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A disturbing new study from Harvard Medical School researchers estimates that roughly 1 in 16 women were coerced or physically forced into their first sexual encounter — a finding associated with long-term gynecological problems and the increased likelihood of a subsequent unwanted first pregnancy or abortion.

The study, published in JAMA Internal Medicine Monday, says 6.5 percent of American women between 18 and 44 years old experienced forced sexual initiation, based on whether they described their first sexual intercourse as voluntary or not voluntary. Those who were forced or coerced tended to be younger at the time of sexual initiation and to have a wider age gap with their male partner. The average age of a woman’s forced sexual initiation was 15.6 the study found; her assailant was, on average, 27.

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The analysis was based on responses to the National Survey of Family Growth, a nationally representative survey conducted every two years by the Centers for Disease Control and Prevention. And though it was inspired by the huge cultural shift that began with the #MeToo movement in October 2017, it does not reflect the heightened reporting or awareness spurred by it. The data was collected between 2011 and September 2017.

“Our findings would not have been influenced by the major cultural shift of the past two years,” said lead author Dr. Laura Hawks, a research fellow at the Cambridge Health Alliance/Harvard Medical School who authored the study, which was done with doctors from City University of New York, Hunter College. The project, she said, was “spawned by our curiosity in keeping with the increased dialogue” around the prevalence of sexual violence.

The study sought to determine the long-term health consequences of forced sexual initiation, expanding on research that previously showed it to be associated with an increased risk for sexually transmitted infections. Women who’d been coerced into first sex were more likely to have a subsequent unwanted first pregnancy or abortion; to not use birth control; and to be diagnosed with pelvic inflammatory disease, endometriosis, or problems with ovulation or menstruation, the study found. They were more likely to report having difficulty completing tasks outside the home owing to a physical or mental condition, and being in fair or poor health.

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The findings did not surprise those who work in the field of rape prevention, who commended researchers for shedding light on the prevalence and impact of sexual trauma. “This study quantifies what we see . . . every day, including the ways that sexual harassment, abuse, and assault are inextricably linked with health problems,” said Gina Scaramella, executive director of the Boston Area Rape Crisis Center. “Rape and sexual assault are much more common than generally recognized, and the effects on long-term health can be significant.”

The study relied on 13,310 participants in the National Survey of Family Growth, sorting them into two groups based on their answer to a question: Was your first vaginal intercourse “voluntary or not voluntary, that is, did you choose to have sex of your own free will or not?” Someone who reported that her first sexual encounter was not voluntary was then asked further questions about the method of coercion.

“Did you do what he said because he was bigger than you or a grown-up, and you were young?”

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“Were you told that the relationship would end if you didn’t have sex?”

“Were you pressured into it by his words or actions, but without threat of harm?”

“Were you threatened with physical harm or injury?”

“Were you physically hurt or injured?”

“Were you physically held down?”

Participants could report more than one type of coercion.

Of those who reported nonvoluntary sexual initiation, 56.4 percent described experiencing verbal pressure, and 46.3 percent said they were held down. Half reported they were coerced by someone bigger or older than them, while 22 percent said they were given a drug, 26.5 percent were physically threatened, and 25 percent were harmed.

In commentary published along with the study Monday, two public health researchers from the University of California San Francisco Department of Medicine noted that while the study faces limitations — it cannot prove causality or rule out the effects of additional abuse or mistreatment — it expands on existing knowledge by showing impacts related to nonphysical coercion.

“These findings demonstrate that involuntary sexual experiences are often related to verbal or emotional coercion rather than physical force, while still having potentially powerful and negative consequences,” wrote doctors Alison Huang and Carolyn Gibson.

Particularly unsettling, Hawks said, was the discovery that women who were raped at sexual initiation were younger, on average, and their assailants older than couples who became sexually active voluntarily. Women choosing to have their first sexual encounter were, on average, 17.4 years old, with male partners averaging age 21. Those who were coerced were an average 15.6 years old, with partners who were 27. “That’s just a very disturbing age and power discrepancy that we have to get our heads around,” Hawks said.

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Women and girls of color and those living in poverty were slightly more likely to experience forced sexual initiation, the study found. However, women of all races, ethnicities, and income levels are at risk, noted coauthor Dr. Steffie Woolhandler, a primary care physician and professor at the City University of New York’s Hunter College. “With millions of girls and women experiencing rape at their first sexual encounter, we urgently need a cultural change in gender relations,” she wrote in a press release. “It has to begin with every public and private sphere, including medicine, valuing females and males as equals.”

Relying upon existing data from a long-term government survey, the analysis examined only heterosexual initiation and cisgender females.

Its findings showed slightly lower prevalence of forced sexual initiation than a previous analysis of data from the 1995 National Survey of Family Growth, which found that 9.1 percent of women ages 15 to 24 described their first intercourse as nonvoluntary.

The younger age range and slight changes in wording make direct comparisons difficult, however, the study notes.

It’s not clear exactly how forced sexual initiation would be associated with adverse health outcomes, the researchers note.

However, they wrote, “Our findings are compatible with the hypothesis that experiencing sexual violence at a time of heightened psychological and physical vulnerability” could have long-term negative effects. The health problems were not limited to those raped as children, however; the study found negative effects regardless of age of forced sexual initiation.

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Scaramella, of the Boston Area Rape Crisis Center, echoed the researchers’ hopes that increased awareness of the ubiquity and apparent effects of forced sexual initiation would encourage doctors to handle their patients with care.

“This new study should underscore the need for all clinicians to be trained in providing care that is trauma-informed, meaning that the provider has the skills to responsibly and compassionately provide care and treatment so survivors feel supported rather than retraumatized,” she said.


Stephanie Ebbert can be reached at Stephanie.Ebbert@globe.com. Follow her on Twitter @StephanieEbbert