Sexual assault among North Carolina women: Prevalence and health risk factors. (Research Report).(Statistical Data Included)

Study objective: Sexual assault is traumatic at the time it occurs, but it also may have longlasting negative effects on physical health. Much of the research linking specific health problems to sexual assault victimisation has used samples from special populations. The goals of this study are to estimate the prevalence of sexual assault in a representative sample of women in North Carolina and examine sexual assault in relation to specific health risk factors for leading causes of morbidity and mortality in women.

Design: The North Carolina Behavioral Risk Factor Surveillance System (BRFSS) is a household telephone survey of non-institutionalised adults, 18 years of age and older, conducted by random digit dialling.

Setting: This investigation focuses on the study participants in the 1997 survey.

Participants: The sample includes 2109 women who responded to the sexual assault questions in the 1997 North Carolina BRFSS interview.

Main results: The lifetime prevalence of sexual assault was 19% (95% Cl 17% to 20%), of which 73% of victims experienced or were threatened with forced sexual intercourse. Sexual assault victims, particularly victims of forced intercourse or the threat thereof, were more likely to perceive their general health as being fair or poor (OR=2.3, 95% Cl 1.5 to 3.4) and were more likely to have suffered poor physical and mental health in the past month (poor physical health, OR=2.1, 95% Cl 1.6 to 2.8; poor mental health, OR = 2.6, 95% Cl 1.9 to 3.5). After controlling for sociodemographic factors and health care coverage, victims of forced intercourse or the threat thereof were more likely to smoke cigarettes (OR=2.0, 95% Cl 1.4 to 2.8), to have hypertension (OR=1.5, 95% Cl 1.1 to 2.2), to have high cholesterol (OR=1.7, 95% Cl 1.2 to 2.5), and to be obese (OR=1.7, 95% Cl 1.3 to 2.4).

Conclusions: This study shows associations between sexual victimisation and health risk factors in a non-clinical statewide population of women. Future research should determine whether clinically screening for and identifying a history of sexual victimisation among women seen in a variety of health care settings leads to the initiation of effective interventions that help women successfully cope with these violent experiences. There is also a need for further research to investigate the temporal sequence of assaults and subsequent health outcomes by assessing physical health status before and after victimisation.

Sexual assault of women is a serious public health problem that is pervasive within the United States. Prevalence estimates vary widely depending on the definition used (for example, legal definitions of rape; forced anal, oral, or vaginal penetration; any unwanted sexual contact; etc) and the population sampled. The lifetime prevalence of sexual abuse is estimated at 7% in crime statistics, (1) 5%-28% in community samples, (2-4) and 32%-57% in clinical samples. (5 6) Estimates of the prevalence of childhood sexual abuse range from 27% in a national sample (7) to 37% from a clinical sample. (5) Prevalence estimates of sexual assault in women that occurred only in adulthood range from 10% to 50%, with estimates in clinical samples (5 8 9) higher than those in community samples. (1 3) Although these estimates vary, taken together, they indicate that sexual assault is not a rare occurrence in women's lives.

There is evidence that the prevalence of violent victimisation decreases as women get older, with girls under the age of 18 having the highest prevalence. (2 8) Almost two thirds of sexual assault victims in the US are girls under 16 years of age, (10) who make up less than a quarter of the female population. (11) Among adults, women under age 40 have a higher prevalence of sexual assault than older women. (3)

Long term health sequelae may be associated with sexual assault regardless of whether the assault occurred during childhood or in adulthood. For instance, some research has found sexual assault to be associated with sexually transmitted diseases and gynaecological problems in adult women, (12-17) even when the abuse occurred in childhood. (18) Moreover, some studies suggest that women with a history of childhood or adult sexual victimisation are more likely than non-victims to experience a lower health related quality of life, (19) to report more physical symptoms, (9 12 16 19-22) and to perceive their health status as being poor. (16 20 23 24)

Several studies have reported that victims of sexual assault seek medical care, or are hospitalised, more frequently than non-victims. (5 16 21 22 25 26) Koss et al (24) found that the number of physician visits by rape victims increased in both the first and second years after the rape, compared with the two years before the rape. However, in a study of primary care patients in a managed care setting, no association was found between medical utilisation and childhood sexual assault, other than an increase in the number of ongoing prescriptions. (8)

Clinically based investigations have reported a greater likelihood of sexual assault victims to engage in unhealthy behaviours such as alcoholism, illicit drug use, cigarette smoking, and sedentary lifestyle, both among adult victims 24 and child victims. (9 25) Primary health care patients with a history of childhood sexual abuse also are more likely to suffer from obesity. (25 27) Two studies (28 29) that examined the relation between various adverse childhood experiences (including sexual abuse) and adult health status in female patients found positive associations between the number of adverse childhood experiences and health risks such as alcoholism, drug misuse, poor self rated health, and obesity. Felitti et al (28) also reported a link between severity of adverse childhood experiences and the incidence of smoking, physical inactivity, ischaemic heart disease, cancer, chronic lung disease, skeletal fractures, and liver disease.

Much of the research linking specific health problems to sexual assault victimisation has used samples from special populations, particularly patient populations. None the less, a few studies have looked at non-patient populations. Golding, in particular, has examined community samples of women with and without histories of sexual assault in relation to various indicators of health. In one study, (20) she found that sexually assaulted women were less likely than non-victims to perceive their health as excellent and were more likely to experience medically explained somatic symptoms. In addition, a history of sexual assault was associated with having a physical disability, diabetes, and arthritis, but not with hypertension, heart disease, or respiratory disease. In another study, Golding found that headaches were more common among …