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Adverse factors associated with forced sex among southern adolescent girls

Pediatrics - November 1, 1995

ABBREVIATIONS. OR, odds ratio; CI, confidence interval.

Adolescent sexual abuse and its adverse psychologic and physical consequences have been identified as an important public health and clinical care issue. Recently, guidelines from the American Medical Association recommend that physicians screen adolescents for histories of sexual abuse on an annual basis.[1] Assessing a history of sexual abuse through screening procedures is especially important, because physical examinations are ineffective in adequately detecting sexual abuse.[2] Moreover, physicians generally tend to underreport and underrecognize child maltreatment.[3]

Sexual abuse in children and adolescents has been associated with a broad spectrum of adverse health and psychologic sequelae, including truancy,[4] depression,[5] inappropriate sexual behavior,[6] substance use,[7] and pregnancy.[6,7] Although informative, this area of research has been problematic. Of particular importance has been the reliance on data derived from clinical populations.[8,9] In addition, there is no uniform definition of what constitutes sexual abuse. Nonetheless, although the lack of a uniform operational definition of sexual abuse and data from nonclinical populations remains problematic, it is generally agreed that repetitive incidences and/or violent episodes accompanying sexual abuse are more detrimental to victims' psychologic and physical health.[6]

The sequelae of sexual victimization may be the development of risk-taking, self-destructive, or deviant behaviors, and this presents problems to physicians, because adolescents vary markedly in their behavioral practices. However, some distinctions may be observed between sexually inactive and sexually abused adolescents. Recent preliminary findings from our research[10] indicates that risk-taking and deviant behaviors are more prevalent among sexually abused adolescents than among nonabused adolescents. However, among the nonabused group, the sexually experienced adolescents report a markedly increased prevalence of deviant behaviors compared with their sexually inactive counterparts. There is little empirical data characterizing the prevalence of risk-taking and deviant behaviors among sexually victimized adolescents relative to other sexually active adolescents who have not been victimized.

The present study describes a profile of risk-taking behavior among a nonclinical population of sexually victimized adolescent girls relative to a nonabused sexually active adolescent female population.

METHODS

Data were collected using an instrument that retained a core of items from two previous surveys conducted in 1988[11] and 1990[12] and examined a variety of health behaviors and attitudes. Unique to the 1993 questionnaire were items on sexual abuse and forced sex experiences. Sexual abuse was broadly defined as "someone touching you in a place that you did not want to be touched, or did something to you sexually that you did not want." Previous experience with similar samples[10] had demonstrated that students had difficulties in distinguishing between forced sex and sexual abuse. Subsequently, students were also asked if they had ever experienced forced sex by asking "has someone ever forced you to have intercourse (sex)?" Students also responded to two questions on the identities of the perpetrators. Because of the age range of the students, school personnel did not allow additional questions addressing oral and anal sex and same-gender sexual experiences.

The questionnaire was reviewed by a panel of experts and pilot tested with 8th and 10th grade students. A correlation of r = .80 was obtained (n = 69) for the majority of items when using a test-retest method with a 4-week interim. Most students completed the survey within a single 50-minute class period.

Students were selected from schools that participated in previous surveys, consisting of schools from two metropolitan school districts, four rural school districts, and three districts in semiurban settings. State health department data on adult mortality and morbidity rates and teenage pregnancy rates show these districts to be similar to surrounding counties. All students present on the day of testing were included. One week before the survey was administered, students were provided with letters to take home informing parents about the study. If parents elected not to involve their children in the study, they were required to return a signed letter indicating their decision. Fewer than 1% of the students returned signed letters.

Data were collected from all students in the rural districts. In larger districts, schools were randomly selected, and at least 250 students from each grade level were included from randomly selected classes. Occasionally, several intact classes were assembled in a cafeteria, gymnasium, or auditorium, and the instrument was administered to all the classes. Students usually were seated to allow for privacy and to allow them to respond unobserved by other students or members of the research team. They were provided with a questionnaire, a computer answer sheet, a pencil, and a separate identification (referral) form for students wishing to speak to counselors about topics addressed in the survey. A member of the research team then read the instructions and indicated that students could elect not to participate or could discontinue at any time. When completed, students deposited their answer sheets and referral forms in a large, enclosed collection box. Before departing from the school premises, researchers provided the referral forms to the principal. Approximately 3% of the students requested counselor contact. No follow-up by the research team occurred in these cases.

DEFINITION OF COMPARISON GROUPS

Students who indicated that they had not been abused and were not sexually experienced constituted 45% of the sample and were not included in the analysis. Comparisons of these students with other students indicated that they were proportionately younger, resided more in two-parent households, and were more likely to be white (P < .001). Another group of adolescents not included in the analysis consisted of adolescents who responded to sexual abuse items but did not indicate experiencing an episode of forced sex and and adolescents who did not respond to the sexual abuse items. This group accounted for 10% of the sample and did not show differences on any of the demographic and behavioral measures when compared with sexually active abused and nonabused students.

We selected a conservative definition of sexual abuse, because it was possible that some adolescents may have had problems in interpreting the sexual abuse questions. For example, when asked whether they had ever been sexually abused "someone touching you or did something to you sexually that you did not want" , 22% of the sample responded positively. However, a more narrow definition was determined based on adolescents' responses to whether they had been forced to have sexual intercourse and also identified their relationships to the perpetrators. By using the more stringent criteria of a positive response to the item on having had forced sex and a positive response to the item that identified the perpetrator of an episode(s) of forced sex, 13% of the adolescents were identified as having been sexually abused. Among this group, 31% identified their perpetrators as boyfriends or girlfriends; 42% identified their perpetrators as immediate family members; and 37% identified their perpetrators as belonging to some other category. Adolescents who had not experienced sexual abuse or forced sex but reported being sexually experienced (32%) constituted the comparison group for these analyses.

Independent Measures

Risk profiles were constructed based on five categories of behavioral measures. These included: (1) truancy from school (whether students had skipped classes during the past month); (2) sexual behavior (the number of sex partners, the age of sexual initiation, condom use, and history of pregnancy); (3) substance, use (prevalence of cigarette and alcohol use, binge drinking of alcohol during the past 2 weeks, and lifetime use of illegal substances); (4) violence (whether the student experienced an assaultive episode during the past year and whether they had committed an assault during the past year); (5) psychologic and emotional health (suicidal ideation during the past year, whether the student practiced bulimia, and the frequency of depressive experiences during the past month).

RESULTS

Data were collected from 6288 students. Responses that were not 90% complete or those that showed visible signs of invalidity (ie, distinguishable patterns of responses) were not included, yielding a usable sample of 5733 student forms. Among this sample, there were 3124 girls (54%) who constituted the group for analysis.

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