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Rape-related pregnancy" Estimates and descriptivecharacteristics from a national sample of womenMelisa M. Holmes, MD, Heidi S. Resnick, PhD, Dean G. Kilpatrick, PhD, andConnie L. Best , PhDCharles ton, South Carol ina

OBJECTIVE: We attem pted to de termine the national rape-related pregnancy rate and provide descript ivecharacteristics of pregn ancies that result from rape.STUDY DESIGN: A national probabi l i ty sample of 4008 adult American women to ok part in a 3-yearlongitudinal survey that assessed the prevalence and incidence of rape and related physical and mentalhealth outcomes.RESULTS; The national rape-related pregnancy rate is 5.0% per rape among vict ims of reproductive age(aged 12 to 45); amo ng adult wom en an estim ated 32,101 pregnan cies result from rape each year.Amon g 34 cases of rape-related pregnancy, the majori ty occurred amo ng adolescents and resulted fromassault by a known, often related perpetrator. Only 11.7% of these vict ims received immed iate medicalattention after the assault, and 47.1% received no medical attention related to the rape. A total 32.4% ofthese vict ims did not discover they were pregnant unt il they had already entered the second tr imester;32.2% opted to keep the infant whereas 50% underwent abort ion and 5.9% placed the infant foradoption; an addit ional 11.8% had spontaneous abort ion.CONCLUSIONS: Rape -related pregnancy occurs with significant frequency. It is a cause of manyunwanted pregnancies and is closely linked with family and d omes tic violence. As we address theepidem ic of unintended pregnancies in the United States, greater attent ion and effort should be aimed atpreventing and identi fying unwanted pregnancies that result from sexual vict imizat ion. (Am J ObstetGynecol 1996;175:320-5.)

Key words: Sexual assault, rape, un int end ed pregn ancy

Sexual assault is a significant societal problem, currentlyaffecting approxim ately 12.1 million wome n in the Uni tedStates?' 2Within the pastyear an estimated 683,000 women>18 years old have expe rien ced a rape in cident. 1The inci-dence of the past year would have been estimated to bemuch higher if adolescents had be en included, becauseapproxim ately 60% of all rape cases occur a mong girlsyounger than 18 years old. The short- and long-term se-quelae of rape are complex. Psychologically, rape has beenidentified as a significant risk factor for posttraumaticstress disorde r, with 35% to 50% of all victims affected. 2' 3Less is known about the prevalenc e of significant physicalhealth pr oblems resulting from rape because data are lim-ited to reports f rom th e 4000 women, 12% of whom had expe rien ced at leastone rape in the ir lifetime. 1 Data are pr esent ed on preg-nancy rates of women raped during their reproductiveyears. The representative nature of the sample allowsestimates of national lifetime rape-related pregnancyrates and past-year rape-rela ted pr egnancy rates. In addi-

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T a b l e I . I n t r o d u c t i o n a n d q u e s t i o n s u s e d t o a s se s s a s s a u l t" . . . A n o t h e r t y p e o f st re s sf u l e v e n t t h a t m a n y w o m e n h a v e e x p e r i e n c e d i s u n w a n t e d s e x u a l a d v a n c es . W o m e n d o n o t a lw a ys r e -p o r t s u c h e x p e r i e n c e s t o t h e p o l i c e o r d i s c u ss t h e m w i t h fa m i l y o r f r i e n d s . T h e p e r s o n m a k i n g t h e a d v a n c e s i s n ' t al w ay s as t ra n g e r , b u t c a n b e a f ri e n d , b o y f r ie n d , o r e v e n a f a m i l y m e m b e r . S u c h e x p e r i e n c e s c a n o c c u r a n y t i m e i n a w o m e n ' sl i f e - - e v e n a s a c h i ld . R e ga r d l es s o f h o w l o n g a g o i t h a p p e n e d o r w h o m a d e t h e a d v a n c e s , . . "H a s a m a n o r b o y e v e r m a d e y o u h a v e s e x by u s in g f o rc e o r t h r e a t e n i n g t o h a r m y o u o r s o m e o n e c l os e t o y o u ? J u s t s o t h e r e i sn o m i s ta k e , b y se x w e m e a n p u t t i n g a p e n i s i n y o u r v a g i n a.H a s a n y o n e e v e r m a d e y o u h a v e o r a l s e x b y fo r c e o r t h r e a t o f h a r m ? J u s t s o t h e r e i s n o m i s ta k e , b y o ra l s e x w e m e a n t h a t a m a no r b o y p u t h i s p e n i s i n y o u r m o u t h o r s o m e o n e p e n e t r a t e d y o u r v a g in a o r a n u s w i t h t h e i r m o u t h o r t o n g u e .H a s a n y o n e e v e r m a d e y o u h a v e a n a l s e x b y f o r c e o r t h r e a t o f h a r m ?H a s a n y o n e e v e r p u t f i n g e r s o r o b j e c t s in y o u r v a g i n a o r a n u s a g a i n s t y o u r w il l b y u s i n g f o r c e o r t h r e a t s ?

t i o n , c h a r a c t e r i s ti c s o f t h e s u b s e t o f c a s e s in w h i c h r a p e -r e l a t e d p r e g n a n c y o c c u r r e d a r e p r o v i d e d .

M e t h o d sT h e N a t i o n a l W o m e n ' s S t u d y w a s s u p p o r t e d b y t h e

N a t i o n a l I n s t it u t e o n D r u g A b u s e a n d w a s u n d e r t a k e n t oi n v e st ig a t e t h e r e la t i o n s h i p s b e tw e e n w o m e n ' s t r a u m ah i s to r i es a n d m e n t a l a n d p h y s i ca l h e a l t h o u t c o m e s , i n -c l u d i n g s u b s t a n c e u s e a n d a b u s e. T h e s t ud y in v o l v e d a3 - y e ar l o n g i t u d i n a l t e l e p h o n e s u r v e y o f a l a r g e n a t i o n a lp r o b a b i l i t y s a m p le . P o t e n t i a l r e s p o n d e n t s i n c l u d e d a llw o m e n i n t h e re s i d e n t i a l p o p u l a t i o n o f t h e U n i t e d S t at esw h o w e r e > 1 8 y e a r s o l d a t t h e t i m e o f t h e i n i t i a l s u rv e y .S a m p l e c o n s t r u c t i o n y ie l d e d a p o p u l a t i o n - b a s e d r a n d o md i g i t d i a l in g s a m p l e O f h o u s e h o l d s . A t o t a l o f 4 0 0 8 i n t e r -v ie w s w e r e c o n d u c t e d ; 2 0 0 8 o f w h i c h w e r e a n o v e r s a m -p l i n g o f w o m e n b e t w e e n t h e a g e s o f 18 a n d 3 4 ye a rs .A t t e m p t s w e r e m a d e t o in t e r v ie w e a c h o f t h e o r i g in a l4 0 0 8 r e s p o n d e n t s t h r e e t i m e s a t 1 -y e a r i n t e rv a l s .

T h e i n i ti a l i n t e rv i e w , d e s i g n a t e d w a v e 1 , e s t a b l i s h e dl i f e ti m e p r e v a l e n c e r a t e s o f r a p e a n d o b t a i n e d d e s c r i p t i v ei n f o r m a t i o n a b o u t r a p e c a se s. I n f o r m a t i o n a b o u t t h ep a s t -y e a r i n c i d e n c e o f r a p e w a s o b t a i n e d i n t h e w a v e 2( 1 -y e ar fo l lo w - u p ) i n t e rv i e w b y d e t e r m i n i n g h o w m a n yw o m e n w e r e r a p e d i n t h e ye a r b e t w e e n w a ve 1 a n d w a v e 2.T h e w a v e 3 i n t e r v i e w f o r m e d t h e b a s is o f th i s r e p o r t a n di n c l u d e d m e d i c a l o u t c o m e s a n d m e d i c a l t r e a t m e n t r e -

c e i v e d a f t er e a c h o f u p t o t h r e e r a p e e x p e r i e n c e s t h a t m a yh a v e o c c u r r e d d u r i n g a w o m a n ' s l i f e ti m e : a f ir s t r a p ei n c i d e n t , a m o s t r e c e n t r a p e i n c i d e n t , a n d a w o r s t su c hi n c i d e n t , i f d i s t i n c t f r o m t h e f i r st o r m o s t r e c e n t r a p ei n c i d e n t . W a v e 3 al so g a t h e r e d d a t a o n r a p e v i c t im s ' c o n -c e r n s , w i l li n g n e s s to r e p o r t f u t u r e r a p e s t o p o l i c e , a n do p i n i o n s a b o u t d i s c lo s u re . M e n t a l h e a l t h p r o b l e m s w e r ea s s es s e d d u r i n g e a c h o f t h e t h r e e w a v es . A l l s u r v e y i n t e r-v i e w in g w as d o n e b y fe m a l e i n t er v i e w e r s f r o m S c h u l m a n ,R o n c a , a n d B u c u v a l a s , I n c ., a n a t i o n a l s u r v e y r e s e a r c ho r g a n i z a t i o n b a s e d i n N e w Y o r k C ity .

W i t h i n t h e i n t e r v i ew , s e x u a l a s s a u l t ( " r a p e " ) w a s d e -f i n e d a s n o n c o n s e n s u a l a s s a u l t w i t h fo r c e o r t h r e a t o ff o rc e a n d s o m e t y pe o f s ex u a l p e n e t r a t i o n o f t h e v ic t i m 'sv a g i n a , r e c t u m , o r m o u t h . T h e s p e c i f i c q u e s t i o n s t o as se s sr a p e u s e d s e n si ti v e , b e h a v i o r a l l y s p e c if i c p h r a s i n g a c c o r d -i n g t o a n o r i e n t i n g p r e f a c e a s o u t l i n e d i n T a b l e I .

W h e t h e r t h e w o m a n d i d o r d i d n o t s u bj e ct iv e ly d e f i n e t h ei n c i d e n t ( s ) a s r a p e o r r e p o r t e d i t t o p o li c e o r o t h e r a u -t h o r i ti e s , a n a f f i r m a t i v e r e s p o n s e t o a n y o f t h e s e q u e s -t io n s i n d i c a t e d t h a t t h e w o m a n h a d b e e n a v ic t im o f ra p e .

B e c a u s e t h e s u r v e y i n c l u d e d a n o v e r s a m p l e o f y o u n g e rw o m e n a n d b e c a u s e s o m e a t t r i t i o n o c c u r r e d o v e r th e2 - y ea r f o l lo w - u p p e r i o d o f th e s tu d y , t h e a c h i e v e d s a m p l ed a t a w e r e w e i g h t e d b y a g e a n d r a c e t o t h e U . S . C e n s u sp r o j e c t i o n s o f t h e 1 9 9 0 ( w a v e 1 ) , 1 9 9 1 ( w a v e 2 ), a n d 1 9 9 2( w av e 3) a d u l t f e m a l e p o p u l a t i o n .

Re s u l t sE i g ht y -f iv e p e r c e n t o f w o m e n i n it i al l y c o n t a c t e d a g r e e d

t o p a r t i c i p a t e a n d c o m p l e t e d t h e w a v e 1 i n t e r v i e w( n = 4 0 0 8 ) . A t t h e 1 - y e a r f o l l o w - u p , 8 0 % ( n = 3 2 2 0 ) o f t h es tu d y p a r ti c i p a n ts w e r e l o c a t ed a n d c o m p l e t e d t h e w a ve 2i n t e rv i e w . O f t h e o r i g i n a l p a r t i c i p a n t s , 7 6 % ( n = 3 0 3 1 )c o m p l e t e d t h e w a v e 3 i n t e rv i e w . T h e m e a n a g e f o r t h ee n t i r e s a m p l e w a s 4 4 .9 y e a r s ( S D 1 8 .4 ) . T h e m a j o r i t y o fw o m e n w e r e h i g h s c h o o l g ra d u a t e s ( 6 3. 4 % ). T h e m a j o r it yo f t h e s a m p l e ( 6 3 .7 % ) w e r e m a r r i e d o r c o h a b i t a t in g .M o r e t h a n h a l f o f t h e s a m p le r e p o r t e d h o u s e h o l d i n c o m eb e t w e e n $ 1 5 , 0 0 1 a n d $ 5 0 ,0 0 0 , w i t h a s u b s t a n t i a l m i n o r i t y( 2 7 . 3 % ) r e p o r t i n g i n c o m e s < $ 1 5 ,0 0 0 . F o r m o r e d e t a i l o nd e s c r i p t i v e d a t a f r o m w a v e 1 o f t h e s t u d y s e e R e s n i c k e t a l. 2

D a t a o n t h e p r e v a l e n c e o f r a p e a n d r a p e - r e l a t e d p r e g -n a n c y o b s e r v e d a s p a r t o f t h e 'w a ve 3 a s s e s s m e n t i n t e r v i e wa r e f ir s t p r e s e n t e d a s w e i g h t e d b y ag e a n d r a c e t o t h e U . S .a d u l t p o p u l a t i o n o f w o m e n . T h e s e d a t a a l l ow fo r e st i-m a t e s t o b e m a d e o f n a t io n a l r a t e s o f r a p e - r e l a t e d p r e g -n a n c y . T h e s e d a t a a r e f o ll o w e d b y u n w e i g h t e d d e s c r i p t iv ed a t a a b o u t p r e g n a n c y o u t c o m e s a n d m e d i c a l t r e a tm e n tr e c e iv e d b y w o m e n w h o r e p o r t e d a p r e g n a n c y r e s u l t i n gf r o m r a p e.

O f t h e 3 03 1 a d u l t w o m e n , 4 1 3 h a d e x p e r i e n c e d 6 1 6c o m p l e t e d r a p e i n c i d e n t s a t s o m e t i m e d u r i n g t h e i r li ve s,r e s u l t i n g i n a 1 3 . 6 % l i f e t im e p r e v a l e n c e r a t e o f r ap e .A g e - s p e c i f ic f i n d i n g s a r e d e t a i l e d i n T a b l e I I. P r e g n a n c yr e s u l t i n g f r o m r a p e w a s r e p o r t e d b y a t o ta l o f 19 w o m e n :O n e w o m a n r e p o r t e d t w o r a p e - r e l a t e d p r e g n a n c i e s ;t h e r e f o r e a t o t a l o f 2 0 c as e s o f r a p e - r e l a t e d p r e g n a n c yw e r e i d e n t i f i e d . W h e n o n l y v i c t im s o f r e p r o d u c t i v e a g ew e r e c o n s i d e r e d , t h e r a p e - r e l a t e d p r e g n a n c y r a t e w a s 5 %p e r r a p e o r 6 % p e r v i c t im .

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Table II. Rape-related pregnancy rates per rape incidentTotal No. Age 12-17 yr Age >18 yr Age 12 to 45

Rape cases 616 187 214 404Rape-relatedpregnancies 20 (3.2%) 10 (5.3%) 10 (4.7%) 20 (5.0%)Victims r413 148 183 315

Table III. Relationship between victim andperpetrator among rape-related pregnancies

Stranger 8.8%Boyfriend 29.4%Husband 17.6%Friend 14.7%Other relative 11.8%Known, nonrelative 8.8%Father-stepfather 5.9%Unknown-refused 2.9%

The weighted prevalence of rape-related pregnancy asa result of rape at any age(s) among all adult women is0.63% or a total of 606,690, o n the basis of an estim ated96.3 million adult women in the population from the1989 U.S. Census Bureau: The National Women's Studyalso identified an incidence of 683,000 rapes in 1 yearamong adult women in the United States. Thus it canbe estimated on the basis of the adult rape-related preg-nancy case rate of 4.7% tha t th ere m ay be 32,101 rape-related pregnancies annually among American womenolder than 18 years.

Analysis of the Natio nal Wo men' s Study raw data (with-out statistical weighting required for deter mining repre-sentative population estimates) indicates that there were34 cases of rape-related pregnancy. A total of 30 womenreported one rape-related pregnancy and two additionalwomen re ported two rape-related pregnancies. Of the 34cases 21% oc cur red when the victi m was aged 12 to 15years, 27% occurred among women aged 16 and 17, and52% occurred after age 18. After the assault only 24%(n = 8) underwe nt a medical examination. Among these8 cases the physician was notified that a rape had oc-curre d in only 3. Of the cases in which medical att entionwas received 11.7% of patients were exa mine d within 48hours after the rape, 5.9% were exa mine d within 1 week,and an additional 5.9% were examined within 1 month ofthe assault. In those cases in which there was no medicalattention, only half of the patients reported being coun-seled about the possibility of pregnancy resulting fromthe assault. Subsequently, in 61.7% of cases the preg-nancy was discovered within 11 weeks after the rape. Anadditional 32.4% did not discover they were pregnantuntil they had already enter ed the se cond trime ster (12 to26 weeks after the rape), and 5.9% were unsure of thetime elapsed after the rape. Outcomes of rape-relatedpregnancy cases confirmed that the majority of thesepregnancies were unwanted. The infant was kept by themot her in 32.3% of cases, 50% under wen t aborti on, and5.9% placed the infant for adoption. A total of 11.8% of

the rape-related pregnancies resulted in spontaneousabortion.

The majority of rape-related pregnancies involved aknown perpetrator rather than a stranger. The relation-ships between the victims and the perpetrators are pro-vided in Table III. Rape-related pregnancy resulted froma single assault in 58.8% of cases, but 41.2% of casesinvolved repetitive assaults, one of which was assumed toresult in the pregnancy. Rape cases leading to pregnancyincluded the use of alcohol or drugs by the victim in20.6% of cases and by the perpe trat or in 55.9% of cases.

The ma ximum expected sampling error for simple ran-dom samples of 4000, 3200, and 3000 cases are +1.5%,+1.7%, and +1.8%, respectively, which is at the 95% co n-fidence level.

C o m m e n tWith >32,000 rape-related pregnancies occurring each

year among adult women in the U nit ed Stats and an as yetundetermined number occurring among adolescents,rape-related pregnancy is a significant problem that war-rants closer attention. Al thoug h the total num ber of rape-related pregnancies may account for only a small portionof the estimated 3 million unintende d pregnancies occur-ring annually in the Unit ed States, the occurr ence o f preg-nancy resulting from rape or incest holds importan t publichealt h and policy implications. For example, policy de-bates surround ing abortion f undi ng for cases of rape andincest have historically lacked scientific found atio n as theyhave been based on data from the small proportion ofreported cases. Additionally, rape victims have not beenafforded adequate funding under crime victim compensa-tion programs to cover follow-up that could reduce theoccurrence of rape-related pregnancy and other seriousphysical and mental health sequelae. The National Wom-en's Study represents the first national empiric data onlifetime prevalence and past-year incidence of rape amo ngadult women. Population-based rape-related pregnancyrates similarly have not been previously reporte d.

Unintended pregnancy has been identified as a na-tional epidemic , 17 and substantial hum an and financialresources have been dedicated to addressing and improv-ing this problem . To date, rape- related pre gnancy has notbeen identified as a contributing factor in unintendedpregnancy rates. The United States Public Health Ser-vice, in its publica tion Heal thy Peop le 2000 , has establishednational health objectives that specifically target a largereduction in all unintended pregnancies to a rate of

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r o o t in g r e s p o n s ib le s e x u a l ity , a n d in c r e a s in g e f f e c t iv e u s eo f f a mi ly p l a n n in g me t h o d s . 17~9 Al l o f th e s e me a s u r e sa s s u m e t h a t t h e p r e g n a n t w o m a n c o n c e i v e d t h r o u g h c o n -s e n s u a l i n t e r c o u r s e a n d i s r e s p o n s i b l e f o r h e r p r e g n a n c y .

A p a r t i c u la r ly d i s tu r b in g f in d in g in th i s s tu d y in c lu d e st h e i d e n t i f i c a t i o n o f t h e p e r p e t r a t o r a s b e i n g k n o w n ,o f t e n w e l l k n o w n , t o t h e v i c t im . T h i s e v i d e n c e i m p l i e st h a t r a p e - r e l a t e d p r e g n a n c y i s cl o s el y l i n k e d w i t h d o m e s -t i c a n d f a m i l y v i o l e n c e . T h i s c o n c e p t i s f u r t h e r s u p p o r t e db y t h e f ac t t h a t > 4 0% o f t h e r a p e - r e l a t e d p r e g n a n c i e sr e s u l t e d f r o m m u l t i p l e a s sa u lt s r a t h e r t h a n f r o m a si n g l ea t t a ck a n d t h u s o c c u r r e d i n t h e s e t t i n g o f o n g o i n g v i o -l e n c e o r a b u s e . P r e v i o u s r e p o r t s i n t h e m e d i c a l l i t e r a t u r eh a v e f a i l e d t o i d e n t if y t h is f a c e t o f t h e p r o b l e m b e c a u s eth e y h a v e r e l i e d o n d a ta f r o m r e p o r t e d c a s e s on ly . 7-1B e c a u s e b a t t e r e d w o m e n a n d a b u s e d c h i l d r e n d o n o tr e a d i ly d i s c lo s e th e i r a b u s e , 2 p r e g n a n c ie s o c c u r r in g inth i s s e t t in g a r e u n l ik e ly to b e d i s c lo s e d e a r ly in g e s ta t io na n d a r e m o r e l i k el y t o r e su l t i n c o m p l i c a t i o n s a n d l o n g -t e r m s e q u e l a e t h a t a f f e c t t h e v i c ti m a n d e v e n t h e f e t usa n d in f a n t . 2' 21 A ls o , b e c a u s e p r e g n a n c y ma y b e a s so c i -a te d w ith in crease s in ba t t e r in g , 22-24r a p e - r e l a t e d p r e g n a n -c ie s a f f e c t in g v ic t ims in th i s s e t t in g wo u ld b e e x p e c te d toh a v e a p a r t i c u la r ly h ig h r i s k f o r a d v e r s e p h y s ic a l a n dp s y c h o l o g i c o u t c o m e s .

As fe w a s 1 0% to 2 0 % o f s e x u a l a s sa u l ts a r e e v e rr e p o r t e d t o l aw e n f o r c e m e n t . / ' 5 M o s t s t at e s h a v e c r i m ev i c t i m c o m p e n s a t i o n p r o g r a m s t h a t p r o v i d e f i n a n c i a ls u p p o r t f o r e v i d e n c e c o l l e c t i o n a n d i m m e d i a t e m e d i c a le x a mi n a t io n in c a s e s o f s e x u a l a s sa u l t. Ho s p i t a l s a r et h e r e f o r e r e q u i r e d t o r e p o r t s e x u a l as s au l t i f a n e v i d e n -t i a ry e x a m i n a t i o n i s p e r f o r m e d . 2~ F o r t h o s e v i c ti m sc h o o s i n g n o t t o r e p o r t t o l aw e n f o r c e m e n t , m e d i c a la t t e n t io n i s o f t e n u n a v a i l a b le u n le s s th e v ic t im p a ys f o ri t h e r s el f ; p r o v i d i n g t h e o p p o r t u n i t y f o r a n o n y m o u s r e -p o r t i n g c a n i m p r o v e v i c t i m s ' a cc e s s to c a r e. N o n e t h e l e s s ,b o t h t h e c u r r e n t l o w r a t e o f r e p o r t i n g a n d t h e l a c k o fa p p r o p r i a t e m e d i c a l s e r v i c es f o r n o n r e p o r t e r s m a y co n -t r i b u t e t o t h e o c c u r r e n c e o f r a p e - r e l a t e d p r e g n a n c y. F o rv i c t im s r e c e i v i n g i m m e d i a t e m e d i c a l a t t e n t i o n , t h e o p -t i o n t o r e c ei v e p o s tc o i t a l c o n t r a c e p t i o n s h o u l d b e o f-f e r e d . 26 Ad d i t io n a l ly , p h y s ic i a n s a r e e x p e c t e d to e n c o u r -a g e a n d a r r a n g e m e d i c a l a n d p s y c h o l o g i c f o l l o w - u p f o rs e x u a l a s s a u l t v i c t ims . T h e r e f o r e w i th p r o p e r a n d a c c e s -s i bl e m e d i c a l c a r e r a p e - r e l a t e d p r e g n a n c y c a n b e p r e -v e n t e d o r a t l e a s t r e c o g n i z e d e a r l y e n o u g h d u r i n g f o l -l o w - u p c a r e t o a l l ow f o r s af e t e r m i n a t i o n o r a p p r o p r i a t ep r e n a t a l c a r e .

T h i s s tu d y i s n o t w i th o u t l imi ta t io n s . By i t s n a tu r e , at e l e p h o n e s u r v e y i s l i m i t e d t o t h e 9 4 % o f t h e p o p u l a t i o nl i v in g i n h o u s e h o l d s w i t h t e l e p h o n e s . O t h e r l i m i t a t i o n si n h e r e n t i n t h is t y pe o f d a t a c o l l e c t i o n i n c l u d e t h e r e t r o -s p e ct i v e n a t u r e o f c o l l e c t i n g l i f e t i m e i n f o r m a t i o n a n d t h ein a b i l i ty to c o n f i r m th e f a c tu a l i ty o f r e s p o n s e s . O n th eo t h e r h a n d , t h e r e p r e s e n t a t i v e n a t u r e o f a l a r g e p o p u l a -t io n - b a s e d s a mp le s u c h a s th i s a l lo ws f o r mo r e a p p r o p r i -a t e g e n e ra l i z a t i o n s t h a n d a t a c o l l e c t e d f r o m t r e a t m e n t -

s e e k in g g r o u p s . Ho p e f u l ly , th e s e d a ta ma y s e r v e a s a p o in to f d e p a r t u r e f o r f u t u r e p r o s p e c t i v e r e s e a r c h t h a t c a nm o r e c l e a r l y a n d p r e c i s e l y d e t e r m i n e t h e e x t e n t o f t h ep r o b l e m o f r a p e -r e l a t e d p r e g n a n c y a n d o t h e r r a p e - re -l a t e d h e a l t h o u t c o m e s .

T o m a x i m i z e n a t i o n a l e f f o r t s t o r e d u c e t h e n u m b e r o fu n i n t e n d e d p r e g n a n c ie s a n d t o p r e v e n t t h e c o m p l i c a t e ds e q u e l a e o f r a p e t h a t a f f e c t w o m e n , c h i l d r e n , a n d s o c i e t yi n g e n e r a l , t h e r e m u s t b e g r e a t e r e f f o r ts f r o m m e d i c a l ,s o c ia l, e d u c a t io n a l , a n d p u b l i c p o l i c y p r o f e s s io n a l s a im e dt o w a rd r e c o g n i t i o n a n d p r e v e n t i o n o f u n i n t e n d e d p r e g-n a n c y r e s u l t i n g f r o m s e x u a l v i c t i m i z a t i o n . T h e s e e f f o r t sn o t o n l y s h o u l d f o c u s o n t h e p r i m a r y p r e v e n t i o n o fs e x u a l a s s a u l t , i n c lu d in g d a te r a p e , ma r i t a l r a p e , a n din c e s t , b u t a l s o s h o u l d a im to imp r o v e th e a v a i l a b i l i ty a n da c c e s s ib i l i ty o f me d ic a l s e r v ic e s th a t p r o v i d e me d ic a le v a l u a t i o n , c o u n s e l i n g , p o s t c o i t a l c o n t r a c e p t i o n , p r e g -n a n c y t e r m i n a t i o n s e rv i c es , o r a p p r o p r i a t e p r e n a t a l c a r ea s d e s i r e d a f t e r r a p e .

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D i s c u s s i o nD R . J o n ~ G . M o o ~ , A t l a n t a , G e o r g i a ( O f f i c i a l G u e s t ) .

T h e a u t h o r s a r e t o be c o m p l i m e n t e d f o r t hi s o r i g i n a ls tu d y , w h i c h a t t e m p t s t o d e v e l o p v a l i d d a t a c o n c e r n i n gr a p e - r e l a t e d p r e g n a n c y . H e r e t o f o r e , p u b l i s h e d s t u d i e sg e n e r a l l y r e l i e d o n d a t a f r o m e i t h e r c r is i s c e n t e r s o r p o -l i c e r e p o r t s i n d e v e l o p i n g p r e v a l e n c e f i g u r e s f o r r a p e -r e l a t e d p r e g n a n c i e s . H o w e v e r , i t i s w i d e l y k n o w n t h a t al a r g e m a j o r i t y o f r a p e s a r e n o t r e p o r t e d a n d t h a t a si g n if -i c a n t n u m b e r o f w o m e n f a i l t o s ee k m e d i c a l c a r e a f t e r t h eo c c u r r e n c e o f r a p e . A s a r es u lt , p u b l i s h e d p r e v a l e n c ef i g u r e s a r e c l o u d e d b y i n a c c u r a c i e s a n d s p e c u l a t i o n . T h i ss t u d y a t t e m p t e d t o c o l l e c t a c c u r a t e d a t a t h a t c o u l d b ee x t r a p o l a t e d t o t h e g e n e r a l p o p u l a t i o n . T h e m e t h o d o ft h e s t u d y i n v o l v e d a 3 -y e a r l o n g i t u d i n a l t e l e p h o n e s u r v e yo f > 4 0 0 0 w o m e n . A s t u d y s u c h a s t h is i s f r a u g h t w i t hd i f f ic u l t y b e c a u s e o f t h e l i m i t a t i o n s o f t h e s u r v e y t e c h -n i q u e .

W h e n e v a l u a t i n g t h i s st u dy , o n e m u s t i n i ti a l ly c o n s i d e rt h e d i f f i c u l t i es a s s o c i a t e d w i t h i n t e r v i e w e r b i a s . T h e i n t e r -v i e w e r h a d t h e d i s c r e t i o n t o c l as s if y a n e v e n t a s a r a p ee v e n i f t h e w o m a n d i d n o t i d e n t i f y it as s u c h , s e e k m e d i c a lc a r e , o r n o t i f y p o l i c e a u t h o r i t i e s . I n a c c o r d a n c e w i t h t h ew o r d i n g a n d i n t e r p r e t a t i o n o f t h e q u e s t io n s , s o m e v a r i-a b i li t y in t h e c l a s s if i c a ti o n o f i n d i v i d u a l c a s es c o u l d o c c u r .F u r t h e r m o r e , t h e w e l l - r e c o g n iz e d r e l u c t a n c e t o d is c us si n t i m a t e s e x u a l d e ta il s , w h i c h w o u l d n o t b e s u r m o u n t e db y t h e a n o n y m i t y o f t h e t e l e p h o n e i n t e r v i e w pr o c es s ,i n t r o d u c e s y e t a n o t h e r s a m p l i n g b i a s. ! n a d d i t i o n , t h e r e i sn o w a y t o q u a n t i f y t h e a c c u r a c y a n d v e r a c i t y o f t h e r e -s p o n d e r s o r t o c o m p a r e o n e i n d i v i d u a l ' s r e s p o n s e o b j e c -t iv e l y w i t h t h e r e s p o n s e s o f o t h e r s s u r v e y e d . F i n a ll y , th er e t r o s p ec t i v e n a t u r e o f th i s s tu d y i n t r o d u c e s u n c e r t a i n t ya s a r e s u l t o f t h e v a r y i n g a b i l i t y o f i n d i v i d u a l s t o r e c a l l p a s te v e n t s .

D r. H o l m e s r e p o r t s t h a t 3 2% o f w o m e n w h o b e c a m ep r e g n a n t a s a r e s u lt o f a r a p e w e r e n o t a w a r e o f t h ep r e g n a n c y u n t i l t h e s e c o n d t r i m e s t e r . A r e c e n t s t u d y t h a t

u s e d d e o x y r i b o n u c l e i c a c i d a na ly s is t e c h n i q u e s r e p o r t e dt h a t 6 0% o f w o m e n w h o b e c a m e p r e g n a n t a f t e r a n a s sa u ltw e r e i n s t e a d p r e g n a n t b y a c o n s e n s u a l p a r t n e r . ' I n a s-m u c h a s 6 4 % o f t h e w o m e n i n t h i s s t ud y w e r e e i t h e rm a r r i e d o r c o h a b i t a ti n g , i t m u s t b e a s s u m e d t h a t t h es ei n d i vi d u a ls w e r e e x p o s e d t o c o n s e n s u a l i n t e r co u r s e .T h e r e f o r e w i t h o u t t h e a p p r o p r i a t e d e o x y r i b o n u c l e i c a ci da n a ly s i s t h e p r e g n a n c i e s c a n n o t c o n c l u s i v e l y b e a s c r i b e dt o th e r a p e i n c i d e n t . T h e i s s u e i s f u r t h e r c o m p l i c a t e dw h e n t h e r e p o r t e d a s s ai la n t is e i t h e r t h e v i c t i m ' s h u s b a n do r h e r b o y f r i e n d a n d s e x u al r e l a ti o n s w e r e a t t im e s c o n -s e n s u a l a n d a t o t h e r t i m e s f o r c e d . I n t h e la t t e r c i r c u m -s t a n c e i t i s i m p o s s i b l e t o d i f f e r e n t i a t e w h e t h e r t h e p r e g -n a n c y w a s a re s u l t o f c o n s e n t i n g v e r s u s f o r c e d s e x u a le x p o s u r e .

L a c k o f m e d i c a l c a r e a f t e r a n a s s a u l t i s a m a j o r m e d i c a la n d s o c i a l p r o b l e m . O n l y 1 1 . 7 % o f t h e i n d i v i d u a l s d e -s c r i b e d i n t h e s t u d y w e r e s e e n w i t h i n 4 8 h o u r s o f t h ei n c i d e n t . F u r t h e r m o r e , i t i s o f c o n c e r n t h a t o n l y 5 0 % o ft h e w o m e n w h o r e c e i v e d m e d i c a l a t t e n t i o n r e p o r t e d t h a tt h e y h a d b e e n c o u n s e l e d a b o u t t h e p o s s i b i li t y o f a p r e g -n a n c y r e s u l t i n g f r o m t h e e v e n t . T h i s i s a g l a r i n g d e fi -c i e n c y i n t h e s t a n d a r d o f m e d i c a l c a r e a n d p o i n t s t o a na r e a i n w h i c h w e a s g y n e c o l o g i s t s m u s t s t ri v e to i m p r o v et h e h e a l t h c a r e d e l i v e r y s y s te m . T h e r e c o g n i z e d r e l u c -t a n c e o f w o m e n t o s e e k c a r e a f t e r a s e x u a l a s s au l t o r e v e nt o d is c u s s s u c h a n i n c i d e n t e m p h a s i z e s t h e n e e d f o r u s t om a i n t a i n a h i g h i n d e x o f su s p i c io n r e g a r d i n g t h e p o ss i-b i l it y o f a s sa u l t, w h i c h w o u l d t h e n a l l o w u s to a s k t h en e c e s s a r y q u e st i o n s a n d i n i t ia t e a p p r o p r i a t e t r e a t m e n ta n d c o u n s e l in g . 2

A n o t h e r l i m i t a t i o n o f t h i s s t u d y i s t h e e x c l u s i o n o fw o m e n < 1 8 y e a rs o l d. A l t h o u g h t h e r e i s a c l e a r u n d e r -s t a n d i n g t h a t m o r e t h a n h a l f o f r a p e s o c c u r a m o n g a d o -l e s c e n t s y o u n g e r t h a n 1 8 y e a rs , t h e s t u d y fa i ls t o a d d r e s st h i s s i g n i f i c a n t p r o b l e m . I n d e e d , a s i s w e l l r e c o g n i z e d ,y o u n g g i r l s a n d a d o l e s c e n t s a r e q u i te i g n o r a n t r e g a r d i n gs e x u a l i ty a n d r e p r o d u c t i v e r e a l it i e s . I n f a c t, i n o n e s t u d yo f t e e n a g e r s w h o b e c a m e p r e g n a n t , 3 3 % r e p o r t e d e x p e -r i e n c i n g f o r c e d o r u n w a n t e d s e x u a l i n t e r c o u r s e ? T h ec u r r e n t s t u d y t h e r e f o r e l e a v e s a l a r g e a n d s i g n i f i c a n t p o r -t i o n o f t h e q u e s t i o n r e g a r d i n g r a p e a n d p r e g n a n c y u n a n -s w e r ed . I t w o u l d b e a m u c h m o r e p o w e r f u l a n d s ig n if i-c a n t s t u dy i f t h e e n t i r e c o h o r t h a d b e e n s u r ve y e d .

I n c l o s i n g , I w i l l a s k D r. H o l m e s t h e f o l l o w i n g q u e s -t i o n s . F ir s t , c a n y o u a d d r e s s t h e i s s u e o f i n t e r v i e w e r b i a s,p a r t i c u l a r l y i n t h e c l a s s if i c a ti o n o f w h a t c o n s t i t u t e s s e x u a la s sa u lt i n t h o s e w o m e n w h o t h e m s e l v e s fa i l t o r e c o g n i z et h e i r e x p e r i e n c e a s a r a p e - r e l a t e d i n c i d e n t ? S e c o n d , I a s kD r. H o l m e s w h a t a re h e r r e c o m m e n d a t i o n s t o e n c o u r a g ew o m e n t o r e p o r t s e x u a l a s sa u lt a n d s e e k ea r ly m e d i c a lc a r e ? F in a ll y , I w o n d e r w h e t h e r y o u h a v e a n y p l a n s f o ri n c l u d i n g w o m e n u n d e r a g e 1 8 y e a rs i n y o u r f u t u r e r e -s e a r c h e f f o r ts ?

I e n c o u r a g e D r . H o l m e s t o c o n t i n u e w i t h h e r s t u d i e sa n d f a v o r u s w i t h o n g o i n g r e p o r t s c o n c e r n i n g t h is i m p o r -t a n t a n d s o c i al l y r e l e v a n t t o p i c .

R E F E R EN C E S1 . H a m m o n d H A , R e d m a n J B , C a sk e y CT . I n u t e r o p a t e r n i t ytes t ing fo l lowing a l leged sexua l a ssau l t . JAMA 1995 ;273 :1774-7.

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2 . B a n g L . R a p e v i c t i m s - - a s s a u l t s , i n j u r i e s a n d t r e a t m e n t a t am e d i c a l r a p e t r a u m a s e r v i c e a t O s l o E m e r g e n c y H o s p i t a l .Scand J P r im He a l th Care 1993 ; 11 :15-20 .3 . H e i s e L L . G e n d e r - b a s e d v i o l e n c e a n d w o m e n ' s r e p r o d u c t i v ehea l th . I n t J G yneco l Obs te t 1994 ;46 :221-9 .D R. H u c n M O RE NO , A t l a n t a , G e o r g i a . I n G r a d y M e m o -

r i a l H o s p i t a l R a p e C e n t e r , w e s e e a n a v e r a g e o f t h r e e t of i v e c a s e s o f r a p e w e e k l y . I n a l l t h o s e c a s e s w i t h o u t a c t i v ec o n t r a c e p t i o n t h e p a t i e n t s a r e o f f e r e d t h e " m o r n i n g -a f t e r p il l ." I w o u l d l ik e t o k n o w w h a t p e r c e n t a g e o f t h ep a t i e n t s i n th e s t u d y w e r e e x a m i n e d a n d w h a t p e r c e n t a g eo f t h o s e p a t i e n t s w e r e o f f e r e d t h i s t y p e o f c o n t r a c e p t i o n .

D R, H OL ME S ( C l o s i n g ). W e a t t e m p t e d t o m i n i m i z e i n t e r -v i e w e r b i a s b y u s i n g a v e r y r e p u t a b l e p r o f e s s i o n a l r e -s e a r c h s u r v e y f i r m t h a t i s o b v i o u s ly v e r y f a m i l i a r w i t ha v o i d i n g b i as i n q u e s t i o n i n g c l ie n t s o v e r t h e t e l e p h o n e .A l l q u e s t i o n s w e r e o b j e c t i v e a n d w e r e a c t u a l l y s c r i p t e d s ot h a t v a r i a t i o n a m o n g t h e i n t e r v i e w e r s w a s a v o i d e d . F i-n al ly , w e d i d n o t i n c l u d e a t t e m p t e d r a p e s i n o u r d a t a b u ti n c l u d e d o n l y r a p e s t h a t w e r e c o m p l e t e d a n d f o r c e d . I fw e r e v i e w t h e a c t u a l q u e s t i o n s a s k e d , w e se e t h a t t h e y a r ev e r y s p ec i fi c a n d l e a v e l it d e o r n o r o o m f o r i n t e r p r e t a t i o no f w h e t h e r a r a p e d i d o r d i d n o t o c c u r.

H o w c a n w e i n c re a s e r e p o r t i n g a m o n g o u r p a t ie n t s? I no u r c o u n t r y t h a t ' s a p r o b l e m w e al l h a v e t o f a c e , a n d i t 'sa p r o b l e m t h a t l aw e n f o r c e m e n t i s d e a l i n g w i th a s w e ll .O b v i o u s l y t h e a n sw e r , as in s o m a n y o t h e r a r e as o f m e d i -c i n e , is n o t j u s t p a t i e n t e d u c a t i o n b u t a l s o p u b l i c e d u c a -t i o n . S p e c if i c al l y, as a p h y s i c i a n p r o v i d i n g h e a l t h c a r e t o

w o m e n , I t h i n k t h e b e s t t h i n g w e c a n d o i s r o u t i n e l yi n c o r p o r a t e q u e s t i o n s a b o u t p r i o r s e x u a l v i c t i m i z a ti o na n d p h y s ic a l t ra u m a i n t o o u r r o u t i n e h e a l t h a s s e s sm e n t .T h a t m a k e s o u r p a t i e n t s r e a li z e th a t e x p e r i e n c i n g s u c ht r a u m a h a s i m p o r t a n t i m p l i c a t i o n s f o r th e i r h e a l t h . I f ap a t i e n t sh o u l d b e u n f o r tu n a t e e n o u g h t o e x p e r i e n c e a .r a p e . o r p h y s i c a l a b u s e i n t h e f u t u r e , s h e m i g h t b e m o r el i k e ly t o r e p o r t i t; o n c e y o u a s a p h y s i c i a n h a v e a s k e da b o u t i t, y o u ' v e o p e n e d t h e d o o r f o r h e r t o d is c u s s i t. T h eo n ly r e c o m m e n d a t i o n I ha v e r ig h t n o w i n m a k i n g g r e a ts t r i d e s i n i m p r o v i n g r e p o r t i n g i s t o r o u t i n e l y a s k.

R e g a r d i n g t h e q u e s t i o n a b o u t m i n o r s , a n y o n e w h o h a st r i e d t o d o r e s e a r c h i n v o l v i n g a d o l e s c e n t s r e a l i z e s w e a r es e v e r e l y l i m i t e d b y c o n s e n t i s s u es . A l t h o u g h a m i n o r c a nc o n s e n t t o h e a l t h c a r e r e l a t e d t o h e r r e p r o d u c t i v e h e a l t h ,s h e c a n n o t c o n s e n t t o p a rt i c i p a t e i n p r o s p e c t i v e r e se a r c h .W h a t w e a r e f a c e d w i t h is h a v i n g t o d o t h i s r e tr o s p e c t i v e ly ,a n d w e a c t u a ll y a r e i n v o l v e d i n d o i n g s u c h a s t u d y r i g h tn o w . W e h a v e i n c o r p o r a t e d a v e r y d e t a i l e d s e x u a l h i s t o r yi n t o o u r A d o l e s c e n t C l i n ic , a n d w h e n w e h a v e e n o u g hp a r t i c i p a n t s , w e w i ll r e v i e w :r e c o rd s a n d h o p e t o h a v es o m e i m p o r t a n t d a t a o n a d o l e sc e n t s.

R e g a r d i n g D r . M o r e n o ' s q u e s t i o n o n p o s t c o i t a l c o n tr a -c e p t i o n , I d o n o t h a v e t h e J i n f o rm a t i o n o n h o w m a n yw o m e n w e r e e x a m i n e d a t r a p e c r i si s c e n t e r s v e r s u s ap h y s i c i a n ' s o f f i c e o r i n f o r m a t i o n o n t h e a v a i i a bi l it y o fp o s t c o i t a l c o n t r a c e p t i o n .