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Opportunities for Appropriate Care
Health Care and Contraceptive Use Among Adolescents Reporting Unwanted Sexual Intercourse
Karen M. Wilson, MPH;
Jonathan D. Klein, MD, MPH
Arch Pediatr Adolesc Med. 2002;156:341-344.
ABSTRACT
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Background Unwanted sexual contact, reported by 30% to 42% of young women and 10%
to 34% of young men, has been associated with negative health outcomes and
increased teenaged pregnancy.
Objective To determine health services and contraceptive use among adolescents
reporting unwanted sexual intercourse.
Methods Random-digit dial methods were used to survey 1040 adolescents in Monroe
County, New York; 389 (37%) were sexually active and answered a question about
whether they had ever been forced or pressured to have sexual intercourse.
The data were weighted to reflect the county population.
Results Among sexually active adolescents, 20% of females and 7% of males reported
unwanted intercourse (P<.001). For 37% of male
and 17% of female adolescents, the survey was the first time they had disclosed
the incident (P = .17). Among female adolescents
reporting unwanted intercourse, 91% have a usual source of care and 62% reported
a well visit in the previous 6 months. Female adolescents reporting unwanted
sex were more likely to have wanted contraceptives but not gotten them because
of fear their parents would find out (32% vs 11%; P
= .01) and to have had sex without contraception (69% vs 52%; P = .05) than those who had not had unwanted sex.
Conclusions Many adolescents have been forced or pressured to have sexual intercourse.
Although many have never told anyone about the incident, most have visited
a primary care physician or clinician. Physicians and other clinicians should
screen for a history of unwanted intercourse and provide needed referrals
for counseling and/or contraceptive information.
INTRODUCTION
UNWANTED SEXUAL contact in adolescence has long-term implications on
the health, well-being, and future victimization of those who experience it.1 Adolescents who have had unwanted intercourse are
more likely to consider suicide, to have sex earlier, to have been pregnant,
to have not used a condom at last intercourse, and to report eating disorder
symptoms and psychological distress.2-3
Several studies4-6
have linked unwanted sexual activity to psychological distress and alcohol
and other drug use. Physical and sexual dating violence is also associated
with risky behaviors, including alcohol use, unprotected intercourse, and
disordered eating.7
Unwanted sexual experiences are common, particularly for adolescent
girls. Between 30% and 42% of young women2, 8-9
and between 10% and 34% of young men2, 8, 10
reported unwanted sexual experiences. The 1995 National Survey of Family Growth11 found that 8% of young women aged 15 to 44 years
reported that their first intercourse was not voluntary. For those whose first
intercourse was before the age of 16 years, the proportion was even higher
(16%).11
While teenage pregnancy rates have been declining, 94.3 of 1000 US adolescents
still become pregnant every year.12 Teenage
mothers are less likely to finish school,13
and their children are more likely to live in poverty and become teenaged
parents themselves.14 High rates of teenage
pregnancy among young women who report unwanted sexual experiences, and the
high percentage who did not use condoms at last intercourse, has led to a
call for increased information and availability of emergency contraception.15
However, physicians are not generally seen as sources of help for adolescents
who have been sexually assaulted. In one study,9
only 1.3% of college-aged individuals who experienced sexual coercion sought
help from a physician. Sexual abuse and sexual intercourse are often not discussed
during office visits; in one study,16 only
20% of adolescents who reported being sexually abused had ever discussed abuse
with their physician or other provider. If adolescents see their physician
with their parents present, they may be reluctant to disclose unwanted intercourse,
particularly if their parents do not know that they are sexually active. However,
the emotional and behavioral consequences of unwanted sexual activity would
argue for an increased need for these adolescents to be connected with clinicians
who can provide confidential referrals for mental health services, contraceptive
information, and substance use counseling.
Few studies have examined the use of health services by adolescents
with a history of unwanted sexual intercourse. This study examines a representative
county-based sample of adolescents to determine health services use among
adolescents with and without a history of unwanted intercourse and to determine
whether contraceptive use differs between the groups.
SUBJECTS AND METHODS
We surveyed adolescents in Monroe County, New York, an area of about
1 million residents surrounding Rochester, NY. Between October 1998 and April
2000, 1040 adolescents aged 14 to 19 years were surveyed using random-digit
dial methods. A list of telephone exchanges in Monroe County was obtained,
and business exchanges were verified and excluded. Urban areas with high minority
populations were oversampled to improve estimates for African American and
Hispanic youth. A random list of unduplicated 4-digit numbers was generated
for each exchange; a total of 55 600 numbers were called up to 5 times,
and numbers were identified as households or businesses. Respondents were
screened for whether there were 14- to 19-year-old persons living in the household,
and an algorithm was used to randomly select an adolescent. Consent was obtained
from adolescents and from parents for adolescents younger than 18 years. Protocols
were approved by the Research Subjects Review Board at the University of Rochester
School of Medicine.
The 15- to 25-minute questionnaire included items based on the Youth
Risk Behavior Survey,2, 7 the Prevention
Minimum Evaluation Data Set,17 the Commonwealth
Fund Survey of the Health of Adolescent Girls,16
and previous studies18-19 of adolescents.
Questions included ever having had sexual intercourse, condom and birth control
use ever and at last intercourse, knowledge and use of emergency contraception,
and history of pregnancy. Health services measures included having a regular
physician, last well visit, confidential care, use of care without parental
knowledge, and insurance and socioeconomic status. Unwanted sexual intercourse
was determined by the following question, "Have you ever been forced or pressured
to have sex with someone when you didn't want to?"; this was only asked of
adolescents who reported having been sexually active. Those who responded
affirmatively were asked whether they had told anyone about it.
Data were double entered into a database (Microsoft Access, Microsoft
Corporation, Redmond, Wash) and compared using SAS statistical software (PROC
COMPARE),20 and discrepancies were resolved.
Weighting variables were created based on population data for Monroe County
extrapolated from 1990 census data by Claritas21
to approximate the county population by sex, ethnicity (white or Hispanic,
African American or multiracial, and other), and urbanicity (city, inner-city
oversample, and suburban). Frequencies and descriptive statistics and  2 and logistic regression analyses were performed using SAS and SUDAAN22 statistical software to adjust SEs to account for
the clustered sample design. A total of 1040 adolescents completed the survey.
Of the household respondents, 27% refused, and an additional 12% of adolescents
also refused. Telephone numbers for which household eligibility could not
be determined were attributed using standard methods,23
resulting in a final adjusted completion rate for eligible teenagers of 58%.
Nine adolescents did not answer the question about race and could not be assigned
a weight; therefore, they were excluded from these analyses.
RESULTS
A total of 389 adolescents (37% of the sample) reported having had sexual
intercourse. The sexually active adolescents were 50% female; 58% were white,
22% were African American, 9% were Hispanic or Latino, 7% were multiracial,
less than 1% each were Asian and Native American, and 3% were another ethnicity.
Adolescents reporting sexual activity tended to be older and nonwhite and
their family had a lower financial status than those not reporting sexual
activity. Most (56%) reported having enough money to buy necessities and special
things; 22% reported few problems, 18% had just enough, and 3% believed their
families had a hard time buying what they needed (percentages do not total
100 because of rounding). The average age of respondents was 17.6 years.
Of the sexually active adolescents, 13% had ever been forced or pressured
to have sex (20% of female and 7% of male adolescents; P<.001). There was no difference by age or family financial status.
Rates of unwanted sex were similar between white and African American adolescents
(13% and 12%, respectively), somewhat higher among multiracial adolescents
(20%), and lower among Hispanic adolescents (6%) (overall P = .04). Among adolescents reporting unwanted sexual intercourse,
37% of males and 17% of females had not told anyone about the incident before
the telephone interview (P = .17) (Table 1). The number of male adolescents who reported unwanted intercourse
was too low to describe precise estimates for most variables.
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Health Services and Contraceptive Use by Sexually Active Adolescents
Reporting Unwanted Intercourse*
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More than two thirds of all female adolescents (67%) stated that they
usually go to a physician's office for medical care, and 29% usually go to
a neighborhood or hospital-based clinic or a health care center (Table 1). The source of primary care did
not differ by whether the female adolescents reported unwanted intercourse
(overall P = .91). There were also no differences
in the percentage of female adolescents reporting a recent well visit, having
discussed confidentiality, having had private time with their physician, or
having insurance. A somewhat higher proportion of female adolescents reporting
unwanted intercourse reported having gone to see a physician or nurse without
their parents' knowledge; this association was not significant (Table 1). These female adolescents were also more likely to report
wanting contraception but not getting it because of fear that their parents
would find out.
Adolescent girls reporting unwanted sexual intercourse were more likely
to report ever having had sex without a condom or other birth control, but
were equally likely to have used a condom or other birth control at their
last intercourse (Table 1). Adolescent
girls who reported unwanted intercourse were equally likely to have heard
of or have used emergency contraception and were significantly more likely
to have been told about emergency contraception by a clinician. Nearly one
third of the adolescent girls reporting unwanted sex had ever been pregnant;
this was not significantly different than those without a history of unwanted
sex (Table 1).
COMMENT
Of sexually active adolescent girls and boys, 20% and 7%, respectively,
have experienced unwanted sexual intercourse. Although similar to rates found
in other studies,7 this is a troubling proportion,
because early sexual intercourse increases their risk of sexually transmitted
diseases, human immunodeficiency virus, teenage pregnancy,4
and cervical cancer.24 Many adolescents who
had unwanted intercourse have also had sex without contraception. These data
raise concerns about whether adolescents have the tools they need to be able
to negotiate sexual encounters to their desired conclusion, whether that goal
is sex using contraception or no sex at all. Programs that aim to prevent
teenage pregnancy must consider ways to help young people set, and keep, boundaries
with sexual partners and others who may pressure them to have sex.
Many of the adolescents who reported having had unwanted intercourse
had never told anyone about the incident, despite the many adolescents in
this sample who had a regular physician or other provider and a well visit
in the past year. Although some of these incidents may have taken place after
the visits, it is likely that in some cases, a clinician might have uncovered
this history. Given the short-term consequences of unprotected sexual intercourse,
and the long-term impact of coercive sexual experiences on risk behavior and
health, clinicians are in the position to offer emergency contraception, referrals
to counseling, and other needed services. On a positive note, many teenagers
in our sample had heard of emergency contraception and teenagers with a history
of unwanted intercourse were more likely to have had a clinician tell them
about it. This may indicate that information about emergency contraception
is reaching youth at risk in our community.
It is concerning that almost one third of adolescent girls who reported
unwanted intercourse had wanted birth control but not gotten it because of
fear that their parents would find out. One quarter had not discussed confidentiality
with their physician or other provider and, thus, may have been concerned
that their physician would disclose information to their parents. However,
as most of these adolescents reported ever having had sex without contraception,
these data emphasize the need for better access to and information about birth
control and condoms.
While the number of male adolescents in our study who reported having
unwanted intercourse was too small to detect significant differences between
the groups, the proportion of adolescent boys who reported unwanted sex was
concerning, especially because male adolescents are much less likely than
female adolescents to have disclosed these incidents. Although the societal
preconception is that men are usually the sexual aggressors, this study and
others6, 25 suggest that young
men are vulnerable to unwanted advances and may experience some of the same
negative effects as young women.
There are several limitations to this study. Our sample was slightly
biased toward female respondents and to adolescents whose families have telephones;
it was also limited to Monroe County. However, we adjusted for nonresponse
and sample/population differences, and telephone surveys are able to accurately
reflect the population of youth.19 We piloted
the survey to determine the face validity of the questions, and many items
are similar to the Youth Risk Behavior Survey,2, 7
but we cannot be sure items were interpreted the same way by all respondents.
In addition, because consent was required for some adolescents, there may
have been bias in the response. While we were unable to collect information
on those who refused, 58% is a reasonable response rate and is comparable
to other recent random-dialed telephone surveys.26
Also, because we asked the question only of adolescents who reported ever
having sexual intercourse, it is possible that there were respondents who
had been forced to have sex but who did not say they had sexual intercourse.
Finally, this study only focused on heterosexual intercourse, and likely underestimates
the proportion of young men affected by male-male unwanted contact and of
young men and women affected by unwanted contact other than intercourse. Future
research is needed on young men to determine whether those who have had unwanted
sexual experiences are also more likely to engage in risky sexual behaviors
and whether they have the same health services use (and thus opportunities
for intervention) as other adolescent boys.
Physicians and allied health professionals can play an important role
in mitigating the effects of unwanted sexual intercourse on adolescents, providing
information on emergency contraception and contraceptive options, and referring
patients for counseling if the episodes have triggered emotional distress
or reactionary sexual activity. This study underscores the need for clinicians
to screen for unwanted sexual activity among female and male adolescents and
to ensure that these discussions remain confidential. Clinicians can also
play an important role in helping adolescents learn to say no in coercive
encounters or to avoid situations that may increase their risk. Clinicians
need to ask their adolescent patients whether they have been forced or pressured
into sexual intercourse; as difficult as it may be for adolescents to discuss
these issues, ignoring them can only make a difficult situation worse.
| What This Study Adds
Unwanted sexual contact is associated with adverse health outcomes among
adolescents. Primary care clinicians often miss opportunities to screen for
unwanted contacts and their sequelae, and this is an important aspect of health
services and reproductive care for these youth. Most adolescents with a history
of unwanted intercourse (20% of females and 6% of males) have received routine
primary care, but many have never disclosed these incidents to their physicians.
Adolescent girls with a history of unwanted sex were less likely to use contraception
and more likely to have deferred care because they feared loss of confidentiality.
Clinicians should confidentially screen all adolescents for a history of unwanted
sexual contact and for reproductive care needs.
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AUTHOR INFORMATION
Accepted for publication January 3, 2002.
This study was supported by a grant from the Centers for Disease Control
and Prevention, Division of Reproductive Health, Atlanta, Ga, to the Rochester
Coalition Partnership for the Prevention of Teen Pregnancy; and by the Robert
Wood Johnson Foundation, Princeton, NJ.
We thank the city of Rochester and the Monroe Council on Teen Pregnancy
for their support of this study.
Corresponding author and reprints: Jonathan D. Klein, MD, MPH, Department
of Pediatrics, Division of Adolescent Medicine, University of Rochester Medical
Center, 601 Elmwood Ave, Box 690, Rochester, NY 14642 (e-mail: jonathan_klein{at}urmc.rochester.edu).
From the Strong Children's Research Center and the Division of Adolescent
Medicine, Department of Pediatrics, University of Rochester, Rochester, NY.
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