JOURNAL OF WOMEN’S HEALTH

Volume 26, Number 11, 2017 Commentary

ª Mary Ann Liebert, Inc.
DOI: 10.1089/jwh.2016.6161

Sexual Violence Against Adolescent Girls:

Labeling It to Avoid Normalization

Giussy Barbara, MD,1 Federica Collini, MD,1,2 Cristina Cattaneo, PhD,1,2 Federica Facchin, PhD,3
Paolo Vercellini, MD,4 Laura Chiappa, MD,5 and Alessandra Kustermann, MD1

Abstract

Violence against women is a pervasive complex phenomenon that destroys women’s feelings of love, trust, and
self-esteem. In this commentary, we specifically focus on sexual violence against adolescent girls, whose impact is
particularly harmful since it may lead to impaired mental health, social functioning, and neurodevelopment.
Between 12% and 25% of adolescent girls throughout the world experience sexual violence, very often perpe-
trated by a family member or a friend. Moreover, for an alarming proportion of girls, the first sexual experience is
coerced. In this article, we review the multiple negative effects of sexual violence against adolescent girls. We also
report data derived from our practice in a public Italian referral Centre for Sexual and Domestic Violence (SVSeD)
and address the importance of a multidisciplinary clinical approach with adolescent victims of sexual violence.

Keywords: adolescent girls, gender violence, multidisciplinary clinical practice, prevalence of sexual violence

s acknowledged by the World Health Organization,1
A violence against women is a major health problem that
involves different forms of violent acts, resulting in re-
markable physical and psychological suffering, especially
when perpetrated within intimate relationships. Sexual vio-
lence is one of the most pervasive types of gender violence
overall and especially when perpetrated against young ado-
lescents. Although either boys or girls can be victims of
sexual abuse, in this commentary, we specifically focus on
sexual violence as experienced by girls on the basis of our
clinical practice in a public Italian referral Service for Sexual
and Domestic Violence (SVSeD) against women.
Young people are frequently victims of sexual violence. It is
generally estimated that throughout the world 12% to 25% of
girls younger than 18 years of age experience some type of
sexual violence, with regional and cultural variations.2 The
Center for Disease Control (CDC) reports that in the United
States about one in four girls is sexually abused before the age
of 18 and 35.8% of sexual assaults occur when the girl is be-
tween the ages of 12 and 17.3 In a survey of the Baltic countries,
about 42%–56% of girls reported having been touched in an
offensive way, and about 10% reported abusive sexual inter-
course.4 In a recent Italian national survey,5 about 10% of the
women interviewed reported sexual violence before the age of
16. Perpetrators are usually relatives, parents, or stepfathers
(19.5%), family friends (11.4%), friends of victims (15.4%), or
acquaintances, including those met online (23.8%). Unknown
perpetrators are less common, representing 20.2% of the cases.
Sexual violence against adolescent girls, especially when
reiterated, can lead to a long-lasting devastating impact on
mental health, as well as on interpersonal and intimate rela-
tionships, with negative emotional and sexual outcomes.6–9
Cumulative exposure to trauma, such as sexual abuse by a
family member and in general by someone known to the vic-
tim, is associated with increased risk of psychological suffer-
ing (including the onset of borderline or schizoid personality
disorders), social adjustment problems, and decreased school
functioning.8,10–12 Reiterated and prolonged violence also
affects the neurodevelopment of a growing person, with a
negative impact on different neural systems (such as reticular
activating system, locus coeruleus, hippocampus, amygdala and
emotional memory, and hypothalamic–pituitary–adrenal axis),
which will regulate the neurobiological response to constant
negative stimuli.13,14 Moreover, sexually abused girls younger

1
Department of Obstetrics and Gynecology and Service for Sexual and Domestic Violence (SVSeD), Fondazione IRCCS Ca’ Granda,
Ospedale Maggiore Policlinico, Milan, Italy.
2
Sezione di Medicina Legale e delle Assicurazioni, Dipartimento di Scienze Biomediche per la Salute, Università degli Studi di Milano,
Milan, Italy.
3
Faculty of Psychology, Catholic University of Milan, Milan, Italy.
4
Unità Operativa Dipartimentale di Ginecologia Chirurgica ed Endometriosi, Fondazione IRCCS Ca’ Granda Ospedale Maggiore
Policlinico e Università degli Studi di Milano, Milan, Italy.
5
Health Director, Fondazione IRCCS Ca’ Granda, Ospedale Maggiore Policlinico, Milan, Italy.

1146
SEXUAL VIOLENCE AGAINST ADOLESCENT GIRLS
than 16 years of age are at higher risk to reexperience some type
of sexual violence in their adulthood (58.5% vs. 31.5% of the
total examined female population).5
Early indicators of risky lifestyle (such as getting drunk,
using marijuana, having sex) and/or having deviant friends or
older sisters who engage in risky behaviors are associated
with a higher likelihood of subsequent sexual victimization.15
These findings suggest that behaviors and social network
patterns established in early adolescence increase girls’ vul-
nerability to sexual assault in late adolescence.
In our SVSeD, founded in 1996 at the IRCCS Ca’ Granda
Ospedale Maggiore Policlinico, Milan (Italy), over 1000
sexually abused adolescent girls were assisted. Based on our
recent data, about 6 in 10 of the abused adolescent girls pre-
sented risk factors in terms of vulnerability to sexual violence,
such as history of recurrent maltreatment, alcohol and/or drug
abuse, having a multiproblematic family of origin (and thus
being for example in foster care), having psychological or
psychiatric disorders, being a foreign citizen, or a victim of
prostitution. In the majority of cases, the perpetrator of the
sexual violence was someone known to the victim. Among the
adolescents assisted by the SVSeD in the first week after vi-
olence, the most frequent type of sexual assault was coerced
penile–vaginal penetration; in the acute and subacute period,
genital/anal lesions were present in at least one in two cases.
Noticeably, for about one-third of these adolescent girls, the
sexual assault represented the first sexual experience.
Normalization of Sexual Violence Among
Young People: A Major Health Risk
According to data from the World Health Organization,
almost one-third of young girls report that their first sexual
experience was coerced,6 and there is evidence that girls are
more likely to experience forced sex as compared with boys.16
In most cases, sexual coercion through physical or verbal
pressure occurs in dating relationships, to the point that teen
dating violence (including cyber dating victimization) has
been identified as a major problem among young adoles-
cents.17 Girls may comply to unwanted sex due to fear of being
beaten18 as well as to personal concerns of preserving the
relationship and thus not being rejected by their partner.17 In
these cases, sex remains forced and nonconsensual, but girls
may not be fully aware of this. Moreover, there is evidence that
young women tend to frame sexual violence as a ‘‘normal
part’’ of everyday life in middle and high school, as well as in
college.4,16 For example, a study exploring college women’s
resistance strategies to sexual assault19 showed that 26% of the
women interviewed displayed normalization or minimization
of the sexual assault experience (e.g., ‘‘it was not a big deal’’).
If one considers how culturally shared discourses may shape
girls’ explanations of their own experiences,16 the fact that
intimate partner violence, including sexual violence, is often
normalized or romanticized in famous books, movies, TV
shows, or music videos is particularly alarming.20
We believe that normalization or trivialization of violence,
which should be considered as a cultural rather than a merely
individual process, represents an important reason for not
reporting an incident of sexual violence to adults, besides the
victim’s feelings of shame and self-blame, and the fear of not
being believed or even being accused and thus revictimized
by the justice system. Overall, violence against young women
1147
remains largely unreported, and the cases known to authori-
ties represent only the tip of the iceberg.6 Moreover, teens
who report often struggle with an overall difficulty finding
adequate interventions.21
Key Elements of Effective Practices
The evidences presented above substantiate the need for
more effective public policies and intervention programs
aimed at either preventing sexual violence or reducing its
negative effects on the young victims. Overall, sexual violence
against adolescents has been increasingly acknowledged as a
human rights and public obligation. Several national calls to
actions were promoted in the past years. For example, the U.S.
President Barack Obama established the ‘‘White House Task
Force to Protect Students from Sexual Assault’’ to share best
practices, increase transparency, prevent gender violence, and
support its victims.22 Public health organizations underline the
importance of a timely recognition and primary prevention of
sexual violence. The Center for Control and Disease of Atlanta
suggests to adopt specific strategies and approaches to affect
not only individual behaviors but also families, schools,
communities, and social structures that influence risk and
protective factors for sexual violence.23 The approach sug-
gested involves different actions: (1) promoting social norms
that protect against sexual violence; (2) teaching safety skills
(such as safe dating) and healthy sexuality to adolescents; (3)
providing opportunities to empower and support girls and
women (i.e., strengthening economic supports for women and
families, as well as leadership and opportunities for girls); (4)
creating protective environments (i.e., improving safety and
monitoring in schools, establishing and consistently applying
workplace policies, and addressing community-level risks
through environmental approaches); (5) supporting victims to
lessen harms (i.e., victim-centered services, treatment for
victims of sexual violence, treatment for at-risk children, and
families to prevent problem behavior).23
Throughout the world there are currently multiple orga-
nizations dedicated to prevent gender violence and promote
the overall wellbeing of women and their children.24–26
Based on our knowledge of the way, in which these organi-
zations work, as well as on our own experience, we now
outline key elements of good practice with girls victims of
sexual violence in terms of prevention and treatment.
How to prevent sexual violence
In a review of 142 studies presenting the outcomes of in-
terventions addressing intimate partner violence and sexual
violence among adolescents, Lundgren and Amin27 identified
three effective approaches: school-based dating violence in-
terventions, aimed at reducing or preventing violence by im-
proving gender-equitable attitudes and younger adolescents’
likelihood to intervene in situations of violence; community-
based programs aimed at promoting gender-equitable norms
and awareness of sexual violence, with decreased tolerance
toward this type of victimization; and parenting programs and
interventions with children subjected to maltreatment, aimed
at preventing future perpetration by creating a safe home en-
vironment without any type of interpersonal violence (which is
particularly important if one considers that victims of abuse
often become perpetrators). Overall, interventions with a long-
term investment and a repeated exposure to ideas of gender
1148
equality had better outcomes than single awareness-raising or
discussion sessions. However, the interventions evaluated
were carried out in developed countries and research is needed
to gain further evidences.
In our opinion, community-based and school-based inter-
ventions should be implemented as part of shared national
prevention programs focused not only on violence itself but
also on sexual and reproductive health in general. Sexual
health education in schools should not be exclusively focused
on how to avoid diseases or pregnancies and should embrace
a more comprehensive notion of healthy sexuality that in-
volves believing in gender equality, adopting positive and
respectful relational behaviors, as well as being actively able
to protect oneself and his or her own rights as a human being.
This is pivotal if one considers that adolescence is the critical
period when thoughts, opinions, attitudes, values, and ideals
start to develop. These education programs—still lacking in
many countries, as in Italy for example—should be offered to
children and young people very early, since the beginning of
the school cycle, because the proper timing of intervention
may significantly reduce vulnerability and thus decrease
gender violence. Talking about gender differences, respect
for the opposite sex, kindness, tolerance, and affectivity in an
appropriate language for a young audience is pivotal to
modify the predominant culture of male dominance.28
Since there are well-known vulnerability factors for sexual
abuse in adolescence, prevention strategies should be tar-
geted on the specific characteristics of at-risk populations;
public national programs involving health practitioners and
all community members working with children and adoles-
cents should be implemented to better and timely recognize
the cases of sexual violence. Again, schools represent an
important setting because compulsory school attendance may
facilitate reaching at-risk adolescent populations.
How to treat sexual violence
‘‘Patient centered care’’ is fundamental when working
with sexual assault survivors. The adolescent victim should
not be considered too young to be actively engaged in the
whole decision process as an equal partner, which means
taking into account her individual preferences and needs, be-
sides her specific family, social, and cultural conditions. Such
an approach to treatment requires continuity between different
services (i.e., medical, social, and legal) and facilities to offer
people free access to appropriate care at any time.
The team involved in any case of sexual violence should be
composed of different professional figures, such as gyne-
cologists, forensic medical doctors, social workers, pedia-
tricians, pediatric surgeons, psychologists/psychotherapists,
sexologists, and lawyers, with a constant positive dialogue
with the authorities. All team members have to be trained not
only in gender-based violence (given that sexual violence is
often associated with other forms of violence) but also in
trauma-informed care, because sexual assault is indeed a
major trauma with multiple negative effects on the person, as
well as on the whole system involved. A trauma-informed
approach allows to recognize the overall impact of the trauma
(either on an individual or a contextual level) and to avoid
retraumatization due to wrong treatment practices that put the
victim in a powerless position, for instance by not involving
her in the decision-making process. A trauma-informed ap-
BARBARA ET AL.
proach should be implemented in any service addressing
violence against women, involving programs supporting
safety, trustworthiness and transparency, peer support, mu-
tuality, collaboration, empowerment, and knowledge.29
If the victim of sexual violence is younger than 13 years of
age, clinical forensic examiners are fundamental members of
the multidisciplinary team, because their knowledge and
approach is indispensable for the correct analysis, docu-
mentation, and interpretation of trauma and consequent
manner of reporting to the judicial authority. Forensic ex-
aminer provides descriptions and interpretation of findings in
an accurate, reliable, and understandable format for the
Court. Moreover, clinical forensic professionals help prop-
erly collect all needed evidence, such as DNA swabs, sperm
slides, or blood and urine samples, to identify drugs in a
growing scenario of drug-facilitated rapes.30 Our 20-year
experience has shown that collecting data for the judicial
system is as important as clinical assistance; we have in fact
observed in our population that appropriate and professional
management of forensic evidence and at times even the
condemnation of the perpetrator may significantly improve
the victim’s psychological outcome and everyday life.
Gynecologists, clinical forensic examiners, psychologists,
and lawyers together play an important role since they can help
the victim reach good results in the judicial process by facili-
tating an accurate collection of data that the judge can effec-
tively use to figure out the nature of the assault. In this regard,
the timeliness of the clinical assessment in cases of sexual vi-
olence is crucial and should be strongly encouraged. In fact,
physical examination may come too late if it is performed after
the first 72 hours following the sexual assault, because the
genital area has a quick capacity of recovery and most injuries
may no longer be visible after this period. There is evidence
that, among sexually abused adolescent girls, tears of the pos-
terior fourchette or fossa are the most common findings, while
hymenal tears are uncommon.31 Providing training on gender
violence to general physicians, gynecologists, pediatricians,
social workers, psychologists, teachers, lawyers, judges, and
police officers is also important to identify cases of violence and
remove obstacles to disclosure in a timely manner.
Conclusive Thoughts
In describing her own almost fatal sexual assault and the
aftermath,32 the American philosopher Susan Brison reminds
us how ‘‘trauma not only haunts the conscious and unconscious
mind, but also remains in the body, in each of the senses, ready
to resurface whenever something triggers a reliving of the
traumatic event.’’ As clinicians, we have to be fully aware of the
devastating impact of sexual violence, which can be even more
pervasive when the victims are children or young adolescents.
Treating injuries cannot be the only final goal of healthcare.
Helping a woman of any age reconstruct her life and identity
after violence is indeed our mission and can only be reached if
shared by a team composed by several different professionals.
Author Disclosure Statement
The authors report no conflicts of interest. No financial
support or funding was received for this article. G.B., F.C.,
and A.K. conceived the article; G.B. and F.C. wrote the
manuscript. A.K., C.C., P.V., L.C., and F.F. critically
SEXUAL VIOLENCE AGAINST ADOLESCENT GIRLS
reviewed and commented the article. All authors approved
the content of the article.
References
1. WHO, Department of Reproductive Health and Research,
London School of Hygiene and Tropical Medicine, South
African Medical Research Council. Global and regional es-
timates of violence against women: Prevalence and health
effects of intimate partner violence and non-partner sexual
violence. WHO, 2013;978 92 4 156462 5. Available at: www
.who.int/mediacentre/factsheets/fs239/en Accessed August
30, 2016.
2. Sapp MV, Vandeven AM. Update on childhood sexual
abuse. Curr Opin Pediat 2005;17:258–264.
3. ‘‘Child Sexual Abuse: What Parents Should Know,’’
American Psychological Association. Available at: www.apa
.org/pi/families/resources/child-sexual-abuse.aspx (February
19, 2014). Accessed August 30, 2016.
4. European institute for gender equality’s studies on gen-
der biased violence. Available at: http://eige.europa.eu/
gender-based-violence/eiges-studies-gender-based-violence/
study-identify-and-map-existing-data-and-resources-sexual-
violence-against-women-eu Accessed August 30, 2016.
5. ISTAT, Istituto Nazionale di Statistica. La violenza contro le
donne dentro e fuori la famiglia. Anno 2014. 2015. Available
at: www.istat.it/it/archivio/161716 Accessed August 30, 2016.
6. WHO, Violence and Injury Prevention. The Global Campaign
for Violence Prevention. October 2015. Available at: www
.who.int/violence_injury_prevention/violence/global_campain/
en/chap6.pdf Accessed December 15, 2016.
7. Kaltman S, Krupnick J, Stockton P, Hooper L, Green B.
Psychological impact of types of sexual trauma among
college women. J Trauma stress 2005;18:547–555.
8. Krupnick J, Green B, Stockton P, Goodman L, Corcoran C,
Petty R. Mental health effects of adolescent trauma exposure
in a female college sample: Exploring differential outcomes
based on experiences of unique trauma types and dimen-
sions. Psychiatry 2004;67:264–279.
9. Nahapetyan L, Orpinas P, Song X, Holland K. Longitudinal
association of suicidal ideation and physical dating vio-
lence among high school students. J Youth Adolesc 2014;
43:629–640.
10. Kashani J, Shekim WO, Burk J, Beck N. Abuse as a
predictor of psychopathology in children and adolescents.
J Clin Child Psychol 1987;16:43–50.
11. Herman J, Perry J, van der Kolk B. Childhood trauma in
borderline personality disorder. Am J Psychiatry 1989;146:
490–495.
12. Kilpatrick D, Resnick H, Acierno R. Health impact of in-
terpersonal violence. Implication for clinical practice and
public policy. Behav Med 1997;23:79–85.
13. Vrana S, Lauterbach D. Prevalence of traumatic events and
post-traumatic psychological symptoms in a nonclinical
sample of college students. J Trauma Stress 1994;7:289–302.
14. Perry BD. The neurodevelopmental impact of violence in
childhood. Chapter 18: In: Schetky D, Benedek EP, eds. Text-
book of child and adolescent forensic psychiatry. Washington,
D.C.: American Psychiatric Press, Inc., 2001:221–238.
15. East PL, Hokoda A. Risk and protective factors for sexual
and dating violence victimization: A longitudinal, pro-
spective study of Latino and African American adolescents.
J Youth Adolesc 2015;44:1288–1300.
16. Hlavka HR. Normalizing sexual violence. Young women ac-
count for harassment and abuse. Gender Soc 2014;28:337–358.
1149
17. Johnson SE, Hoffman JA, Kruger LJ, Rizzo CJ. Teaching
school psychology students about dating violence: A
snapshot of training practices across the USA. School Ment
Health 2015;7:249–270.
18. Jewkes R, Vundule C, Maforah F, Jordaan E. Relationship
dynamics and adolescent pregnancy in South Africa. Soc
Sci Med 2001;5:733–744.
19. Edwards KM, Probst DR, Tansill EC, Dixon CJ, Bennett S,
Gidycz CA. In their own words: A content-analytic study of
college women’s resistance to sexual assault. J Interpers
Violence 2014;29:2527–2547.
20. Bonomi AE, Altenburger LE, Walton NL. ‘‘Double crap!’’
Abus and harm identity in Fifty Shades of Grey. J Womens
Health (Larchmt) 2013;22:733–744.
21. Martin CE, Houston AM, Mmari KN, Decker MR. Urban
teens and young adults describe drama, disrespect, dating
violence and help-seeking preferences. Matern Child
Health J 2012;16:957–966.
22. Jarrett V. A Renewed Call to Action to End Rape and Sexual
Assault. January 22, 2014. Available at: www.whitehouse.gov/
blog/2014/01/22/renewed-call-action-end-rape-and-sexual-
assault Accessed December 15, 2016.
23. CDC National Center for Injury Prevention and Control,
Division of Violence Prevention. Stop sexual violence: A
technical package to prevent sexual violence. Atlanta: CDC,
2016. Available at: www.cdc.gov/violenceprevention/pdf/sv-
prevention-technical-package.pdf Accessed December 15, 2016.
24. National Center on Domestic and Sexual Violence. Avail-
able at: www.ncdsv.org Accessed December 15, 2016.
25. Center Against Domestic Violence. Available at: www
.cadvny.org Accessed December 15, 2016.
26. L.I. Against Domestic Violence. Available at: www.liadv
.org Accessed December 15, 2016.
27. Lundgren R, Amin A. Addressing intimate partner violence
and sexual violence among adolescents: emerging evidence of
effectiveness. J Adolesc Health 2015; 56(1 Suppl):S42–S50.
doi: 10.1016/j.jadohealth.2014.08.012.
28. Council of Europe. Instanbul Convention Action against
violence against women and domestic violence. Available at:
www.coe.int/en/web/istanbul-convention/home Accessed
September 3, 2016.
29. National Center for Trauma Informed Care (NCTIC). Avail-
able at: www.samsha.gov.nctic Accessed December 15, 2016.
30. Bechtel K, Carroll M. Medical and forensic evaluation of
the adolescent after sexual assault. Clin Ped Emerg Med
2003;4:37–46.
31. Adams JA, Girardin B, Faugno D. Adolescent sexual assault:
Documentation of acute injuries using photo-colposcopy. J
Pediatr Adolesc Gynecol 2001;14:175–180.
32. Brison SJ. Aftermath: Violence and the remaking of a self.
Princeton, NJ: Princeton University Press, 2003.
Address correspondence to:
Giussy Barbara, MD
Department of Obstetrics and Gynecology
and Service for Sexual and Domestic Violence (SVSeD)
Fondazione IRCCS Ca’ Granda
Ospedale Maggiore Policlinico
Via della Commenda 12
Milan 20122
Italy
E-mail: giussy.barbara@gmail.com
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