Version May 2024
INTRODUCTION — The epidemiology, risk factors, and prevention of date rape will be discussed here. The identification and management of date rape, adolescent relationship abuse, sexual abuse, and the evaluation and management of sexual assault are discussed separately.
●(See "Date rape: Identification and management".)
●(See "Adolescent relationship abuse including physical and sexual teen dating violence".)
●(See "Evaluation of sexual abuse in children and adolescents".)
●(See "Management and sequelae of sexual abuse in children and adolescents".)
TERMINOLOGY
●Sexual assault/sexual violence – Sexual assault or sexual violence is an inclusive term that refers to any form of forced or inappropriate unwanted sexual contact ranging from forced touching or kissing to verbally or physically coerced vaginal, oral, or anal penetration [1-4]. This includes situations in which the victim is unable to consent because of intoxication, inability to understand the consequences, misperceptions because of age, or other incapacities.
●Rape – The legal definition of rape varies from state to state [5]. It generally encompasses nonconsensual vaginal, anal, or oral penetration (by penis, finger, or object) that involves force or threat of force (physical or psychological), lack of consent, or inability to provide consent because of age, intoxication, or mental status [5-8]. One way in which rape is categorized is by the relationship between perpetrator and victim.
•Stranger rape describes nonconsensual sexual penetration between individuals who do not know each other before the sexual act [8].
•Acquaintance rape describes nonconsensual sexual penetration between individuals who know each other in some capacity before the sexual act [8].
-Date rape is a subset of acquaintance rape in which nonconsensual sexual penetration occurs between two people who may be romantically involved or more casually connected (eg, on a date, "hooking up") [8]. Date rape can occur when the victim is alert and able to make decisions, semiconscious, or unable to respond due to alcohol or other drug use. It can occur between two individuals who have had prior consensual sexual intercourse or other forms of intimacy. Verbal coercion, threats or use of physical force, or the use of alcohol or illicit drugs may occur as precipitating events.
In many cases, date rape occurs within the context of a heterosexual dating relationship, with the male as perpetrator and the female as the victim. Same sex and female-to-male sexual violence also occur in dating relationships [9,10]. The prevalence of sexual violence victimization among transgender and nonbinary individuals is increasingly recognized [11]. However, because these types of dating and sexual violence have not yet been adequately studied, the epidemiology and available research focus on heterosexual dating and sexual violence, generally violence used by men and boys against women and girls. Although this topic refers to people who have experienced sexual violence as "victims," there is a growing body of literature that emphasizes the strengths of those who have been harmed, using terms such as "survivors" [12,13].
EPIDEMIOLOGY — Adolescent and young adult women (16 to 24 years of age) are more likely to be victims of sexual assault than are women in all other age groups [7,14]. Most sexual assault survivors (80 percent) experience their first assault before the age of 24 years [15]. Adolescents who have experienced a rape or attempted rape are three to four times as likely as those without this history to experience subsequent sexual assault during their college years [16-19].
The majority of rape incidents in adolescent and young adult females are committed by someone who is known to the victim; as many as 80 to 90 percent of sexual assaults on college campuses are perpetrated by a date or acquaintance [16,20]. Approximately one-fourth of college-age men report having used coercion during sexual contact [21].
Although nonconsensual sexual activity is common among adolescents and young adults, prevalence estimates vary widely depending on how the data are collected and measured, as illustrated below [22-26]:
●In the 2019 Youth Risk Behavior Survey, 7 percent of high school students reported that at some point during their lifetime they had been physically forced to have sexual intercourse when they did not want to [27]. The prevalence of forced sexual intercourse was greater among females than males (11 versus 3 percent). Among the 66 percent of students who dated or went out with someone in the 12 months before the survey, 8 percent reported sexual dating violence (including kissing, touching, or being physically forced to have sexual intercourse when they did not want to by someone they were dating or going out with) at least once in the 12 months before the survey (approximately 13 percent for girls and 4 percent for boys) [28]. In addition, 8 percent of those who dated or went out with someone in the 12 months before the survey reported physical dating violence (eg, being hit, slammed into something, or injured with an object or weapon) at least once in that time period (approximately 9 percent for girls and 7 percent for boys).
●In a longitudinal cohort, 40 percent of adolescent women (14 to 17 years of age) reported having had unwanted penile-vaginal intercourse within a relationship in the previous three months in face-to-face interviews [22].
●In a cross-sectional survey of adolescent and young adult women (14 to 23 years of age) at an urban health care facility, 30 percent reported an unwanted sexual experience (touching or kissing without permission, rape/attempted rape, or being talked or pressured into having unwanted intercourse) within a dating relationship in the previous 12 months [23].
●In a cross-sectional survey of dating violence among adolescents (13 to 21 years of age) evaluated in an urban pediatric emergency department, 34 percent of females reported sexual victimization (eg, physical assault, psychological aggression, sexual coercion) in the previous 12 months [29].
●In a 2011 literature review, the rate of reported rapes (by either acquaintance or stranger) among female college students ranged from 14 to 22 percent [9].
Most sexual assaults reported in individuals ≥18 years occur in the late evening and early morning hours (between 9 PM and 3 AM) [30].
RISK FACTORS — An understanding of the risk factors for date rape is the first step in prevention. Risk factors for date rape can be broadly classified into those related to the victim, those related to the perpetrator, and those related to the dating situation (table 1) [7]. Although these are factors may influence the likelihood of experiencing or using sexual violence in relationships, they are not determinants. They should be interpreted with caution and never used to blame victims.
Risk factors associated with victimization — Victim characteristics that are associated with an increased risk of date and acquaintance rape include [7,23,25,31,32]:
●Chronologic age – Adolescents and young adults 16 to 24 years of age experience sexual assault in greater numbers than women in other age groups [16-19].
●Previous history of victimization – Past history of victimization (sexual or physical) is one of the most important risk factors for date and acquaintance rape [16-19,33]. Adolescents who have experienced a rape or attempted rape before the age of 18 are three to four times more likely to experience a subsequent sexual assault during their college years than those without this history. The increased risk of revictimization may be related to increased use of alcohol or drugs, increased numbers of consensual sexual partners, and/or decreased ability to resist unwanted sexual advances [33-37]. However, it is not clear whether these associated factors are precursors to victimization, consequences of victimization, or both [38]. An observational study found that women who reported past experience with sexual aggression during dating situations were more accepting of violence toward women and rape myths than women who did not report victimization [39].
●Greater number of dating or sexual partners (which increases the exposure to potential perpetrators) and early onset of sexual activity (which is often associated with exposure to childhood sexual abuse) [40].
Perpetrator characteristics — Potential perpetrators of date rape are difficult to identify in advance [7]. However, some characteristics that may increase the possibility of sexual coercion include [41]:
●Strong belief in traditional gender roles – When establishing their sexual identity, adolescent and young adult men who have strong belief in traditional gender roles may feel the need to be forceful, aggressive, or dominant [42-44]. Men with strong belief in traditional gender roles have attitudes more accepting of rape [45]. These attitudes may be reinforced by certain types of media [46]. (See 'Adolescent perceptions of sexual behavior' below.)
●Acceptance of violence or hostility toward women and fear of being labeled "gay" [47,48].
●Acceptance of rape myths – Acceptance of rape myths encourages and reinforces sexual violence. (See 'Acceptance of rape myths' below.)
●Early involvement in sexual experiences (forced or voluntary) [49].
●Alcohol misuse and abuse [50].
●Sexual fantasies involving coercion.
●History of sexual victimization or perpetration.
Situational factors — Situational factors that may predispose to acquaintance or date rape include:
●Existing relationship – An existing relationship between the victim and perpetrator where there is a power differential [7].
●Misperceptions – Misperceptions of date-specific factors by the perpetrator may increase the risk of sexual aggression. The perpetrator may perceive the victim's nonverbal communication, mode of dress, use of alcohol, or willingness to be alone as a willingness to have sex despite verbalizations and nonverbal signals to the contrary. Acceptance of rape myths, the use of alcohol or other drugs, and belief in traditional gender roles may contribute to such misperceptions. (See 'Other contributing factors' below.)
●Date-specific factors – Certain factors specific to the date may increase the risk of date or acquaintance rape. These include who initiated the date, how expensive the date was, who paid the expenses, who drove, and the location of the dating activity [42,51]. (See 'Adolescent perceptions of sexual behavior' below.)
●Predatory behaviors – Sexual violence perpetrators (especially those who engage in serial rape) specifically seek out marginalized youth (eg, young people who appear socially withdrawn, queer youth, youth aging out of foster care, or youth in other unstable social situations) because they may be easier targets for sexual violence perpetration [52].
Gender and ethnic differences in perceptions of the role of date-specific factors in date rape have been reported among adolescents and young adults [53-55].
Alcohol use — Alcohol use contributes to the occurrence of date and acquaintance rape [38,56-63]. Alcohol consumption by the perpetrator, victim, or both, is estimated to be involved in approximately one-half of sexual assaults among adolescents and young adults [61]. Sexual assaults between partners who are acquaintances or casual dates often involve alcohol [64].
Alcohol contributes to sexual assault through multiple pathways, often exacerbating other risk factors [65,66]. It is the number one "date rape" drug and is often used to subdue and control victims. The use of alcohol may affect both the perpetrator and the victim [59]. Alcohol use may lead the perpetrator to misinterpret cues as sexual invitation, to inaccurately discriminate the date's sexual intentions, to be unable to recognize the perpetrator's own inappropriate sexual behavior, or to overestimate the date's sexual arousal [59,67]. Several studies suggest that men perceive a woman who is drinking alcohol to be more sexually available and more likely to have sex with her partner than a woman who is not drinking [68]. Some male perpetrators may encourage their dates to drink because they believe that alcohol increases the woman's interest in sex, decreases her sexual inhibition, and increases her sexual initiative [7,66,69-71], whereas others may consume alcohol as a means of justifying their behavior [61]. (See 'Acceptance of rape myths' below.)
The effects of alcohol may reduce the victim's perception of sexual assault risk, diminish the victim's ability to cope with or ward off unwanted sexual advances, or to be aware of or remember the assault [59,72,73]. Victims who have used alcohol may feel responsible for the sexual assault. Such perception of self-responsibility may have long-lasting psychological implications for the victim [7]. Such psychological consequences can also include heavy drinking as a coping strategy after sexual violence victimization. (See "Date rape: Identification and management", section on 'Symptoms and sequelae'.)
Drug use — Drug use also may contribute to date and acquaintance rape and coercive sexual violence, whether the drugs are used voluntarily by the victim, perpetrator, or both or administered to the victim surreptitiously or coercively to facilitate sexual assault (ie, "date rape drugs") [3,60,63].
Any drug that causes sedation, decreases inhibition, or increases libido may be used to facilitate sexual assault [74]. Such drugs include benzodiazepines (including commonly prescribed benzodiazepines as well as flunitrazepam [Rohypnol]), 3,4-methylendioxymethamphetamine (MDMA or ecstasy), ketamine, gamma hydroxybutyrate (GHB), cannabinoids, and over-the-counter antihistamines, among others [63,75]. The combination of alcohol with any of these drugs can lead to adverse reactions and death.
Flunitrazepam is a sedative that is prescribed in Latin America and Europe for the treatment of insomnia and as a preanesthetic medication; it has not been approved in the United States [76]. It is used illicitly to heighten the effect of alcohol and other drugs. It is 10 times more potent than diazepam. When mixed with alcohol it is incapacitating and amnestic, increasing vulnerability to sexual assault. In a cross-sectional survey of adolescents and young women attending university-based ambulatory reproductive health clinics, 1 in 10 adolescent and young adult females who reported voluntary use of flunitrazepam also reported experiencing physical or sexual assault [77].
MDMA, GHB, and ketamine are additional "date rape" drugs. MDMA is a psychoactive drug with amphetamine and hallucinogenic properties. It reduces inhibitions and produces feelings of empathy for others [78]. Effects of MDMA include confusion, severe dehydration, muscle tension, and blurred vision. Trends in MDMA use among adolescents and adults are discussed separately. (See "MDMA (ecstasy) intoxication", section on 'Epidemiology'.)
Ketamine and GHB are central nervous system depressants. They are often colorless, tasteless, and odorless, and can easily be added to beverages. Ketamine can cause delirium, amnesia, and depression. GHB induces dizziness, nausea, and visual disturbances. (See "Ketamine poisoning", section on 'Clinical presentation' and "Gamma hydroxybutyrate (GHB) intoxication", section on 'Clinical features of acute toxicity'.)
OTHER CONTRIBUTING FACTORS — Other factors that may contribute to date rape include acceptance of rape myths, adolescent perceptions of sexual behavior, and cultural considerations.
Acceptance of rape myths — Rape myths are prejudiced, stereotyped, or false beliefs about rape, rape victims, and rapists [39]. Acceptance of rape myths perpetuates unwanted sexual contact by encouraging and reinforcing coercive sexual behavior. Examples of rape myths include [39,42,43,79]:
●"Most rapists are strangers."
●"Acquaintance rape is not 'real rape' and does not harm the victim."
●"All women want to be raped."
●"No means yes."
●"Only bad girls get raped."
●"Any healthy woman can resist a rapist if she really wants to."
●"Women who dress promiscuously are 'asking for it.'"
●"Women who lead men on therefore deserve to be raped."
●"Women 'cry rape' only when they've been jilted or have something to cover up."
●"A woman who goes to a man's home on their first date implies that she is willing to have sex."
Adolescent perceptions of sexual behavior — An understanding of how adolescents view sexual behavior is critical to the prevention of date rape. Many adolescents do not perceive date rape as rape unless it occurred with physical force or verbal threats [80,81]. When presented with vignettes depicting date rape scenarios, adolescents rarely describe rape that occurred in a dating relationship as "real rape" because of the voluntary association between the victim and the perpetrator [80]. In many instances, there may have been prior consensual sex or some other form of intimacy with this partner.
Male and female adolescents often follow a script in which males are viewed as initiators and females as "gatekeepers" of sexual intercourse. Because of these perceived roles, date-specific characteristics can be over-interpreted as signals for sex [80,82]. Females who wear short skirts, for example, may be viewed by males as willing to have sex, regardless of their actual intent. Similarly, it is assumed that females who have reputations for being "easy" are going to have sex with every dating partner.
Strong belief in traditional gender roles — Males and females with strong beliefs in traditional gender roles have attitudes more accepting of sexual coercion [45].
Acceptability of forced sexual activity — In surveys of adolescents and young adults, the degree of perceived acceptability of sexual coercion varies depending upon the context. However, in a survey of high school students, it was universally perceived that when a female uses physical force and says "no" to sexual advances, she does not want to engage in sexual activity and the male does not have the right to use coercion or force against her [83]. Similarly, college students identified inappropriate sexual activity earlier in a date rape vignette when they had heard a clearly articulated sexual boundary than when they had not [84].
Among college women, forced sexual intercourse appears to be perceived as more permissible when the perpetrator is a date or acquaintance than a stranger [8,85]. Young women may endorse some of the same cultural stereotypes and attitudes reported by those who use sexual violence. Such attitudes may encourage victims of date rape to believe that they were responsible for the rape and prevent them from disclosure. (See 'Acceptance of rape myths' above and "Date rape: Identification and management", section on 'Barriers to disclosure'.)
College women who report experiences of sexual victimization may not self-identify as victims. Greater acquaintance with the perpetrator, higher levels of self-blame, and victim substance use at the time of the assault are associated with labeling the sexual assault as a serious miscommunication, rather than as a sexual assault, date rape, rape, or crime [86].
Sexual rights and responsibilities — Some adolescents may perceive that a dating relationship comes with specific entitlements, contributing to norms that condone sexual violence [80]. Studies suggest that these attitudes regarding sexual relationships are present in early adolescence. In one survey, four of five adolescents reported that forced sex is acceptable if a couple has been dating for six or more months and almost 50 percent reported that forced sex is acceptable if the female has gotten the male sexually excited [80]. In another survey of high school students, 39 percent of boys and 12 percent of girls reported that it was "okay for a boy to force a girl to have sex with him if they have had sex before," and 37 percent of boys and 23 percent of girls reported that it was "okay for a boy to force a girl to have sex with him if she gets him sexually excited" [54]. More recent studies have underscored that these perceptions of gender relations and sexual hierarchies form early in adolescence [87].
Women may believe that once they are in a dating relationship they no longer have sexual choices. Data collected in a reproductive health clinic revealed that 20 percent of women aged 14 to 26 years who reported having a steady partner believed that they did not have the right to stop sexual foreplay at any time, including at the point of intercourse [88]. Moreover, 20 percent reported believing that once consensual sex between dating partners has occurred, they cannot refuse to have intercourse in the future.
Interpretation of nonverbal communication — The occurrence of sex is often determined more by perceptions and beliefs about nonverbal behaviors than by open and honest verbal communications. Unfortunately, cues and signals for sexual intimacy are perceived and interpreted differently by adolescents and young adults [80,83].
Cultural considerations — Adolescent rape occurs in a sociocultural context in which male dominance, appropriate gender behaviors, victimization, violence, and power imbalance in relationships are highly visible [89]. Religious and/or ethnic values may affect perceptions of appropriate gender roles and sexual behavior [55]. The dominant cultural beliefs of the patient's community, especially when the community has strict ideas about appropriate women's social roles and rights, play a role in assigning moral as well as causal responsibility in sexual victimization [90]. In communities that experience marginalization and oppression, shaming, internalized discrimination, and structural inequities further contribute to isolation and silence surrounding sexual violence [91]. Assessing parent/caregiver expectations about dating and relationships may be helpful in providing anticipatory guidance about healthy dating relationships and sexual communication.
PREVENTION
Anticipatory guidance — Anticipatory guidance for the prevention of date rape has several components, including the promotion of healthy dating relationships by helping patients learn to communicate effectively about sexual beliefs, desires, and boundaries; dispelling rape myths; educating patients about harm reduction strategies to mitigate risk for date rape; and advising them about what to do if they experience sexual assault. Anticipatory guidance about healthy dating and sexual relationships should be provided to all adolescents using materials inclusive of diverse sexual attraction and gender identities [3].
The American Academy of Pediatrics' Connected Kids: Safe, Strong, Secure program recommends that the concept of healthy dating be introduced at 11 to 14 years and reinforced at subsequent visits [92]. The program includes educational brochures for teens and caregivers.
Process — To foster a better awareness and understanding of sexual violence, conversations about date rape specifically, and sexual coercion in general, should be interactive and occur at each visit. Universal education and brief counseling interventions may reduce relationship abuse victimization [93].
It is important to avoid lectures. Instead, present facts and listen to the concerns and reactions of the patient. To promote awareness and encourage open and honest conversation about the topic of dating violence, providers can use a normalizing statement for discussing dating violence. As an example, one could start by saying, "Unfortunately, many of my patients have been hurt physically or sexually, either as children or during more recent relationships. Because I want to help my patients, I discuss these issues with every patient. I also know that it may be hard for some patients to talk about being hurt in their lives" [94].
The health care provider must take all concerns seriously and answer questions honestly. In addition, the provider must confront distortions and myths. As an example, providers can say, "While it is okay for a dating partner to be jealous, jealousy is not the same as love. A partner who tries to tell you what to do or who to hang out with, puts you down, or makes you feel guilty or bad about yourself is not acting out of love." Young patients need to be encouraged to trust their instincts about a given dating situation or partner: "If your partner or relationship feels uncomfortable to you, talk about it with an adult you trust."
Empathy induction is a tool that can be used to facilitate attitudinal and behavioral changes in adolescents with regard to sexual assault prevention and may be particularly helpful for adolescents who believe they are invulnerable to sexual assault [95]. Empathy induction involves asking the patient what it would be like for them, their sister, or their close friend to experience date rape. This allows the patient to better understand and listen to the information that the provider is sharing and allows the provider to make attributions to the patient's personal behaviors without being confrontational.
Finally, it is useful to encourage the caregiver to be an active participant in discussions about dating violence and to provide information and/or resources to the caregivers for these discussions [96-98]. Caregivers can continue and extend the conversations after the visit; they can also monitor for signs that their adolescent may be in a violent dating relationship. These include a partner:
●Who is jealous and possessive
●Who is bossy (eg, gives orders, makes all the decisions)
●Embarrasses or puts the adolescent down in front of others
●Has a history of losing his temper or physical violence
●Pressures the adolescent to use alcohol or drugs
Components of anticipatory guidance
●Sexual communication – Health care providers for adolescents and young adults can help their patients to develop sexual communications skills and the corresponding self-efficacy to use them. In a survey of adolescent females, factors associated with consistent refusal to engage in unwanted sex included high safer sex self-efficacy (ie, belief in their ability to enact a behavior), few perceived barriers to negotiation with partners about condoms, and frequent conversations with caregivers about sexual issues [96].
Health care providers can assess their patients' sexual communication skills by asking how the patient communicates sexual preferences and beliefs to their partner. Patients can be empowered by being told that discussing sexual intimacy does not mean that they have to be sexually intimate.
It is important for adolescents and young adults to understand that they have choices in a sexual relationship regardless of the relationship's duration and to be able to effectively communicate those choices [84]. Many adolescent and young adult couples do not openly discuss desires for sexual intimacy. As a result, communication about sexual intent usually relies on nonverbal cues and signals, which can lead to misinterpretation, particularly among younger teens [99]. To minimize misinterpretation, adolescents and young adults must learn to identify and communicate their sexual desires and needs to their partners in a healthy and straightforward manner. (See 'Situational factors' above and 'Adolescent perceptions of sexual behavior' above.)
●Correcting rape myths – The acceptance and perpetuation of rape myths contributes to date rape. Dispelling rape myths is an important component of date rape prevention. This entails helping adolescents understand that [3,100,101]:
•Forced intercourse without consent is rape, regardless of the context (eg, previous consensual sex; use of alcohol or drugs; ongoing dating relationship); this includes incapacitated rape (being drunk or high and not able to give consent); individuals who are raped should seek medical care
•The majority of rapes of adolescents and young adults are perpetrated by people they know and may trust; perpetrators usually cannot be identified before an attempt is made
•They have choices in a sexual relationship regardless of the relationship's duration; they have the right to set sexual limits and insist that their partner honor the limits; talking about sexual intimacy does not mean that they have to have sexual intercourse
•They should not be afraid to fight back; reinforcing verbal refusal of unwanted sexual activity with physical force (eg, kicking, biting, or hitting) may be effective in stopping the attack [83,102]
●Harm reduction strategies and protective behaviors – Adolescents should be able to identify strategies that can help them and their friends increase safety and avoid situations that may increase likelihood of harm, such as [3,101,103]:
•Leaving a party with someone they do not know
•Taking a drink from someone they do not know and trust – alcohol is the number one "date rape" drug and is often used to subdue and control victims
•Leaving their drinks unattended
•Meeting alone with people with whom they made initial contact through internet
•Walking alone at night
•Being pressured into using alcohol or drugs
•Accepting help from someone they do not know if they fall ill at a party (whether from having too much to drink or the possibility that a date rape drug was added to their drink)
•Dating individuals who are jealous and possessive, bossy, embarrass or put them down in front of others, or have a history of losing their temper or physical violence
Adolescents should learn to trust their feelings and intuitions about potentially risky situations – if it feels wrong or unsafe, it probably is. That said, with any discussion of harm reduction strategies, unsafe situations, and protective behaviors, the message to young people should be clear: No one ever deserves to experience sexual violence; victims are not to blame. Many incidents of sexual violence occur between people who know each other and in familiar locations.
Prevention programs — Providers who are interested may advocate for date rape prevention programs in schools, college campuses, and other locations where youth congregate in their communities. Formal date and acquaintance rape prevention programs typically target changes in rape awareness, as well as attitudes and assertiveness, to minimize the likelihood of rape [104].
Programs targeting both male and female participants generally focus on cross-gender communication and dating expectations, with some emphasizing the "shared responsibility" of both partners in date/acquaintance rape; they consistently report a decrease in rape-supportive attitudes or behaviors [95,105].
The Safe Dates Project evaluated the effects of primary and secondary prevention of dating violence among rural eighth and ninth graders [106,107]. Using school- and community-based activities, the intervention program increased awareness, addressed help-seeking for dating violence, and provided training to improve health care providers' ability to care for adolescents experiencing dating violence or date/acquaintance rape. Participants in the intervention group reported less psychologic abuse, sexual violence, and dating violence 12 months after the program ended. Most program effects were related to changes in dating violence norms, gender stereotyping, and awareness of services.
Programs targeting women have been effective in improving participants' awareness of rape and decreasing the incidence of completed rape [95,108-110]. Personalizing the program may increase the perception of vulnerability and the intent to avoid risk-taking behaviors (eg, using alcohol on dates and dating hostile or jealous individuals) [109]. Women with a history of victimization are at particular risk for revictimization. (See 'Risk factors associated with victimization' above.)
In an open-label randomized trial in 893 female first-year university students, those who participated in the Enhanced AAA (assess, acknowledge, act) Sexual Assault Education Resistance program had a lower risk of self-reported completed rape at one year than control students who had access to brochures on sexual assault (5.2 versus 9.8 percent, relative risk reduction 46 percent, 95% CI 7-69) [110]. The Enhanced AAA Sexual Assault Education Resistance program consisted of four three-hour sessions that focused on assessing the risk of sexual assault by an acquaintance, acknowledging the danger in coercive situations and overcoming emotional barriers to acknowledging danger, engaging in effective verbal and physical self-defense, and sexuality and relationships. Other programs have been ineffective or less effective (eg, effective for shorter durations or only in particular subgroups) [108,111-114]. Compared with these programs, the Enhanced AAA Sexual Assault Resistance education program had more hours of programming, more interactive and practice exercises, and a greater focus on escalation of resistance in response to a perpetrator's perseverance.
Programs targeting males also report success in modifying attitudes following program participation [115-118]. One program, called "Coaching Boys into Men," specifically trains athletic coaches to deliver sexual and partner violence prevention messages to their male athletes. In a cluster randomized trial, athletes exposed to the program demonstrated greater likelihood of intervening when witnessing peers' disrespectful and harmful behaviors three months later and reduced abuse perpetration one year later [117,118]. This program has also been shown to be effective in increasing positive bystander behaviors and reducing dating abuse perpetration among middle school male athletes [119]. However, another program observed a "backlash" effect, wherein a small number of males reported increased aggressive attitudes following an intervention, suggesting that males who are already sexually aggressive may require secondary, rather than primary, prevention [120,121].
Programs on college campuses designed to mobilize bystanders to take action against sexual assault have reported success in changing date rape knowledge and attitudes and increasing bystander efficacy and intention to intervene [122-125]. One program for male undergraduate students also reported that program participants had less hostility toward women, had less positive views of nonconsensual sex, and less comfort with other men's inappropriate behaviors than nonparticipants [126,127].
RESOURCES — Resources related to date/acquaintance rape for patients, caregivers, and providers are listed below:
●The Centers for Disease Control and Prevention: Preventing Teen Dating Violence
●Futures Without Violence
•Protocol for Adolescent Relationship Abuse Prevention and Intervention
●National Center for Education in Maternal and Child Health (Georgetown University)
●The National Center for the Victims of Crime
●The National Sexual Violence Resource Center
●Rape, Abuse & Incest National Network
SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Sexual assault".)
SUMMARY AND RECOMMENDATIONS
●Terminology – Date rape refers to nonconsensual sexual penetration that occurs between two people who are in a romantic relationship, dating, or involved sexually. (See 'Terminology' above.)
●Risk factors – Date rape occurs predominantly in adolescent and young adult women (age 16 through 24 years). Other risk factors for date rape are listed in the table (table 1). (See 'Risk factors' above.)
●Other contributing factors – Other factors that contribute to date rape include acceptance of rape myths (prejudiced, stereotyped, or false beliefs about rape, rape victims, and rapists), strong belief in traditional gender roles, perceptions that forced sexual activity is acceptable in certain circumstances (eg, the victim has led the perpetrator on), the belief that sexual rights and responsibilities are inherent in a dating relationship, and the misperception of nonverbal cues or signals for desired sexual intimacy. (See 'Other contributing factors' above.)
●Prevention and resources – Adolescents and young adults should be provided with anticipatory guidance to prevent date rape. This includes promoting healthy dating and sexual relationships by helping patients learn to communicate effectively about sexual beliefs, desires, and boundaries; dispelling rape myths; educating patients to avoid risk factors for date rape; and advising them about what to do if they or someone they know is sexually assaulted despite their precautions. (See 'Prevention' above and 'Resources' above.)
ACKNOWLEDGMENTS — The UpToDate editorial staff acknowledges Samantha Harrykissoon, JD, MPH, who contributed to an earlier version of this topic review, and Vaughn Rickert, PsyD, who also contributed to an earlier version of this topic review and passed away in June 2015.
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