Sexual violence victimization is an urgent public health problem in the U.S. that affects the mental and physical health of survivors.^1–3 Penetrative forms of sexual violence, such as rape (i.e., physically forced or alcohol/drug facilitated vaginal, oral, or anal penetration) and sexual coercion (i.e., non-physically pressured sex), can seriously impact the reproductive health of victims given the risk they pose for victims to acquire sexually transmitted infections and become pregnant.¹ In the U.S. during 2016/2017, one in four women (26.8%) reported completed or attempted rape, and similarly one in four women (23.4%) reported sexual coercion at some point in their life.¹

There is little scholarship on the intersection of rape or sexual coercion and pregnancy using population-based samples. Holmes et al.,⁴ in a study conducted nearly three decades ago, reported a weighted prevalence of rape-related pregnancy of 0.6% in the U.S., and estimated that 6.0% of reproductive age female rape victims experienced a rape-related pregnancy. Although this study was an important contribution to the field’s understanding, it was limited by sample size and the operational definition of rape used in the estimates, which included not just vaginal but also anal and oral penetration that cannot result in pregnancy. Data from the 2010 National Intimate Partner and Sexual Violence Survey (NISVS) on rape-related pregnancy in the context of intimate partner violence (IPV) revealed that 1.7% or approximately two million women in the U.S. experienced pregnancy after rape by an intimate partner, and 2.4% of U.S. women experienced a rape-related pregnancy during their lifetimes from any perpetrator.³

More recent 2016/2017 NISVS data reported that one in seven female vaginal rape victims (14.9%) and 1 in 6 female sexual coercion victims (16.6%) became pregnant as a result of the rape or sexual coercion, respectively.¹ This is the only publication known to the authors that reported the prevalence of sexual coercion-related pregnancy, yet it is equally important to understand prevalence and characteristics of pregnancy from this type of violence.

Further, there is little information on racial/ethnic group differences regarding these experiences. Evidence suggests that some racial and ethnic minority women are heavily burdened by rape and sexual coercion; for example, more than two in five non-Hispanic American Indian/Alaska Native (43.7%) and non-Hispanic Multiracial (48.0%) women experienced rape in their lifetimes.¹ Similarly, one in three non-Hispanic American Indian/Alaska Native (32.0%) and two in five non-Hispanic Multiracial women (39.5%) had a lifetime experience of sexual coercion victimization.¹ Understanding the extent of the risk with nationally representative data is critically important to informing prevention activities.

The current study advances the knowledge about the prevalence of experiencing rape-related pregnancy and sexual coercion-related pregnancy, which has not been examined before, in important ways by building on the recent work of Basile et al.³ This study contributes more recent national estimates among U.S. women overall, and among female rape victims; provides estimates for sexual coercion-related pregnancy; and looks at findings by race/ethnicity, region of residence in the U.S., and age at the time of interview. Other impacts of these types of violence were also examined. Taken together, the more recent data, the addition of sexual coercion-related pregnancy, and additional contextual information can help inform violence prevention activities and efforts to ensure access to reproductive healthcare services for survivors of sexual violence.

This study used data from the 2016/2017 NISVS, an ongoing, nationally representative survey of non-institutionalized English- and Spanish-speaking adults (18 years and older) in the U.S. For the 2016/2017 data, sampling was conducted through a random-digit-dial methodology including a dual frame strategy of both landline and cell phones. The response rate was 7.6%; however, the cooperation rate was 58.6%, indicating that among adults who were contacted and determined to be eligible, most agreed to participate. Additional details about the NISVS 2016/2017 data collection methodology are described elsewhere.⁵ Institutional Review Board approval was received for NISVS by the data collection contractor, RTI International.

In their lifetimes, 4.8% or 5.9 million U.S. women have become pregnant as a result of either rape, sexual coercion, or both. Examined independently, 2.7% or 3.4 million women became pregnant as a result of rape during their lifetimes, and 3.9% or nearly 4.9 million U.S. women became pregnant as a result of sexual coercion in their lifetimes. There were no differences in prevalence by region for any of the estimates.

Among U.S. women overall, the analysis by race/ethnicity showed that some groups experienced pregnancy from rape more than other groups. For example, non-Hispanic Multiracial women had significantly higher prevalence (6.3%, 95% CI: 3.6–10.8) compared with Hispanic women (2.0%, 95% CI: 1.2–3.5) and non-Hispanic Black women (2.3%, 95% CI: 1.5–3.7) (Table 2).

For pregnancy from sexual coercion, non-Hispanic Multiracial women (10.2%, 95% CI: 6.5–15.7) had higher prevalence compared with non-Hispanic White women (3.9%, 95% CI: 3.3–4.6). Non-Hispanic Multiracial women and non-Hispanic White women, as well as non-Hispanic Black women (5.4%, 95% CI: 3.8–7.6), had higher prevalence compared with Hispanic women (2.2%, 95% CI: 1.3–3.6) (Table 2).

For pregnancy from any experience (either rape, sexual coercion, or both), non-Hispanic White (4.8%, 95% CI: 4.1–5.5), non-Hispanic Black (5.8%, 95% CI: 4.2 –8.0), and non-Hispanic Multiracial women (12.2%, 95% CI: 8.0–18.0) all had higher prevalence compared with Hispanic women (3.1%, 95% CI 2.1–4.8). In addition, non-Hispanic Multiracial women had higher prevalence compared with non-Hispanic White and non-Hispanic Black women (Table 2).

Among all U.S. women, the prevalence of lifetime experiences of pregnancy from rape, sexual coercion, and any experience was significantly lower in the 65+ age group compared to all other age categories with stable estimates (i.e., the 18–24 age group prevalence estimates were unstable for pregnancy from rape) (Table 2).

Separate analyses specific to victims of rape or sexual coercion (instead of all U.S. women) were conducted, as well. Results indicated that 16.0% (5.9 million) of female victims became pregnant as a result of any of these experiences (either rape, sexual coercion, or both) during their lifetimes. In looking at the prevalence among victims by racial/ethnic group, no significant differences were found for pregnancy from rape. For pregnancy from sexual coercion, non-Hispanic Black (23.0%, 95% CI: 16.8–30.7) and non-Hispanic Multiracial (25.9%, 95% CI: 16.8–37.5) victims had significantly higher prevalence than Hispanic victims (13.1%, 95% CI: 8.1–20.4). For pregnancy from any of these experience, non-Hispanic Multiracial victims (25.5%, 95% CI: 17.2–35.9) had significantly higher prevalence than non-Hispanic White victims (14.9%, 95% CI: 12.9–17.2). Similar to the findings for all U.S. women, among female victims, a smaller proportion of the 65+ age group reported any of the experienced compared to all other age categories with stable estimates (Table 3).

Approximately a quarter of victims who experienced a pregnancy from rape (28.3%) and about one third of victims who experienced a pregnancy from sexual coercion or any experience (34.8% and 34.5%, respectively) also reported contracting an STD from the victimization. For victims who experienced a pregnancy from rape, 66.3% suffered an injury, 82.0% were concerned for their safety, and 85.7% felt fearful because of the violence against them (Table 4).

Based on findings from this study, among U.S. women overall, one in twenty (approximately 5%) have experienced a pregnancy from either rape, sexual coercion, or both in their lifetimes. Among victims of any of these experiences, a subset of all U.S. women, 16% reported a pregnancy in their lifetime. Victims who experienced rape or sexual coercion that resulted in a pregnancy often reported other negative health impacts such as concerns for safety, feeling fearful, being injured, and contracting an STD.

Estimates for pregnancy from rape in the current study are similar to 2010–2012 NISVS estimates (2.7% and 2.4%, respectively), and higher than what was reported by Holmes in the 1990s (0.6%).⁴ Noting the range of estimates, it is important to consider that measuring experiences of rape on surveys can be difficult and the use of varying methodologies or question wording can lead to differing estimates. For example, rape estimates from other sources such as the National College Women Sexual Victimization study and the National Violence Against College Women study ranged from 4.4% to 10.4% (for rape in the last 6–9 months), however these estimates did not relate to pregnancies from rape.⁶

Recognizing and better understanding sexual coercion-related pregnancies is also important, and comparable information from prior studies is not available. In this analysis, a greater prevalence of this form of sexual violence was found compared with pregnancy from rape (3.9% vs. 2.7%, respectively). Sexual coercion may not involve physical force, but similar underlying drivers related to exerting power or control over another person are likely at play. Sexual coercion might be happening in the context of reproductive coercion in which female victims are manipulated into becoming pregnant by false promises or threats or tricked. Examples include when a male perpetrator uses birth control sabotage such as engaging in behaviors like stealthing, secretly taking off a condom during sex, or not telling their partner if a condom breaks.^7–10

Rape-related pregnancy has been associated with reproductive coercion³ and other types of intimate partner violence, such as physical violence.¹¹ A systematic review on reproductive coercion, found that women who experienced IPV disproportionately experienced concurrent reproductive coercion, and that 1%–19% of women across 3 studies reported a partner pressuring or threatening them to get them pregnant, or pregnancy coercion.¹² Intimate partner violence during pregnancy can put the victim and fetus at high risk for adverse pregnancy or birth outcomes.¹³ Further, since the pregnancy may result in a live birth, the impact on the infant or child is also important to consider.¹⁴ Studies have found relationships between maternal experience of coercive intimate partner violence and child neglect,¹⁵ and physical intimate partner violence before or during pregnancy with child protective service reports of alleged child maltreatment.¹⁶ Adverse childhood experiences (ACEs) such as experiencing or witnessing violence in the home have been linked to numerous negative health effects for children that can extend into adulthood.¹⁷

Regarding the findings by age, higher prevalence may have been expected among older women, who would have more years during which to experience violence, however these findings may rather be reflecting a concentration of experiences earlier in life. According to NISVS data, age at first experience of rape was less than 25 years old for over 80% of female victims, and age at first experience of sexual coercion was less than 25 years old for 74% of female victims.¹

Differences in experiences of either rape, sexual coercion, or both by race and ethnicity were also found. The finding of higher levels of violence against non-Hispanic Black and non-Hispanic Multiracial women is consistent with other studies documenting the disproportionate burden of violence experienced by women from marginalized racial and ethnic groups that has persisted unabated over time in multiple forms including pregnancy-associated homicides,^18,19 IPV and reproductive coercion,^20–22 and abductions and murders.²³ Underlying structural factors such as inequities in access to safe housing, quality education, livable wages, and other social determinants of health, often rooted in racism, have been associated with these differences in experiencing violence.^24,25 Significantly higher prevalence was found among non-Hispanic Multiracial women compared with non-Hispanic Black women and women of other race/ethnicities for several indicators. Multiracial women may experience unique stressors related to racial identity, as well as discrimination within each of the racial communities that they belong to leading to potential isolation and other factors that can increase risk for experiencing violence.^22,26 Of note, there were wide confidence intervals around the estimates for Multiracial women, indicating a need to interpret these findings with caution and explore these results through future research.

Reducing sexual violence overall may help reduce the prevalence of rape-related and sexual coercion-related pregnancies. Research has shown that sexual violence starts early in life, is associated with other forms of violence, and is related to numerous risk factors and consequences beyond pregnancy.²⁷ The results from this study showed that women who experienced rape, sexual coercion, or both that result in pregnancy experienced other impacts from this or other rape/sexual coercion victimization including STDs, fear, and injury. Other long-lasting effects of sexual violence in the literature include consequences such as chronic physical health conditions, depression, and post-traumatic stress disorder symptoms.^28–30

A comprehensive public health approach for the prevention of sexual violence is critical. Primary prevention includes strategies and approaches such as promoting healthy norms, engaging men and boys as allies, helping to develop healthy dating and relationship skills, modeling positive masculinity, providing and strengthening economic opportunities for women and families, and creating protective environments.³¹ In addition, screening for violence during healthcare encounters is important to identify, refer, and support sexual violence victims.^32,33

There is broad recognition of the seriousness of rape as a form of violence. This study is one of the few to highlight the national prevalence of pregnancy as an outcome of rape and sexual coercion building on past work with recent estimates making an important contribution to understanding the overlap of sexual violence and reproductive health in the U.S. This information is critical to advancing efforts to ensure services and reproductive healthcare access to victims of violence. Sexual violence can be prevented, and prevention efforts may include screening to identify violence exposure during pregnancy and use of evidence-based primary prevention approaches that teach skills, promote social norms and environments that are protective against violence, and support and empower women and girls.