CSIRO PUBLISHING
Sexual Health, 2014, 11, 472–480 http://dx.doi.org/10.1071/SH14103
Experiences of sexual coercion in a representative sample of adults: the Second Australian Study of Health and Relationships Richard O. de Visser A,I, Paul B. Badcock B,C, Chris Rissel D, Juliet Richters E, Anthony M. A. Smith B,H, Andrew E. GrulichF and Judy M. SimpsonG A
School of Psychology, Pevensey 1, University of Sussex, Falmer BN1 9QH, UK. Australian Research Centre in Sex, Health and Society, La Trobe University, 215 Franklin Street, Melbourne, Vic. 3000, Australia. C Centre for Youth Mental Health, University of Melbourne, Orygen Youth Health Research Centre, 35 Poplar Road, Parkville, Vic. 3052, Australia. D Sydney School of Public Health, Charles Perkins Centre (D17), University of Sydney, Sydney, NSW 2006, Australia. E School of Public Health and Community Medicine, University of New South Wales, Sydney, NSW 2052, Australia. F The Kirby Institute, Wallace Wurth Building, University of New South Wales, Sydney, NSW 2052, Australia. G Sydney School of Public Health, Edward Ford Building (A27), University of Sydney, Sydney, NSW 2006, Australia. H Deceased. I Corresponding author. Email: [email protected] B
Abstract. Background: It is important to have current reliable estimates of the prevalence, correlates and consequences of sexual coercion among a representative sample of Australian adults and to identify changes over time in prevalence and consequences. Methods: Computer-assisted telephone interviews were completed by a representative sample of 20 094 Australian men and women aged 16–69 years. The participation rate among eligible people was 66.2%. Results: Sexual coercion (i.e. being forced or frightened into sexual activity) was reported by 4.2% of men and 22.4% of women. Sexual coercion when aged 16 years was reported by 2.0% of men and 11.5% of women. Correlates of sexual coercion were similar for men and women. Those who had been coerced reported greater psychosocial distress, were more likely to smoke, were more anxious about sex and more likely to have acquired a sexually transmissible infection. Few people had talked to others about their experiences of sexual coercion and fewer had talked to a professional. There were no significant differences between the First and Second Australian Study of Health and Relationships in whether men or women had experienced coercion, talked to anyone about this or talked to a counsellor or psychologist. Conclusion: Sexual coercion has detrimental effects on various aspects of people’s lives. It usually occurs at the ages at which people become sexually active. There is a need to reduce the incidence of sexual coercion, better identify experiences of sexual coercion, and provide accessible services to minimise the detrimental effects of sexual coercion. Additional keywords: sex, wellbeing. Received 7 June 2014, accepted 22 August 2014, published online 7 November 2014
Introduction It is an unfortunate fact that many people experience unwanted sexual activity, and in patriarchal societies women are particularly vulnerable to sexual coercion. Studies of representative samples in the US reveal that ~20% of women and ~5% of men have experienced sexual coercion.1,2 Such sex differences have been found in studies of large nonrepresentative samples in other developed Western nations.3–5 Journal compilation CSIRO 2014
In Britain the third National Survey of Sexual Attitudes and Lifestyles (Natsal-3) revealed that 19% of women and 5% of men had experienced attempted non-volitional sex and that 10% of women and 1% of men had experienced completed non-volitional sex.4 In the population-representative sample recruited for the First Australian Study of Health and Relationships (ASHR1), 21% of women and 5% of men reported that they had been forced or frightened into unwanted www.publish.csiro.au/journals/sh
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sexual activity.5 Approximately half of these people had been sexually coerced when they were aged 16 years or younger (10% of all women, 3% of all men). Sexual coercion has negative impacts on the psychological, physical and sexual health of men and women.1,3,6–18 These personal impacts also incur costs for the broader society in the form of greater use of healthcare services and lost work productivity.8 People who have experienced sexual coercion have higher levels of psychosocial distress, depression, anxiety, suicidality and anger.4,6–11 They also have poorer physical health and are more likely to smoke tobacco, drink alcohol excessively, use illicit drugs and to have injected illicit drugs.4–8,10–12 The effects on sexual health are also clear; those who have been coerced are more likely to have been diagnosed with a sexually transmissible infection (STI) and are more likely to be anxious about sexual performance, lack interest in sex and not find sex pleasurable.4–8,13–16 The analysis of women’s responses in ASHR1 revealed that any experience of sexual coercion was associated with poorer psychological, physical and sexual health; that is, poor health outcomes tended not to depend on age when coerced, number of times coerced or time since being coerced. One important exception to this was that women who had been coerced more than once had poorer psychological wellbeing.19 ASHR1 identified some significant demographic correlates of experience of coercion. As noted above, coercion was more likely among women.19 Among women and men, coercion was significantly more likely among respondents who identified as homosexual or bisexual and respondents with lower incomes. Among women only, coercion was significantly less likely among women aged 50–59 years and women from nonEnglish-speaking backgrounds. Experience of coercion did not vary significantly according to education, region of residence or occupation. Professional services may be able to minimise the detrimental effects of sexual coercion,19–22 but many people do not talk to others about their experiences of sexual coercion.4,19–23 In ASHR1, only one-third of men and women who had been coerced had talked to someone about their experiences and few of these had talked to someone professionally qualified to address these issues.6 Intervening by providing appropriate support services is important for at least two reasons: first, to minimise the psychosocial impact2 noted above1,6–18 and second, to reduce the likelihood of people who have been coerced going on to coerce others. The latter is important because men who have been sexually coerced are significantly more likely than other men to report having sexually coerced another person.24 This significant association remains after controlling for nonsexual antisocial behaviour and non-coercive sexual behaviour.24 Given the observed links between sexual coercion and various aspects of wellbeing, the aim of the analyses reported here was to examine the current prevalence and correlates of sexual coercion among a representative sample of Australian adults and to identify changes in the prevalence of sexual coercion between 2002 and 2013. It is important to obtain accurate estimates of the prevalence of sexual coercion via studies of population-representative samples, because
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estimates based on reports from studies of non-probability samples may be less accurate.25 Methods The methodology used in the Second Australian Study of Health and Relationships (ASHR2) is described elsewhere in this issue.26 Briefly, between October 2012 and November 2013, computer-assisted telephone interviews were completed by a representative sample of 20 094 Australian residents aged 16–69 years from all states and territories. Ethical approval was obtained from the researchers’ host universities. Respondents were selected using dual-frame modified random digit dialling (RDD), combining directory-assisted landline-based RDD with RDD of mobile telephones. The participation rate among eligible people was 66.2%. To maximise the number of interviews with people who had engaged in less common and/or more risky behaviours, all respondents who had had no sexual partners in the previous year, who had had more than one partner in the previous year, and/or who reported any homosexual experience ever completed a long form of the survey instrument, which collected detailed data on their sexual attitudes, relationships and behaviours. Of the larger proportion of respondents who reported one partner in the previous year and no homosexual experience, 20% were randomly selected to complete the longform interview and the other 80% completed a short-form interview. As a consequence, 8577 completed the long-form interview and 11 517 completed the short-form interview. Answers to questions that occurred only in the long-form interview are reported after weighting to reflect the sample as a whole. Questions asked about experiences of unwanted sex and sexual coercion are presented in Box 1. These questions were only asked of people who completed a long-form interview. Sexual coercion was defined as ‘being forced or frightened into doing something sexually that you did not want to do’. After being asked the questions in Box 1, all interviewees were offered the contact details of relevant organisations for advice or support. The correlates of sexual coercion examined in this paper included a range of demographic characteristics, which were recoded to facilitate analysis and several other variables. Respondents’ ages were recoded into six groups: 16–19, 20–29, 30–39, 40–49, 50–59 and 60–69 years. Languages spoken at home were recoded as English or a language other than English. Sexual identity (in answer to the question: ‘Do you think of yourself as . . .’) was coded as heterosexual, homosexual or bisexual; too few respondents stated that they were ‘queer’, ‘other’ or ‘undecided’ to allow analysis of these groups. Respondents’ reported highest completed level of education was recoded to distinguish between those who had not (yet) completed secondary school, those who had completed secondary school and those who had completed post-secondary education. Respondents’ postcodes were used with the Accessibility/Remoteness Index of Australia to determine whether respondents lived in a major city, a regional area or a remote area (i.e. areas with relatively unrestricted, restricted and very restricted access to goods, services and opportunities
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Box 1. Ascertainment of experiences of sexual coercion
The next section is about sexual situations that both women and men have encountered. We understand that sometimes these are difficult issues to discuss. Have you ever had a sexual experience with a male or a female when you didn’t want to because you were too drunk or high at the time? Have you ever been forced or frightened by a male or a female into doing something sexually that you did not want to do? [if yes] How many times has this happened to you? How old were you when it started? (or ‘How old were you the first time?’ or ‘How old were you at the time?’ as appropriate.) Did you talk to someone else about it or seek help? [if yes] Who did you talk to? If you would like I can give you a phone number of someone to talk to (more) about this. The number is (interviewer reads out appropriate number from sheet).
for social interaction respectively).27 To approximate the gross annual household income quintiles reported by the Australian Bureau of Statistics for 2009–10, respondents’ reported annual household income was grouped into five categories: up to $28 000, $28 001–$52 000, $52 001– $83 000, $83 001–$125 000 and more than $125 000.28 Respondents’ reported occupation was coded into the nine major categories of the Australian Standard Classification of Occupations29 and then recoded to distinguish between managerial/professional occupations, white-collar occupations and blue-collar occupations. Psychological distress was measured by the Kessler-6 (K6) psychological distress scale. Respondents used a five-point scale (all of the time/most of the time/some of the time/a little of the time/none of the time) to indicate their experience of depressive and anxious symptoms over the previous month.30 To maintain consistency with the distress scale used in ASHR1, the word ‘depressed’ in the item ‘How often have you felt so depressed that nothing could cheer you up?’ was replaced with ‘sad’. As with ASHR1, a score of one standard deviation above the mean was chosen as a marker of elevated psychosocial distress.19 Respondents indicated whether they had ever been diagnosed with an STI. They also indicated whether, in the year before being interviewed, they had experienced any of the following sexual difficulties for a period of at least 3 months: lacking of interest in sex, not finding sex pleasurable and anxiety about ability to perform sexually. Respondents indicated whether they were current smokers, former smokers or had never smoked. Reports of alcohol consumption frequency and volume were used to determine whether respondents’ alcohol consumption was in excess of National Health and Medical Research Council (NHMRC) guidelines at the time of ASHR1 (28 standard drinks a week for men, 14 for women).31 Respondents also indicated if they had ever injected drugs. Data were weighted to adjust for the probability of each respondent being selected for a landline or mobile phone interview, a long-form interview and (for landline participants), the number of in-scope adults in the household. Data were then weighted to match the Australian population on the basis of age, gender, area of residence (i.e. state by ARIA category) and telephone ownership (i.e. mobile telephone only vs other), resulting in an adjusted sample of 10 056 men and 10 038
women (total 20 094). The data were thus weighted to account for the specifics of our sample design and the fact that particular types of people were slightly over- or under-represented. Therefore, the data presented describe a representative sample of the Australian population aged 16–69 years, subject to the biases noted elsewhere in this issue.26 The main outcome variables were compared with those of ASHR1 to identify significant changes over time. Weighted data were analysed using survey estimation commands in Stata Version 11.2.32 Data were analysed using univariate logistic regression for dichotomous outcomes, including comparisons of ASHR1 and ASHR2. Correlates of polytomous outcomes were identified using univariate multinomial logistic regression. Percentages are presented in this article without standard errors or 95% confidence intervals. This decision was made to maximise both readability and brevity and is in keeping with the style of other studies of a similar scope and intent.2,6,33 Further information about the precision of estimates is found elsewhere in this issue.26 Due to the number of participants in ASHR2, it is important to recognise that often there is the statistical power to detect even small changes as statistically significant, but these do not necessarily correspond to significant differences in a public health sense. Results Overall, 13.3% of respondents reported being forced or frightened into sexual behaviour. Table 1 shows that women (22.4%) were significantly more likely than men (4.2%) to report experience of sexual coercion (P < 0.001). The ages at which men were first coerced to have sex ranged from 5 to 41 years (mean = 16.8 years; median = 17 years). The ages at which women were first coerced into sexual activity ranged from 4 to 40 years (mean = 16.3 years; median = 16 years). There was no significant difference between the mean ages at which men and women were first coerced into sexual activity (P = 0.37). If we take 16 years of age as the upper limit of childhood, 2.0% of men and 11.5% of women had been sexually coerced when aged 16 years or younger. Among men who had been forced or frightened into sexual activity, 48.6% reported one instance of sexual coercion and 5.3% reported that it happened too many times to count, or
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Table 1. Experiences of being forced or frightened into doing something sexually Unless indicated otherwise, data show the percentage of n in each section who reported each experience. Unadjusted odds ratios (OR) and 95% confidence intervals (CI) are of coercion for women versus men Men (%) All respondents Ever forced or frightened into doing something sexually?
Women (%)
OR (95% CI)
n = 9823 n = 9778 4.2 22.4 6.63 (5.40–8.15)
Respondents who had been coerced n = 403 n = 2159 Age (in years) when (first) coerced 1 standard deviation above the sample mean. Experienced for at least 3 months in the previous year. C Consumption in excess of National Health & Medical Research Council guidelines. A B
Table 4. Prevalence of sexual coercion among men and women: comparison of the first Australian Study of Health and Relationships (ASHR1) and the Second Australian Study of Health and Relationships (ASHR2) People aged 60–69 years have been removed from the ASHR2 sample for comparison. Unless indicated otherwise, data show the number of respondents asked each question, with the percentage of this number giving affirmative responses shown in parentheses. Unadjusted odds ratios (OR) and confidence intervals (CI) are for ASHR2 versus ASHR1 Experience of coercion Forced/frightened into doing something sexually? If yes, talked to somebody? If yes, talked to counsellor/ psychologist? Forced/frightened into doing something sexually in childhood?
ASHR1
Men ASHR2
OR (95% CI)
9373 (4.8%)
8292 (4.4%)
0.89 (0.69–1.17)
9218 (21.1%) 8475 (22.3%) 1.07 (0.91–1.26)
362 (26.5%) 0.79 (0.45–1.38) 96 (10.9%) 0.56 (0.19–1.66)
1948 (37.9%) 1890 (43.4%) 1.28 (0.96–1.71) 739 (25.6%) 819 (22.1%) 0.82 (0.50–1.34)
455 (31.5%) 143 (17.7%) 9373 (2.8%)
8292 (2.0%)
Discussion The headline findings reported here are that 22% of women and 4% of men had ever been forced or frightened into doing something sexual and that 12% of women and 2% of men had been sexually coerced when aged 16 years or younger. Although it is not coercion, per se – that is, people may subsequently regret decisions made when drunk – the finding that half of the sample reported having an unwanted sexual experience due to being affected by alcohol or other drugs suggests that there is a need to enable people to make better decisions about their sexual behaviour when intoxicated. The proportions of men and women reporting experience of sexual coercion were similar to those reported in comparable surveys conducted in the US and Europe.1–3,5 However, lower proportions were found in Natsal-3 in Britain. There are several possible reasons for this difference. First, Natsal-3 only asked
0.73 (0.51–1.06)
ASHR1
Women ASHR2
OR (95% CI)
9218 (10.3%) 8475 (11.5%) 1.14 (0.91–1.42)
about non-consensual sexual activity that occurred after age 13 years and the data in Table 1 indicate that over one-quarter of the people who were coerced reported that this (first) happened before age 13 years. Second, ASHR used the term ‘anything sexual’ whereas Natsal-3 used more precise and restrictive terms. Reported rates of sexual coercion vary depending on the definition used,34,35 and may be affected by whether victims categorise non-consensual sex as part of their sexual experiences. The ASHR2 questionnaire specified being ‘forced or frightened into doing something sexual’, but it must be acknowledged that force and fear may be but two of many coercive tactics. Third, willingness to report sensitive sexual experiences such as coercion may vary between countries and within the same country at different times.36 Fourth, differences in modes of data collection (with the interviewer physically present in Natsal-3) may have affected reporting. Finally, there may also be real differences in the rates of sexual coercion,
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which is indicated by studies deploying standardised modes of data collection in different countries.37 The proportions of men and women reporting experience of sexual coercion during childhood were similar to those found in ASHR1 and in a recent population-representative UK study,38 but lower than those reported in the Australian Longitudinal Study of Women’s Health (ALSWH).39 However, it should be noted that the ALSWH report was based on data that were collected in 1994 and derived from sampling that was likely to be less representative of the population than that used in ASHR1 and ASHR2. There were no significant changes in the prevalence of sexual coercion during childhood between ASHR1 and ASHR2, but greater awareness and public discussion of this issue (including the current Royal Commission into institutional responses to child sexual abuse) may lead to changes in incidence and/or reporting.40 In accordance with the findings of similar studies, men and women who were sexually coerced reported poorer physical, psychological, and sexual and relationship wellbeing.1,3,6–18 These findings reflect the observation that sexual coercion appears to have direct effects on psychological and physical wellbeing as well as indirect effects via higher rates of unhealthy and risky behaviour.41,42 Although we asked respondents about their behaviour, it is important to note that an individual’s behaviour is likely to be influenced by biographical and social contextual factors that we could not assess during a brief telephone interview. For men, the correlates of forcing were as in ASHR1, but for women, there were some differences. In ASHR2, women living in regional areas were significantly more likely than others to have been coerced, but this was not so in ASHR1. Whereas in ASHR1 women in the oldest age group and women who spoke a language other than English at home were less likely to have been coerced, in ASHR2 no such significant differences were found.6 Few people who had been coerced talked to others about these experiences, and among those who did talk to others, it is not known whether the responses they received were supportive and helpful. The finding that women were significantly more likely than men to have talked to someone about being coerced denotes a significant change from ASHR1, in which men and women were equally unlikely to have spoken to someone. Between ASHR1 and ASHR2, the proportions of men and women who had talked to someone did not change significantly (Table 4), but these two non-significant changes in opposite directions resulted in a significant sex difference in the ASHR2 sample. Another difference between the two studies was the finding in ASHR2 that people who had spoken to somebody about their experiences of coercion reported a significantly lower age when (first) coerced; in ASHR1, no such association was found.6 Further research would be required to determine the reason for this association and whether it resulted in better psychological, physical or sexual health outcomes. As in ASHR1, there was no significant association between talking about experiences of coercion and better psychological wellbeing.6 There are several possible explanations for this lack of association. First, this study employed a simple dichotomous measure of talking to professionals, but did not assess a range of factors that may affect outcomes, such as the
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timing of seeking help, the duration of any therapy or support, the time since any therapy or support was received and satisfaction with the care given.43 More detailed measures would be needed to determine whether the absence of a significant association between consulting professionals and more favourable outcomes was real or an artefact of measurement, but the broad scope of ASHR2 interviews meant that it was not possible to collect such information. Second, women who experienced worse coercion may be more likely to consult professionals and be more susceptible to poorer health outcomes and health behaviour.19,44 Third, counsellors and psychologists may have been ineffective in alleviating the negative impact of sexual coercion. Indeed, it has been noted that there is a need for evidence from welldesigned studies to determine which forms and/or combinations of therapy or support are most effective for addressing the various negative consequences of sexual coercion.41–43,45 A recent review of experiences of counselling services after sexual coercion highlighted the importance of the therapeutic relationship and having therapists who were aware of issues specific to sexual assault.42 A key strength of the study reported in this paper was the focus on a population-representative sample to provide accurate estimates of rates and correlates of sexual coercion. However, it is important to note some study limitations. The definition of sexual coercion that was employed referred to ‘something sexual’ rather than specifying behaviours. Although this may seem vague, our interest was in a subjective experience of sexual coercion rather than any externally applied definition of what did or did not ‘count’ as coercion. However, this may have meant that the question was interpreted and responded to differently according to the respondent’s age, sex, ethnicity or other demographic characteristics. Furthermore, because the questions about coercion were embedded in a longer and more broadly focussed telephone interview, it was not possible (or appropriate) to ask detailed questions about experience of coercion. Ideally, it would have been informative to have data relating to the nature of first or subsequent experiences of sexual coercion (e.g. number and nature of sexual acts, relationship between survivor and perpetrator), because such characteristics may affect how people experience and respond to coercion in the short- and long-term.1–4,6–18 The results presented here do not include multivariate analyses or analyses adjusted for demographic confounders of measures of wellbeing. Such analyses may be presented in subsequent papers, which would also focus in more detail on the characteristics of sexual coercion. Discussion of the consequences of coercion highlights the issue of whether cross-sectional studies can identify causal relationships. References to ‘consequences’ were made in this paper because we examined current or recent wellbeing and behaviour in relation to reports of past sexual coercion. However, longitudinal prospective designs would be better able to determine whether the observed correlations are causal associations. The public health implications of the findings reported here include a need to reduce rates of sexual coercion and to provide services to minimise the detrimental effect that sexual
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coercion has on people’s physical, psychological and sexual wellbeing. In addition to identifying and providing effective treatment, there is a clear need to prevent sexual coercion occurring in the first place. Cross-national variation in sexual coercion highlights that this form of violence is not inevitable and may be amenable to a public health approach designed to identify and address causes and allow early identification and appropriate responses to both coercion and perpetrators of coercion. It may be necessary to give greater attention to sexual coercion in school-based sexuality education and the training of health professionals.37,41 Conflicts of interest None declared. Acknowledgements This study was funded by the National Health and Medical Research Council (grant no. 1002174). The authors are indebted to David Shellard and the staff of the Hunter Valley Research Foundation for managing data collection and undertaking the interviews for this study; and to the Social Research Centre for producing weights for the data. The authors also thank the 21 139 Australians who took part in the two phases of the project and so freely shared the sometimes intimate aspects of their lives. Professor Anthony Smith died during the course of this project and we intend this work to be a tribute to, and further example of, the extraordinary contribution his work has made to the sexual health and wellbeing of Australians.
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Domestic Violence against Women Study Team Prevalence of intimate partner violence: findings from the WHO multi-country study on women’s health and domestic violence. Lancet 2006; 368: 1260–9. doi:10.1016/S0140-6736(06)69523-8 Radford L, Corral S, Bradley C, Fisher H, Bassett C, Howa N, et al. Child abuse and neglect in the UK today. London: National Society for the Prevention of Cruelty to Children; 2011. Available online at: https://www.nspcc.org.uk/Inform/research/ findings/child_abuse_neg lect_research_wda84173.html [verified 25 July 2014]. Fleming JM. Prevalence of childhood sexual abuse in a community sample of Australian women. Med J Aust 1997; 166: 65–8. Commonwealth of Australia. Royal Commission into Institutional Responses to Child Sexual Abuse Interim Report. Canberra: Royal Commission into Institutional Responses to Child Sexual Abuse; 2014. Available online at: http://www.childabuseroyalcommission. gov.au/about-us/reports [verified 25 July 2014]. Basile KC, Smith SG. Sexual violence victimization of women: prevalence, characteristics, and the role of public health and prevention. Am J Lifestyle Med 2011; 5: 407–17. doi:10.1177/155982 7611409512 Chouliara Z, Karatzias T, Scott-Brien G, Macdonald A, MacArthur J, Frazer N. Adult survivors of childhood sexual abuse perspectives of services: a systematic review. Couns Psychother Res 2012; 12: 146–61. doi:10.1080/14733145.2012.656136 Leserman J. Sexual abuse history: prevalence, health effects, mediators, and psychological treatment. Psychosom Med 2005; 67: 906–15. doi:10.1097/01.psy.0000188405.54425.20 Ullman SE, Filipas HH. Correlates of formal and informal support seeking in sexual assault victims. J Interpers Violence 2001; 16: 1028–47. doi:10.1177/088626001016010004 Martsolf DS, Draucker CB. Psychotherapy approaches for adult survivors of childhood sexual abuse: an integrative review of outcomes research. Issues Ment Health Nurs 2005; 26: 801–25. doi:10.1080/01612840500184012
www.publish.csiro.au/journals/sh
Sexual Health, 2014, 11, 472–480 http://dx.doi.org/10.1071/SH14103
Experiences of sexual coercion in a representative sample of adults: the Second Australian Study of Health and Relationships Richard O. de Visser A,I, Paul B. Badcock B,C, Chris Rissel D, Juliet Richters E, Anthony M. A. Smith B,H, Andrew E. GrulichF and Judy M. SimpsonG A
School of Psychology, Pevensey 1, University of Sussex, Falmer BN1 9QH, UK. Australian Research Centre in Sex, Health and Society, La Trobe University, 215 Franklin Street, Melbourne, Vic. 3000, Australia. C Centre for Youth Mental Health, University of Melbourne, Orygen Youth Health Research Centre, 35 Poplar Road, Parkville, Vic. 3052, Australia. D Sydney School of Public Health, Charles Perkins Centre (D17), University of Sydney, Sydney, NSW 2006, Australia. E School of Public Health and Community Medicine, University of New South Wales, Sydney, NSW 2052, Australia. F The Kirby Institute, Wallace Wurth Building, University of New South Wales, Sydney, NSW 2052, Australia. G Sydney School of Public Health, Edward Ford Building (A27), University of Sydney, Sydney, NSW 2006, Australia. H Deceased. I Corresponding author. Email: [email protected] B
Abstract. Background: It is important to have current reliable estimates of the prevalence, correlates and consequences of sexual coercion among a representative sample of Australian adults and to identify changes over time in prevalence and consequences. Methods: Computer-assisted telephone interviews were completed by a representative sample of 20 094 Australian men and women aged 16–69 years. The participation rate among eligible people was 66.2%. Results: Sexual coercion (i.e. being forced or frightened into sexual activity) was reported by 4.2% of men and 22.4% of women. Sexual coercion when aged 16 years was reported by 2.0% of men and 11.5% of women. Correlates of sexual coercion were similar for men and women. Those who had been coerced reported greater psychosocial distress, were more likely to smoke, were more anxious about sex and more likely to have acquired a sexually transmissible infection. Few people had talked to others about their experiences of sexual coercion and fewer had talked to a professional. There were no significant differences between the First and Second Australian Study of Health and Relationships in whether men or women had experienced coercion, talked to anyone about this or talked to a counsellor or psychologist. Conclusion: Sexual coercion has detrimental effects on various aspects of people’s lives. It usually occurs at the ages at which people become sexually active. There is a need to reduce the incidence of sexual coercion, better identify experiences of sexual coercion, and provide accessible services to minimise the detrimental effects of sexual coercion. Additional keywords: sex, wellbeing. Received 7 June 2014, accepted 22 August 2014, published online 7 November 2014
Introduction It is an unfortunate fact that many people experience unwanted sexual activity, and in patriarchal societies women are particularly vulnerable to sexual coercion. Studies of representative samples in the US reveal that ~20% of women and ~5% of men have experienced sexual coercion.1,2 Such sex differences have been found in studies of large nonrepresentative samples in other developed Western nations.3–5 Journal compilation CSIRO 2014
In Britain the third National Survey of Sexual Attitudes and Lifestyles (Natsal-3) revealed that 19% of women and 5% of men had experienced attempted non-volitional sex and that 10% of women and 1% of men had experienced completed non-volitional sex.4 In the population-representative sample recruited for the First Australian Study of Health and Relationships (ASHR1), 21% of women and 5% of men reported that they had been forced or frightened into unwanted www.publish.csiro.au/journals/sh
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sexual activity.5 Approximately half of these people had been sexually coerced when they were aged 16 years or younger (10% of all women, 3% of all men). Sexual coercion has negative impacts on the psychological, physical and sexual health of men and women.1,3,6–18 These personal impacts also incur costs for the broader society in the form of greater use of healthcare services and lost work productivity.8 People who have experienced sexual coercion have higher levels of psychosocial distress, depression, anxiety, suicidality and anger.4,6–11 They also have poorer physical health and are more likely to smoke tobacco, drink alcohol excessively, use illicit drugs and to have injected illicit drugs.4–8,10–12 The effects on sexual health are also clear; those who have been coerced are more likely to have been diagnosed with a sexually transmissible infection (STI) and are more likely to be anxious about sexual performance, lack interest in sex and not find sex pleasurable.4–8,13–16 The analysis of women’s responses in ASHR1 revealed that any experience of sexual coercion was associated with poorer psychological, physical and sexual health; that is, poor health outcomes tended not to depend on age when coerced, number of times coerced or time since being coerced. One important exception to this was that women who had been coerced more than once had poorer psychological wellbeing.19 ASHR1 identified some significant demographic correlates of experience of coercion. As noted above, coercion was more likely among women.19 Among women and men, coercion was significantly more likely among respondents who identified as homosexual or bisexual and respondents with lower incomes. Among women only, coercion was significantly less likely among women aged 50–59 years and women from nonEnglish-speaking backgrounds. Experience of coercion did not vary significantly according to education, region of residence or occupation. Professional services may be able to minimise the detrimental effects of sexual coercion,19–22 but many people do not talk to others about their experiences of sexual coercion.4,19–23 In ASHR1, only one-third of men and women who had been coerced had talked to someone about their experiences and few of these had talked to someone professionally qualified to address these issues.6 Intervening by providing appropriate support services is important for at least two reasons: first, to minimise the psychosocial impact2 noted above1,6–18 and second, to reduce the likelihood of people who have been coerced going on to coerce others. The latter is important because men who have been sexually coerced are significantly more likely than other men to report having sexually coerced another person.24 This significant association remains after controlling for nonsexual antisocial behaviour and non-coercive sexual behaviour.24 Given the observed links between sexual coercion and various aspects of wellbeing, the aim of the analyses reported here was to examine the current prevalence and correlates of sexual coercion among a representative sample of Australian adults and to identify changes in the prevalence of sexual coercion between 2002 and 2013. It is important to obtain accurate estimates of the prevalence of sexual coercion via studies of population-representative samples, because
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estimates based on reports from studies of non-probability samples may be less accurate.25 Methods The methodology used in the Second Australian Study of Health and Relationships (ASHR2) is described elsewhere in this issue.26 Briefly, between October 2012 and November 2013, computer-assisted telephone interviews were completed by a representative sample of 20 094 Australian residents aged 16–69 years from all states and territories. Ethical approval was obtained from the researchers’ host universities. Respondents were selected using dual-frame modified random digit dialling (RDD), combining directory-assisted landline-based RDD with RDD of mobile telephones. The participation rate among eligible people was 66.2%. To maximise the number of interviews with people who had engaged in less common and/or more risky behaviours, all respondents who had had no sexual partners in the previous year, who had had more than one partner in the previous year, and/or who reported any homosexual experience ever completed a long form of the survey instrument, which collected detailed data on their sexual attitudes, relationships and behaviours. Of the larger proportion of respondents who reported one partner in the previous year and no homosexual experience, 20% were randomly selected to complete the longform interview and the other 80% completed a short-form interview. As a consequence, 8577 completed the long-form interview and 11 517 completed the short-form interview. Answers to questions that occurred only in the long-form interview are reported after weighting to reflect the sample as a whole. Questions asked about experiences of unwanted sex and sexual coercion are presented in Box 1. These questions were only asked of people who completed a long-form interview. Sexual coercion was defined as ‘being forced or frightened into doing something sexually that you did not want to do’. After being asked the questions in Box 1, all interviewees were offered the contact details of relevant organisations for advice or support. The correlates of sexual coercion examined in this paper included a range of demographic characteristics, which were recoded to facilitate analysis and several other variables. Respondents’ ages were recoded into six groups: 16–19, 20–29, 30–39, 40–49, 50–59 and 60–69 years. Languages spoken at home were recoded as English or a language other than English. Sexual identity (in answer to the question: ‘Do you think of yourself as . . .’) was coded as heterosexual, homosexual or bisexual; too few respondents stated that they were ‘queer’, ‘other’ or ‘undecided’ to allow analysis of these groups. Respondents’ reported highest completed level of education was recoded to distinguish between those who had not (yet) completed secondary school, those who had completed secondary school and those who had completed post-secondary education. Respondents’ postcodes were used with the Accessibility/Remoteness Index of Australia to determine whether respondents lived in a major city, a regional area or a remote area (i.e. areas with relatively unrestricted, restricted and very restricted access to goods, services and opportunities
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Box 1. Ascertainment of experiences of sexual coercion
The next section is about sexual situations that both women and men have encountered. We understand that sometimes these are difficult issues to discuss. Have you ever had a sexual experience with a male or a female when you didn’t want to because you were too drunk or high at the time? Have you ever been forced or frightened by a male or a female into doing something sexually that you did not want to do? [if yes] How many times has this happened to you? How old were you when it started? (or ‘How old were you the first time?’ or ‘How old were you at the time?’ as appropriate.) Did you talk to someone else about it or seek help? [if yes] Who did you talk to? If you would like I can give you a phone number of someone to talk to (more) about this. The number is (interviewer reads out appropriate number from sheet).
for social interaction respectively).27 To approximate the gross annual household income quintiles reported by the Australian Bureau of Statistics for 2009–10, respondents’ reported annual household income was grouped into five categories: up to $28 000, $28 001–$52 000, $52 001– $83 000, $83 001–$125 000 and more than $125 000.28 Respondents’ reported occupation was coded into the nine major categories of the Australian Standard Classification of Occupations29 and then recoded to distinguish between managerial/professional occupations, white-collar occupations and blue-collar occupations. Psychological distress was measured by the Kessler-6 (K6) psychological distress scale. Respondents used a five-point scale (all of the time/most of the time/some of the time/a little of the time/none of the time) to indicate their experience of depressive and anxious symptoms over the previous month.30 To maintain consistency with the distress scale used in ASHR1, the word ‘depressed’ in the item ‘How often have you felt so depressed that nothing could cheer you up?’ was replaced with ‘sad’. As with ASHR1, a score of one standard deviation above the mean was chosen as a marker of elevated psychosocial distress.19 Respondents indicated whether they had ever been diagnosed with an STI. They also indicated whether, in the year before being interviewed, they had experienced any of the following sexual difficulties for a period of at least 3 months: lacking of interest in sex, not finding sex pleasurable and anxiety about ability to perform sexually. Respondents indicated whether they were current smokers, former smokers or had never smoked. Reports of alcohol consumption frequency and volume were used to determine whether respondents’ alcohol consumption was in excess of National Health and Medical Research Council (NHMRC) guidelines at the time of ASHR1 (28 standard drinks a week for men, 14 for women).31 Respondents also indicated if they had ever injected drugs. Data were weighted to adjust for the probability of each respondent being selected for a landline or mobile phone interview, a long-form interview and (for landline participants), the number of in-scope adults in the household. Data were then weighted to match the Australian population on the basis of age, gender, area of residence (i.e. state by ARIA category) and telephone ownership (i.e. mobile telephone only vs other), resulting in an adjusted sample of 10 056 men and 10 038
women (total 20 094). The data were thus weighted to account for the specifics of our sample design and the fact that particular types of people were slightly over- or under-represented. Therefore, the data presented describe a representative sample of the Australian population aged 16–69 years, subject to the biases noted elsewhere in this issue.26 The main outcome variables were compared with those of ASHR1 to identify significant changes over time. Weighted data were analysed using survey estimation commands in Stata Version 11.2.32 Data were analysed using univariate logistic regression for dichotomous outcomes, including comparisons of ASHR1 and ASHR2. Correlates of polytomous outcomes were identified using univariate multinomial logistic regression. Percentages are presented in this article without standard errors or 95% confidence intervals. This decision was made to maximise both readability and brevity and is in keeping with the style of other studies of a similar scope and intent.2,6,33 Further information about the precision of estimates is found elsewhere in this issue.26 Due to the number of participants in ASHR2, it is important to recognise that often there is the statistical power to detect even small changes as statistically significant, but these do not necessarily correspond to significant differences in a public health sense. Results Overall, 13.3% of respondents reported being forced or frightened into sexual behaviour. Table 1 shows that women (22.4%) were significantly more likely than men (4.2%) to report experience of sexual coercion (P < 0.001). The ages at which men were first coerced to have sex ranged from 5 to 41 years (mean = 16.8 years; median = 17 years). The ages at which women were first coerced into sexual activity ranged from 4 to 40 years (mean = 16.3 years; median = 16 years). There was no significant difference between the mean ages at which men and women were first coerced into sexual activity (P = 0.37). If we take 16 years of age as the upper limit of childhood, 2.0% of men and 11.5% of women had been sexually coerced when aged 16 years or younger. Among men who had been forced or frightened into sexual activity, 48.6% reported one instance of sexual coercion and 5.3% reported that it happened too many times to count, or
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Table 1. Experiences of being forced or frightened into doing something sexually Unless indicated otherwise, data show the percentage of n in each section who reported each experience. Unadjusted odds ratios (OR) and 95% confidence intervals (CI) are of coercion for women versus men Men (%) All respondents Ever forced or frightened into doing something sexually?
Women (%)
OR (95% CI)
n = 9823 n = 9778 4.2 22.4 6.63 (5.40–8.15)
Respondents who had been coerced n = 403 n = 2159 Age (in years) when (first) coerced 1 standard deviation above the sample mean. Experienced for at least 3 months in the previous year. C Consumption in excess of National Health & Medical Research Council guidelines. A B
Table 4. Prevalence of sexual coercion among men and women: comparison of the first Australian Study of Health and Relationships (ASHR1) and the Second Australian Study of Health and Relationships (ASHR2) People aged 60–69 years have been removed from the ASHR2 sample for comparison. Unless indicated otherwise, data show the number of respondents asked each question, with the percentage of this number giving affirmative responses shown in parentheses. Unadjusted odds ratios (OR) and confidence intervals (CI) are for ASHR2 versus ASHR1 Experience of coercion Forced/frightened into doing something sexually? If yes, talked to somebody? If yes, talked to counsellor/ psychologist? Forced/frightened into doing something sexually in childhood?
ASHR1
Men ASHR2
OR (95% CI)
9373 (4.8%)
8292 (4.4%)
0.89 (0.69–1.17)
9218 (21.1%) 8475 (22.3%) 1.07 (0.91–1.26)
362 (26.5%) 0.79 (0.45–1.38) 96 (10.9%) 0.56 (0.19–1.66)
1948 (37.9%) 1890 (43.4%) 1.28 (0.96–1.71) 739 (25.6%) 819 (22.1%) 0.82 (0.50–1.34)
455 (31.5%) 143 (17.7%) 9373 (2.8%)
8292 (2.0%)
Discussion The headline findings reported here are that 22% of women and 4% of men had ever been forced or frightened into doing something sexual and that 12% of women and 2% of men had been sexually coerced when aged 16 years or younger. Although it is not coercion, per se – that is, people may subsequently regret decisions made when drunk – the finding that half of the sample reported having an unwanted sexual experience due to being affected by alcohol or other drugs suggests that there is a need to enable people to make better decisions about their sexual behaviour when intoxicated. The proportions of men and women reporting experience of sexual coercion were similar to those reported in comparable surveys conducted in the US and Europe.1–3,5 However, lower proportions were found in Natsal-3 in Britain. There are several possible reasons for this difference. First, Natsal-3 only asked
0.73 (0.51–1.06)
ASHR1
Women ASHR2
OR (95% CI)
9218 (10.3%) 8475 (11.5%) 1.14 (0.91–1.42)
about non-consensual sexual activity that occurred after age 13 years and the data in Table 1 indicate that over one-quarter of the people who were coerced reported that this (first) happened before age 13 years. Second, ASHR used the term ‘anything sexual’ whereas Natsal-3 used more precise and restrictive terms. Reported rates of sexual coercion vary depending on the definition used,34,35 and may be affected by whether victims categorise non-consensual sex as part of their sexual experiences. The ASHR2 questionnaire specified being ‘forced or frightened into doing something sexual’, but it must be acknowledged that force and fear may be but two of many coercive tactics. Third, willingness to report sensitive sexual experiences such as coercion may vary between countries and within the same country at different times.36 Fourth, differences in modes of data collection (with the interviewer physically present in Natsal-3) may have affected reporting. Finally, there may also be real differences in the rates of sexual coercion,
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which is indicated by studies deploying standardised modes of data collection in different countries.37 The proportions of men and women reporting experience of sexual coercion during childhood were similar to those found in ASHR1 and in a recent population-representative UK study,38 but lower than those reported in the Australian Longitudinal Study of Women’s Health (ALSWH).39 However, it should be noted that the ALSWH report was based on data that were collected in 1994 and derived from sampling that was likely to be less representative of the population than that used in ASHR1 and ASHR2. There were no significant changes in the prevalence of sexual coercion during childhood between ASHR1 and ASHR2, but greater awareness and public discussion of this issue (including the current Royal Commission into institutional responses to child sexual abuse) may lead to changes in incidence and/or reporting.40 In accordance with the findings of similar studies, men and women who were sexually coerced reported poorer physical, psychological, and sexual and relationship wellbeing.1,3,6–18 These findings reflect the observation that sexual coercion appears to have direct effects on psychological and physical wellbeing as well as indirect effects via higher rates of unhealthy and risky behaviour.41,42 Although we asked respondents about their behaviour, it is important to note that an individual’s behaviour is likely to be influenced by biographical and social contextual factors that we could not assess during a brief telephone interview. For men, the correlates of forcing were as in ASHR1, but for women, there were some differences. In ASHR2, women living in regional areas were significantly more likely than others to have been coerced, but this was not so in ASHR1. Whereas in ASHR1 women in the oldest age group and women who spoke a language other than English at home were less likely to have been coerced, in ASHR2 no such significant differences were found.6 Few people who had been coerced talked to others about these experiences, and among those who did talk to others, it is not known whether the responses they received were supportive and helpful. The finding that women were significantly more likely than men to have talked to someone about being coerced denotes a significant change from ASHR1, in which men and women were equally unlikely to have spoken to someone. Between ASHR1 and ASHR2, the proportions of men and women who had talked to someone did not change significantly (Table 4), but these two non-significant changes in opposite directions resulted in a significant sex difference in the ASHR2 sample. Another difference between the two studies was the finding in ASHR2 that people who had spoken to somebody about their experiences of coercion reported a significantly lower age when (first) coerced; in ASHR1, no such association was found.6 Further research would be required to determine the reason for this association and whether it resulted in better psychological, physical or sexual health outcomes. As in ASHR1, there was no significant association between talking about experiences of coercion and better psychological wellbeing.6 There are several possible explanations for this lack of association. First, this study employed a simple dichotomous measure of talking to professionals, but did not assess a range of factors that may affect outcomes, such as the
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timing of seeking help, the duration of any therapy or support, the time since any therapy or support was received and satisfaction with the care given.43 More detailed measures would be needed to determine whether the absence of a significant association between consulting professionals and more favourable outcomes was real or an artefact of measurement, but the broad scope of ASHR2 interviews meant that it was not possible to collect such information. Second, women who experienced worse coercion may be more likely to consult professionals and be more susceptible to poorer health outcomes and health behaviour.19,44 Third, counsellors and psychologists may have been ineffective in alleviating the negative impact of sexual coercion. Indeed, it has been noted that there is a need for evidence from welldesigned studies to determine which forms and/or combinations of therapy or support are most effective for addressing the various negative consequences of sexual coercion.41–43,45 A recent review of experiences of counselling services after sexual coercion highlighted the importance of the therapeutic relationship and having therapists who were aware of issues specific to sexual assault.42 A key strength of the study reported in this paper was the focus on a population-representative sample to provide accurate estimates of rates and correlates of sexual coercion. However, it is important to note some study limitations. The definition of sexual coercion that was employed referred to ‘something sexual’ rather than specifying behaviours. Although this may seem vague, our interest was in a subjective experience of sexual coercion rather than any externally applied definition of what did or did not ‘count’ as coercion. However, this may have meant that the question was interpreted and responded to differently according to the respondent’s age, sex, ethnicity or other demographic characteristics. Furthermore, because the questions about coercion were embedded in a longer and more broadly focussed telephone interview, it was not possible (or appropriate) to ask detailed questions about experience of coercion. Ideally, it would have been informative to have data relating to the nature of first or subsequent experiences of sexual coercion (e.g. number and nature of sexual acts, relationship between survivor and perpetrator), because such characteristics may affect how people experience and respond to coercion in the short- and long-term.1–4,6–18 The results presented here do not include multivariate analyses or analyses adjusted for demographic confounders of measures of wellbeing. Such analyses may be presented in subsequent papers, which would also focus in more detail on the characteristics of sexual coercion. Discussion of the consequences of coercion highlights the issue of whether cross-sectional studies can identify causal relationships. References to ‘consequences’ were made in this paper because we examined current or recent wellbeing and behaviour in relation to reports of past sexual coercion. However, longitudinal prospective designs would be better able to determine whether the observed correlations are causal associations. The public health implications of the findings reported here include a need to reduce rates of sexual coercion and to provide services to minimise the detrimental effect that sexual
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coercion has on people’s physical, psychological and sexual wellbeing. In addition to identifying and providing effective treatment, there is a clear need to prevent sexual coercion occurring in the first place. Cross-national variation in sexual coercion highlights that this form of violence is not inevitable and may be amenable to a public health approach designed to identify and address causes and allow early identification and appropriate responses to both coercion and perpetrators of coercion. It may be necessary to give greater attention to sexual coercion in school-based sexuality education and the training of health professionals.37,41 Conflicts of interest None declared. Acknowledgements This study was funded by the National Health and Medical Research Council (grant no. 1002174). The authors are indebted to David Shellard and the staff of the Hunter Valley Research Foundation for managing data collection and undertaking the interviews for this study; and to the Social Research Centre for producing weights for the data. The authors also thank the 21 139 Australians who took part in the two phases of the project and so freely shared the sometimes intimate aspects of their lives. Professor Anthony Smith died during the course of this project and we intend this work to be a tribute to, and further example of, the extraordinary contribution his work has made to the sexual health and wellbeing of Australians.
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