Additive interactions between sex and forced sexual intercourse victimization on depressive symptoms and suicidality: Youth risk behavior survey 2001–2017

Published:November 14, 2022DOI:


      • Forced Sexual Intercourse Victimization is strongly associated with depressive symptoms in both male and female adolescents, but the effect is larger in females.
      • Forced sex is also strongly associated with suicidal ideation and suicide attempts in both male and female adolescents, but the effect is larger in males.
      • Both male and female adolescents who attempt suicide requiring treatment have an extremely high probability—approximately 40%–of having a history of forced sexual victimization, which highlights the importance of screening adolescents for both sexual victimization and suicidality.



      Adolescents who have been forced to have sexual intercourse have higher rates of depressive symptoms and suicidality.


      This research investigated whether the association between adolescent forced sexual intercourse victimization and depressive symptoms or suicidality varies significantly by sex.


      This secondary analysis pooled cross-sectional data from the Youth Risk Behavior Survey 2001 through 2017 (N = 132,580) using R to estimate adjusted risk differences and additive interactions.


      Results show an extremely high prevalence of depressive symptoms and suicidality among adolescents who experience forced sexual victimization. This association is significantly higher among females for depressive symptoms, but significantly higher among males for suicide attempt or suicide attempt requiring treatment.


      also showed that approximately 40% of both males and females who attempted suicide requiring treatment also had a history of forced sexual intercourse victimization.


      These findings highlight the importance of screening for sexual victimization, depression and suicidality among adolescents.


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        • Ackers S.M.
        • Colbert A.M.
        • Fraley H.E.
        • Schreiber J.B.
        Exploring screening practices for child sexual abuse in school settings: An integrative review.
        The Journal of School Nursing. 2022;
        • Altman D.G.
        • Bland J.M.
        Interaction revisited: The difference between two estimates.
        BMJ (Clinical Research Ed.). 2003; 326: 219
        • Avery Morris H.
        • Galvin E.
        • Misso M.
        • Savaglio M.
        • Skouteris H.
        Systematic review of school-wide trauma-informed approaches.
        Journal of Child & Adolescent Trauma. 2020; 14: 381-397
        • Baiden P.
        • Xiao Y.
        • Asiedua-Baiden G.
        • LaBrenz C.A.
        • Boateng G.O.
        • Muehlenkamp J.J.
        Sex differences in the association between sexual violence victimization and suicidal behaviors among adolescents.
        Journal of Affective Disorders Reports. 2020; 1,100011
        • Basile K.C.
        • Black M.C.
        • Simon T.R.
        • Arias I.
        • Brener N.D.
        • Saltzman L.E.
        The association between self-reported lifetime history of forced sexual intercourse and recent health-risk behaviors: Findings from the 2003 National Youth Risk Behavior Survey.
        Journal of Adolescent Health. 2006; 39: 752.e1-752.e7
        • Bedi S.
        • Nelson E.C.
        • Lynskey M.T.
        • Mc Cutcheon V.V.
        • Heath A.C.
        • Martin N.G.
        Risk for suicidal thoughts and behavior after childhood sexual abuse in women and men.
        Suicide & Life-Threatening Behavior. 2011; 41: 406-415
        • Brener N.D.
        • Kann L.
        • McManus T
        • Kinchen S.A.
        • Sundberg E.C.
        • Ross J.G.
        Reliability of the 1999 Youth Risk Behavior Survey questionnaire.
        Journal of Adolescent Health. 2002; 31: 336-342
        • Centers for Disease Control and Prevention, National Center for HIV/AIDS, Division of Adolescent and School Health
        Trends in the Prevalence of Behaviors that Contribute to Violence National YRBS: 1991-2015.
        2018 (Available at:)
        • Centers for Disease Control and Prevention
        Questionnaires | YRBSS | Data | Sleath Adolescent and School Health.
        (August 14) YRBS Questionnaires, 2017 (Available at:)
        • Centers for Disease Control and Prevention
        YRBSS Data & Documentation.
        (July 17) Adolescent and School Health, 2018 (Available at:)
        • Chapman D.P.
        • Whitfield C.L.
        • Felitti V.J.
        • Dube S.R.
        • Edwards V.J.
        • Anda R.F.
        Adverse childhood experiences and the risk of depressive disorders in adulthood.
        Journal of affective disorders. 2004; 82 (Available at:): 217-225
        • Chapleau K.M.
        • Oswald D.L.
        • Russell B.L.
        • Sheppard M.
        • Gates A.
        • Stein Z.
        • Stone D.M.
        Male rape myths: the role of gender, violence, and sexism.
        Journal of Interpersonal Violence. 2008; 23: 600-615
        • Charpignon M.L.
        • Ontiveros J.
        • Sundaresan S.
        • Puri A.
        • Chandra J.
        • Majumder M.S.
        Evaluation of Suicides Among US Adolescents During the COVID-19 Pandemic.
        JAMA Pediatrics. 2022; 176: 724-726
        • Chisholm C.A.
        • Bullock L.
        • Ferguson J.E.J.
        Intimate partner violence and pregnancy: Screening and intervention.
        American journal of obstetrics and gynecology. 2017; 217 (Available at:): 145-149
        • Curtin S.C.
        • Hedgegaard H.
        • Minimo A.
        • Warner M.
        • Simon T.
        QuickStats: Suicide rates for teens aged 15–19 years, by sex—United States, 1975–2015.
        MMWR Morbidity Mortality Weekly Report 2017. 2017; 66 (Available at:): 816
        • Cutter-Wilson E.
        • Richmond T.
        Understanding teen dating violence: Practical screening and intervention strategies for pediatric and adolescent healthcare providers.
        Current opinion in pediatrics. 2011; 23 (Available at:): 379
        • Devries K.
        • Watts C.
        • Yoshihama M.
        • Kiss L.
        • Schraiber L.B.
        • Deyessa N.
        • Garcia-Moreno C.
        Violence against women is strongly associated with suicide attempts: Evidence from the WHO multi-country study on women's health and domestic violence against women.
        Social Science & Medicine. 2011; 73: 79-86
        • Dickerson-Amaya N.
        • Coston B.M.
        Invisibility is not invincibility: The impact of intimate partner violence on gay, bisexual, and straight men's mental health.
        American Journal of men's health. 2019; 13
        • Doolan D.M.
        • Froelicher E.S.
        Using an existing data set to answer new research questions: A methodological review.
        Research and Theory for Nursing Practice. 2009; 23: 203-215
        • Draucker C.B.
        • Mazurczyk J.
        Relationships between childhood sexual abuse and substance use and sexual risk behaviors during adolescence: An integrative review.
        Nursing Outlook. 2013; 61: 291-310
        • Dunn S.L.
        • Arslanian-Engoren C.
        • DeKoekkoek T.
        • Jadack R.
        • Scott L.D.
        Secondary Data Analysis as an Efficient and Effective Approach to Nursing Research.
        Western Journal of Nursing Research. 2015; 37: 1295-1307
        • Dworkin E.R.
        • Menon S.V.
        • Bystrynski J.
        • Allen N.E.
        Sexual assault victimization and psychopathology: A review and meta-analysis.
        Clinical Psychology Review. 2017; 56: 65-81
        • Dworkin E.R.
        • DeCou C.R.
        • Fitzpatrick S.
        Associations between sexual assault and suicidal thoughts and behavior: a meta-analysis.
        Psychological Trauma: Theory, Research, Practice, and Policy. 2022; 14: 1208-1211
        • Ellsberg M.
        • Arango D.
        • Morton M.
        • Gennari F.
        • Kiplesund S.
        • Contreras M.
        • Watts C.
        Prevention of violence against women and girls: What does the evidence say?.
        The Lancet. 2015; 385: 1555-1566
        • Felitti V.J.
        • Anda R.F.
        • Nordenberg D.
        • Williamson D.F.
        • Spitz A.M.
        • Edwards V.
        • Marks J.S.
        Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults. The Adverse Childhood Experiences (ACE) Study.
        American Journal of Preventive Medicine. 1998; 14: 245-258
        • Gallo E.A.G.
        • De Mola C.L.
        • Wehrmeister F.
        • Gonçalves H.
        • Kieling C.
        • Murray J.
        Childhood maltreatment preceding depressive disorder at age 18 years: A prospective Brazilian birth cohort study.
        Journal of Affective Disorders. 2017; 217: 218-224
        • García-Moreno C.
        • Jansen H.A.
        • Ellsberg M.
        • Heise L.
        • Watts C.
        WHO multi-country study on women's health and domestic violence against women.
        World Health Organization, 2005
        • García-Moreno C.
        • Pallitto C.
        • Devries K.
        • Stöckl H.
        • Watts C.
        • Abrahams N.
        Global and regional estimates of violence against women: Prevalence and health effects of intimate partner violence and non-partner sexual violence.
        World Health Organization, Geneva, Switzerland2013
      1. Gelman, A. (2018. March 15). You need 16 times the sample size to estimate an interaction than to estimate a main effect « Statistical Modeling, Causal Inference, and Social Science. Statistical Modeling, Causal Inference, and Social Science. Available at:

        • Gerke J.
        • Koenig A.
        • Conrad D.
        • Doyen-Waldecker C.
        • Pauly M.
        • Gündel H.
        • Kolassa I.
        Childhood maltreatment as risk factor for lifetime depression: The role of different types of experiences and sensitive periods.
        Mental Health & Prevention. 2018; 10: 56-65
        • Hanna J.D.
        Staff attitudes and male victims of intimate partner violence: Implications for human service professionals.
        ProQuest Dissertations and Theses (UMI No. 3732842), 2015
      2. Healthy People (2020). [Internet]. Washington, DC: U.S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion. Available at:

        • Hepworth I.
        • McGowan L.
        Do mental health professionals enquire about childhood sexual abuse during routine mental health assessment in acute mental health settings? A substantive literature review.
        Journal of Psychiatric and Mental Health Nursing. 2013; 20: 473-483
        • Hines D.
        • Brown J.
        • Dunning E.
        Characteristics of callers to the domestic abuse helpline for men.
        Journal of Family Violence. 2007; 22: 63-72
        • Howard D.E.
        • Wang M.Q.
        Psychosocial correlates of U.S. adolescents who report a history of forced sexual intercourse.
        Journal of Adolescent Health. 2005; 36: 372-379
        • Huitema A.
        • Vanwesenbeeck I.
        Attitudes of Dutch citizens towards male victims of sexual coercion by a female perpetrator.
        Journal of Sexual Aggression. 2016; 22: 308-322
        • Javaid A.
        Feminism, masculinity and male rape: Bringing male rape ‘out of the closet.
        Journal of Sex Studies. 2016; 25: 283-293
        • Jozkowski K.N.
        • Sanders S.A.
        Health and sexual outcomes of women who have experienced forced or coercive sex.
        Women & Health. 2012; 52: 101-118
        • Kann L.
        • McManus T.
        • Harris W.A.
        • Shanklin S.L.
        • Flint K.H.
        • Queen B.
        • Ethier K.A.
        Youth Risk Behavior Surveillance—United States, 2017.
        MMWR Surveillance Summaries. 2018; 67: 1-114
        • Keyes K.M.
        • Galea S.
        Re: Some thoughts on consequential epidemiology and ausal architecture.
        Epidemiology. 2017; 28: e31
        • Lavine K.
        • Hardy E.
        Emergency department visits and helpline calls in Rhode Island for acute sexual assault before and during the COVID-19 pandemic.
        Academic Emergency Medicine. 2022; 29: 905-907
        • Lewandowski R.E.
        • O'Connor B.
        • Bertagnolli A.
        • Beck A.
        • Tinoco A.
        • Gardner W.P.
        • Horwitz S.M.
        Screening for and diagnosis of depression among adolescents in a large health maintenance organization.
        Psychiatric Services. 2016; 67: 636-641
        • Littleton H.L.
        • Berenson A.B.
        • Radecki Breitkopf C.
        An evaluation of health care providers’ sexual violence screening practices.
        American Journal of Obstetrics and Gynecology. 2007; 196: 564.e1-564.e7
        • Lowry R.
        • Crosby A.E.
        • Brener N.D.
        • Kann L.
        Suicidal thoughts and attempts among U.S. high school students: Trends and associated health-risk behaviors.
        Journal of Adolescent Health. 2014; 54: 100-108
        • Lumley T.S.
        Predictive margins like SUDAAN does them.
        GitHubGist, 2018 (Available at:)
      3. Lumley, T. S. (2020). Survey: Analysis of complex survey samples. R package (R package version 4.0) [R]. Available at:

        • Lundgren R.
        • Amin A.
        Addressing intimate partner violence and sexual violence among adolescents: Emerging evidence of effectiveness.
        Journal of Adolescent Health. 2015; 56: S42-S50
        • Magee T.
        • Lee S.M.
        • Giuliano K.K.
        • Munro B.
        Generating new knowledge from existing data: The use of large data sets for nursing research.
        Nursing Research. 2006; 55
        • May A.
        • Klonsky E.D.
        Validity of suicidality items from the Youth Risk Behavior Survey in a high school sample.
        Assessment (Odessa, Fla.). 2011; 18: 379-381
        • Meade C.S.
        • Kershaw T.S.
        • Hansen N.B.
        • Sikkema K.J.
        Long-term correlates of childhood abuse among adults with severe mental illness: Adult victimization, substance abuse, and HIV sexual risk behavior.
        AIDS and Behavior. 2009; 13: 207-216
        • Miron O.
        • Yu K.
        • Wilf-Miron R.
        • Kohane I.S.
        Suicide rates among adolescents and young adults in the United States, 2000-2017.
        JAMA. 2019; 321 (2019): 2362-2364
        • Moher D.
        • Hopewell S.
        • Schulz K.F.
        • Montori V.
        • Gøtzsche P.C.
        • Devereaux P.J.
        • Altman D.G.
        CONSORT 2010 Explanation and Elaboration: Updated guidelines for reporting parallel group randomised trials.
        Bmj. 2010; 340
        • Norton E.C.
        • Dowd B.E.
        • Maciejewski M.L.
        Marginal effects—Quantifying the effect of changes in risk factors in logistic regression models.
        Jama. 2019; 321: 1304-1305
      4. Office of Disease Prevention and Health Promotion. (n.d.). Reduce suicide attempts by adolescents—MHD-02. Healthy People 2030. U.S. Department of Health and Human Services. Available at:

        • Oliffe J.L.
        • Creighton G.
        • Robertson S.
        • Broom A.
        • Jenkins E.K.
        • Ogrodniczuk J.S.
        • Ferlatte O.
        Injury, interiority, and isolation in men's suicidality.
        American journal of men's health. 2017; 11: 888-899
        • Olshen E.
        • McVeigh K.H.
        • Wunsch-Hitzig R.A.
        • Rickert V.I.
        Dating violence, sexual assault, and suicide attempts among urban teenagers.
        Archives of Pediatrics & Adolescent Medicine. 2007; 161: 539-545
        • Perry
        • Daniels M.L.
        Implementing Trauma—Informed Practices in the School Setting: A Pilot Study.
        School Mental Health. 2016; 8: 177-188
        • Pontes N.
        • Ayres C.G.
        • Pontes M.C.
        Trends in depressive symptoms and suicidality: Youth Risk Behavior Survey 2009–2017.
        Nursing Research. 2020; 69: 176-185
      5. R Core Team. (2020). R: A language and environment for statistical computing (4.0) [Mac OSX]. R Foundation for Statistical Computing. Available at:

        • Racine N.
        • Killam T.
        • Madigan S.
        Trauma-informed care as a universal precaution: Beyond the adverse childhood experiences questionnaire.
        JAMA pediatrics. 2020; 174: 5-6
        • Rew L.
        • Koniak-Griffin D.
        • Lewis M.A.
        • Miles M.
        • O'Sullivan A.
        Secondary data analysis: New perspective for adolescent research.
        Nursing Outlook. 2000; 48: 223-229
        • Rhodes A.E.
        • Boyle M.H.
        • Tonmyr L.
        • Wekerle C.
        • Goodman D.
        • Leslie B.
        • Manion I.
        Sex differences in childhood sexual abuse and suicide-related behaviors.
        Suicide & Life-Threatening Behavior. 2011; 41: 235-254
        • Rosenberg H.J.
        • Jankowski M.K.
        • Sengupta A.
        • Wolfe R.S.
        • Ii G.L.W.
        • Rosenberg S.D.
        Single and multiple suicide attempts and associated health risk factors in New Hampshire adolescents.
        Suicide and Life-Threatening Behavior. 2005; 35: 547-557
        • Rothman K.J.
        Six consistent research misconceptions.
        Journal of General Internal Medicine. 2014; 29: 1060-1064
        • Rothman K.J.
        • Greenland S.
        • Walker A.M.
        Concepts of interaction.
        American Journal of Epidemiology. 1980; 112: 467-470
        • Schaefer J.D.
        • Moffitt T.E.
        • Arseneault L.
        • Danese A.
        • Fisher H.L.
        • Houts R.
        • Caspi A.
        Adolescent victimization and early-adult psychopathology: Approaching causal inference using a longitudinal twin study to rule out noncausal explanations.
        Clinical Psychological Science. 2018; 6: 352-371
        • Shrier L.A.
        • Pierce J.D.
        • Emans S.J.
        • DuRant R.H.
        Sex differences in risk behaviors associated with forced or pressured sex.
        Archives of Pediatrics & Adolescent Medicine. 1998; 152
        • Sleath E.
        • Bull R.
        Male rape victim and perpetrator blaming.
        Journal of Interpersonal Violence. 2010; 25: 969-988
        • Stemple L.
        • Meyer I.H.
        The sexual victimization of men in America: New data challenge old assumptions.
        American Journal of Public Health. 2014; 104: e19-e26
        • Sullivan E.M.
        • Annest J.L.
        • Simon T.T.
        • Luo F.
        • Dahlberg L.L.
        Suicide trends among persons aged 10 to 24 years—United States, 1994-2012.
        MMWR Morbidity and Mortality Weekly Report. 2015; 64 (Available at:): 201-205
        • Sutherland M.A.
        • Hutchinson M.K.
        Intimate partner and sexual violence screening practices of college health care providers.
        Applied Nursing Research. 2018; 39: 217-219
        • Tomasula J.L.
        • Anderson L.M.
        • Littleton H.L.
        • Riley-Tillman T.C.
        The association between sexual assault and suicidal activity in a national sample.
        School Psychology Quarterly. 2012; 27: 109-119
        • Turchik J.A.
        • Edwards K.M.
        Myths about male rape: A literature review.
        Psychology of Men & Masculinity. 2012; 13: 211
        • Turchik J.A.
        • Hebenstreit C.L.
        • Judson S.S.
        An examination of the sex inclusiveness of current theories of sexual violence in adulthood: Recognizing male victims, female perpetrators, and same-sex violence.
        Trauma, Violence, & Abuse. 2016; 17: 133-148
      6. US Department of Health and Human Services, Office of Disease Prevention and Health Promotion. (2014). Healthy People 2020. Available at:

        • Vandenbroucke J.P.
        • Elm E.Von
        • Altman D.G.
        • Gøtzsche P.C.
        • Mulrow C.D.
        • Pocock S.J.
        • Egger M.
        • et al.
        Strengthening the Reporting of Observational Studies in Epidemiology (STROBE): Explanation and elaboration.
        PLOS Medicine. 2007; 4: e297
        • Villanti A.C.
        • LePine S.E.
        • Peasley-Miklus C.
        • West J.C.
        • Roemhildt M.
        • Williams R.
        • Copeland W.E.
        COVID-related distress, mental health, and substance use in adolescents and young adults.
        Child and Adolescent Mental Health. 2022; 27: 138-145
        • Walfield S.M.
        Men Cannot Be Raped”: Correlates of Male Rape Myth Acceptance.
        Journal of Interpersonal Violence. 2021; 36: 6391-6417
        • Williams S.B.
        • O'Connor E.A.
        • Eder M.
        • Whitlock E.P.
        Screening for child and adolescent depression in primary care settings: A systematic evidence review for the US Preventive Services Task Force.
        Pediatrics (Evanston). 2009; 123: e716-e735
        • World Health Organization
        Global and regional estimates of violence against women: Prevalence and health effects of intimate partner violence and non-partner sexual violence.
        World Health Organization, 2013 (Available at:)
        • Yard E.
        • Radhakrishnan L.
        • Ballesteros M.F.
        • Sheppard M.
        • Gates A.
        • Stein Z.
        • Stone D.M.
        Emergency Department Visits for Suspected Suicide Attempts Among Persons Aged 12–25 Years Before and During the COVID-19 Pandemic — United States, January 2019–May 2021.
        MMWR. Morbidity and Mortality Weekly Report. 2021; 70: 888-894
        • Ziegler J.
        An Examination of Violent Victimization from Adolescence to Early Adulthood.
        ProQuest Dissertations Publishing, 2017