Rape-related pregnancy" Estimates and descriptive characteristics from a national sample of women

Melisa M. Holmes, MD, Heidi S. Resnick, PhD, Dean G. Kilpatrick, PhD, and Connie L. Best, PhD
Charleston, South Carolina OBJECTIVE: We attempted to determine the national rape-related pregnancy rate and provide descriptive characteristics of pregnancies that result from rape. STUDY DESIGN: A national probability sample of 4008 adult American women took part in a 3-year longitudinal survey that assessed the prevalence and incidence of rape and related physical and mental health outcomes. RESULTS; The national rape-related pregnancy rate is 5.0% per rape among victims of reproductive age (aged 12 to 45); among adult women an estimated 32,101 pregnancies result from rape each year. Among 34 cases of rape-related pregnancy, the majority occurred among adolescents and resulted from assault by a known, often related perpetrator. Only 11.7% of these victims received immediate medical attention after the assault, and 47.1% received no medical attention related to the rape. A total 32.4% of these victims did not discover they were pregnant until they had already entered the second trimester; 32.2% opted to keep the infant whereas 50% underwent abortion and 5.9% placed the infant for adoption; an additional 11.8% had spontaneous abortion. CONCLUSIONS: Rape-related pregnancy occurs with significant frequency. It is a cause of many unwanted pregnancies and is closely linked with family and domestic violence. As we address the epidemic of unintended pregnancies in the United States, greater attention and effort should be aimed at preventing and identifying unwanted pregnancies that result from sexual victimization. (Am J Obstet Gynecol 1996;175:320-5.)

Key words: Sexual assault, rape, unintended pregnancy

Sexual assault is a significant societal problem, currently affecting approximately 12.1 million women in the United States?' 2Within the pastyear an estimated 683,000 women >18 years old have experienced a rape incident. 1The incidence of the past year would have been estimated to be much higher if adolescents had been included, because approximately 60% of all rape cases occur among girls younger than 18 years old. The short- and long-term sequelae of rape are complex. Psychologically, rape has been identified as a significant risk factor for posttraumatic stress disorder, with 35% to 50% of all victims affected. 2' 3 Less is known about the prevalence of significant physical health problems resulting from rape because data are limited to reports from the <15% of victims who report the
From the Department of Obstetrics and Gynecology and the National Crime Victims Research and Treatment Center, Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina. Supported by National Institute on Drug Abuse Grant No. ROIDA05220. Presented as Invited Guest at the Fifty-eighth Annual Meeting of The South Atlantic Association of Obstetricians and Gynecologists, Lake Buena Vista, Florida, January 27-30, 1996. Reprint requests: Melisa M. Holmes, MD, Department of Obstetrics and Gynecology, Medical University of South Carolina, 171 Ashley Ave., Charleston, SC 29425-2233. Copyright 1996 by Mosby-Year Book, Inc. 0002-9378/96 ~5.00 + 0 6/6/74482 320

crime to law enforcement and undergo an immediate evidentiary and medical examination. 1' ~6 Rates of resultant medical sequelae obtained from reported cases thus may greatly underestimate actual population rates. Available data indicate a variety of acute physical health outcomes, including nongenital trauma occurring in 25% to 45% of victims, 7-9genital trauma in 19% to 22% ,8-10sexually transmitted diseases occurring in up to 40%, 11'i2 and pregnancy in <1% to 5%. 4' 7. lo, 13 Rape has also been associated with many long-term sequelae, including chronic pelvic pain and other chronic pain syndromes, depression, substance abuse, eating disorders, sexual dysfunction, chronic vaginitis, marital discord, and suicide. 1446Rates for the occurrence of these long-term manifestations are largely speculative and based on rates of patient disclosure of past victimization, as well as rates of physician inquiry when a medical history is taken regarding prior victimization, This report focuses on rape-related pregnancy assessed within the National Women's Study, a national sample of >4000 women, 12% of whom had experienced at least one rape in their lifetime. 1 Data are presented on pregnancy rates of women raped during their reproductive years. The representative nature of the sample allows estimates of national lifetime rape-related pregnancy rates and past-year rape-related pregnancy rates. In addi-

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T a b l e I. I n t r o d u c t i o n a n d q u e s t i o n s u s e d to assess assault " . . . Another type of stressful event that many women have experienced is unwanted sexual advances. Women do not always report such experiences to the police or discuss them with family or friends. The person making the advances isn't always a stranger, but can be a friend, boyfriend, or even a family member. Such experiences can occur anytime in a women's life--even as a child. Regardless of how long ago it happened or who made the advances,.." Has a man or boy ever made you have sex by using force or threatening to harm you or someone close to you?Just so there is no mistake, by sex we mean putting a penis in your vagina. Has anyone ever made you have oral sex by force or threat of harm? Just so there is no mistake, by oral sex we mean that a man or boy put his penis in your mouth or someone penetrated your vagina or anus with their mouth or tongue. Has anyone ever made you have anal sex by force or threat of harm? Has anyone ever put fingers or objects in your vagina or anus against your will by using force or threats?

tion, characteristics o f t h e subset of cases in w h i c h r a p e r e l a t e d p r e g n a n c y o c c u r r e d are provided.

W h e t h e r t h e w o m a n did or d i d n o t subjectively d e f i n e t h e i n c i d e n t ( s ) as r a p e or r e p o r t e d it to police o r o t h e r authorities, a n affirmative r e s p o n s e to any of these questions i n d i c a t e d t h a t t h e w o m a n h a d b e e n a victim of rape. Because the survey i n c l u d e d a n o v e r s a m p l e o f y o u n g e r w o m e n a n d b e c a u s e some a t t r i t i o n o c c u r r e d over t h e 2-year follow-up p e r i o d of t h e study, t h e a c h i e v e d s a m p l e data were w e i g h t e d by age a n d race to t h e U.S. Census p r o j e c t i o n s o f t h e 1990 (wave 1), 1991 (wave 2), a n d 1992 (wave 3) a d u l t f e m a l e p o p u l a t i o n .

Methods
T h e N a t i o n a l W o m e n ' s Study was s u p p o r t e d by t h e N a t i o n a l Institute o n D r u g A b u s e a n d was u n d e r t a k e n to investigate t h e r e l a t i o n s h i p s b e t w e e n w o m e n ' s t r a u m a histories a n d m e n t a l a n d physical h e a l t h o u t c o m e s , inc l u d i n g s u b s t a n c e use a n d abuse. T h e study involved a 3-year l o n g i t u d i n a l t e l e p h o n e survey of a large n a t i o n a l p r o b a b i l i t y sample. P o t e n t i a l r e s p o n d e n t s i n c l u d e d all w o m e n in t h e r e s i d e n t i a l p o p u l a t i o n of t h e U n i t e d States w h o were >18 years old at the time o f the initial survey. S a m p l e c o n s t r u c t i o n yielded a p o p u l a t i o n - b a s e d r a n d o m digit dialing s a m p l e Of h o u s e h o l d s . A total of 4008 interviews were c o n d u c t e d ; 2008 of w h i c h were a n oversamp l i n g o f w o m e n b e t w e e n t h e ages o f 18 a n d 34 years. A t t e m p t s were m a d e to interview e a c h o f t h e original 4008 r e s p o n d e n t s t h r e e times at 1-year intervals. T h e initial interview, d e s i g n a t e d wave 1, e s t a b l i s h e d lifetime p r e v a l e n c e rates o f r a p e a n d o b t a i n e d descriptive i n f o r m a t i o n a b o u t r a p e cases. I n f o r m a t i o n a b o u t t h e past-year i n c i d e n c e o f r a p e was o b t a i n e d in the wave 2 (1-year follow-up) i n t e r v i e w by d e t e r m i n i n g h o w m a n y w o m e n were r a p e d in t h e year b e t w e e n wave 1 a n d wave 2. T h e wave 3 i n t e r v i e w f o r m e d the basis o f this r e p o r t a n d i n c l u d e d m e d i c a l o u t c o m e s a n d m e d i c a l t r e a t m e n t rec e i v e d after e a c h o f u p to t h r e e r a p e e x p e r i e n c e s t h a t may have o c c u r r e d d u r i n g a w o m a n ' s lifetime: a first r a p e i n c i d e n t , a m o s t r e c e n t r a p e i n c i d e n t , a n d a worst such i n c i d e n t , if distinct f r o m t h e first or m o s t r e c e n t r a p e i n c i d e n t . Wave 3 also g a t h e r e d data o n r a p e victims' concerns, willingness to r e p o r t f u t u r e r a p e s to police, a n d o p i n i o n s a b o u t disclosure. M e n t a l h e a l t h p r o b l e m s were assessed d u r i n g e a c h o f t h e t h r e e waves. All survey interviewing was d o n e by f e m a l e interviewers f r o m S c h u l m a n , Ronca, a n d Bucuvalas, Inc., a n a t i o n a l survey r e s e a r c h o r g a n i z a t i o n b a s e d in New York City. W i t h i n the interview, sexual assault ( " r a p e " ) was def i n e d as n o n c o n s e n s u a l assault with force or t h r e a t of force a n d s o m e type o f sexual p e n e t r a t i o n o f the victim's vagina, r e c t u m , o r m o u t h . T h e specific q u e s t i o n s to assess r a p e u s e d sensitive, behaviorally specific p h r a s i n g according to a n o r i e n t i n g preface as o u t l i n e d in Table I.

Results
Eighty-five p e r c e n t o f w o m e n initially c o n t a c t e d a g r e e d to p a r t i c i p a t e a n d c o m p l e t e d t h e wave 1 interview ( n = 4008). A t t h e 1-year follow-up, 80% ( n = 3220) o f t h e study p a r t i c i p a n t s were located a n d c o m p l e t e d t h e wave 2 interview. O f t h e original participants, 76% (n = 3031) c o m p l e t e d the wave 3 interview. T h e m e a n age for t h e e n t i r e sample was 44.9 years (SD 18.4). T h e majority o f w o m e n were h i g h school g r a d u a t e s (63.4%). T h e majority of t h e s a m p l e (63.7%) were m a r r i e d o r c o h a b i t a t i n g . More than half of the sample reported household income b e t w e e n $15,001 a n d $50,000, with a substantial m i n o r i t y (27.3%) r e p o r t i n g i n c o m e s <$15,000. For m o r e detail o n descriptive data f r o m wave 1 o f t h e study see Resnick et al. 2 Data o n t h e p r e v a l e n c e of r a p e a n d r a p e - r e l a t e d pregn a n c y o b s e r v e d as p a r t of t h e 'wave 3 assessment interview are first p r e s e n t e d as w e i g h t e d by age a n d race to the U.S. a d u l t p o p u l a t i o n o f w o m e n . T h e s e d a t a allow for estim a t e s to b e m a d e of n a t i o n a l rates o f r a p e - r e l a t e d pregnancy. T h e s e d a t a are followed by u n w e i g h t e d descriptive data about pregnancy outcomes and medical treatment received by w o m e n w h o r e p o r t e d a p r e g n a n c y r e s u l t i n g f r o m rape. O f t h e 3031 a d u l t w o m e n , 413 h a d e x p e r i e n c e d 616 c o m p l e t e d r a p e i n c i d e n t s at some time d u r i n g t h e i r lives, r e s u l t i n g in a 13.6% lifetime p r e v a l e n c e rate o f rape. Age-specific f i n d i n g s are d e t a i l e d in Table II. P r e g n a n c y r e s u l t i n g f r o m r a p e was r e p o r t e d by a total o f 19 w o m e n : O n e w o m a n r e p o r t e d two r a p e - r e l a t e d p r e g n a n c i e s ; t h e r e f o r e a total o f 20 cases o f r a p e - r e l a t e d p r e g n a n c y were identified. W h e n only victims of r e p r o d u c t i v e age were c o n s i d e r e d , t h e r a p e - r e l a t e d p r e g n a n c y rate was 5% p e r r a p e or 6% p e r victim.

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Table II. Rape-related pregnancy rates per rape incident Total No. Rape cases Rape-relatedpregnancies
Victims

Age 12-17 yr 187 10 (5.3%) 148

Age >18 yr 214 10 (4.7%) 183

Age 12 to 45 404 20 (5.0%) 315

616 20 (3.2%) r413

Table III. Relationship between victim and perpetrator among rape-related pregnancies Stranger Boyfriend Husband Friend Other relative Known, nonrelative Father-stepfather Unknown-refused 8.8% 29.4% 17.6% 14.7% 11.8% 8.8% 5.9% 2.9%

The weighted prevalence of rape-related pregnancy as a result of rape at any age(s) among all adult women is 0.63% or a total of 606,690, on the basis of an estimated 96.3 million adult women in the population from the 1989 U.S. Census Bureau: The National Women's Study also identified an incidence of 683,000 rapes in 1 year among adult women in the United States. Thus it can be estimated on the basis of the adult rape-related pregnancy case rate of 4.7% that there may be 32,101 raperelated pregnancies annually among American women older than 18 years. Analysis of the National Women's Study raw data (without statistical weighting required for determining representative population estimates) indicates that there were 34 cases of rape-related pregnancy. A total of 30 women reported one rape-related pregnancy and two additional women reported two rape-related pregnancies. Of the 34 cases 21% occurred when the victim was aged 12 to 15 years, 27% occurred among women aged 16 and 17, and 52% occurred after age 18. After the assault only 24% (n = 8) underwent a medical examination. Among these 8 cases the physician was notified that a rape had occurred in only 3. Of the cases in which medical attention was received 11.7% of patients were examined within 48 hours after the rape, 5.9% were examined within 1 week, and an additional 5.9% were examined within 1 month of the assault. In those cases in which there was no medical attention, only half of the patients reported being counseled about the possibility of pregnancy resulting from the assault. Subsequently, in 61.7% of cases the pregnancy was discovered within 11 weeks after the rape. An additional 32.4% did not discover they were pregnant until they had already entered the second trimester (12 to 26 weeks after the rape), and 5.9% were unsure of the time elapsed after the rape. Outcomes of rape-related pregnancy cases confirmed that the majority of these pregnancies were unwanted. The infant was kept by the mother in 32.3% of cases, 50% underwent abortion, and 5.9% placed the infant for adoption. A total of 11.8% of

the rape-related pregnancies resulted in spontaneous abortion. The majority of rape-related pregnancies involved a known perpetrator rather than a stranger. The relationships between the victims and the perpetrators are provided in Table III. Rape-related pregnancy resulted from a single assault in 58.8% of cases, but 41.2% of cases involved repetitive assaults, one of which was assumed to result in the pregnancy. Rape cases leading to pregnancy included the use of alcohol or drugs by the victim in 20.6% of cases and by the perpetrator in 55.9% of cases. The maximum expected sampling error for simple random samples of 4000, 3200, and 3000 cases are +1.5%, +1.7%, and +1.8%, respectively, which is at the 95% confidence level.

Comment
With >32,000 rape-related pregnancies occurring each year among adult women in the United Stats and an as yet undetermined number occurring among adolescents, rape-related pregnancy is a significant problem that warrants closer attention. Although the total number of raperelated pregnancies may account for only a small portion of the estimated 3 million unintended pregnancies occurring annually in the United States, the occurrence of pregnancy resulting from rape or incest holds important public health and policy implications. For example, policy debates surrounding abortion funding for cases of rape and incest have historically lacked scientific foundation as they have been based on data from the small proportion of reported cases. Additionally, rape victims have not been afforded adequate funding under crime victim compensation programs to cover follow-up that could reduce the occurrence of rape-related pregnancy and other serious physical and mental health sequelae. The National Women's Study represents the first national empiric data on lifetime prevalence and past-year incidence of rape among adult women. Population-based rape-related pregnancy rates similarly have not been previously reported. Unintended pregnancy has been identified as a national epidemic, 17 and substantial human and financial resources have been dedicated to addressing and improving this problem. To date, rape-related pregnancy has not been identified as a contributing factor in unintended pregnancy rates. The United States Public Health Service, in its publication Healthy People 2000, has established national health objectives that specifically target a large reduction in all unintended pregnancies to a rate of <30% (objective 5.2). 18 Recommendations for achieving these goals include reducing rates of sexual activity, pro-

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rooting responsible sexuality, and increasing effective use of family p l a n n i n g methods. 17~9 All of these measures assume that the p r e g n a n t w o m a n conceived t h r o u g h consensual intercourse and is responsible for h e r pregnancy. A particularly disturbing finding in this study includes the identification of the p e r p e t r a t o r as being known, often well known, to the victim. This evidence implies that rape-related p r e g n a n c y is closely linked with domestic and family violence. This c o n c e p t is further supported by the fact that >40% of the rape-related pregnancies resulted f r o m multiple assaults rather than f r o m a single attack and thus o c c u r r e d in the setting of o n g o i n g violence or abuse. Previous reports in the medical literature have failed to identify this facet of the p r o b l e m because they have relied on data f r o m r e p o r t e d cases only. 7-1 Because battered w o m e n and abused children do n o t readily disclose their abuse, 2 pregnancies o c c u r r i n g in this setting are unlikely to be disclosed early in gestation and are m o r e likely to result in complications and longt e r m sequelae that affect the victim and even the fetus and infant. 2' 21 Also, because p r e g n a n c y may b e associated with increases in battering, 22-24rape-related pregnancies affecting victims in this setting would be e x p e c t e d to have a particularly high risk for adverse physical and psychologic outcomes. As few as 10% to 20% of sexual assaults are ever r e p o r t e d to law enforcement./' 5 Most states have crime victim c o m p e n s a t i o n p r o g r a m s that provide financial support for evidence collection and i m m e d i a t e medical e x a m i n a t i o n in cases of sexual assault. Hospitals are therefore r e q u i r e d to r e p o r t sexual assault if an evidentiary e x a m i n a t i o n is p e r f o r m e d . 2~ For those victims choosing not to r e p o r t to law e n f o r c e m e n t , medical attention is often unavailable unless the victim pays for it herself; providing the opportunity for a n o n y m o u s rep o r t i n g can improve victims' access to care. Nonetheless, both the c u r r e n t low rate of r e p o r t i n g and the lack of appropriate medical services for n o n r e p o r t e r s may contribute to the o c c u r r e n c e of rape-related pregnancy. For victims receiving i m m e d i a t e medical attention, the option to receive postcoital contraception should be offered. 26 Additionally, physicians are e x p e c t e d to encourage and arrange medical and psychologic follow-up for sexual assault victims. T h e r e f o r e with p r o p e r and accessible medical care rape-related pregnancy can be prevented or at least recognized early e n o u g h during follow-up care to allow for safe t e r m i n a t i o n or appropriate prenatal care. This study is n o t without limitations. By its nature, a t e l e p h o n e survey is limited to the 94% of the population living in households with telephones. O t h e r limitations i n h e r e n t in this type of data collection include the retrospective nature of collecting lifetime information and the inability to c o n f i r m the factuality of responses. O n the o t h e r hand, the representative nature of a large population-based sample such as this allows for m o r e appropriate generalizations than data collected f r o m treatment-

seeking groups. Hopefully, these data may serve as a p o i n t of d e p a r t u r e for future prospective research that can m o r e clearly and precisely d e t e r m i n e the extent of the p r o b l e m of rape-related p r e g n a n c y and o t h e r rape-related health outcomes. To maximize national efforts to reduce the n u m b e r of u n i n t e n d e d pregnancies and to prevent the complicated sequelae of rape that affect women, children, and s o c i e t y in general, there must be greater efforts f r o m medical, social, educational, and public policy professionals aimed toward recognition and prevention of u n i n t e n d e d pregnancy resulting f r o m sexual victimization. These efforts n o t only should focus on the primary prevention of sexual assault, including date rape, marital rape, and incest, but also should aim to improve the availability and accessibility of medical services that provide medical evaluation, counseling, postcoital contraception, pregnancy termination services, or appropriate prenatal care as desired after rape.

REFERENCES

1. Kilpatrick DG, Edmunds CN, Seymonr AK. Rape in America: a report to the nation. Charleston (SC): The National Victim Center mad the National Crime Victims Research and Treatment Center at the Medical University of South Carolina, 1992 Apr. 2. Resnick HS, Kilpatrick DG, Dansky BS, Saunders BE, Best CL. Prevalence of civilian trauma and posttraumatic stress disorder in a representative national sample of women. J Consult Clin Psychol, 1993;61:984-91. 3. Rothbaum BO, Foa EB, Riggs DS, Murdock T, Walsh W. A prospective examination of posttraumatic stress disorder in rape victims. J Trauma Stress, 1992;5:455-75. 4. Goodman LA, Koss MP, Russo NE Violence against women: physical and mental health effects. I. Research findings. Appl Prev Psychol 1993;2:79-89. 5. Federal Bureau of Investigation. Crime in the United States: uniform crime reports for the United States, 1991. Washington (DC): The Bureau, 1991. 6. Koss MP, Heslet L. Somatic consequences of violence against women. Arch Fam Med 1992;1:53-9. 7. Beebe DK. Emergency management of the adult female rape victim. Am Fam Physician 1991;43:2041-6. 8. SololaA, Scott C, Severs H, HowellJ. Rape: management in a noninstitutional setting. Obstet Gynecol 1983;61:373-6. 9. Cartwright PS, Moore RA, Anderson JR, Brown DH. GenitM injury and implied consent to alleged rape. J Reprod Med 1986;31:1043-4. 10. TintinalliJE, Hoelzer M. Clinical findings and legal resolution in sexual assault. Ann Emerg Med 1985;14:447-53. 11. Jenny C, Hooten TM, Bowers A, Compass MK, Krieger JN, Hillier SL. Sexually transmitted diseases in victims of rape. N EnglJ Med 1990;322:713-6. 12. Glaser JB, Hammerschlag MR, McCormack WM. Epidemiology of sexually transmitted diseases in rape victims. Rev Infect Dis 1989;11:246-54. 13. Evrard JR, Gold EM. Epidemiology and management of sexual assault victims. Obstet Gynecol 1979;53:381-7. 14. Kilpatrick DG, Veronen LJ, Best CL. Factors predicting psychological distress among rape victims. In: Figley CR, editor. Trauma and its wake. New York: Brunner Mazel, 1985. 15. Resick P, Calhoun K, Atkeson B, Ellis EM. Adjustment in victims of sexual assault. J Consult Clin Psychol 1981;49:705-12. 16. Reiter RC, GamboneJC. Demographic and historic variables in women with idiopathic chronic pelvic pain. Obstet Gynecol 1990;75:428-32. 17. Grimes DA. Unplanned pregnancies in the United States. Obstet Gynecol 1986;67:438-42.

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18. Public Health Service. Healthy people 2000: National health promotion and disease prevention objectives--full report, with commentary. Washington (DC): US Department of Health and Human Services, Public Health Service; 1991. DHHS publication No.: (PHS)91-50212. 19. Fleissig A. Unintended pregnancies and the use of contraception: changes from 1984 to 1989. BMJ 1991;302: 147. 20. Council on Scientific Affairs, American Medical Association. Violence against women: relevance for medical practitioners. JAMA 1992;267:3184-9. 21. Dagg PKB. The psychological sequelae of therapeutic abort i o n - d e n i e d and completed. AmJ Psychiatry 1991;148:57885. 22. Satin AJ, Hemsell DL, Stone ICJr, Theriot S, Wendel GDJr. Sexual assault in pregnancy. Obstet Gynecol 1991;77:710-4. 23. Helton AS, McFarlane J, Anderson ET. Battered and pregnant: a prevalence study. Am J Public Health 1987;77: 1337-9. 24. Hillard PJA. Physical abuse in pregnancy. Obstet Gynecol 1985;66:185-90. 25. Young WW, Bracken AC, Goddard MA, Matheson S. Sexual assault: review of a national model protocol for forensic and medical evaluation. Obstet Gynecol 1992;80:878-83. 26. The American College of Obstetricians and Gynecologists. Sexual assault. Washington (DC): The College, 1992. Technical Bulletin No.: 172.

Discussion

DR. Jon~ G. M o o ~ , Atlanta, Georgia (Official Guest). T h e authors are to be c o m p l i m e n t e d for this original study, which attempts to develop valid data c o n c e r n i n g rape-related pregnancy. Heretofore, published studies generally relied on data f r o m either crisis centers or police reports in developing prevalence figures for raperelated pregnancies. However, it is widely known that a large majority of rapes are not r e p o r t e d and that a significant n u m b e r of w o m e n fail to seek medical care after the o c c u r r e n c e of rape. As a result, published prevalence figures are clouded by inaccuracies and speculation. This study attempted to collect accurate data that could be extrapolated to the general population. T h e m e t h o d of the study involved a 3-year longitudinal t e l e p h o n e survey of >4000 women. A study such as this is fraught with difficulty because of the limitations of the survey technique. W h e n evaluating this study, one must initially consider the difficulties associated with interviewer bias. T h e interviewer had the discretion to classify an event as a rape even if the w o m a n did n o t identify it as such, seek medical care, or notify police authorities. In accordance with the wording and interpretation of the questions, some variability in the classification of individual cases could occur. F u r t h e r m o r e , the well-recognized reluctance to discuss intimate sexual details, which would n o t be s u r m o u n t e d by the anonymity of the t e l e p h o n e interview process, introduces yet a n o t h e r sampling bias. ! n addition, there is no way to quantify the accuracy and veracity of the responders or to c o m p a r e one individual's response objectively with the responses of others surveyed. Finally, the retrospective nature of this study introduces uncertainty as a result of the varying ability of individuals to recall past events. Dr. H o l m e s reports that 32% of w o m e n who b e c a m e p r e g n a n t as a result of a rape were n o t aware of the pregnancy until the second trimester. A recent study that

used deoxyribonucleic acid analysis techniques r e p o r t e d that 60% of w o m e n who b e c a m e p r e g n a n t after an assault were instead p r e g n a n t by a consensual partner.' Inasm u c h as 64% of the w o m e n in this study were either m a r r i e d or cohabitating, it must be assumed that these individuals were exposed to consensual intercourse. T h e r e f o r e without the appropriate deoxyribonucleic acid analysis the pregnancies c a n n o t conclusively be ascribed to the rape incident. T h e issue is further complicated when the r e p o r t e d assailant is either the victim's husband or h e r boyfriend and sexual relations were at times consensual and at o t h e r times forced. In the latter circumstance it is impossible to differentiate w h e t h e r the pregnancy was a result of consenting versus forced sexual exposure. Lack of medical care after an assault is a major medical and social problem. Only 11.7% of the individuals described in the study were seen within 48 hours of the incident. F u r t h e r m o r e , it is of c o n c e r n that only 50% of the w o m e n who received medical attention r e p o r t e d that they had b e e n counseled about the possibility of a pregnancy resulting f r o m the event. This is a glaring deficiency in the standard of medical care and points to an area in which we as gynecologists must strive to improve the health care delivery system. The recognized reluctance of w o m e n to seek care after a sexual assault or even to discuss such an incident emphasizes the n e e d for us to maintain a high i n d e x of suspicion regarding the possibility of assault, which would then allow us to ask the necessary questions and initiate appropriate t r e a t m e n t and counseling. 2 A n o t h e r limitation of this study is the exclusion of w o m e n <18 years old. A l t h o u g h there is a clear understanding that m o r e than half of rapes occur a m o n g adolescents younger than 18 years, the study fails to address this significant problem. Indeed, as is well recognized, young girls and adolescents are quite i g n o r a n t regarding sexuality and reproductive realities. In fact, in one study of teenagers who b e c a m e pregnant, 33% r e p o r t e d experiencing forced or unwanted sexual intercourse? The c u r r e n t study therefore leaves a large and significant portion of the question regarding rape and pregnancy unanswered. It would be a m u c h m o r e powerful and significant study if the entire c o h o r t had b e e n surveyed. In closing, I will ask Dr. H o l m e s the following questions. First, can you address the issue of interviewer bias, particularly in the classification of what constitutes sexual assault in those w o m e n who themselves fail to recognize their e x p e r i e n c e as a rape-related incident? Second, I ask Dr. H o l m e s what are h e r r e c o m m e n d a t i o n s to e n c o u r a g e w o m e n to r e p o r t sexual assault and seek early medical care? Finally, I w o n d e r whether you have any plans for including w o m e n u n d e r age 18 years in your future research efforts? I e n c o u r a g e Dr. H o l m e s to continue with her studies and favor us with o n g o i n g reports c o n c e r n i n g this important and socially relevant topic.
REFERENCES

1. Hammond HA, Redman JB, Caskey CT. In utero paternity testing following alleged sexual assault. JAMA 1995;273: 1774-7.

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2. Bang L. Rape victims--assaults, injuries and treatment at a medical rape trauma service at Oslo Emergency Hospital. Scand J Prim Health Care 1993; 11:15-20. 3. Heise LL. Gender-based violence and women's reproductive health. IntJ Gynecol Obstet 1994;46:221-9. DR. H u c n MORENO, Atlanta, Georgia. In Grady M e m o rial Hospital Rape Center, we see an average of three to five cases of rape weekly. In all those cases without active c o n t r a c e p t i o n the patients are offered the " m o r n i n g after pill." I would like to know what percentage of the patients in the study were e x a m i n e d and what percentage of those patients were offered this type of contraception. DR, HOLMES (Closing). We a t t e m p t e d to minimize interviewer bias by using a very reputable professional research survey firm that is obviously very familiar with avoiding bias in questioning clients over the telephone. All questions were objective and were actually scripted so that variation a m o n g the interviewers was avoided. Finally, we did n o t include a t t e m p t e d rapes in our data but i n c l u d e d only rapes that were c o m p l e t e d and forced. If we review the actual questions asked, we see that they are very specific and leave litde or no r o o m for interpretation of w h e t h e r a rape did or did n o t occur. H o w can we increase r e p o r t i n g a m o n g our patients? In our c o u n t r y that's a p r o b l e m we all have to face, and it's a p r o b l e m that law e n f o r c e m e n t is dealing with as well. O b v i o u s l y t h e answer, as in so many o t h e r areas of medicine, is n o t just patient education but also public education. Specifically, as a physician providing health care to

women, I think the best thing we can do is routinely incorporate questions about prior sexual victimization and physical trauma into our routine health assessment. T h a t makes our patients realize that e x p e r i e n c i n g such trauma has i m p o r t a n t implications for their health. If a patient should be u n f o r t u n a t e e n o u g h to e x p e r i e n c e a. rape. or physical abuse in the future, she m i g h t be m o r e likely to r e p o r t it; once you as a physician have asked about it, you've o p e n e d the d o o r for h e r to discuss it. T h e only r e c o m m e n d a t i o n I have right now in m a k i n g great strides in i m p r o v i n g r e p o r t i n g is to routinely ask. Regarding the question a b o u t minors, anyone who has tried to do research involving adolescents realizes we are severely limited by consent issues. A l t h o u g h a m i n o r can consent to health care related to h e r reproductive health, she c a n n o t consent to participate in prospective research. What we are faced with is having to do this retrospectively, and we actually are involved in d o i n g such a study right now. We have i n c o r p o r a t e d a very detailed sexual history into our Adolescent Clinic, and w h e n we have e n o u g h participants, we will review :records and h o p e to have some i m p o r t a n t data on adolescents. Regarding Dr. M o r e n o ' s question on postcoital contraception, I do n o t have the Jinformation on how many w o m e n were e x a m i n e d at rape crisis centers v e r s u s a physician's office or i n f o r m a t i o n on the avaiiability of postcoital contraception.