Women in the United States are more likely than men to experience sexual violence. In 2010, 92% of reported rapes or sexual assaults in the United States were against women, and 17.7 million women compared with 2.8 million men have reported being raped (forced vaginal, oral, or anal sex) at some time in their lives (Berzofsky, Krebs, Langton, Planty, & Smiley-McDonald, 2013). A recent national survey showed that almost one in five adult women in the United States reported that they had been raped, including attempted penetration, completed penetration, or alcohol- or drug-facilitated completed penetration (Black et al., 2011). Data from this national survey demonstrated that some minority women bear a higher risk for rape victimization compared with White women (rape reported by 36% of women of multiple races, 27% of American Indian/Alaska Native women, 22% of Non-Hispanic African American women, 19% of Non-Hispanic White women, and 15% of all Hispanic women; Black et al., 2011).

Women who experience physically forced sex may subsequently suffer a wide range of negative psychological, social, and behavioral outcomes later in life that have implications for their overall health (Basile & Smith, 2011; Hansen, Brown, Tsatkin, Zelgowski, & Nightingale, 2012; Leserman, 2007; Sachs-Ericsson, Cromer, Hernandez, & Kendall-Tackett, 2009; Wegman & Stetler, 2009; D. R. Wilson, 2009). These outcomes may include lower self-esteem, depression, problems with intimate relationships, eating disorders, binge drinking, drug use, exchange sex (providing sex for money, drugs, shelter, or other material goods), unprotected sex, high numbers of sexual partners, and sexually transmitted infections (STIs; Bournovaluova, Gwadz, Kahler, Akline, & Lejuez, 2008; Brown-Peterside, Ren, Chiasson, & Koblin, 2002; Hien et al., 2010; Meade, Kershaw, Hansen, & Sikkema, 2009; Mehrabadi et al., 2008; Stockman, Campbell, & Celentano, 2010; H. W. Wilson & Widom, 2009, 2011). Moreover, women who have experienced forced sex are at increased risk for medical disorders (e.g., Wegman & Stetler, 2009) and subsequent victimization (Daigle, Fisher, & Cullen, 2008; Desai, Arias, Thompson, & Basile, 2002).

This study explored whether women who had experienced physically forced sex (referred to hereafter as forced sex) earlier in life were at risk for engaging in sexual and drug behaviors and experiencing mental health problems later in life. We examined this issue in the context of several age-related parameters that have not been given much attention in previous studies. Specifically, we examined whether recent behavioral and mental health outcomes differed between women who first experienced unwanted forced sex at an early age in comparison with women who first experienced the event at an older age. It was theorized that recent sexual-risk and drug-risk behaviors and mental health problems would be more likely to be observed among women who first experience forced sex at a young age because of limited coping skills or psychological capacity to deal with such a traumatic event (Resick, Nishith, & Griffin, 2003). Alternatively, it was also theorized that given the sheer psychological and physical trauma of forced sex, recent sexual-risk and drug-risk behaviors and mental health problems might be observed regardless of the age at which forced sex first occurred. National surveys have shown that the average age of first sex for minority women in the United States is approximately 16 years old (Cavazos-Rehg et al., 2010; Haydon, Herring, Prinstein, & Halpern, 2012; Pettifor et al., 2011). We examined whether recent behavioral and health outcomes differed between women who first experienced unwanted forced sex when they were 15 years of age or younger and women who first experienced unwanted forced sex when they were older than 15 years of age.

When assessing the impact of forced sex on recent behavioral and mental health outcomes, age at the time of the assessment must be considered. For example, older women, regardless of whether or not they have experienced forced sex, may be less likely than younger women to exhibit current risk behaviors. Thus, it may be difficult to statistically detect associations with prior experience of forced sex. However, it is also possible that older women who first experienced forced sex at an early age may be less likely to exhibit current risk behaviors due to the length of time since the event. This issue was addressed by examining the pattern of outcomes among younger (younger than 35 years old) and older (aged 35 years and older) women by three groups (forced sex first occurred at age 15 years or younger, forced sex first occurred at 15 years or older, no experience of forced sex). Additionally, we examined the outcomes according to the length of time (number of years) since forced sex first occurred relative to the woman’s age at enrollment in the study. We reasoned that recent sexual-risk and drug-risk behaviors and mental health problems may be more likely to be observed among women who report that the event first occurred relatively recently compared with women who report that the event first occurred in the distant past.

Our study was conducted with heterosexually active African American and Hispanic women residing predominately in nonurban areas of the Southeastern United States. Most prior studies have focused on higher-risk women (drug users, sex workers, those at STI clinics) living in urban locations (McLellan-Lemal et al., 2012) or have had a preponderance of Non-Hispanic White women in the samples (Stockman et al., 2010), and research among diverse women in the Southern United States (Fleming, Lansky, Lee, & Nakashima, 2006) and among Hispanic women (Moreno, 2007; Surratt, Kurtz, Chen, & Mooss, 2012) is needed. We examined whether the occurrence of unwanted physically forced sex was associated with recent sexual-risk and drug-risk behaviors and mental health outcomes, stratified by age parameters. We were particularly interested in assessing a range of recent behaviors that may place the women at risk for HIV infection, including engaging in anal intercourse without condoms, having multiple sexual partners without using condoms, prior HIV testing, having sex with partners who have other concurrent partners, alcohol binging, and illicit drug use. We also assessed whether the women had recently experienced psychological distress and recently received professional counseling for a mental health problem.

Approximately 90% of the women screened for eligibility met enrollment criteria (1,821 of 2,015). The most common reason for noneligibility was not having had sexual intercourse in the previous 12 months. Eighty-four percent of eligible women (1,527 of 1,821) enrolled in the study. Only 1 eligible woman declined enrollment. The main reasons eligible women were not enrolled were because they missed study appointments, did not respond to contact attempts, or had transportation difficulties. Enrollment rates were similar across sites. Enrollees included 514 Hispanic women from Florida, 501 African American women from North Carolina, and 512 African American women from Alabama. The analytic sample included 1,509 of the 1,527 women due to missing data for the forced sex variable; the sample sizes fluctuated slightly for other variables due to item-specific missing data.

We found that 20% of the African American and Hispanic women in this study experienced unwanted forced sex at some point in their lives. Occurrence was more likely among African American women than Hispanic women. Of women who experienced the event, approximately half first experienced it at age 15 years or younger, and half experienced it when older than 15 years. Compared with women who never experienced forced sex, both early and later first occurrence of the event were significantly associated with recent multiple sequelae including sexual risk behaviors, selection of risky sexual partners, binge drinking, noninjection drug use, and mental health problems. A couple of the outcomes (recent STI diagnosis and multiple unprotected sexual partners in the previous 12 months) were more likely to occur among women who first experienced forced sex less than 10 years ago (relative to their age at enrollment) compared with women who experienced the first event less recently. But taken as a whole, our findings indicated that experience of forced sex among the women in our study, regardless of the age at which the event first occurred and regardless of the women’s age at enrollment (younger than 35 years vs. 35 years or older), was associated with wide-ranging behavioral and psychological outcomes later in life. Our findings are consistent with, and expand upon, previous studies of the associations between forced sex and risk outcomes (El-Bassel, Gilbert, Witte, Wu, & Chang, 2011; El-Bassel et al., 2010; Senn, Carey, & Vanable, 2008; Stockman et al., 2010; H. W. Wilson & Widom, 2011).

Our analysis focused on whether women had ever experienced forced sex and their age at first occurrence of the event, though some women may have experienced multiple instances of forced sex, and we did not know the woman’s age at the time of the most recent event. Other contextual factors such as the woman’s relationship with the perpetrator and the severity of the abuse obviously have important implications for understanding the magnitude of psychological and behavioral effects of such abuse. The fact that our analysis did not address these contextual factors, however, does not negate the importance of what our findings suggest: Girls or women who experience unwanted forced sex may suffer multiple adverse behavioral and psychological outcomes years after the first occurrence.

Prior studies have shown that women who first experienced forced sex in adulthood presented with a less complex constellation of traumatic symptoms than did women with a history of forced sex in childhood (Resnick et al., 2003). Women with a combined history of childhood and adult trauma were also more likely to have lasting pathology (Nishith, Mechanic, & Resick, 2000), which may in part stem from the woman’s relationship with the perpetrator and the severity of abuse (Wyatt & Newcomb, 1990). Our study did not examine traumatic symptoms or psychological issues beyond screening for psychological distress and whether women had sought mental health counseling from a professional. Thus, our findings should not be interpreted as inconsistent with these prior studies showing the differential psychological effects depending on the age at which forced sex first occurred and the pattern of abuse across time.

Other research studies have shown that to promote women’s health, interventions need to assess and address the context of women’s sexual experiences (Cavanaugh, Hansen, & Sullivan, 2010; Logan, Cole, & Leukefeld, 2002). Sensitive behavioral assessments that aim to better understand the contextual factors surrounding forced sex may inform client-centered approaches to intervene with women who have experienced the event. A variety of sexual trauma and risk-reduction intervention models have been developed, tested, and implemented for use with women who have experienced forced sex (e.g., Hien et al., 2010; Puffer, Kochman, Hansen, & Sikkema, 2011; Sikkema et al., 2007, 2008; Wyatt et al., 2004). Those interventions emphasize the women’s psychological processing of the event and the development of self-efficacy and coping skills. Trauma processing, in its later stages, relies upon strategies in which women “test” their skills at assertiveness and sexual negotiation. Historically, male partners have not been included in those interventions, but recent studies have shown that couples can benefit from such interventions (e.g., increased condom use in couples in which the woman has a history of sexual trauma; Jones, Kashy, Villar-Loubet, Cook, & Weiss, 2013). Thus, incorporating partners as potential facilitators in the women’s processing of sexual trauma, skill development, and behavior change may be useful. Indeed, recent reviews of risk-reduction interventions have called for the development and assessment of couples-focused risk-reduction approaches (Burton, Darbes, & Operario, 2010).

Our study was limited because we focused on the first occurrence of forced sex and do not have information about revictimization or the perpetrator of the abuse. Methodologically, some women in our study may have underreported the occurrence of forced sex as well as some behavioral outcomes (e.g., unprotected anal sex) due to concerns about social desirability, although the use of ACASI to collect the data typically promotes more candid responses (Harvey, Bird, Henderson, Beckman, & Huszti, 2004). In 2010, an estimated 65% of rapes or sexual assaults in the United States were not reported to law enforcement (Truman, 2011). Reporting of forced-sex experiences involves multiple complex factors and minority women may experience additional stressors associated with race and/or ethnicity (Olive, 2012). For Hispanic women, issues involving acculturation, economic resources, immigrant status, language barriers, and access to community resources (Cuevas, Sabina, & Bell, 2012; Sabina, Cuevas, & Schally, 2012) may contribute to underreporting. African American women may also underreport forced sex because of beliefs in sexual stereotypes and rape myths, self-blame, stigma, a cultural mandate to protect an African American male perpetrator as well as a lack of health insurance (Bryant-Davis, Chung, & Tillman, 2009; Long, Ullman, Starzynski, Long, & Mason, 2007; Tillman, Bryant-Davis, Smith, & Marks, 2010). Our findings are based on convenient samples of African American women primarily from rural counties of North Carolina and Alabama and Hispanic women from South Florida who were sexually active in the previous 12 months. Caution is warranted in generalizing our findings beyond the immediate sample or to other women who have experienced forced sex or rape. Finally, due to the cross-sectional design of our study, causal inferences cannot be drawn. It is possible that some of the behavioral and psychological outcomes we observed existed prior to the first forced-sex event or earlier than the recall periods for our outcome variables for some women.

In summary, we found that 20% of the African American and Hispanic women in our study reported having experienced unwanted physically forced sex at some time in their lives. Regardless of when the event first occurred (15 years or younger vs. older than 15 years) and regardless of women’s age at time of enrollment in the study (younger than 35 years vs. 35 years or older), those who experienced forced sex were significantly more likely to report recently engaging in vaginal and anal sex without condoms, having multiple unprotected sex partners, having a diagnosed STI, binge drinking, and using illicit drugs. They were also more likely to currently exhibit psychological distress and to have recently received professional counseling for a mental health problem. The experience of unwanted forced sex may have wide-ranging behavioral and mental health consequences years after the event first occurred.