Sexual Assault and Victimization

Vaughn I. Rickert

Dillon J. Etter

Mariam R. Chacko

SEXUAL ASSAULT

Sexual assault and victimization (SAV) among adolescents and young adults (AYAs) is of particular concern because of its high occurrence in this population, its infrequent disclosure, and the significant health consequences associated with this type of violence.¹ Slightly more than 25% of girls and about 6% of boys will experience some form of SAV before they turn 18.² Rates of SAV are four times higher among females aged 16 to 24 years compared to women in all other age-groups.¹ SAV estimates for gay, lesbian, or bisexual individuals suggest that these subgroups may also be at increased risk.³ Sexual violence on college campuses is another area of concern, especially due to a recent increase in media exposure.

A history of SAV not only makes it more difficult for individuals to develop healthy intimate relationships as adults, but it also significantly increases the risk of negative health outcomes, including human immunodeficiency virus (HIV), depression, suicidal ideation, and substance abuse.⁴ Health care providers play a key role in the early identification of victims of SAV and the prevention of subsequent negative health outcomes. SAV disclosure requires prompt medical and psychological intervention. When forensic evidence is required, providers who are willing to devote the time and support needed should examine the sexual assault victim. Thus, the clinician must be familiar with the proper protocol for intervention, including clinical, legal, and psychosocial techniques.

A victim of SAV is the object of a hostile, dehumanizing attack that can have long-lasting effects on concepts of self-worth and identity.⁵ During adolescence, an individual is learning to manage feelings of sexual arousal, developing new forms of intimacy and autonomy, experiencing intimate interpersonal relationships, and building skills to control the consequences of sexual behavior. SAV or attempted SAV as a first or early sexual experience may cause confusion between intercourse and violence, jeopardizing the young person’s sexual health. For young adults, SAV may initiate mental health problems, cause problems in future relationship decision making, increase psychological burden relative to self-attribution of the assault, and result in secondary victimization from family and friends.

Provider-initiated screening to detect sexual victimization represents an important public health strategy to overcome the difficulty that some AYAs face when disclosing these violent events.⁶ Despite recommendations to screen AYA females and endorsement of screening acceptability by these young women, routine screening for SAV does not occur, especially among sexual minorities.⁷

The terms used to describe the range of victimizations included in sexual assault are sometimes used interchangeably, frequently unclear, and require definition. These labels have legal ramifications and reporting requirements that impact prevalence and incidence rates. Below is a summary of common terminology associated with SAV:

“Sexual assault” can be defined as any act, either physical or verbal, of a sexual nature committed against another person that is accompanied by actual or threatened physical force.
“Rape” is a legal term with a definition that varies widely. Generally, this term implies unlawful nonconsensual sexual activity carried out forcibly or under threat of injury against the will of the victim. Nonconsensual sex is divided into two categories—stranger rape is perpetrated by a stranger and acquaintance rape is perpetrated by someone known to the individual. Date rape, occurring between two people in a romantic relationship or potential sexual relationship, is a subset of acquaintance rape.
“Sexual abuse” typically refers to the sexual victimization of a minor and is primarily a legal term. In certain contexts, the term can include consensual sex between minors or a minor and an adult (statutory rape).
“Sex trafficking,” as it pertains to children and adolescents, includes trafficking a minor for the purpose of sexual exploitation, exploiting a minor through prostitution, and exploiting a minor though survival sex.⁸
“Prostitution” typically refers to sex in exchange for money.
“Survival sex” is the exchange of sex for food, money, shelter, drugs, or other wants and needs.

Epidemiology

Trends of completed or attempted rape among all women from 1995 to 2010 have declined 58%.⁹ The reporting of rape and sexual assault has also declined considerably in recent years from 56% in 2003 to 28% in 2012.¹⁰ According to 2009 National Crime Victimization Survey (NCVS) data,⁹ of the 106,100 rape and sexual assault cases where a female was the victim, only 31% of perpetrators were identified as strangers. Among the 19,820 male rape and sexual assault victims, a stranger perpetrated 52% of the attacks. Thus, for these data, which include all ages, female victims are five times more likely to know the perpetrator than male victims.

Data from the US Department of Justice¹ suggest a significant period of vulnerability for females between the ages of 12 and 24 years, with the largest number occurring between the ages of 16 and 24. Risk factors include female gender (age 16 to 24 years); history of abuse (sexual or other); for females, younger age at menarche, greater number of dating and/or sexual partners, and a sexually active peer group; for males, homelessness and disability (physical, cognitive, psychiatric); alcohol use by perpetrator or victim, especially in a dating situation; and dating relationships that include verbal or physical abuse.

Incidence

Gender: Across all age-groups, females experience significantly higher rates of SAV than males. Of AYAs aged 12 to 25, compared to males, females face 17 times the risk of SAV¹¹ (Fig. 73.1).
Age: For White and Black AYAs, females aged 18 to 25 experience the highest rates of SAV, followed closely by females aged 12 to 17. For Hispanic AYAs, females aged 12 to 17 experience the highest rates of SAV.¹¹
Race: Black females experience the highest rates of SAV. Among AYAs aged 12 to 25, Black females are 62% and 200% more likely to experience SAV than White and Hispanic females, respectively.¹¹
Eight percent of youth (11.8% of females and 4.5% of males) report that they have been forced to have sexual intercourse.¹²
Adults are responsible for relatively few victimizations (15% of general sexual victimizations and 29% of sexual assault) confirming that a vast majority of victimizations are perpetrated by peer acquaintances.¹³
Two-thirds of sexual assault victimizations reported to the police involve juvenile victims.
Adolescents <18 years who experience sexual victimization are twice as likely to experience a future assault during their college years.
Approximately 60% of sexual assaults occur at home or at the home of an acquaintance.

Sequelae

Most of the sexual violence that clinicians will encounter when treating AYA women has been perpetrated by an acquaintance, date, or a significant other. As a result, spontaneous disclosure by the victim is not likely—either because AYAs do not perceive it as sexual assault, they are embarrassed, or they believe it is their own fault.

FIGURE 73.1 Sexual assault rates (per 100,000) by gender, race, and age-group, in the US, 2013. (From the Centers for Disease Control and Prevention. Web-based Injury Statistics Query and Reporting System (WISQARS) [Online], 2013.)

AYAs who have been victimized experience significantly higher levels of depression and anxiety. Male and female high school-aged victims report decreased life satisfaction coupled with suicidal ideation and attempts. Moreover, the individual’s sexual health is greatly impacted by victimization. Typically, sexually victimized youth engage in higher-risk sexual behaviors, have poorer attitudes and beliefs regarding sex, and demonstrate a greater prevalence of consequences from sexual activity, that is, unintended pregnancies and sexually transmitted infections (STIs). Common SAV responses include phobias, self-blame, loss of appetite, sleep disturbances, somatic responses, and drug and alcohol use. Sequelae, particular to date rape, may include self-blame, decreased self-esteem, and a difficult time maintaining relationships. Somatic responses can manifest as chronic pelvic pain or recurrent abdominal pain. In the most general case, the first 2 months postvictimization is a time of particular vulnerability for severe depression. Signs of stress disorder (PTSD) are not uncommon within the first year. Victimized AYAs can be two or even three times as likely to begin using illicit drugs, smoke, or regularly consume alcohol compared to their nonvictimized peers.¹⁴

SEXUAL ABUSE

Incidence

Sexual abuse accounted for almost 10% of all substantiated claims of child victimization, totaling 65,984 cases—29 of which resulted in death.¹⁵ However, data from the National Incidence Survey 4 (NIS-4) suggest striking declines in both the rate and numbers of sexually abused children.¹⁶ Indicators that should alert the provider to suspect abuse include the following:

STIs in a prepubertal adolescent or any adolescent with no history of sexual intercourse
Recurrent somatic complaints, particularly involving the gastrointestinal, genitourinary, or pelvic areas
Behavioral indicators, including significant changes in mood, onset of withdrawal from usual family, school, and social
activities; patterns of disordered eating; running away from home; suicidal and self-injurious gestures; rapid escalation of alcohol and/or drug abuse; onset of promiscuous sexual activity; early adolescent pregnancy; and onset of sexual activity before age 13 years

Sequelae

The occurrence of sexual abuse during childhood has been linked to a variety of psychological and emotional problems during adolescence, with some continuing into adulthood. The relationship between severity of abuse, frequency of abuse, and subsequent mental health disorders remains elusive. Sequelae include depression, suicidal ideation and attempts, substance abuse, PTSD, eating disorders, and precocious sexual behaviors (e.g., earlier age at first coitus and greater number of lifetime partners). In addition, childhood sexual abuse for females has been linked to acquaintance and date rape in adolescence or young adulthood.

SEX TRAFFICKING

Sex trafficking of AYAs for prostitution and other forms of sexual exploitation is an often-overlooked form of SAV. Sex trafficking of minors occurs daily and can lead to serious long-term consequences for victims as well as their families, communities, and society.⁸ Sex trafficking can include commercial sex work (prostitution, exotic dancing, and pornography) as well as personal service (domestic or sexual servitude). This criminal endeavor is fast growing and is fueled by a growing demand by customers who pay for illicit sex.¹⁷ Young women and adolescents are a particularly vulnerable group for international and domestic sex trafficking.¹⁷,¹⁸,¹⁹ Experts estimate that there are currently at least 100,000 victims of sexual exploitation under the age of 18 in the US²⁰ and as many as 325,000 victims in the US, Canada, and Mexico.²¹ Many victims report being sexually assaulted while they were trafficked.²²

Victims of sex trafficking can be male, female, or transgender and can come from a variety of backgrounds and experiences. It is important to note that victims of sex trafficking can be much younger than victims of other forms of SAV, as the average age of entry into prostitution in the US is 12 to 14 years old.²² Human trafficking victims are at increased risk for developing health problems due to substandard living conditions as well as physical, sexual, and emotional trauma. Warning signs for possible sex trafficking include those for victims of sexual assault in addition to homelessness and/or chronic running away¹⁷; presence of an older boyfriend or age disparity in an intimate or sexual relationship; tattoos (used to mark victim as property of a particular pimp); travel with an older male who is not a guardian; access to material things that the youth cannot afford; < 18 years and involved in or history of prior prostitution; and not attending school, frequent absences, or academic failures. Sex trafficking is complicated by the fact that many adolescents are trafficked by individuals who they consider to be their boyfriend/girlfriend, fiancée, or lover. In fact, adolescents may continue to have an intimate relationship with their trafficker as they are trafficked.⁸ For this reason, before asking the patient any sensitive questions, you should first try to get the patient alone.

SPECIAL POPULATIONS

College Students

College students represent a unique SAV subgroup. Media attention of SAV on college campuses has recently increased because of several high-profile occurrences. As a result, the government has focused considerable effort on raising awareness of and combating sexual violence on campus.²³,²⁴ It is important to note, however, that hearing boards at colleges and universities operate under different procedural rules and evidence standards than the criminal justice system. The purpose of the judicial process at colleges and universities is to determine whether violations of student conduct occurred rather than determining criminal charges. These judicial processes to investigate occurrences of SAV vary considerably across campuses²⁵ and have recently been scrutinized for a lack of consequences for perpetrators of SAV.²⁶

Incidence rates of SAV among college students differ from those of the general population and are likely underestimates.²⁷ Recent data suggests that, among college students in the US, 3.3% of males and 8.9% of females reported being sexually touched without their consent during the past 12 months.²⁸ About 1% of males and 4% of females reported a sexual penetration attempt without their consent, with 0.7% of males and 2.5% of females reporting actual penetration without their consent. Among college students who reported drinking alcohol, 1.2% of males and 2.6% of females reported someone having sex with them without their consent while drinking alcohol. In the context of dating, about 1% of males and 2% of females reported being in a sexually abusive intimate relationship within the past 12 months. Academic impact is evident, with 9.5% and 1% of college students reporting that relationship difficulties and sexual assault, respectively, impact their grades.

Males

Male adolescents who have been sexually abused are often overlooked and underserved. However, male sexual abuse is not uncommon and is significantly underreported. Since most perpetrators of sexual violence against adolescent males are male themselves, these victims may remain silent due to the homosexual nature of the assault. In addition, practitioners may fail to recognize and pursue this possibility because of their lack of awareness of this problem.

Lesbian, Gay, and Bisexual Youth

There is a significantly higher rate of childhood sexual abuse among individuals who identify as lesbian, gay, and bisexual (LGB).⁴ Over the lifetime, gay and bisexual men were five times more likely to be sexually assaulted than heterosexual men, and lesbian and bisexual women were twice as likely to be assaulted than heterosexual women.²⁹ Another study reported a similar disparity in rates of SAV between heterosexual and LGB individuals. The median estimate of lifetime SAV was 30% for gay and bisexual men and 43% for lesbian and bisexual women. Given that estimates of lifetime sexual assault prevalence among all the US residents are 2% to 3% for men and 11% to 17% for women, these data suggest an increased risk for SAV among LGB individuals.

Researchers have recently begun to explore the impact of SAV on sexual identity formation. While most data clearly suggest that there is no direct causal link between experiencing sexual abuse as a child and developing a nonheterosexual orientation in adulthood, recent studies have reported that there is a 25% to 50% higher prevalence rate of childhood sexual abuse among nonheterosexual individuals.⁴

Transgender and Gender Nonconforming Youth

“Transgender” is a term used to describe individuals whose gender identity is different from their sex assigned at birth. In a large survey, transgender individuals reported the highest victimization and perpetration rates of sexual coercion.³⁰ Over 60% of transgender respondents reported being the victim of sexual coercion, and nearly 18% reported being the perpetrator of sexual coercion. These rates were considerably lower for male youth (9% and 4%, respectively) and female youth (16% and 1%, respectively).³⁰ These figures are particularly notable because they are limited to sexual coercion experienced or perpetrated within the context of dating. They exclude perpetration by strangers and other nonpartners, rates of which would likely increase the already-disproportionate prevalence of sexual coercion experienced by transgender AYAs.

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