Sexual violence is widespread among adolescents and places them on a lifelong trajectory of violence, either as victims or perpetrators.1 Sexual violence refers to sexual activity in which consent is not freely given. It encompasses any sexual act, attempt to obtain a sexual act, or act to traffic for sexual purposes directed against a person using a range of forms of coercion by any person, regardless of the relationship to the victim; it occurs in a range of settings.2 Sexual assault is a comprehensive term for nonvoluntary sexual contact that may include penetration and/or touching of the anogenital area or breasts that occurs because of physical force, psychological coercion, or impairment secondary to alcohol or drug use.3 Giving consent requires an understanding of the consequences of choices; therefore, victims who cannot consent based upon their age or developmental stage also experience sexual assault during nonvoluntary sexual contact.3
Intimate partner violence (IPV) encompasses emotional abuse, physical abuse, sexual abuse, and stalking perpetrated by a person in an intimate or dating relationship.4 Reproductive coercion is defined as contraceptive sabotage (active interference with contraceptive methods, such as disposal of birth control pills or condom manipulation) and/or pregnancy pressure (threats to promote a pregnancy or efforts to block women from seeking access to contraception).5
Although the empirical evidence on commercial sexual exploitation and sex trafficking of adolescents is limited,6 pediatric and adolescent health care providers can play a crucial role in advancing efforts not only to intervene but also to prevent further victimization of vulnerable youth.7–9 According to the Institute of Medicine, the commercial sexual exploitation of minors and sex trafficking of minors is defined as “a range of crimes of a sexual nature committed against children and adolescents, including (1) recruiting, enticing, harboring, transporting, providing, obtaining, and/or maintaining (acts that constitute trafficking) a minor for the purpose of sexual exploitation; (2) exploiting a minor through prostitution; (3) exploiting a minor through survival sex (exchanging sex/sexual acts for money or something of value, such as shelter, food or drugs); (4) using a minor in pornography; (5) exploiting a minor through sex tourism, mail order bride trade, and early marriage; and (6) exploiting a minor by having her or him perform in sexual venues (eg, peep shows or strip clubs).”10 As per the Federal Victims of Trafficking and Violence Protection Act of 2000, for persons younger than age 18 years, any commercial sexual activity is considered criminal sex trafficking, and need not involve force, fraud, or coercion.11
In this clinical review, I delineate the scope of sexual violence in adolescents, specifically, sexual assault, IPV, reproductive coercion, and sex trafficking. Next, I focus on the role of the pediatrician and adolescent medicine provider in screening for sexual violence in adolescents. Finally, I provide recommendations and resources for the comprehensive treatment of adolescents exposed to sexual violence and linkages to care.
Scope of Sexual Violence in Adolescents
Although sexual assault is significantly underreported, it is increasingly recognized as a common tragic experience for adolescents and young adults. Prevalence estimates vary. A report based on data from the Youth Risk Behavior Survey of high-school students found that 11.8% of girls and 4.5% of boys were physically forced to have sexual intercourse at some point in their lives.12 Health disparities exist by race/ethnicity and gender. For example, the prevalence of having been forced to have sexual intercourse is higher among Black male (6.1%) and Hispanic male students (5.4%) than among White male students (3.2%).12 In a study of undergraduate women, 19% reported experiencing attempted or completed sexual assault since entering college.13 In a nationally representative survey of adults, 18.3% of women report being raped in their lifetime; of these women, 29.9% and 37.4% of female rape victims reported a first rape between the ages of 11 and 17 years and 18 and 24 years, respectively.14
Adolescents with developmental disabilities are at an increased risk of sexual violence compared with adolescents without disabilities.15 According to research reports summarized by the Massachusetts Department of Health, 68% to 83% of women with developmental disabilities will be sexually assaulted in their lifetimes.15 Albeit at a much lower prevalence, men with developmental disabilities are also at an increased risk of sexual assault in their lifetimes compared with men without disabilities (13.9% vs 3.7%).15
Sexual violence occurs mostly within intimate relationships. More than one-half (51.1%) of female victims of rape reported being raped by an intimate partner and 40.8% by an acquaintance.14 Nationally, nearly 1 in 10 women (9.4%) reported being raped by an intimate partner.14 Sexual violence in intimate relationships is not unique to heterosexual partnerships with 4% of men who have sex with men experiencing forced sex within their intimate relationships.2
Findings from a national study of adult women age 18 to 49 years in the United States showed that at least 9% of women experienced reproductive coercion.14 Research in adolescents living in communities with elevated adolescent pregnancy rates found even higher rates of reproductive coercion (18%–20%).5,16
There are inherent difficulties in obtaining accurate estimates of commercial sexual exploitation and sex trafficking. It is estimated that 4.5 million people are victims of forced sexual exploitation including approximately 945,000 children.6 The average age of entry into sex trafficking in the US is 12 to 15 years.8 Approximately 300,000 children in the US are estimated to be at risk each year of becoming victims. Risk factors for adolescent victims include those who have been sexually abused; youth who lack stable housing; sexual and gender minority youth; youth who have used or abused drugs or alcohol; and youth who have experienced foster care or juvenile justice involvement.7
Adolescent Health and Sexual Violence
Between 2004 and 2006, an estimated 105,187 females and 6,526 males age 10 to 24 years received medical care in US emergency departments as a result of nonfatal injuries sustained from a sexual assault.17 Critically, these numbers represent only a segment of associated injuries from sexual assault. Moreover, adolescent victims are more likely to delay seeking medical care after a sexual assault and are less likely than adult women to press charges.18
The current evidence is consistent in that IPV, reproductive coercion, and sexual assault are associated with risk of unplanned pregnancy and sexually transmitted infections (STIs) in adolescents and young adult women.5,19–21 A history of nonconsensual sex is associated with sexually transmitted infections, urinary tract infections, reproductive health disorders including pregnancy and abortion complications, traumatic injuries, nutritional deficiencies, mental health disorders including depression and substance use, elevated cholesterol, stroke, and heart disease in both women and men.7,22
International studies of adult women have found that sex trafficking and commercial sexual exploitation is associated with STIs, HIV, pregnancy, miscarriage, abortions, repeated urinary tract infections, multiple injuries from physical abuse, and mental health conditions such as posttraumatic stress disorder, anxiety disorders, depression, substance abuse, and suicidality.8
Treatment Recommendations for Adolescents with Recent Sexual Assault
When an adolescent discloses an acute sexual assault, medical providers should discuss limits of confidentiality, obtain a history, perform medical evaluation and forensic evaluation (if requested), and assess safety and psychological needs.3 For those younger than age 18 years, it is important for providers to be familiar with adolescent-specific reporting requirements that depend on, such as the patient's current age and age at time of the event, and the identity and relationship to the alleged perpetrator.3 Pediatricians need to be aware of specific reporting laws in the state and jurisdiction in which they practice, which are available through the Child Welfare Information Gateway.11
Adolescents should be reassured that whether or not they choose to have a forensic evaluation does not affect their ability to receive medical care. Providers should screen adolescents for human trafficking. Finally, safety should be assessed by directly asking them if they feel safe as well as if they have any specific concerns related to the perpetrator threatening them, previously assaulting them, or having access to weapons.3
Adolescents who request forensic examination can be referred to emergency departments or sexual assault treatment centers. A forensic medical examination includes a history, physical examination, documentation of findings by still imaging or video, collection of potential forensic evidence, and discussion of treatment options for potential sexually transmitted infections.3 In addition, pregnancy testing and emergency contraception should be offered within 120 hours of sexual assault to adolescents who may have been vaginally penetrated or at risk for pregnancy.23 If the adolescent victim presents 1 week or longer after an assault, there is no need for forensic collection.3
Treatment guidelines for STIs from the Centers for Disease Control and Prevention (CDC) include empirical treatment of chlamydia, gonorrhea, and trichomonas.24 Whether to undergo STI testing should be discussed with the adolescent. Importantly, an adolescent's previous sexual or infection history is prohibited in all 50 states from being used to undermine the credibility of the adolescent's history of assault. Specifically, the American Academy of Pediatrics (AAP) and the CDC recommend nucleic acid-amplification tests for chlamydia, gonorrhea, and trichomonas using urine or vaginal specimens, as well as additional testing at other penetration sites, such as the anus, as indicated.3,24 In addition, serum samples should be obtained for baseline testing for hepatitis B, hepatitis C, syphilis, and HIV. HIV postexposure prophylaxis should be considered ideally within 72 hours of sexual assault if genital or anal penetration with ejaculation has occurred.3,24 Youth who have not completed the immunization series against hepatitis B can be offered the vaccine. Additionally, the CDC recommends HPV vaccination beginning at age 9 years for children and youth with any history of sexual abuse or assault who have not initiated or completed the series.25
The AAP recommends toxicology sample collection when the adolescent presents with symptoms and signs of substance use, such as a fluctuating level of consciousness or when concerns of possible drug involvement are raised by the adolescent or accompanying persons or witnesses. It is important to obtain informed consent before toxicology sample collection, if possible. If the adolescent is not able to give consent for toxicology sample collection due to altered mental status, it should not delay toxicology sample collection when indicated, as the first urine produced after the assault is recommended. Alcohol is the most common substance involved in sexual assault.3 Drug facilitated sexual assault (DFSA) with the benzodiazepine sedative/hypnotic flunitrazepam, ketamine, and hydroxybutyrate have been used increasingly in adolescent acquittance rape.3 Of note, these DFSA drugs are not included in standard drug-screening panels; specifically, flunitrazepam is not identified in routine tests for benzodiazepines. Thus, health care providers should consult Poison Control Centers and inquire about the best means of detecting the presence of suspected drugs.3
Within 1 to 2 weeks of initial presentation for sexual assault, adolescents should present for a follow-up visit and be assessed for mental health sequelae, including posttraumatic stress disorder. At 2 weeks, pregnancy testing can be performed. The CDC further recommends that syphilis and fourth-generation HIV testing be repeated at 4 to 6 weeks and at 3 months, and HIV testing again at 6 months.24
Screening for Sexual Violence in Adolescents
The AAP recommends that all adolescents and young adults be routinely screened for sexual assault at annual examinations as part of a social history referred to as a H.E.A.D.S.S. (Home, Education/Employment, Activities, Drugs, Sexuality, and Suicide/Depression) assessment. In addition, adolescents should be screened for sexual assault when referred for contraception, sexuality issues, psychological problems, and substance use. All adolescents with disabilities should be included in screening for sexual violence, given their elevated risk.
The AAP recommends self-administered screening for IPV using validated screening tools,26 as studies have shown improved patient comfort and higher detection rates compared to verbally administered assessments.27 The American College for Obstetricians and Gynecologists recommends universal screening for IPV27 and reproductive coercion.28 Adolescents should be screened for commercial sexual exploitation and sex trafficking. Potential indicators include no documentation, poorly explained injuries, and being accompanied by a domineering figure. Providers can screen for sexual violence by asking, “Has anyone ever asked you to have sex with someone else?,” “Have you ever had to exchange sex for something you needed or wanted?,” “Has anyone threatened your family or friends?,” and “Do you feel safe talking to me right now?”7
Anticipatory Guidance to Adolescents
Pediatricians should stress with all adolescents (boys and girls) that sexual violence is most commonly perpetrated by people known to them. In addition to offering STI testing and treatment and emergency contraception, pediatricians can offer contraception that is less likely to have partner interference such as an intrauterine device, contraceptive implant, or depot medroxyprogesterone acetate injections if adolescents are identified as experiencing sexual violence including reproductive coercion.
Health care providers should discuss with adolescents and college students their increased vulnerability to assault when drinking and the risks of drug-facilitated sexual assault. Although interpersonal and individual-level strategies to decrease the likelihood of sexual assault are often mentioned (eg, attending parties with friends, not sipping from an unattended drink) research has shown that the most effective interventions change attitudes, knowledge, and culture, including bystander interventions to reduce sexual violence and community-based interventions to form gender equitable attitudes among boys and girls.1 Pediatricians should advocate for evidence-based sexual violence prevention activities in their communities focused on nonviolent conflict resolution, gender equitable norms, and education regarding sexually transmitted infections, contraception, and labeling rape scenarios as rape.1 Importantly, pediatricians should be aware of child abuse resources and sexual violence prevention programs designed specifically for adolescents with intellectual disabilities.
Health care providers, including pediatricians, have an important role in the identification, assessment, and treatment of adolescents who experience sex trafficking as well as linking them to mental health providers and community resources. Pediatricians have unique and trusted access, given that 46% of children who have experienced commercial sexual exploitation reported contact with the health care system in the past 2 months.10 Finally, pediatricians can fill critical roles in preventing sex trafficking of adolescents at multiple levels, including delivering tailored interventions to adolescents to address individual and relationship risk factors for sex trafficking, and being part of multidisciplinary efforts to develop policies and protocols to prevent sex trafficking of adolescents and young adults.8,29
Mental Health Resources
Many adolescents who experience sexual violence may require psychological counseling and/or psychotropic medications for posttraumatic stress disorder and other mental health needs. Adolescent dating violence is associated with future dating violence, substance use, depression, suicidal ideation, and poorer educational outcomes.4 Trauma-focused cognitive-behavioral therapy has been found to be effective for adolescents who have been sexually assaulted. The Rape, Abuse & Incest National Network is an excellent resource for locating psychological support ( https://centers.rainn.org/). It includes a list of independent sexual assault service providers, including National Sexual Assault Hotline affiliate organizations and other local providers. Specifically, for adolescents who have experienced commercial sexual exploitation, providers can call the National Human Trafficking Resource Center Hotline (800-656-4673) to both determine all relevant child abuse mandatory reporting laws, as well as to obtain community resources.
Despite the prevalence of sexual violence in adolescents, studies have documented that many medical providers do not screen them for sexual violence. Given the consequential reproductive health and mental health sequelae, screening for sexual assault, IPV, reproductive coercion, and commercial sexual exploitation is recommended for all adolescents. Identification of adolescents who have experienced sexual violence as well as those who are at risk for sexual violence is the first step in intervening, and pediatricians have unique trusted access to their patients. Finally, it is incumbent for pediatricians to be aware of national and local resources for sexual violence treatment and prevention, including for sex trafficking, to most effectively advocate for the health and well-being of adolescents and prevent further victimization.
- Lundgren R, Amin A. Addressing intimate partner violence and sexual violence among adolescents: emerging evidence of effectiveness. J Adolesc Health. 2015;56(suppl):S42–S50. doi:. doi:10.1016/j.jadohealth.2014.08.012 [CrossRef]
- Dartnall E, Jewkes R. Sexual violence against women: the scope of the problem. Best Pract Res Clin Obstet Gynaecol. 2013;27(1):3–13. doi:. doi:10.1016/j.bpobgyn.2012.08.002 [CrossRef]
- Crawford-Jakubiak JE, Alderman EM, Leventhal JMAAP Committee on Child Abuse and NeglectAAP Committee on Adolescents. Care of the adolescent after an acute sexual assault. Pediatrics. 2017;139(3):e20164243. doi:. doi:10.1542/peds.2016-4243 [CrossRef]
- Holmes K, Sher L. Dating violence and suicidal behavior in adolescents. Int J Adolesc Med Health. 2013;25(3):257–61. doi:. doi:10.1515/ijamh-2013-0059 [CrossRef]
- Northridge JL, Silver EJ, Talib HJ, Coupey SM. Reproductive coercion in high school-aged girls: associations with reproductive health risk and intimate partner violence. J Pediatr Adolesc Gynecol. 2017;30(6):603–608. doi:. doi:10.1016/j.jpag.2017.06.007 [CrossRef]
- International Labor Organization Special Action. ILO 2012 global estimate of forced labour executive summary. https://www.ilo.org/wcmsp5/groups/public/@ed_norm/@declaration/documents/publication/wcms_181953.pdf. Accessed January 29, 2019.
- Chung RJ, English A. Commercial sexual exploitation and sex trafficking of adolescents. Curr Opin Pediatr. 2015;27(4):427–433. doi:. doi:10.1097/MOP.0000000000000242 [CrossRef]
- Chaffee T, English A. Sex trafficking of adolescents and young adults in the United States: healthcare provider's role. Curr Opin Obstet Gynecol. 2015;27(5):339–344. doi:. doi:10.1097/GCO.0000000000000198 [CrossRef]
- Varma S, Gillespie S, McCracken C, Greenbaum VJ. Characteristics of child commercial sexual exploitation and sex trafficking victims presenting for medical care in the United States. Child Abuse Negl. 2015;44:98–105. doi:. doi:10.1016/j.chiabu.2015.04.004 [CrossRef]
- Institute of Medicine and National Research Council. Confronting Commercial Sexual Exploitation and Sex Trafficking of Minors in the United States. Washington, DC: The National Academies Press; 2013.
- Child Welfare Information Gateway. Definitions of human trafficking. https://www.childwelfare.gov/topics/systemwide/laws-policies/statutes/definitions-trafficking/. Accessed January 29, 2019.
- Centers for Disease Control and Prevention. Youth Risk Behavior Surveillance--United States, 2011. MMWR Morb Mortal Wkly Rep. 2012;61(4):1–162.
- Krebs CP, Linquist CH, Warner TD, Fisher BS, Martin SL. College women's experiences with physically forced, alcohol- or other drug-enabled, and drug-facilitated sexual assault before and since entering college. J Am Coll Health. 2009;57(6):639–647. doi:. doi:10.3200/JACH.57.6.639-649 [CrossRef]
- Black MC, Basile KC, Breiding MJ, et al. National intimate partner and sexual violence survey: 2010 summary report. https://www.cdc.gov/violenceprevention/pdf/nisvs_report2010-a.pdf. Accessed January 18, 2019.
- Mitra M, Mouradian VE, Diamond M. Sexual violence victimization against men with disabilities. Am J Prev Med. 2011;41(5):494–497. doi:. doi:10.1016/j.amepre.2011.07.014 [CrossRef]
- McCauley HL, Dick RN, Tancredi DJ, et al. Differences by sexual minority status in relationship abuse and sexual and reproductive health among adolescent females. J Adolesc Health. 2014;55(5):652–658. doi:. doi:10.1016/j.jadohealth.2014.04.020 [CrossRef]
- Centers for Disease Control and Prevention. Sexual and reproductive health of persons aged 10–24 years--United States, 2002–2007. MMWR Morb Mortal Wkly Rep. 2009;58(4):1–162.
- Peipert JF, Domagalski LR. Epidemiology of adolescent sexual assault. Obstet Gynecol. 1994;84(5)867–71.
- Coker AL. Does physical intimate partner violence affect sexual health? A systematic review. Trauma Violence Abuse. 2007;8(2):149–177. doi:10.1177/1524838007301162 [CrossRef]
- Decker MR, Miller E, McCauley HL, et al. Recent partner violence and sexual and drug-related STI/HIV risk among adolescent and young adult women attending family planning clinics. Sex Transm Infect. 2014;90(2):145–149. doi:. doi:10.1136/sextrans-2013-051288 [CrossRef]
- Hess KL, Javanbakht M, Brown JM, Weiss RE, Hsu P, Gorbach PM. Intimate partner violence and sexually transmitted infections amount young adult women. Sex Transm Dis. 2012;39(5):1–12. doi:. doi:10.1097/OLQ.0b013e3182478fa5 [CrossRef]
- Smith SG, Breiding MJ. Chronic disease and health behaviors linked to experiences of non-consensual sex among women and men. Public Health. 2011;125(9):653–659. doi:. doi:10.1016/j.puhe.2011.06.006 [CrossRef]
- Committee on Adolescents. Emergency contraception. Pediatrics. 2012;130(6):1174–1182. doi:. doi:10.1542/peds.2012-2962 [CrossRef]
- Centers for Disease Control and Prevention. 2015 Sexually transmitted diseases treatment guidelines. Sexual assault and abuse and STDs. www.cdc.gov/std/tg2015/sexual-assault.htm. Accessed January 18, 2019.
- Markowitz LE, Dunne EF, Saraiya M, et al. Centers for Disease Control and Prevention (CDC). Human papillomavirus vaccination: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep. 2014;63(5):1–30.
- Thackeray JD, Hibbard R, Dowd MD. Intimate partner violence: the role of the pediatrician. Pediatrics. 2010;125(5):1094–1100. doi:. doi:10.1542/peds.2010-0451 [CrossRef]
- [No authors listed]. ACOG Committee Opinion No. 518: Intimate partner violence. Obstet Gynecol. 2012;119(2 Pt 1):412–417. doi:. doi:10.1097/AOG.0b013e318249ff74 [CrossRef]
- American College of Obstetricians and Gynecologists. ACOG Committee Opinion No. 554: reproductive and sexual coercion. Obstet Gynecol. 2013;121(2 Pt 1):411–415. doi:. doi:10.1097/01.AOG.0000426427.79586.3b [CrossRef]
- Greenbaum VJ, Titchen K, Walker-Descartes I, et al. Multi-level prevention of human trafficking: the role of health care professions. Prev Med. 2018;114:164–167. doi:. doi:10.1016/j.ypmed.2018.07.006 [CrossRef]