Adolescent sexual assault and abuse are some of the last frontiers within the field of child abuse still in great need of enhanced research and services. Although reports of sexual abuse of younger children have decreased steadily over the past several years, adolescent females continue to have the highest rates of sexual assault compared to all other age groups. An estimated 46% of women with a history of sexual assault say they were first assaulted before the age 18. One third of the women assaulted before age 18 say their assault occurred between ages 12 and 17 years. ,
A national survey of adolescents found 8% overall prevalence among 4023 participants reporting being victims of at least one sexual assault. , Many young victims are particularly reluctant to report sexual assault because of embarrassment, fear of retribution, feelings of guilt or a lack of knowledge regarding victim’s rights. The adolescent victim can also feel he or she contributed to the abuse or they might not identify what happened to them as rape because their experience did not fit the popular conception of sexual assault. A better understanding of adolescents’ vulnerability and response to sexual abuse and assault is needed for improved outcomes for victims.
Adolescent Perceptions and Attitudes
Adolescence is a time of rapid physical growth and social development. Many teens have not yet acquired the skills needed to recognize and avoid potentially dangerous social situations. Cassidy and Hurrell found that when adolescents were presented with a vignette of unwanted sexual activity accompanied by a photograph of the victim dressed in provocative clothing, they were more likely to conclude that the victim was in part responsible for the assault, were more likely to view the assailant’s behavior as justified, and were less likely to interpret the unwanted sexual experience as rape. In another study, 32% of the adolescent girls surveyed believed forced sex was acceptable if the couple had been dating a long time, 31% believed the unwanted sexual activity was acceptable if the girl agreed to have sex with her partner but later changed her mind, and 27% of the girls believed forced sex was acceptable if the female “led him on. ” In the same study, 54% of the adolescent boys questioned believed that forced sex was acceptable if his date initially said “yes” even though she later changed her mind. Forty percent of the boys also believed that forced sex was acceptable if the male had spent a lot of money on the date. These attitudes and perceptions should serve as a wake-up call for increased education and guidance surrounding adolescent physical, sexual, and social behavior and development.
Changes in behavior noted by parents, friends, and teachers can raise concerns for possible sexual abuse. Worrisome behaviors include sudden changes in clothes or make-up, falling grades, dropping out of school, avoiding or changing friends, sudden changes in mood, sudden changes in sleeping or eating habits, depression, anxiety, suicidal ideations and suicide attempts, and high-risk sexual behavior. , Concerning behaviors can be markedly different depending on the age and the developmental and cognitive levels of the child. While none of these behaviors are diagnostic of abuse, clinicians should be mindful of the need to explore abuse issues with adolescents as part of a work-up for behavior problems.
Populations at Risk
Adolescent “runaways” often leave dysfunctional and abusive families hoping to find jobs and new lives. Life on the street, however, is often characterized by hunger, prostitution, chronic illness, violence, and the threat of HIV/AIDS. Research on street youth 12 to 19 years of age in three cities (Denver, New York, and San Francisco) found prevalence rates of sexual abuse of 35% in females and 24% in males. The mean age of first sexual abuse was 9.0 years for females and 9.9 for males. Respondents were more likely to report sexual abuse while living at home than while living on the street. Of the abused youth, 52% were abused at home, 15% on the street, and 33% both at home and on the street. Significantly higher rates of suicide attempts were noted among homeless youth who were sexually or physically abused before leaving home. Compelling research begs for enhanced medical and social interventions to decrease the long-term medical and mental health sequelae of homeless and runaway adolescents.
Other groups with a high prevalence of sexual abuse include intravenous drug users, incarcerated youth, and teens exploited through the sex industry and prostitution. Studies evaluating both prevalence of sexual assault and factors associated with sexual violence found that IV drug-using men and women had a 36% reported lifetime history of sexual violence, with 21% reporting sexual assault during the adolescent years (33% for women and 13% for men). Among incarcerated youth, victimization and perpetration rates of sexual abuse also were found to be higher than the general population.
Teenage prostitution is one of the nation’s least recognized public health epidemics. At any given time an estimated 325,000 children nationwide are being sexually exploited through prostitution and/or pornography. Criminal justice data estimates that 25% of all individuals involved in sex work are under the age of 18, with an estimated age of entry into sexual exploitation as young at 13. Research suggests that nearly one third of this nation’s runaway youth (yearly estimate of 1.5 million) have had some involvement or exposure to prostitution or pornography. This sector of America’s youth is a diverse group representing all racial, economic, and cultural backgrounds. They are seriously underserved medically, with limited resources available to them.
The health problems associated with child prostitution include infectious diseases, pregnancy, mental illness, substance abuse, violence, and malnutrition. Prostituted children contract an estimated 300,000 cases of human immunodeficiency virus (HIV), 500,000 cases of hepatitis B virus (HBV), and 4.5 million new cases of human papilloma virus (HPV) annually. The morbidity and mortality associated with these infections are staggering and are likely increased because of inadequate and inaccessible medical services. The United States accounts for approximately 15% of the world’s exploited children and youth, and thus we are facing a health care crisis in our own backyard. The crisis is not only limited to developing countries.
The Clinical Implications of Sexual Assault and Abuse
It is important to understand and differentiate sexual abuse from sexual assault. Both forms of inappropriate adolescent sexual experiences have much in common but they differ in many ways. Sexual abuse is ongoing sexual activity with an adolescent, often by someone in the victim’s family or social network. Sexual assault by definition involves the use of force and restraint to engage the victim in sexual acts (rape). Rape involves forceful vaginal, anal, or oral penetration by the offender. The penetrating object can be a penis, a finger, or a foreign object. In some cases, the victim’s ability to give consent is compromised by intoxication or developmental disability. , A large percentage of rapes are never reported to the police and greater than 50% of rape victims tell no one about their experiences. Only 5% of rape victims visit rape crisis centers. , Fifty percent of all rape victims are under the age of 18 and 16% are under the age of 12. More than 75% of adolescent rapes are committed by an acquaintance of the victim, with less than 25% committed by a stranger. ,
Historically, the definition of rape has been gender specific, referring to the forced penetration of a female by a male assailant. Many states have now abandoned this concept in favor of the gender-neutral term of sexual assault. Thus the legal definition of criminal sexual assault is any genital, oral, or anal penetration by a part of the accused’s body or by an object, using force or without the victim’s consent.
As a general rule, adolescents are more likely to be assaulted by someone they do not know compared to adults and younger children. Stranger assaults are also less likely to be repeated events. Stranger assaults are more likely to result in genital/anal and extragenital trauma, and have the potential for serious bodily harm. The extent to which injuries are incurred depends on the degree of force, the size differential between the victim and the assailant, the degree of resistance on the part of the victim, and whether drugs and alcohol played a part. Stranger assault has the potential for serious long-term physical and mental health sequelae. Victims of sexual assault are not only frightened by the event itself, they are frequently told if they tell anyone about the assault they will experience further harm or even be killed. Consequently many sexually assaulted adolescents never disclose their experiences, or if they do, they do so long after the event occurred when they feel safe. Adolescent victims frequently blame themselves for what happened and harbor feelings of shame, stigmatization, and embarrassment. In stranger assaults, victims will not feel safe nor likely be able to begin the process of recovery until the assailant is apprehended.
Intimate Partner Violence
Adolescents are not immune to intimate partner violence, and approximately 45.5% of female and 43.2% of male high school students report they have been victims of physical aggression by dating partners at least once. , Other studies conducted in U.S. high schools report that a substantial number of adolescents have experienced some form of sexual assault in a dating relationship. The Sexual Experience Survey, administered to 6159 women and men enrolled in 32 higher-education institutions across the United States, revealed that since the age of 14 years, 27.5% of college women had experienced an act that met the legal definition of rape and 7.7% of college men had committed such an act. The vast majority of sexual assaults committed on college campuses are perpetrated by boyfriends, friends, or acquaintances of the victim, with more than 59% occurring on a date. Acquaintance rape among younger adolescents is frequently incestuous. The United States Bureau of Justice Statistics reported that 20% of rape victims aged 12 to 17 years were attacked by family members. By definition, acquaintance rape refers to sexual abuse committed by someone known to the victim, such as a date, teacher, employer, or family member. Assault by a perpetrator related to the victim is defined as incest. Although incest refers to sexual intercourse among family members (those legally barred from marriage), this definition has been broadened also to include step relatives and parental figures living in the home. The highest incidence of acquaintance rape is among girls in the 12th grade and young women in the first year of college.
Date rape is considered a subset of acquaintance rape and generally refers to forced or unwanted sexual activity that occurs within a dating relationship. Adolescent girls intentionally hurt by a date or intimate partner in the previous year were found to be more likely to experience sexual heath risks, including increased vulnerability to human immunodeficiency virus infections and other sexually transmitted infections. Other studies found similar results regarding the associations of both severe dating violence and sexual abuse histories with pregnancy and sexual risks among adolescents. Adolescent victims of dating violence were less likely to use condoms consistently or to negotiate condom use, suggesting a possible coercive role on the part of the male dating partner resulting in an increased incidence of unsafe sex practices.
A significant percentage of sexually abused adolescents are abused by someone whom they know, love, and trust. The identity of the perpetrator is rarely an issue. Force and restraint are less likely to be involved. Instead, coercion, deceit, intimidation, bribery, threats, and misrepresentation of moral standards are more likely to be used by the perpetrator. Most perpetrators will avoid causing physical injury because they intend to engage the adolescent in the acts repeatedly over time. Threats are used to maintain secrecy, and the intrusiveness of the sexual acts often increase over time. Adolescents who are victims of sexual abuse are more vulnerable to sexual assault than adolescents who have not been previously sexually abused.
Statutory Rape
Statutory rape is defined as sexual intercourse between a person 18 years or older and a person under the age of legal consent. Statutory rape laws are based on the premise that until a person reaches a certain age, he or she is legally incapable of consenting to sexual intercourse. The age at which an adolescent may consent to sexual intercourse varies from state to state and ranges from 14 to 18 years. Data from the National Maternal and Infant Health Survey indicate that 24% of births to 17-year-old women, 27% of births to 16-year-old girls and 40% of births to 14 year olds were fathered by men at least 5 years older than the mother. ,
Earlier concerns over a possible link between statutory rape and teen pregnancy led many states to enact legislation requiring mandatory reporting of statutory rape as child abuse. In 1996, Congress enacted amendments to the federal Child Abuse Prevention and Treatment Act (CAPTA), which changed the definition of rape to include some forms of statutory rape. Clinicians and health care providers have voiced concern about the impact that statutory rape reporting and enforcement might have on the adolescent’s access to health care. Researchers have looked at the effects of increased criminalization of statutory rape and have not found any associated improvement in the child welfare system response or health care access for adolescents following reporting. Furthermore, researchers have not found any proven link or relationship between expanded statutory rape laws, increased mandatory reporting, and a reduction in the incidence of teenage pregnancy. Concern remains that the new laws and mandatory reporting statutes could have a significant impact on the interaction between the health care providers and the adolescent patient. Some adolescents might refuse to seek medical care or disclose personal risk information because of the possible reporting of their sexual partner. ,
Medical and Psychological Consequences of Sexual Abuse and Assault
Sexual victimization is often accompanied by wide-ranging physical and mental health adverse outcomes. A strong relationship exists between sexual abuse and the development of pain disorders, infectious diseases, and multiple psychiatric conditions such as depression, anxiety, sleep disturbances, low self-esteem, suicidality, cutting, and alcohol and substance abuse. In the United States the incidence of psychiatric diagnoses occurring over a lifetime is 56% for women and 47% for men who report histories of childhood sexual abuse. The rates of psychiatric diagnoses when no history of child sexual abuse is reported are significantly lower at 32% for women and 34% for men. The prevalence of women with lifetime alcohol dependence was 15.6% among those reporting child sexual abuse, compared with 7.6% among those not reporting abuse. The equivalent percentages among men were 38.7% and 19.2%. Unwanted sexual experiences in adolescence have also led to gender-reversal patterns such as internalizing behaviors in males (e.g., bulimia) and externalizing behaviors such as fighting in females. Other associations between adolescent rape and behavioral changes include younger age of first voluntary sexual intercourse, increased seeking and receipt of psychological services, and greater amounts of illegal drug use. ,
Sexual Abuse and Assault and Pregnancy
The risk of pregnancy following sexual assault is estimated to be as high as 5% and thus postassault pregnancy prophylaxis is recommended. Pregnancy prevention and postcoital contraception should be addressed with every adolescent female sexual abuse and assault victim. Several forms of emergency contraception are available for women who are victims of sexual assault. Intrauterine devices are not recommended because of the risk of complications. Hormonal therapy is the safest option for emergency contraception. Multiple drug combination regimens are available, but more recently, high-dose progesterone has been used with a reported decrease in adverse side effects and an 89% efficacy rate in prevention of unwanted pregnancy. Plan B (Duramed Pharmacueticals, Inc., Cincinnati), for example, is an FDA-approved high-dose progesterone-only emergency contraceptive that can prevent a pregnancy after contraceptive failure, unprotected sex, and in cases of sexual assault, if taken within 72 hours of the sexual contact. Plan B is not the “abortion pill” (RU498 or misoprostal [Mifeprex, Danco Laboratories, New York]) and does not work if you are already pregnant. Plan B, like other hormone preparations, does not protect against HIV and other sexually transmitted diseases, but when used as instructed, it serves as an effective method for prevention of unwanted pregnancies resulting from sexual assault and abuse. (Information is available at http://www.go2planb.com . )
Discussions with victims should include risks of failure of contraception, side effects of medication, and options for pregnancy management. Always obtain a baseline urine pregnancy test during the initial abuse evaluation because the adolescent could be pregnant from sexual activity that occurred before the assault.
Rape Trauma Syndrome
Posttraumatic stress disorder occurs in up to 80% of rape victims. Results from The National Survey of Adolescents indicated that sexual assault was a significant risk factor for a range of comorbid disorders, including posttraumatic stress disorder (PTSD), major depression, and substance abuse. Many rape and sexual assault survivors will experience the condition known as rape trauma syndrome. This syndrome is characterized by an initial phase lasting days to weeks during which the victim experiences disbelief, anxiety, fear, emotional lability, and guilt. The reorganization phase can last months to years, where the victim progresses through a period of adjustment, integration, and recovery. In general, adolescents often feel that their trust has been violated. They also experience increased self-blame, less positive self-esteem, anxiety, alcohol abuse, and adverse effects on sexual activity, including increased sexual risk behaviors. ,