’s mother’s educational level attainment, and experience of forced intercourse at a time other than sexual initiation, yielded closely similar results to our main analysis. For example, pelvic inflammatory disease was significantly associated in all 3 analyses: aOR, 2.0 (95% CI, 1.3-3.0) (eTable 3 in the Supplement); aOR, 2.2 (95% CI, 1.6-44) (eTable 4 in the Supplement); and aOR, 1.9 (95% CI, 1.3-2.9) (eTable 5 in the Supplement).

    Discussion

    For more than 3.3 million reproductive-age women (1 in 16 women in this age group), the first experience with intercourse was involuntary. A practicing physician is likely to see several patients each week who have experienced this form of trauma. Forced sexual initiation was reported by women of all racial and ethnic groups and varied modestly by poverty status, level of educational attainment, or place of birth. The male partner/assailant was usually much older than the girl or woman, which was an age discrepancy not present for those reporting voluntary sexual initiation. In addition, women who had experienced forced sexual initiation had elevated rates of subsequent adverse reproductive, gynecologic, general health, and functional outcomes.

    United States studies have found elevated rates of sexually transmitted diseases and HIV risk behaviors associated with forced sexual initiation.17-19 Studies conducted predominantly outside the United States have suggested a link between forced sexual initiation and earlier age of first intercourse, risk of future sexual assault, number of lifetime sexual partners, and likelihood of experiencing unwanted pregnancy.9,11-13,15,16 One study from Ireland, which reported low rates of forced sexual initiation (0.8%), suggested worse self-reported general and mental health among women with forced sexual initiation.9 Our findings are generally consistent with these earlier studies but extend them by demonstrating that forced sexual initiation is associated with a broader range of adverse health outcomes in a contemporary sample of US women.

    The mechanisms through which forced sexual initiation may be associated with adverse health outcomes is not clear. Our findings are compatible with the hypothesis that experiencing sexual violence at a time of heightened psychological and physical vulnerability may have long-term deleterious sequelae. In subsidiary analyses, our main results were minimally affected by controlling or stratifying for age at forced sexual initiation, having experienced repeated sexual assaults, the respondent's mother's educational attainment, or follow-up interval.

    Some previous investigators have equated forced sexual initiation with childhood sexual abuse, which is known to be associated with adverse mental and physical health outcomes.3-5 However, our first subsidiary analysis suggests that adverse outcomes are associated with forced sexual initiation regardless of the age at which it is experienced.

    Women who experience early sexual violence are at increased risk of repeated sexual victimization later in life, which may suggest that our findings reflect the composite outcomes of repeated sexual assault.29 However, our second subsidiary analysis suggests that forced sexual initiation is associated with adverse outcomes, even among women who experience no further sexual violence. Although our study was not designed to assess whether forced sexual initiation confers different or greater harms than subsequent forced intercourse, the subsidiary analyses support the view that forced sexual initiation may be an important independent risk factor for adverse physical and mental health outcomes.

    The rate of forced sexual initiation that we identified is somewhat lower than in a study that analyzed data from the 1995 National Survey of Family Growth, in which 9.1% of women aged 15 to 24 years described their first intercourse as nonvoluntary.20 This finding may reflect a changing prevalence of forced sexual initiation, although the younger age range in the earlier study and slight changes in question wording make direct comparisons difficult.

    The ubiquity and apparent clinical outcome of forced sexual initiation should encourage those providing clinical care to women to develop tools to identify and treat the sequalae of trauma while avoiding actions that might contribute to retraumatization. The Agency for Healthcare Research and Quality recommends trauma-informed care “that recognizes the presence of trauma symptoms and acknowledges the role that trauma has played in their lives.”30 Medical organizations, including the American Academy of Family Physicians and American College of Obstetricians and Gynecologists, have advocated trauma-informed care, but such care has not been widely adopted in clinical practice.31-33

    Our findings also underscore the need for public health strategies to prevent forced sexual initiation and other forms of sexual violence. A Centers for Disease Control and Prevention report recommended disseminating local programs that address sexual culture and violence prevention skills, enhancing educational and job opportunities for women and girls, and creating protective environments within schools and work places.34 However, as the report acknowledges, the evidence supporting these recommendations is scant.

    The efficacy of the current criminal justice system in facilitating recovery among victims of sexual crimes is controversial.35 Hence, alternative forms of justice may be appropriate in some circumstances. The model of restorative justice, a conferencing model focusing on the experience of the victim and guided by a trained facilitator, may have a role in gendered crimes and warrants further research.35 Efforts should be devoted to the development of evidence-based public health approaches to sexual assault prevention and their effective dissemination.

    Limitations

    Our study has several limitations. First, its cross-sectional design precludes causal inference. Owing to the survey design, we were unable to adjust for some potentially important confounders, such as sexual experiences prior to or following sexual initiation. Although the associations that we identified do not establish causation, they may be important for clinicians to consider. Second, women who experienced forced sexual initiation may have experienced or begun experiencing some of the adverse health outcomes that we analyzed before their assault. However, the young age at which forced sexual initiation often occurred makes it likely that most outcomes followed the assault. An unknown proportion of US boys and men experience forced sexual initiation, a phenomenon that has been poorly studied; however, the survey did not collect data from men regarding forced sexual initiation. As with all survey data, responses may be subject to recall bias, and it is possible that some health outcomes, such as those related to chronic pain, may influence women to recall sexual experiences differently. However, the negative control analysis provides some support that confounding and recall bias are not likely to be very large in our study.

    Conclusions

    A substantial proportion of American women may experience forced sexual initiation, and the individual and public health implications of this exposure are far reaching. Although additional research is needed, physicians should incorporate trauma-informed measures into their practices while advocating for the reduction of structural causes of sexual violence.

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    Article Information

    Accepted for Publication: June 22, 2019.

    Corresponding Author: Laura Hawks, MD, Department of Medicine, Cambridge Health Alliance, 1493 Cambridge St, Cambridge, MA 02143 (lhawks@hsph.harvard.edu).

    Published Online: September 16, 2019. doi:10.1001/jamainternmed.2019.3500

    Author Contributions: Dr Hawks had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

    Concept and design: Hawks, Woolhandler, Himmelstein, Bor, McCormick.

    Acquisition, analysis, or interpretation of data: Hawks, Woolhandler, Himmelstein, Gaffney.

    Drafting of the manuscript: Hawks.

    Critical revision of the manuscript for important intellectual content: All authors.

    Statistical analysis: Hawks, Himmelstein.

    Obtained funding: Bor.

    Administrative, technical, or material support: Bor, McCormick.

    Supervision: Woolhandler, Himmelstein, Bor, McCormick.

    Conflict of Interest Disclosures: Dr Hawks reported receiving grants from the National Institutes of Health during the conduct of the study. Dr Gaffney reported serving as a leader of Physicians for a National Health Program, a nonprofit organization that favors coverage expansion through a single payer program, without financial compensation. No other disclosures were reported.

    Funding/Support: Dr Hawks received funding support from Institutional National Research Service Award T32HP32715 and from the Cambridge Health Alliance.

    Role of the Funder/Sponsor: The funding organizations had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

    References
    1.
    National Institute of Justice. Rape and sexual violence. https://www.nij.gov/topics/crime/rape-sexual-violence/Pages/welcome.aspx. Published March 21, 2017. Accessed June 7, 2019.
    2.
    Breiding  MJ, Smith  SG, Basile  KC, Walters  ML, Chen  J, Merrick  MT.  Prevalence and characteristics of sexual violence, stalking, and intimate partner violence victimization: National Intimate Partner and Sexual Violence Survey, United States, 2011.  MMWR Surveill Summ. 2014;63(8):1-18.PubMedGoogle Scholar
    3.
    Ruggiero  KJ, McLeer  SV, Dixon  JF.  Sexual abuse characteristics associated with survivor psychopathology.  Child Abuse Negl. 2000;24(7):951-964. doi:10.1016/S0145-2134(00)00144-7PubMedGoogle ScholarCrossref
    4.
    Lange  A, de Beurs  E, Dolan  C, Lachnit  T, Sjollema  S, Hanewald  G.  Long-term effects of childhood sexual abuse: objective and subjective characteristics of the abuse and psychopathology in later life.  J Nerv Ment Dis. 1999;187(3):150-158. doi:10.1097/00005053-199903000-00004PubMedGoogle ScholarCrossref
    5.
    Schoedl  AF, Costa  MCP, Mari  JJ,  et al.  The clinical correlates of reported childhood sexual abuse: an association between age at trauma onset and severity of depression and PTSD in adults.  J Child Sex Abus. 2010;19(2):156-170. doi:10.1080/10538711003615038PubMedGoogle ScholarCrossref
    6.
    McFarlane  J, Malecha  A, Watson  K,  et al.  Intimate partner sexual assault against women: frequency, health consequences, and treatment outcomes.  Obstet Gynecol. 2005;105(1):99-108. doi:10.1097/01.AOG.0000146641.98665.b6PubMedGoogle ScholarCrossref
    7.
    Byrne  CA, Resnick  HS, Kilpatrick  DG, Best  CL, Saunders  BE.  The socioeconomic impact of interpersonal violence on women.  J Consult Clin Psychol. 1999;67(3):362-366. doi:10.1037/0022-006X.67.3.362PubMedGoogle ScholarCrossref
    8.
     Understanding and Addressing Violence Against Women: Sexual Violence. Geneva, Switzerland: World Health Organization; 2012.
    9.
    McCarthy-Jones  S, Bulfin  A, Nixon  E, O’Keane  V, Bacik  I, McElvaney  R.  Associations between forced and “persuaded” first intercourse and later health outcomes in women.  Violence Against Women. 2019;25(5):528-548. doi:10.1177/1077801218793223PubMedGoogle ScholarCrossref
    10.
    Moore  AM, Awusabo-Asare  K, Madise  N, John-Langba  J, Kumi-Kyereme  A.  Coerced first sex among adolescent girls in sub-Saharan Africa: prevalence and context.  Afr J Reprod Health. 2007;11(3):62-82. doi:10.2307/25549732PubMedGoogle ScholarCrossref
    11.
    Shamu  S, Munjanja  S, Zarowsky  C, Shamu  P, Temmerman  M, Abrahams  N.  Intimate partner violence, forced first sex and adverse pregnancy outcomes in a sample of Zimbabwean women accessing maternal and child health care.  BMC Public Health. 2018;18(1):595. doi:10.1186/s12889-018-5464-zPubMedGoogle ScholarCrossref
    12.
    Stockman  JK, Lucea  MB, Campbell  JC.  Forced sexual initiation, sexual intimate partner violence and HIV risk in women: a global review of the literature.  AIDS Behav. 2013;17(3):832-847. doi:10.1007/s10461-012-0361-4PubMedGoogle ScholarCrossref
    13.
    Sano  Y, Sedziafa  AP, Tenkorang  EY.  Correlates of forced first sexual intercourse among women in the Philippines.  Sex Cult. 2016;20(3):717-730. doi:10.1007/s12119-016-9356-zGoogle ScholarCrossref
    14.
    Koenig  MA, Lutalo  T, Zhao  F,  et al.  Coercive sex in rural Uganda: prevalence and associated risk factors.  Soc Sci Med. 2004;58(4):787-798. doi:10.1016/S0277-9536(03)00244-2PubMedGoogle ScholarCrossref
    15.
    Koenig  MA, Zablotska  I, Lutalo  T, Nalugoda  F, Wagman  J, Gray  R.  Coerced first intercourse and reproductive health among adolescent women in Rakai, Uganda.  Int Fam Plan Perspect. 2004;30(4):156-163. doi:10.1363/ifpp.30.156.04PubMedGoogle Scholar
    16.
    Maharaj  P, Munthree  C.  Coerced first sexual intercourse and selected reproductive health outcomes among young women in KwaZulu-Natal, South Africa.  J Biosoc Sci. 2007;39(2):231-244. doi:10.1017/S0021932006001325PubMedGoogle ScholarCrossref
    17.
    Stockman  JK, Campbell  JC, Celentano  DD.  Sexual violence and HIV risk behaviors among a nationally representative sample of heterosexual American women: the importance of sexual coercion.  J Acquir Immune Defic Syndr. 2010;53(1):136-143. doi:10.1097/QAI.0b013e3181b3a8ccPubMedGoogle ScholarCrossref
    18.
    Williams  CM, Clear  ER, Coker  AL.  Sexual coercion and sexual violence at first intercourse associated with sexually transmitted infections.  Sex Transm Dis. 2013;40(10):771-775. doi:10.1097/OLQ.0000000000000011PubMedGoogle ScholarCrossref
    19.
    Brookmeyer  KA, Beltran  O, Abad  N.  Understanding the effects of forced sex on sexually transmitted disease acquisition and sexually transmitted disease care: findings from the National Survey of Family Growth (2011-2013).  Sex Transm Dis. 2017;44(10):613-618. doi:10.1097/OLQ.0000000000000651PubMedGoogle ScholarCrossref
    20.
    Abma  J, Driscoll  A, Moore  K.  Young women’s degree of control over first intercourse: an exploratory analysis.  Fam Plann Perspect. 1998;30(1):12-18. doi:10.2307/2991518PubMedGoogle ScholarCrossref
    21.
    Centers for Disease Control and Prevention. National Survey of Family Growth. https://www.cdc.gov/nchs/nsfg/index.htm. Updated June 26, 2019. Accessed June 7, 2019.
    22.
    Centers for Disease Control and Prevention. About the National Survey of Family Growth. https://www.cdc.gov/nchs/nsfg/about_nsfg.htm. Updated January 24, 2019. Accessed Feb 24, 2019.
    23.
    Centers for Disease Control and Prevention. 2011-2015 NSFG: selected data and documentation. https://www.cdc.gov/nchs/nsfg/nsfg_2011_2015_puf.htm. Updated November 14, 2017. Accessed June 7, 2019.
    24.
    Latthe  P, Mignini  L, Gray  R, Hills  R, Khan  K.  Factors predisposing women to chronic pelvic pain: systematic review.  BMJ. 2006;332(7544):749-755. doi:10.1136/bmj.38748.697465.55PubMedGoogle ScholarCrossref
    25.
    Mellins  CA, Walsh  K, Sarvet  AL,  et al.  Sexual assault incidents among college undergraduates: prevalence and factors associated with risk.  PLoS One. 2017;12(11):e0186471. doi:10.1371/journal.pone.0186471PubMedGoogle ScholarCrossref
    26.
    Ullman  SE, Brecklin  LR.  Sexual assault history and health-related outcomes in a national sample of women.  Psychol Women Q. 2003;27(1):46-57. doi:10.1111/1471-6402.t01-2-00006Google ScholarCrossref
    27.
    Sandfort  TG, Orr  M, Hirsch  JS, Santelli  J.  Long-term health correlates of timing of sexual debut: results from a national US study.  Am J Public Health. 2008;98(1):155-161. doi:10.2105/AJPH.2006.097444PubMedGoogle ScholarCrossref
    28.
    Salsberry  PJ, Reagan  PB, Fang  MZ.  Disparities in women’s health across a generation: a mother-daughter comparison.  J Womens Health (Larchmt). 2013;22(7):617-624. doi:10.1089/jwh.2012.4143PubMedGoogle ScholarCrossref
    29.
    Mandoki  CA, Burkhart  BR.  Sexual victimization: is there a vicious cycle?  Violence Vict. 1989;4(3):179-190. doi:10.1891/0886-6708.4.3.179PubMedGoogle ScholarCrossref
    30.
    Agency for Healthcare Research and Quality. Trauma-informed care. https://www.ahrq.gov/professionals/prevention-chronic-care/healthier-pregnancy/preventive/trauma.html. Updated April 2016. Accessed June 7, 2019.
    31.
    American College of Obstetricians and Gynecologists; Committee on Health Care for Underserved Women.  Committee opinion no. 498: adult manifestations of childhood sexual abuse.  Obstet Gynecol. 2011;118(2, pt 1):392-395.PubMedGoogle ScholarCrossref
    32.
    Substance Abuse and Mental Health Services Administration.  SAMHSA’s concept of trauma and guidance for a trauma-informed approach. Rockville, MD: Substance Abuse and Mental Health Services Administration; 2014. HHS Publication No. (SMA) 14-4884.
    33.
    Ravi  A, Little  V.  Providing trauma-informed care.  Am Fam Physician. 2017;95(10):655-657.PubMedGoogle Scholar
    34.
    Basile  KC, DeGue  S, Jones  K,  et al. STOP SV: a technical package to prevent sexual violence. https://www.cdc.gov/violenceprevention/pdf/sv-prevention-technical-package.pdf. Published 2016. Accessed February 25, 2019.
    35.
    van Wormer  K.  Restorative justice as social justice for victims of gendered violence: a standpoint feminist perspective.  Soc Work. 2009;54(2):107-116. doi:10.1093/sw/54.2.107PubMedGoogle ScholarCrossref
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