Association Between Forced Sexual Initiation and Health Outcomes Among US Women Association Between Forced Sexual Initiation and Health Outcomes Among US Women Laura Hawks, MD; Steffie Woolhandler, MD, MPH; David U. Himmelstein, MD; David H. Bor, MD; Adam Gaffney, MD, MPH; Danny McCormick, MD, MPH 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. JAMA Intern Med. 2019;179(11):1551-1558. doi:10.1001/jamainternmed.2019.3500 Published online September 16, 2019. Invited Commentary page 1558 Supplemental content Author Affiliations: Department of Medicine, Cambridge Health Alliance, Cambridge, Massachusetts (Hawks, Bor, McCormick); Harvard Medical School, Boston, Massachusetts (Hawks, Woolhandler, Himmelstein, Bor, Gaffney, McCormick); City University of New York, Hunter College, New York, New York (Woolhandler, Himmelstein); Division of Pulmonary and Critical Care Medicine, Cambridge Health Alliance, Cambridge, MA (Gaffney). Corresponding Author: Laura Hawks, MD, Department of Medicine, Cambridge Health Alliance, 1493 Cambridge St, Cambridge, MA 02143 (lhawks@hsph.harvard.edu). Research JAMA Internal Medicine | Original Investigation (Reprinted) 1551 © 2019 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ by a Carnegie Mellon University User on 04/05/2021 https://jamanetwork.com/journals/jama/fullarticle/10.1001/jamainternmed.2019.3500?utm_campaign=articlePDF%26utm_medium=articlePDFlink%26utm_source=articlePDF%26utm_content=jamainternmed.2019.3500 https://jamanetwork.com/journals/jama/fullarticle/10.1001/jamainternmed.2019.3467?utm_campaign=articlePDF%26utm_medium=articlePDFlink%26utm_source=articlePDF%26utm_content=jamainternmed.2019.3500 https://jamanetwork.com/journals/imd/fullarticle/10.1001/jamainternmed.2019.3500/?utm_campaign=articlePDF%26utm_medium=articlePDFlink%26utm_source=articlePDF%26utm_content=jamainternmed.2019.3500 mailto:lhawks@hsph.harvard.edu N umerous recent high-profile allegations of sexual vio-lence and the social movements that gained momen-tum in response to those events (eg, #MeToo, #TIME- SUP) 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, non- penetrative sexual assault, and rape.1 More than 40% of women have experienced some form of sexual violence in their life- time, of whom half have been raped.2 Exposure to sexual vio- lence 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 psycho- logical 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 asso- ciation between forced sexual initiation and health out- comes, but most focused narrowly on elevated rates of sexu- ally transmitted diseases,17-19 are outdated,17-20 or used measures that combined forced sexual initiation with subse- quent 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 associa- tion between forced sexual initiation and reproductive, gyne- cologic, 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 re- spondents to the 2011-2017 National Survey of Family Growth. The National Survey of Family Growth is a cross-sectional, mul- tistage, household-based nationally representative survey con- ducted 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 reproduc- tive health.21 The Cambridge Health Alliance Institutional Re- view Board, Cambridge, Massachusetts, deemed this study ex- empt 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 respon- dent survey (September 2011-September 2013; September 2013-September 2015; and September 2015-September 2017). Detailed information on survey design and sampling proce- dures 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 re- sponding “voluntary” to this question as having experienced voluntary sexual initiation. All respondents who reported that their first sexual en- counter was not voluntary were then asked the following ques- tions 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 with- out 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 pregnan- cies, age at first pregnancy, number of lifetime sexual part- ners, abortion, unwanted first pregnancy, never using birth con- trol, 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 hav- ing received a diagnosis of fibroids, pelvic inflammatory dis- ease, endometriosis, or problems with ovulation or menstrua- tion. General health outcomes included having a diagnosis of diabetes, obesity (defined as body mass index >30 [calcu- lated as weight in kilograms divided by height in meters 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. Research Original Investigation Association Between Forced Sexual Initiation and Health Outcomes Among US Women 1552 JAMA Internal Medicine November 2019 Volume 179, Number 11 (Reprinted) jamainternalmedicine.com © 2019 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ by a Carnegie Mellon University User on 04/05/2021 http://www.jamainternalmedicine.com/?utm_campaign=articlePDF%26utm_medium=articlePDFlink%26utm_source=articlePDF%26utm_content=jamainternmed.2019.3500 squared]), current smoking, binge drinking (defined as con- suming ≥4 alcoholic beverages on ≥1 occasion in the past month), illicit drug use (defined as self-reported use of co- caine, 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 gyne- cologic health outcomes (uterine fibroids, pelvic inflamma- tory 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 asso- ciated with sexual violence.7,24 Although no mental health di- agnoses were available in the survey data, we included re- sponses 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 sociodemo- graphic 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 tabu- lated the proportions of those reporting each type of coercion during sexual initiation. We then examined the association between having expe- rienced forced vs voluntary sexual initiation and reproduc- tive, gynecologic, and general health outcomes in unad- justed and adjusted analyses. For the adjusted analyses of the 3 continuous outcomes, we estimated the mean adjusted dif- ference between women who experienced forced vs volun- tary sexual initiation using multivariable linear regression mod- els 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 ad- justed odds ratios (aORs) using multivariable logistic regres- sion models that included the same set of control variables. We included 1 negative control variable—ever diagnosis of can- cer (excluding cervical cancer)—to test for unmeasured con- founders. All analyses were conducted with Stata, version 15.1 (Stata- Corp LLC), using the complex survey design command pro- cedures that account for the National Survey of Family Growth’s sampling strategy and weights provided by the Centers for Dis- ease 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 analy- ses 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 experi- enced forced sexual initiation and no other forced vaginal intercourse. We then repeated the analysis assessing asso- ciations between forced sexual initiation and adverse out- comes using only women reporting forced sexual initiation and no other forced intercourse. We performed additional subsidiary analyses to investi- gate 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 en- counter. Second, we added a covariate that captures the re- spondent's mother's level of education, which reflects child- hood 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 apply- ing 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 out- side the United States (21.5% vs 16.1%; P = .01) and have in- comes below the poverty level (35.1% vs 24.9%; P < .001) and Association Between Forced Sexual Initiation and Health Outcomes Among US Women Original Investigation Research jamainternalmedicine.com (Reprinted) JAMA Internal Medicine November 2019 Volume 179, Number 11 1553 © 2019 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ by a Carnegie Mellon University User on 04/05/2021 http://www.jamainternalmedicine.com/?utm_campaign=articlePDF%26utm_medium=articlePDFlink%26utm_source=articlePDF%26utm_content=jamainternmed.2019.3500 Table 1. Sociodemographic Characteristics of US Women Aged 18 to 44 Years According to Forced vs Voluntary Sexual Initiation Characteristic Sexual Initiation, % P Value Forced Voluntary Unweighted No. 993 12 317 Age, mean (95% CI), y 32.6 (31.8-33.3) 31.4 (31.2-31.6) .003 Age at first sexual encounter, mean (95% CI), y 15.6 (15.3-16.0) 17.4 (17.3-17.5) .003 First sexual partner/assailant mean age, mean (95% CI), y 27.0 (24.8-29.2) 21.0 (20.6-21.3) <.001 Age group at first sexual encounter, y ≤10 6.8 0.1 <.001 11-14 29.0 12.2 15-17 39.0 48.1 ≥18 25.3 39.5 Race/ethnicity White 65.3 74.7 <.001Black 20.7 15.8 Other 13.8 9.5 Poverty level or below 35.1 24.9 <.001 Born outside the United States 21.5 16.1 .01 Language spoken English 88.4 89.7 .59Spanish 8.9 7.7 Other 2.7 2.6 Marital status Married 34.2 45.2 <.001 Widowed 0.5 0.6 Divorced 14.1 8.6 Separated 7.3 3.4 Never married 43.8 42.2 Educational level Less than high school 14.6 10.3 .002 High school or equivalent 28.0 25.1 Some college 33.5 32.9 College or beyond 23.9 31.7 Received cash assistance in the past year 14.8 9.8 .001 Family structure No children 39.6 39.9 .0022 Parents with children 37.7 44.2 Single parent with children 22.8 16.0 Characteristics in childhood Did not always live with 2 parents 51.7 41.8 <.01 Ever lived in foster care 11.3 5.9 Age of mother at birth, y ≤18 18.7 16.5 .12 19-24 54.5 55.1 25-29 17.7 19.7 ≥30 6.7 7.7 Unknown 2.3 1.0 Mother's educational level Less than high school 26.6 21.7 .02 High school 26.2 30.3 Some college 24.5 24.5 College degree or beyond 20.7 22.6 Unknown 2.1 0.9 Research Original Investigation Association Between Forced Sexual Initiation and Health Outcomes Among US Women 1554 JAMA Internal Medicine November 2019 Volume 179, Number 11 (Reprinted) jamainternalmedicine.com © 2019 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ by a Carnegie Mellon University User on 04/05/2021 http://www.jamainternalmedicine.com/?utm_campaign=articlePDF%26utm_medium=articlePDFlink%26utm_source=articlePDF%26utm_content=jamainternmed.2019.3500 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 hav- ing 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 fre- quently 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 out- come 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 nega- tive 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 af- ter stratification by age at first intercourse, all outcomes re- mained 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 as- sociated 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 menstrua- tion (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 out- comes showed similar nonsignificant trends with wide 95% CIs, suggesting lack of power. eTable 1 in the Supplement dis- plays the details of the findings. In the subsidiary analysis that compared women report- ing forced sexual initiation but no subsequent sexual assault with women with voluntary sexual initiation, forced sexual ini- tiation 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 inflam- matory 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 out- comes (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 sig- nificantly 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 inter- course 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 sta- tus, 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 Table 2. Type of Coercion Used by Assailant to Force Sex Among Women Who Experienced Forced Sexual Initiationa Type of Coercion Used Estimated Women in United States, No. (%) Any form 2 800 642 (83.6) Verbal pressure 1 868 474 (56.4) Partner larger or older 1 670 892 (50.0) Physically held down 1 544 475 (46.3) Physical threat 885 850 (26.5) Physically harmed 837 366 (25.1) Given a drug 736 554 (22.0) Threatened to end relationship 539 475 (16.2) a Respondents could provide multiple answers. Association Between Forced Sexual Initiation and Health Outcomes Among US Women Original Investigation Research jamainternalmedicine.com (Reprinted) JAMA Internal Medicine November 2019 Volume 179, Number 11 1555 © 2019 American Medical Association. All rights reserved. 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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 experi- encing sexual violence at a time of heightened psychological and physical vulnerability may have long-term deleterious se- quelae. In subsidiary analyses, our main results were mini- mally affected by controlling or stratifying for age at forced sexual initiation, having experienced repeated sexual as- saults, 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 a s s o c i at e d w it h a d ve r s e m e nt a l a n d p hy s i c a l h e a l t h outcomes.3-5 However, our first subsidiary analysis suggests that adverse outcomes are associated with forced sexual ini- tiation 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 subse- quent 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 preva- Table 3. Association Between Forced Sexual Initiation and Reproductive, Gynecologic, and General Health Outcomes Variable First Sexual Experience, % Odds Ratio (95% CI) Forced (n = 3 351 733) Voluntary (n = 48 250 002) Unadjusted Adjusteda Reproductive health measures, mean (95% CI) No. of pregnancies 2.40 (2.2 to 2.6) 1.90 (1.8 to 2.0) 0.5 (0.3 to 0.7)b 0.3 (0.1 to 0.5)b Age at first pregnancy, y 20.6 (20.0 to 21.2) 22.2 (22.0 to 22.4) −1.6 (−2.2 to −1.0) b −1.6 (−2.2 to −1.0)b No. of lifetime sexual partners 9.6 (8.3 to 10.9) 7.4 (7.0 to 7.8) 2.2 (0.9 to 3.5)b 2.2 (0.5 to 3.5b 1st Pregnancy unwanted 30.1 18.9 1.8 (1.5 to 2.3) 1.9 (1.5 to 2.4) Ever had abortion 24.1 17.3 1.5 (1.2 to 2.0) 1.5 (1.2 to 2.0) Never used birth control 2.6 0.9 3.1 (1.8 to 5.2) 2.6 (1.6 to 4.4) Use of fertility services 10.5 9.5 1.1 (0.8 to 1.6) 1.0 (0.7 to 1.4) Gynecologic health measures Recent cervical cancer screeningc 27.4 25.4 1.1 (0.9 to 1.4) 1.1 (0.9 to 1.4) Never had HIV testing 16.0 18.6 0.8 (0.6 to 1.1) 0.9 (0.7 to 1.2) Fibroids 8.0 6.8 1.2 (0.9 to 1.7) 1.0 (0.7 to 1.4) PID 8.1 3.4 2.5 (1.7 to 3.8) 2.2 (1.5 to 3.4) Endometriosis 10.4 6.5 1.7 (1.2 to 2.4) 1.6 (1.1 to 2.3) Problems with ovulation or menstruation 27.0 17.1 1.8 (1.4 to 2.3) 1.8 (1.4 to 2.3) General health measures Diabetes 8.7 6.5 1.4 (1.0 to 1.8) 1.1 (0.8 to 1.5) BMI>30 43.1 39.0 1.2 (0.98 to 1.4) 1.1 (0.9 to 1.4) Current smoking 25.5 22.8 1.2 (0.96 to 1.4) 1.2 (0.9 to 1.4) Binge drinking alcohol used 12.5 12.5 1.0 (0.7 to 1.4) 1.1 (0.7 to 1.5) Illicit drug usee 2.6 0.7 3.8 (2.0 to 7.3) 3.6 (1.8 to 7.0) Fair or poor health 15.5 7.5 2.3 (1.7 to 3.1) 2.0 (1.5 to 2.7) Difficulty completing tasks outside the home 9.0 3.2 3.0 (2.2 to 4.1) 2.8 (2.0 to 3.9) Abbreviations: BMI, body mass index (calculated as weight in kilograms divided by height in meters squared); PID, pelvic inflammatory disease. a Adjusted odds ratios were controlled for age, poverty level, race/ethnicity, and place of birth. b Difference between groups measured. c Analyzed only for women aged 21 years and older. d Defined as consuming 4 or more drinks on 1 occasion during the past month. e Defined as self-reported cocaine, crack, methamphetamine, or injectable drug use in the past 12 months. Research Original Investigation Association Between Forced Sexual Initiation and Health Outcomes Among US Women 1556 JAMA Internal Medicine November 2019 Volume 179, Number 11 (Reprinted) jamainternalmedicine.com © 2019 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ by a Carnegie Mellon University User on 04/05/2021 http://www.jamainternalmedicine.com/?utm_campaign=articlePDF%26utm_medium=articlePDFlink%26utm_source=articlePDF%26utm_content=jamainternmed.2019.3500 lence of forced sexual initiation, although the younger age range in the earlier study and slight changes in question word- ing 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 re- traumatization. The Agency for Healthcare Research and Qual- ity 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, in- cluding the American Academy of Family Physicians and American College of Obstetricians and Gynecologists, have ad- vocated 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 strat- egies to prevent forced sexual initiation and other forms of sexual violence. A Centers for Disease Control and Prevention report rec- ommended disseminating local programs that address sexual cul- ture 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 recommen- dations is scant. The efficacy of the current criminal justice system in facili- tating 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 war- rants further research.35 Efforts should be devoted to the devel- opment of evidence-based public health approaches to sexual assault prevention and their effective dissemination. Limitations Our study has several limitations. First, its cross-sectional de- sign precludes causal inference. Owing to the survey design, we were unable to adjust for some potentially important con- founders, such as sexual experiences prior to or following sexual initiation. Although the associations that we identi- fied do not establish causation, they may be important for cli- nicians to consider. Second, women who experienced forced sexual initiation may have experienced or begun experienc- ing some of the adverse health outcomes that we analyzed be- fore their assault. However, the young age at which forced sexual initiation often occurred makes it likely that most out- comes 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 col- lect 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 expe- riences differently. However, the negative control analysis pro- vides 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 experi- ence forced sexual initiation, and the individual and public health implic ations 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. ARTICLE INFORMATION Accepted for Publication: June 22, 2019. 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. 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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. 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/54.2.107 Invited Commentary Forced and Coerced Sexual Initiation in Women New Insights, Even More Questions Alison J. Huang, MD, MAS; Carolyn J. Gibson, PhD, MPH The #MeToo movement has opened a national conversation about nonconsensual sexual experiences among women, high- lighting the prevalence of problematic sexual behaviors that have historically been normalized or not discussed. More women are now speaking openly about forced or coerced sexual activ- ity, but there is much we still do not know about the long-term effect of these experiences on women’s health. As screening and recognition of the range of situ- ations and interactions that encompass sexual assault expand, we also should determine the consequences of these experiences for women across their lifespan. In this issue of JAMA Internal Medicine, Hawks et al1 present data from a national household-based survey to determine the proportion of reproductive-age US women who considered their first sexual encounter with a male partner to be involuntar y by v irtue of being forced or coerced. Building on prior research that reported increased risk for sexually transmitted infections after involuntary sexual initiation,2 the researchers also assess whether these women were more likely to experience a wide array of reproductive, gynecologic, and general medical conditions important to women’s functioning and well-being. Among US women aged 18 to 44 years with a history of vaginal sexual intercourse, the investigators found that 6.5%, or approximately 1 in 16 women, experienced a first sexual encounter that was forced or coerced. Compared with women whose first sexual experience was voluntary, Related article page 1551 Research Original Investigation Association Between Forced Sexual Initiation and Health Outcomes Among US Women 1558 JAMA Internal Medicine November 2019 Volume 179, Number 11 (Reprinted) jamainternalmedicine.com © 2019 American Medical Association. All rights reserved. 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