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Lifetime Economic Burden of Rape Among U.S. Adults

Published:January 30, 2017DOI:https://doi.org/10.1016/j.amepre.2016.11.014

      Introduction

      This study estimated the per-victim U.S. lifetime cost of rape.

      Methods

      Data from previous studies was combined with current administrative data and 2011 U.S. National Intimate Partner and Sexual Violence Survey data in a mathematical model. Rape was defined as any lifetime completed or attempted forced penetration or alcohol- or drug-facilitated penetration, measured among adults not currently institutionalized. Costs included attributable impaired health, lost productivity, and criminal justice costs from the societal perspective. Average age at first rape was assumed to be 18 years. Future costs were discounted by 3%. The main outcome measures were the average per-victim (female and male) and total population discounted lifetime cost of rape. Secondary outcome measures were marginal outcome probabilities among victims (e.g., suicide attempt) and perpetrators (e.g., incarceration) and associated costs. Analysis was conducted in 2016.

      Results

      The estimated lifetime cost of rape was $122,461 per victim, or a population economic burden of nearly $3.1 trillion (2014 U.S. dollars) over victims’ lifetimes, based on data indicating >25 million U.S. adults have been raped. This estimate included $1.2 trillion (39% of total) in medical costs; $1.6 trillion (52%) in lost work productivity among victims and perpetrators; $234 billion (8%) in criminal justice activities; and $36 billion (1%) in other costs, including victim property loss or damage. Government sources pay an estimated $1 trillion (32%) of the lifetime economic burden.

      Conclusions

      Preventing sexual violence could avoid substantial costs for victims, perpetrators, healthcare payers, employers, and government payers. These findings can inform evaluations of interventions to reduce sexual violence.

      Introduction

      An estimated 19.3% of U.S. women and 1.7% of men have been raped during their lifetime.
      • Breiding M.J.
      • Smith S.G.
      • Basile K.C.
      • Walters M.L.
      • Chen J.
      • Merrick M.T.
      Prevalence and characteristics of sexual violence, stalking, and intimate partner violence victimization— National Intimate Partner and Sexual Violence Survey, United States, 2011.
      Sexual violence victimization is associated with poor short- and long-term physical and mental health outcomes.
      • Chen L.P.
      • Murad M.H.
      • Paras M.L.
      • et al.
      Sexual abuse and lifetime diagnosis of psychiatric disorders: systematic review and meta-analysis.
      • Smith S.G.
      • Breiding M.J.
      Chronic disease and health behaviours linked to experiences of non-consensual sex among women and men.
      Few studies have quantified the per-victim lifetime economic cost of sexual violence, which at a minimum includes victims’ impaired health, as well as lost productivity and criminal justice activities. A per-victim cost here refers to the value of a person entirely avoiding a particular exposure. Previous studies have estimated related cost dimensions—such as cost per sexual assault incident
      • McCollister K.E.
      • French M.T.
      • Fang H.
      The cost of crime to society: new crime-specific estimates for policy and program evaluation.
      • Miller T.
      • Taylor D.
      • Sheppard M.
      Costs of Sexual Violence in Minnesota.
      • Miller T.R.
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      Victim Costs and Consequences: A New Look.
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      Victim costs of violent crime and resulting injuries.
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      Incidence and cost of sexual violence in Iowa.
      —but largely have not accounted for victims’ long-term health. The aim of this study was to use data from previous studies with current administrative and sexual violence surveillance data to estimate the per-victim U.S. lifetime cost and total population economic burden of rape among adults not currently institutionalized.

      Methods

      Study information reported according to Consolidated Health Economic Evaluation Reporting Standards.
      • Husereau D.
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      Consolidated Health Economic Evaluation Reporting Standards (CHEERS)—explanation and elaboration: a report of the ISPOR Health Economic Evaluation Publication Guidelines Good Reporting Practices Task Force.
      Model inputs included the number of U.S. adult (aged ≥18 years) women and men with any lifetime (including childhood) and past 12–month incidence of rape; selected attributable—or marginal—health and other outcomes associated with rape from administrative data and previous studies (hereafter, reference studies); and the marginal cost of those outcomes. Marginal outcome refers to the proportion of victims with an outcome beyond the proportion among non-victims, and is used to calculate the attributable cost of rape. Medical, lost work productivity, and criminal justice costs were included. The main outcome measures were:
      • 1.
        lifetime cost of rape per victim; and
      • 2.
        lifetime cost of rape in the U.S. population (or economic burden) of currently non-institutionalized adults (hereafter, U.S. population), calculated as the lifetime cost per victim multiplied by the population number of victims.
      This analysis used a lifetime time horizon from the societal perspective. Previous studies of lifetime per-person health costs have identified a meaningful age of inception—for example, age 6 years for nonfatal child maltreatment
      • Fang X.
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      The economic burden of child maltreatment in the United States and implications for prevention.
      (estimated cost: $210,012 as 2010 U.S. dollars [USD], or $225,408 as 2014 USD

      U.S. Bureau of Economic Analysis. Table 1.1.4: Price indexes for gross domestic product. www.bea.gov/itable/. Published December 22, 2015. Accessed December 28, 2015.

      ) and age 24 years for smoking
      • Sloan F.
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      • Picone G.
      • Conover C.
      • Taylor D.
      The Price of Smoking.
      (estimated cost: $220,000 for men and $106,000 for women as 2000 USD, or $292,010 and $139,119 as 2014 USD

      U.S. Bureau of Economic Analysis. Table 1.1.4: Price indexes for gross domestic product. www.bea.gov/itable/. Published December 22, 2015. Accessed December 28, 2015.

      ). The authors did not find a robust estimated average age of first rape among victims, although it is known that the age of first completed rape was <18 years for 42% of female victims (and <25 years for 80% of female victims) and <10 years for 25% of male victims.
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      • et al.
      The National Intimate Partner and Sexual Violence Survey (NISVS): 2010 Summary Report.
      The present model assessed lifetime unit costs assuming an average age of first rape victimization of 18 years. Costs incurred after the first year were discounted by 3%
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      Panel on cost-effectiveness in health and medicine.
      and presented as 2014 USD, inflated using selected indices.

      U.S. Bureau of Economic Analysis. Table 1.1.4: Price indexes for gross domestic product. www.bea.gov/itable/. Published December 22, 2015. Accessed December 28, 2015.

      U.S. Bureau of Economic Analysis. Table 2.5.4: Price indexes for personal consumption expenditures by function. www.bea.gov/itable/. Published August 6, 2015. Accessed December 28, 2015.

      The analysis was conducted in 2016 and used publicly available data.

      Definition and Prevalence of Rape

      The economic burden estimate is based on the estimated number of currently non-institutionalized men and women who reported having been raped at some point during their lives in the 2011 U.S. National Intimate Partner and Sexual Violence Survey (NISVS)
      • Breiding M.J.
      • Smith S.G.
      • Basile K.C.
      • Walters M.L.
      • Chen J.
      • Merrick M.T.
      Prevalence and characteristics of sexual violence, stalking, and intimate partner violence victimization— National Intimate Partner and Sexual Violence Survey, United States, 2011.
      (data collection, January–December 2011) where rape was defined as completed or attempted penetration of the victim through the use or threats of physical force or when the victim was drunk, high, drugged, or passed out and unable to consent (Table 1).
      Table 1Estimated Marginal Outcomes, Lifetime Unit Costs, Lifetime Cost Per Victim, and Economic Burden of Rape (2014 USD)
      MeasureMarginal outcome among victims
      Combined marginal outcomes for men and women reflect estimates from studies that controlled for victim sex but did not report final results by sex (Appendix Table 1 has details, available online).
      Marginal lifetime cost per outcome,
      Marginal costs without references are calculated from other data in the table, for example, category sums.
      $
      Lifetime cost
      Per victim cost is marginal probability multiplied by marginal cost. Population cost by outcome is the number of victims by sex multiplied by the per-victim cost. Total per-victim by sex and total population costs are the sum of all per-victim by sex and population costs by outcome.
      Per victim, $Population, $% of total
      WomenMenWomenMen
      Total
       Victims
      Details of reference studies reported in Appendix Table 1 (outcomes); Appendix Table 2 (costs); Appendix Table 3 (discounted cost calculations) (available online).
      (n) and total cost
      23,305,000
      • Breiding M.J.
      • Smith S.G.
      • Basile K.C.
      • Walters M.L.
      • Chen J.
      • Merrick M.T.
      Prevalence and characteristics of sexual violence, stalking, and intimate partner violence victimization— National Intimate Partner and Sexual Violence Survey, United States, 2011.
      1,971,000
      • Breiding M.J.
      • Smith S.G.
      • Basile K.C.
      • Walters M.L.
      • Chen J.
      • Merrick M.T.
      Prevalence and characteristics of sexual violence, stalking, and intimate partner violence victimization— National Intimate Partner and Sexual Violence Survey, United States, 2011.
      122,461122,278124,6313,095,330,073,080100.00
        Medical cost48,02948,18046,2351,213,974,631,14039.2
        Lost productivity cost63,74463,47566,9241,611,187,780,92152.1
        Criminal justice cost9,2509,1949,918233,815,164,6447.6
        Other
      Includes victim property damage/loss, adoption costs, “other” costs attributable to smoking and alcohol abuse (Appendix Table 3 has details, available online).
      1,4381,4281,55436,352,496,3751.2
       Government cost as % of total38,84838,90038,230981,911,926,27831.7
      Acute outcomes
       Victim property loss/damage10.9%
      Unpublished data from the U.S. Department of Justice.
      219
      Unpublished data from the U.S. Department of Justice.
      2424604,283,163<0.1
       Injuries treated by location52052013,155,970,3290.4
        Doctor’s office5.3%
      Unpublished data from the U.S. Department of Justice.
      168

      Machlin SR, Adams SA. Statistical Brief #484: Expenses for Office-Based Physician Visits by Specialty, 2013. Rockville, MD: Agency for Healthcare Research and Quality; 2015

      99226,955,738<0.1
        ED treat-and-release12.1%
      Unpublished data from the U.S. Department of Justice.
      2,251
      Unpublished data from Pacific Institute for Research and Evaluation.
      2722726,866,148,6700.2
        Hospitalization1.0%
      Unpublished data from the U.S. Department of Justice.
      24,481
      Unpublished data from Pacific Institute for Research and Evaluation.
      2402406,062,865,9220.2
       Victim fatalities1414359,334,461<0.1
        Medical0.001%
      U.S. Federal Bureau of Investigation
      Table 12. Expanded homicide data—murder circumstances, 2009–2013.
      11,707

      Centers for Disease Control and Prevention (CDC). Web-based Injury Statistics Query and Reporting System (WISQARS), cost of injury reports 2010, both sexes, all ages, United States. www.cdc.gov/injury/wisqars/index.html. Published 2010.

      0.100.102,517,150<0.1
        Lost productivity0.001%
      U.S. Federal Bureau of Investigation
      Table 12. Expanded homicide data—murder circumstances, 2009–2013.
      1,659,520

      Centers for Disease Control and Prevention (CDC). Web-based Injury Statistics Query and Reporting System (WISQARS), cost of injury reports 2010, both sexes, all ages, United States. www.cdc.gov/injury/wisqars/index.html. Published 2010.

      1414356,817,311<0.1
       Rape-related pregnancy
      Marginal probability represents the estimated probability of each rape-related pregnancy outcome among all female victims with lifetime experience of attempted and completed rape, calculated using the proportion of female attempted and completed rape victims that experienced completed penetration rape from 2011 U.S. NISVS (survey-weighted 13,826,000/23,305,000 female victims, or 59%).1 Marginal outcome presented in this way for consistency with other measures in this table. Supporting calculations demonstrated in Appendix Table 1 (available online).
      445010,367,598,4010.3
        Birth0.9%
      • Holmes M.M.
      • Resnick H.S.
      • Kilpatrick D.G.
      • Best C.L.
      Rape-related pregnancy: estimates and descriptive characteristics from a national sample of women.
      NA15,867
      Truven Health Analytics
      The Cost of Having a Baby in the United States.
      14703,431,432,6510.1
        Adoption0.2%
      • Holmes M.M.
      • Resnick H.S.
      • Kilpatrick D.G.
      • Best C.L.
      Rape-related pregnancy: estimates and descriptive characteristics from a national sample of women.
      NA168,758
      • Barth R.
      • Chung K.
      • Wildfire J.
      • Shenyang G.
      A comparison of the governmental costs of long-term foster care and adoption.
      28606,666,421,1300.2
        Medical abortion1.4%
      • Holmes M.M.
      • Resnick H.S.
      • Kilpatrick D.G.
      • Best C.L.
      Rape-related pregnancy: estimates and descriptive characteristics from a national sample of women.
      NA518
      • Jerman J.
      • Jones R.K.
      Secondary measures of access to abortion services in the United States, 2011 and 2012: gestational age limits, cost, and harassment.
      70173,312,4280.0
        Spontaneous abortion0.3%
      • Holmes M.M.
      • Resnick H.S.
      • Kilpatrick D.G.
      • Best C.L.
      Rape-related pregnancy: estimates and descriptive characteristics from a national sample of women.
      NA1,275
      • Dalton V.K.
      • Liang A.
      • Hutton D.W.
      • Zochowski M.K.
      • Fendrick A.M.
      Beyond usual care: the economic consequences of expanding treatment options in early pregnancy loss.
      4096,432,1920.0
       Victim lost productivity100.0%
      Assumed.
      100.0%
      Assumed.
      516
      • Grosse S.D.
      • Krueger K.V.
      • Mvundura M.
      Economic productivity by age and sex: 2007 estimates for the United States.
      51651613,030,592,5210.4
      Long-term outcomes
       Victim mental health77,66578,8611,965,406,362,72863.5
        Anxiety disorder1.3%
      • Chen L.P.
      • Murad M.H.
      • Paras M.L.
      • et al.
      Sexual abuse and lifetime diagnosis of psychiatric disorders: systematic review and meta-analysis.
      83,5421,0201,02025,791,864,3220.8
         Medical79,967
      • Greenberg P.E.
      • Sisitsky T.
      • Kessler R.C.
      • et al.
      The economic burden of anxiety disorders in the 1990s.
      90490422,860,475,9430.7
         Lost productivity9,089
      • Greenberg P.E.
      • Sisitsky T.
      • Kessler R.C.
      • et al.
      The economic burden of anxiety disorders in the 1990s.
      1161162,931,388,3790.1
        Depression19.7%
      • Chen L.P.
      • Murad M.H.
      • Paras M.L.
      • et al.
      Sexual abuse and lifetime diagnosis of psychiatric disorders: systematic review and meta-analysis.
      328,78864,64764,6471,634,024,259,54952.8
         Medical153,906
      • Greenberg P.E.
      • Fournier A.A.
      • Sisitsky T.
      • Pike C.T.
      • Kessler R.C.
      The economic burden of adults with major depressive disorder in the United States (2005 and 2010).
      30,26130,261764,887,830,13824.7
         Lost productivity174,882
      • Greenberg P.E.
      • Fournier A.A.
      • Sisitsky T.
      • Pike C.T.
      • Kessler R.C.
      The economic burden of adults with major depressive disorder in the United States (2005 and 2010).
      34,38634,386869,136,429,41028.1
        Eating disorder9.4%
      • Chen L.P.
      • Murad M.H.
      • Paras M.L.
      • et al.
      Sexual abuse and lifetime diagnosis of psychiatric disorders: systematic review and meta-analysis.
      32,7663,0773,07777,778,861,0492.5
         Medical32,766
      • Samnaliev M.
      • Noh H.L.
      • Sonneville K.R.
      • Austin S.B.
      The economic burden of eating disorders and related mental health comorbidities: an exploratory analysis using the U.S. Medical Expenditures Panel Survey.
      3,0773,07777,778,861,0492.5
         Lost productivity0
      • Samnaliev M.
      • Noh H.L.
      • Sonneville K.R.
      • Austin S.B.
      The economic burden of eating disorders and related mental health comorbidities: an exploratory analysis using the U.S. Medical Expenditures Panel Survey.
      000<0.1
        Posttraumatic stress disorder18.6%
      • Chen L.P.
      • Murad M.H.
      • Paras M.L.
      • et al.
      Sexual abuse and lifetime diagnosis of psychiatric disorders: systematic review and meta-analysis.
      40,8417,5877,587191,756,565,0876.2
         Medical31,753
      • Ivanova J.I.
      • Birnbaum H.G.
      • Chen L.
      • et al.
      Cost of post-traumatic stress disorder vs major depressive disorder among patients covered by medicaid or private insurance.
      5,8985,898149,083,858,3634.8
         Lost productivity9,089
      • Greenberg P.E.
      • Fournier A.A.
      • Sisitsky T.
      • Pike C.T.
      • Kessler R.C.
      The economic burden of adults with major depressive disorder in the United States (2005 and 2010).
      1,6881,68842,672,706,7241.4
        Medically-serious nonfatal suicide attempt7.7%
      • Chen L.P.
      • Murad M.H.
      • Paras M.L.
      • et al.
      Sexual abuse and lifetime diagnosis of psychiatric disorders: systematic review and meta-analysis.
      • 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.
      14.6%
      • Chen L.P.
      • Murad M.H.
      • Paras M.L.
      • et al.
      Sexual abuse and lifetime diagnosis of psychiatric disorders: systematic review and meta-analysis.
      • 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.
      17,3621,3332,52936,054,812,7211.2
         Medical7,872

      Centers for Disease Control and Prevention (CDC). Web-based Injury Statistics Query and Reporting System (WISQARS), cost of injury reports 2010, both sexes, all ages, United States. www.cdc.gov/injury/wisqars/index.html. Published 2010.

      • Corso P.S.
      • Mercy J.A.
      • Simon T.R.
      • Finkelstein E.A.
      • Miller T.R.
      Medical costs and productivity losses due to interpersonal and self-directed violence in the United States.
      6041,14716,347,640,6050.5
         Lost productivity9,490

      Centers for Disease Control and Prevention (CDC). Web-based Injury Statistics Query and Reporting System (WISQARS), cost of injury reports 2010, both sexes, all ages, United States. www.cdc.gov/injury/wisqars/index.html. Published 2010.

      • Corso P.S.
      • Mercy J.A.
      • Simon T.R.
      • Finkelstein E.A.
      • Miller T.R.
      Medical costs and productivity losses due to interpersonal and self-directed violence in the United States.
      7291,38219,707,172,1170.6
       Victim substance use31,48536,224805,146,485,84726.0
        Alcohol abuse2.8%
      • Smith S.G.
      • Breiding M.J.
      Chronic disease and health behaviours linked to experiences of non-consensual sex among women and men.
      5.5%
      • Smith S.G.
      • Breiding M.J.
      Chronic disease and health behaviours linked to experiences of non-consensual sex among women and men.
      19,8975631,10115,285,251,9890.5
         Medical2,261
      • Sacks J.J.
      • Gonzales K.R.
      • Bouchery E.E.
      • Tomedi L.E.
      • Brewer R.D.
      2010 national and state costs of excessive alcohol consumption.
      • Bouchery E.E.
      • Harwood H.J.
      • Sacks J.J.
      • Simon C.J.
      • Brewer R.D.
      Economic costs of excessive alcohol consumption in the U.S., 2006.
      641251,736,713,6910.1
         Lost productivity14,312
      • Sacks J.J.
      • Gonzales K.R.
      • Bouchery E.E.
      • Tomedi L.E.
      • Brewer R.D.
      2010 national and state costs of excessive alcohol consumption.
      • Bouchery E.E.
      • Harwood H.J.
      • Sacks J.J.
      • Simon C.J.
      • Brewer R.D.
      Economic costs of excessive alcohol consumption in the U.S., 2006.
      40579210,994,807,0390.4
         Other3,324941842,553,731,2590.1
        Illicit drug use10.4%
      • Molnar B.E.
      • Buka S.L.
      • Kessler R.C.
      Child sexual abuse and subsequent psychopathology: results from the National Comorbidity Survey.
      11.4%
      • Molnar B.E.
      • Buka S.L.
      • Kessler R.C.
      Child sexual abuse and subsequent psychopathology: results from the National Comorbidity Survey.
      237,53224,78427,058630,917,593,87220.4
         Medical14,491
      U.S. Department of Justice
      The economic impact of illicit drug use on American Society.
      U.S. DHHS
      Results from the 2007 National Survey on Drug Use and Health: national findings (NSDUH Series H-34, DHHS Publication No. SMA 08-4343).
      1,5121,65138,491,321,1001.2
         Lost productivity147,380
      U.S. Department of Justice
      The economic impact of illicit drug use on American Society.
      U.S. DHHS
      Results from the 2007 National Survey on Drug Use and Health: national findings (NSDUH Series H-34, DHHS Publication No. SMA 08-4343).
      15,37816,788391,463,096,54312.6
         Other75,660
      U.S. Department of Justice
      The economic impact of illicit drug use on American Society.
      U.S. DHHS
      Results from the 2007 National Survey on Drug Use and Health: national findings (NSDUH Series H-34, DHHS Publication No. SMA 08-4343).
      7,8948,619200,963,176,2296.5
        Smoking9.1%
      • Smith S.G.
      • Breiding M.J.
      Chronic disease and health behaviours linked to experiences of non-consensual sex among women and men.
      11.9%
      • Smith S.G.
      • Breiding M.J.
      Chronic disease and health behaviours linked to experiences of non-consensual sex among women and men.
      67,6536,1388,065158,943,639,9865.1
         Medical4,545
      • Sloan F.
      • Ostermann J.
      • Picone G.
      • Conover C.
      • Taylor D.
      The Price of Smoking.
      41254210,678,757,6760.3
         Lost productivity51,816
      • Sloan F.
      • Ostermann J.
      • Picone G.
      • Conover C.
      • Taylor D.
      The Price of Smoking.
      4,7016,177121,736,821,4883.9
         Other11,291
      • Sloan F.
      • Ostermann J.
      • Picone G.
      • Conover C.
      • Taylor D.
      The Price of Smoking.
      1,0241,34626,528,060,8230.9
       Victim physical health5,4352,298131,181,518,2494.2
        Asthma4.2%
      • Smith S.G.
      • Breiding M.J.
      Chronic disease and health behaviours linked to experiences of non-consensual sex among women and men.
      1.6%
      • Smith S.G.
      • Breiding M.J.
      Chronic disease and health behaviours linked to experiences of non-consensual sex among women and men.
      76,5563,2321,24677,785,654,2622.5
         Medical70,141
      • Barnett S.B.
      • Nurmagambetov T.A.
      Costs of asthma in the United States: 2002-2007.
      2,9611,14271,267,682,0872.3
         Lost productivity6,415
      • Barnett S.B.
      • Nurmagambetov T.A.
      Costs of asthma in the United States: 2002-2007.
      2711046,517,972,1750.2
        Cervical cancer
      Marginal probability represents the estimated probability of cervical cancer among all female victims with lifetime experience of attempted and completed rape, calculated as with (g).1
      1.6%
      • Coker A.L.
      • Hopenhayn C.
      • DeSimone C.P.
      • Bush H.M.
      • Crofford L.
      Violence against women raises risk of cervical cancer.
      NA66,5891,086025,308,935,0160.8
         Medical47,380
      • Ekwueme D.U.
      • Yabroff K.R.
      • Guy Jr, G.P.
      • et al.
      Medical costs and productivity losses of cancer survivors—United States, 2008-2011.
      773018,007,793,7100.6
         Lost productivity19,210
      • Ekwueme D.U.
      • Yabroff K.R.
      • Guy Jr, G.P.
      • et al.
      Medical costs and productivity losses of cancer survivors—United States, 2008-2011.
      31307,301,141,3050.2
        Joint conditions7.3%
      • Smith S.G.
      • Breiding M.J.
      Chronic disease and health behaviours linked to experiences of non-consensual sex among women and men.
      6.7%
      • Smith S.G.
      • Breiding M.J.
      Chronic disease and health behaviours linked to experiences of non-consensual sex among women and men.
      14,5701,06597226,733,335,6890.9
         Medical13,614
      • Gaskin D.
      • Richard R.
      Relieving Pain in America: a blueprint for transforming prevention, care, education, and research. Appendix C: The economic costs of pain in the United States.
      99590824,980,459,2880.8
         Lost productivity955
      • Gaskin D.
      • Richard R.
      Relieving Pain in America: a blueprint for transforming prevention, care, education, and research. Appendix C: The economic costs of pain in the United States.
      70641,752,876,4000.1
        Sexually transmitted infections4.6%
      • Hillis S.D.
      • Anda R.F.
      • Felitti V.J.
      • Nordenberg D.
      • Marchbanks P.A.
      Adverse childhood experiences and sexually transmitted diseases in men and women: a retrospective study.
      7.1%
      • Hillis S.D.
      • Anda R.F.
      • Felitti V.J.
      • Nordenberg D.
      • Marchbanks P.A.
      Adverse childhood experiences and sexually transmitted diseases in men and women: a retrospective study.
      1,11651801,353,593,282<0.1
         Medical819
      • Owusu-Edusei Jr, K.
      • Chesson H.W.
      • Gift T.L.
      • et al.
      The estimated direct medical cost of selected sexually transmitted infections in the United States, 2008.
      • Chesson H.W.
      • Ekwueme D.U.
      • Saraiya M.
      • Watson M.
      • Lowy D.R.
      • Markowitz L.E.
      Estimates of the annual direct medical costs of the prevention and treatment of disease associated with human papillomavirus in the United States.
      3858993,572,740<0.1
         Lost productivity297
      • Owusu-Edusei Jr, K.
      • Roby T.M.
      • Chesson H.W.
      • Gift T.L.
      Productivity costs of nonviral sexually transmissible infections among patients who miss work to seek medical care: evidence from claims data.
      1421360,020,5420.0
       Convicted perpetrators6,1756,175156,077,927,3805.0
        Criminal justice1.4%
      See Table 2. DOJ, U.S. Department of Justice; ED, emergency department; IFHP, International Federation of Health Plans; NA, not applicable; NISVS, U.S. National Intimate Partner and Sexual Violence Survey; SAMHSA, Substance Abuse and Mental Health Services Administration; WISQARS, Web-based Injury Statistics Query and Reporting System; USD, U.S. dollars.
      93,105
      See Table 2. DOJ, U.S. Department of Justice; ED, emergency department; IFHP, International Federation of Health Plans; NA, not applicable; NISVS, U.S. National Intimate Partner and Sexual Violence Survey; SAMHSA, Substance Abuse and Mental Health Services Administration; WISQARS, Web-based Injury Statistics Query and Reporting System; USD, U.S. dollars.
      1,3001,30032,851,988,4141.1
        Lost productivity1.4%
      See Table 2. DOJ, U.S. Department of Justice; ED, emergency department; IFHP, International Federation of Health Plans; NA, not applicable; NISVS, U.S. National Intimate Partner and Sexual Violence Survey; SAMHSA, Substance Abuse and Mental Health Services Administration; WISQARS, Web-based Injury Statistics Query and Reporting System; USD, U.S. dollars.
      349,233
      • Grosse S.D.
      • Krueger K.V.
      • Mvundura M.
      Economic productivity by age and sex: 2007 estimates for the United States.
      4,8754,875123,225,938,9664.0
      Note: Cited references were the basis for marginal probabilities and costs demonstrated in this table. Appendix and Appendix Tables 1–3 (available online) demonstrate how data as reported in reference studies were used to calculate data as presented in this table. Costs are 2014 USD.
      a Combined marginal outcomes for men and women reflect estimates from studies that controlled for victim sex but did not report final results by sex (Appendix Table 1 has details, available online).
      b Marginal costs without references are calculated from other data in the table, for example, category sums.
      c Per victim cost is marginal probability multiplied by marginal cost. Population cost by outcome is the number of victims by sex multiplied by the per-victim cost. Total per-victim by sex and total population costs are the sum of all per-victim by sex and population costs by outcome.
      d Details of reference studies reported in Appendix Table 1 (outcomes); Appendix Table 2 (costs); Appendix Table 3 (discounted cost calculations) (available online).
      e Includes victim property damage/loss, adoption costs, “other” costs attributable to smoking and alcohol abuse (Appendix Table 3 has details, available online).
      f Unpublished data from the U.S. Department of Justice.
      g Unpublished data from Pacific Institute for Research and Evaluation.
      h Marginal probability represents the estimated probability of each rape-related pregnancy outcome among all female victims with lifetime experience of attempted and completed rape, calculated using the proportion of female attempted and completed rape victims that experienced completed penetration rape from 2011 U.S. NISVS (survey-weighted 13,826,000/23,305,000 female victims, or 59%).
      • Breiding M.J.
      • Smith S.G.
      • Basile K.C.
      • Walters M.L.
      • Chen J.
      • Merrick M.T.
      Prevalence and characteristics of sexual violence, stalking, and intimate partner violence victimization— National Intimate Partner and Sexual Violence Survey, United States, 2011.
      Marginal outcome presented in this way for consistency with other measures in this table. Supporting calculations demonstrated in Appendix Table 1 (available online).
      i Assumed.
      j Marginal probability represents the estimated probability of cervical cancer among all female victims with lifetime experience of attempted and completed rape, calculated as with (g).
      • Breiding M.J.
      • Smith S.G.
      • Basile K.C.
      • Walters M.L.
      • Chen J.
      • Merrick M.T.
      Prevalence and characteristics of sexual violence, stalking, and intimate partner violence victimization— National Intimate Partner and Sexual Violence Survey, United States, 2011.
      k See Table 2.DOJ, U.S. Department of Justice; ED, emergency department; IFHP, International Federation of Health Plans; NA, not applicable; NISVS, U.S. National Intimate Partner and Sexual Violence Survey; SAMHSA, Substance Abuse and Mental Health Services Administration; WISQARS, Web-based Injury Statistics Query and Reporting System; USD, U.S. dollars.

      Outcomes and Unit Costs

      Rape outcomes, identified through a targeted literature search, were included based on reference studies’ representativeness (Appendix Table 1, available online). National studies and meta-analyses addressing both male and female victims were prioritized. Outcomes had to be reported in a way that facilitated calculation of victims’ marginal probability of the outcome; for example, the outcome prevalence among non-victims and an AOR of the relationship between the outcome and respondents’ experience of rape.
      • Zhang J.
      • Yu K.F.
      What’;s the relative risk? A method of correcting the odds ratio in cohort studies of common outcomes.
      Studies that assessed outcomes among adult (i.e., aged ≥18 years) respondents and aligned with the NISVS rape definition were prioritized. Unit costs represented the attributable cost of analyzed outcomes, based on direct comparison of affected and unaffected individuals (Appendix Table 2, available online). Comprehensive lifetime unit costs that included both medical care and lost work productivity were prioritized. Where only annual unit costs were available, lifetime costs were estimated by multiplying the annual cost over the age range of respondents in the cost reference study (Appendix Table 3, available online), bounded by the average assumed age at first rape victimization (i.e., 18 years) and current life expectancy (i.e., 79 years).
      • Xu J.
      • Murphy S.L.
      • Kochanek K.D.
      • Bastian B.A.
      Deaths: final data for 2013.
      The cost of prevention efforts was excluded.
      Average annual data from the 2010–2014 U.S. National Crime Victimization Survey indicated 10.9% (n=18,012/165,034 survey weighted) of attempted or completed rape victimizations (including male and female victims) involved victim property loss or damage, valued at an average $219 per affected victim (Table 1) (U.S. Department of Justice, Bureau of Justice Statistics, personal communication, 2015).
      Among attempted or completed rape victimizations (N=216,570 surveyed weighted) from annual average 1995–2014 National Crime Victimization Survey data, 5.3% of victims were treated for nonfatal injuries in a doctor’s office, 12.1% in an emergency department, and 1.0% as inpatients (Table 1) (U.S. Department of Justice, Bureau of Justice Statistics, personal communication, 2015). Unit costs were estimated payment for a doctor’s visit

      Machlin SR, Adams SA. Statistical Brief #484: Expenses for Office-Based Physician Visits by Specialty, 2013. Rockville, MD: Agency for Healthcare Research and Quality; 2015

      and the discounted lifetime medical cost associated with an emergency department visit or hospital admission for sexual assault (Pacific Institute for Research and Evaluation, personal communication, 2016) (Table 1). In 2011, there were an estimated 18 murders associated with rape crimes (Appendix Table 1, available online).
      U.S. Federal Bureau of Investigation
      Table 12. Expanded homicide data—murder circumstances, 2009–2013.
      Unit costs were based on an estimated lifetime cost of medical care and lost productivity due to homicide.

      Centers for Disease Control and Prevention (CDC). Web-based Injury Statistics Query and Reporting System (WISQARS), cost of injury reports 2010, both sexes, all ages, United States. www.cdc.gov/injury/wisqars/index.html. Published 2010.

      Data from a national sample of women (N=3,031 respondents) indicated that 4.8% of completed penetration rape victims experienced rape-related pregnancy (Table 1).
      • Holmes M.M.
      • Resnick H.S.
      • Kilpatrick D.G.
      • Best C.L.
      Rape-related pregnancy: estimates and descriptive characteristics from a national sample of women.
      Among a small sample of rape-related pregnancies (N=34), 11.3% resulted in spontaneous abortion, 50.0% in medically assisted abortion, 32.3% of women kept the baby, and 5.9% of women gave the baby up for adoption.
      • Holmes M.M.
      • Resnick H.S.
      • Kilpatrick D.G.
      • Best C.L.
      Rape-related pregnancy: estimates and descriptive characteristics from a national sample of women.
      Unit costs were estimated payments for medical treatment for spontaneous abortion,
      • Dalton V.K.
      • Liang A.
      • Hutton D.W.
      • Zochowski M.K.
      • Fendrick A.M.
      Beyond usual care: the economic consequences of expanding treatment options in early pregnancy loss.
      medically assisted abortion,
      • Jerman J.
      • Jones R.K.
      Secondary measures of access to abortion services in the United States, 2011 and 2012: gestational age limits, cost, and harassment.
      pregnancy and delivery,
      Truven Health Analytics
      The Cost of Having a Baby in the United States.
      and the public payer cost of adoption from age 0 to 18 years (i.e., social services)
      • Barth R.
      • Chung K.
      • Wildfire J.
      • Shenyang G.
      A comparison of the governmental costs of long-term foster care and adoption.
      applied to the estimated proportion of women with rape-related pregnancy by outcome among those with lifetime experience of completed penetration rape among all women victims of attempted and completed rape in 2011 NISVS (n=13,826,000/23,305,000, or 59%) (Table 1).
      • Breiding M.J.
      • Smith S.G.
      • Basile K.C.
      • Walters M.L.
      • Chen J.
      • Merrick M.T.
      Prevalence and characteristics of sexual violence, stalking, and intimate partner violence victimization— National Intimate Partner and Sexual Violence Survey, United States, 2011.
      Female victims of intimate partner rape aged ≥18 years (N=322,230 victimizations, survey weighted) documented in the National Violence Against Women Survey was calculated as an average 3.6 productive days missed per victim (Appendix Table 2 [available online] provides calculations).
      Centers for Disease Control and Prevention (CDC)
      Costs of Intimate Partner Violence Against Women in the United States.
      This number of days was multiplied by an estimated U.S. population (aged ≥15 years) daily production value
      • Grosse S.D.
      • Krueger K.V.
      • Mvundura M.
      Economic productivity by age and sex: 2007 estimates for the United States.
      to estimate the value of short-term lost productivity due to rape ($516 in 2014 USD) (Table 1).
      Funding for victims’ services through the criminal justice system at the federal, state, and local levels—including U.S. Department of Justice grants and Violence Against Women Act (Title IV, P.L. 103-322)
      • Laney G.
      Violence Against Women Act: History and Federal Funding (RL30871).
      funding—are comprehensively included in the criminal justice estimates through a top-down accounting approach (Appendix reports calculation details, available online). This approach was deemed the best use of available data, but means the authors could not identify the cost of individual victim services (e.g., rape kit processing). Although previous studies have estimated the cost of annual victim services for two state governments,
      • Miller T.
      • Taylor D.
      • Sheppard M.
      Costs of Sexual Violence in Minnesota.
      • Yang J.
      • Miller T.R.
      • Zhang N.
      • LeHew B.
      • Peek-Asa C.
      Incidence and cost of sexual violence in Iowa.
      it was determined infeasible to comprehensively and accurately assess the proportion of victims accessing services and the cost of response (as opposed to prevention) services per victim using a bottom-up accounting approach.
      A meta-analysis of studies published in 1980–2008 indicated significantly higher observed prevalence of mental health outcomes—anxiety, depression, eating disorder, post-traumatic stress disorder, and suicide attempt—among adolescent and adult respondents with lifetime (primarily childhood) experience of sexual abuse (Table 1).
      • Chen L.P.
      • Murad M.H.
      • Paras M.L.
      • et al.
      Sexual abuse and lifetime diagnosis of psychiatric disorders: systematic review and meta-analysis.
      The proportion of nonfatal suicide attempts requiring medical care was estimated using data for men (59.0% of attempts) and women (31.1% of attempts) in a separate national sample study of adolescent rape victims.
      • 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.
      Unit costs were estimated lost work productivity and medical costs for anxiety disorder,
      • Greenberg P.E.
      • Sisitsky T.
      • Kessler R.C.
      • et al.
      The economic burden of anxiety disorders in the 1990s.
      major depressive disorder,
      • Greenberg P.E.
      • Fournier A.A.
      • Sisitsky T.
      • Pike C.T.
      • Kessler R.C.
      The economic burden of adults with major depressive disorder in the United States (2005 and 2010).
      eating disorders,
      • Samnaliev M.
      • Noh H.L.
      • Sonneville K.R.
      • Austin S.B.
      The economic burden of eating disorders and related mental health comorbidities: an exploratory analysis using the U.S. Medical Expenditures Panel Survey.
      post-traumatic stress disorder,
      • Greenberg P.E.
      • Sisitsky T.
      • Kessler R.C.
      • et al.
      The economic burden of anxiety disorders in the 1990s.
      • Samnaliev M.
      • Noh H.L.
      • Sonneville K.R.
      • Austin S.B.
      The economic burden of eating disorders and related mental health comorbidities: an exploratory analysis using the U.S. Medical Expenditures Panel Survey.
      and medically serious nonfatal suicide attempts

      Centers for Disease Control and Prevention (CDC). Web-based Injury Statistics Query and Reporting System (WISQARS), cost of injury reports 2010, both sexes, all ages, United States. www.cdc.gov/injury/wisqars/index.html. Published 2010.

      • Corso P.S.
      • Mercy J.A.
      • Simon T.R.
      • Finkelstein E.A.
      • Miller T.R.
      Medical costs and productivity losses due to interpersonal and self-directed violence in the United States.
      (Table 1).
      The 2005 Behavioral Risk Factor Surveillance System survey indicated significantly higher observed prevalence of excess alcohol and tobacco use among adults (aged ≥18 years, N=115,030 respondents) with lifetime experience of unwanted attempted or completed sex (Table 1).
      • Smith S.G.
      • Breiding M.J.
      Chronic disease and health behaviours linked to experiences of non-consensual sex among women and men.
      Unit costs were attributable estimated lost work productivity and medical costs for excess alcohol use
      • Sacks J.J.
      • Gonzales K.R.
      • Bouchery E.E.
      • Tomedi L.E.
      • Brewer R.D.
      2010 national and state costs of excessive alcohol consumption.
      • Bouchery E.E.
      • Harwood H.J.
      • Sacks J.J.
      • Simon C.J.
      • Brewer R.D.
      Economic costs of excessive alcohol consumption in the U.S., 2006.
      and smoking
      • Sloan F.
      • Ostermann J.
      • Picone G.
      • Conover C.
      • Taylor D.
      The Price of Smoking.
      (Table 1). The 1990–1992 National Comorbidity Survey documented significantly higher prevalence of drug problems among adults (aged ≥15 years, N=5,877 respondents) who were raped or molested during childhood or adolescence (Table 1),
      • Molnar B.E.
      • Buka S.L.
      • Kessler R.C.
      Child sexual abuse and subsequent psychopathology: results from the National Comorbidity Survey.
      supporting other research among a national sample of women.
      • Kilpatrick D.G.
      • Resnick H.S.
      • Ruggiero K.J.
      • Conoscenti L.M.
      • McCauley J.M.
      Drug-facilitated, incapacitated, and forcible rape: a national study, NIJ 219181.
      • Zinzow H.M.
      • Resnick H.S.
      • McCauley J.L.
      • Amstadter A.B.
      • Ruggiero K.J.
      • Kilpatrick D.G.
      Prevalence and risk of psychiatric disorders as a function of variant rape histories: results from a national survey of women.
      Unit costs were estimated lost productivity and medical costs
      U.S. Department of Justice
      The economic impact of illicit drug use on American Society.
      ,
      U.S. DHHS
      Results from the 2007 National Survey on Drug Use and Health: national findings (NSDUH Series H-34, DHHS Publication No. SMA 08-4343).
      (Table 1).
      The 2005 Behavioral Risk Factor Surveillance System data indicated significantly higher observed prevalence of asthma and joint conditions among sexual violence victims (Table 1).
      • Smith S.G.
      • Breiding M.J.
      Chronic disease and health behaviours linked to experiences of non-consensual sex among women and men.
      Unit costs were estimated lost work productivity and medical payments for asthma
      • Barnett S.B.
      • Nurmagambetov T.A.
      Costs of asthma in the United States: 2002-2007.
      and joint pain
      • Gaskin D.
      • Richard R.
      Relieving Pain in America: a blueprint for transforming prevention, care, education, and research. Appendix C: The economic costs of pain in the United States.
      (Table 1). Kentucky Women’s Health Registry data indicated significantly higher observed prevalence of cervical cancer among women (aged ≥15 years, N=4,732 respondents) with lifetime forced sexual experiences (Table 1).
      • Coker A.L.
      • Hopenhayn C.
      • DeSimone C.P.
      • Bush H.M.
      • Crofford L.
      Violence against women raises risk of cervical cancer.
      Unit costs were estimated medical payments
      • Ekwueme D.U.
      • Yabroff K.R.
      • Guy Jr, G.P.
      • et al.
      Medical costs and productivity losses of cancer survivors—United States, 2008-2011.
      and lost productivity
      • Ekwueme D.U.
      • Yabroff K.R.
      • Guy Jr, G.P.
      • et al.
      Medical costs and productivity losses of cancer survivors—United States, 2008-2011.
      attributable to cancer, assigned among the estimated number of women with lifetime completed penetration rape in 2011 U.S. NISVS (n=13,826,000) (Table 1). A U.S. health plan study indicated a higher observed prevalence of sexually transmitted infections among adults (aged ≥19 years, N=9,323 respondents) who experienced attempted or completed rape during childhood or adolescence (age ≤18 years)
      • Hillis S.D.
      • Anda R.F.
      • Felitti V.J.
      • Nordenberg D.
      • Marchbanks P.A.
      Adverse childhood experiences and sexually transmitted diseases in men and women: a retrospective study.
      (Table 1). Unit cost were estimated medical costs
      • Owusu-Edusei Jr, K.
      • Chesson H.W.
      • Gift T.L.
      • et al.
      The estimated direct medical cost of selected sexually transmitted infections in the United States, 2008.
      • Chesson H.W.
      • Ekwueme D.U.
      • Saraiya M.
      • Watson M.
      • Lowy D.R.
      • Markowitz L.E.
      Estimates of the annual direct medical costs of the prevention and treatment of disease associated with human papillomavirus in the United States.
      and lost work productivity
      • Owusu-Edusei Jr, K.
      • Roby T.M.
      • Chesson H.W.
      • Gift T.L.
      Productivity costs of nonviral sexually transmissible infections among patients who miss work to seek medical care: evidence from claims data.
      (Table 1).
      An attribution method was used to estimate the per-victim discounted lifetime average criminal justice cost associated with sexual violence among total annual U.S. government criminal justice spending (Table 2 and Appendix [available online]).
      U.S. Department of Justice
      Table 1. Percent distribution of expenditure for the justice system by type of government, fiscal 2012. Justice Expenditure and Employment Extracts, NCJ 248628.
      Lost productivity due to incarceration is the annual production value of the U.S. non-institutional population multiplied by the average estimated number of years sexual violence perpetrators are incarcerated (Table 1, Table 2, Appendix [available online]).
      Table 2Details of Estimated Criminal Justice Costs (2012 USD)
      Attributable to sexual violence
      MeasureInputUnit cost
      Unit cost refers to per offense or person in the corrections population.
      Proportion of totalAnnual costPer convicted perpetrator lifetime cost
      Annual rape victims, n90,130
      Calculated from data elsewhere in the table.
       Women1,929,000
      • Breiding M.J.
      • Smith S.G.
      • Basile K.C.
      • Walters M.L.
      • Chen J.
      • Merrick M.T.
      Prevalence and characteristics of sexual violence, stalking, and intimate partner violence victimization— National Intimate Partner and Sexual Violence Survey, United States, 2011.
       Men219,000
      Unpublished NISVS 2010–2012 data from the U.S. Centers for Disease Control and Prevention.
      Total U.S. Government justice system annual spending, $265,160,340,000
      U.S. Department of Justice
      Table 1. Percent distribution of expenditure for the justice system by type of government, fiscal 2012. Justice Expenditure and Employment Extracts, NCJ 248628.
      2,702,590,946
      Calculated from data elsewhere in the table.
      Police protection annual spending, $126,434,125,000
      U.S. Department of Justice
      Table 1. Percent distribution of expenditure for the justice system by type of government, fiscal 2012. Justice Expenditure and Employment Extracts, NCJ 248628.
       Annual arrests, All offenses, n11,205,833
      U.S. Federal Bureau of Investigation
      Table 29. Estimated number of arrests, Rape—revised definition. Crime in the United States 2013.
      11,283
      Calculated from data elsewhere in the table.
      0.2%
      Calculated from data elsewhere in the table.
      237,019,565
      Calculated from data elsewhere in the table.
       Annual arrests, Rape offense, n21,007
      U.S. Federal Bureau of Investigation
      Table 29. Estimated number of arrests, Rape—revised definition. Crime in the United States 2013.
      Judicial and legal annual spending, $57,935,169,000
      U.S. Department of Justice
      Table 1. Percent distribution of expenditure for the justice system by type of government, fiscal 2012. Justice Expenditure and Employment Extracts, NCJ 248628.
       Annual arrests, All offenses, n11,205,833
      U.S. Federal Bureau of Investigation
      Table 29. Estimated number of arrests, Rape—revised definition. Crime in the United States 2013.
      5,170
      Calculated from data elsewhere in the table.
      0.2%
      Calculated from data elsewhere in the table.
      108,608,088
      Calculated from data elsewhere in the table.
       Annual arrests, Rape offense, n21,007
      U.S. Federal Bureau of Investigation
      Table 29. Estimated number of arrests, Rape—revised definition. Crime in the United States 2013.
      Corrections annual spending, $80,791,046,000
      U.S. Department of Justice
      Table 1. Percent distribution of expenditure for the justice system by type of government, fiscal 2012. Justice Expenditure and Employment Extracts, NCJ 248628.
      11,641
      Calculated from data elsewhere in the table.
      2,356,963,293
      Annual cost of corrections spending attributable to sexual violence refers to the lifetime discounted cost of convicted perpetrators that annually enter the corrections system, calculated as the discounted lifetime cost of corrections per perpetrator ($78,603) multiplied by the estimated number of sexual violence perpetrators that are convicted (1.4% of 1,929,000 + 219,000).
       Total corrections population, n
      Total corrections population refers to individuals in prison, jail, probation, parole.
      6,940,500
      U.S. Department of Justice
      Table 1. Estimated number of persons supervised by adult correctional systems, by correctional status, 2000, 2005, and 2010–2013. Correctional populations in the United States, 2013, NCJ 248479.
      Corrections spending per sexual violence perpetrator, $78,603
      Corrections spending per sexual violence perpetrator calculated as average annual spending per person in the corrections population (i.e., $11,641) multiplied by the total estimated corrections duration per sexual violence perpetrator (i.e., 7.4 years), with annual costs after the first year discounted to present value by 3%.
       Total estimated corrections duration per sexual violence perpetrator, years, M
      Total estimated corrections duration per sexual violence perpetrator calculated as the sum of parole, prison, and probation terms.
      7.4
      Calculated from data elsewhere in the table.
       Proportion of rape perpetrators sentenced to
      Sentence type does not sum to 100% (excludes 3% of convicted perpetrators not sentenced to incarceration or probation; no further disposition data available).
      :
        Probation, %8
      U.S. Department of Justice
      Table 21. Adjudication outcome for felony defendants in the 75 largest counties, by most serious arrest charge. Felony defendants in large urban counties, 2009—statistical tables, NCJ 243777.
         Probation term served, all offenses, years, M1.8
      U.S. Department of Justice
      Table 3. Rate of probation exits, by type of exit, 2008–2013. Probation and parole in the United States, 2013, NCJ 248029.
        Jail, %5
      U.S. Department of Justice
      Table 21. Adjudication outcome for felony defendants in the 75 largest counties, by most serious arrest charge. Felony defendants in large urban counties, 2009—statistical tables, NCJ 243777.
         Jail term served, sexual assault offense, years, M2.2
      U.S. Department of Justice
      Table 6. Length of sentence and time expected to be served of inmates sentenced to jail, by offense, 2002. Profile of jail inmates, NCJ 201932.
        Prison, %84
      U.S. Department of Justice
      Table 21. Adjudication outcome for felony defendants in the 75 largest counties, by most serious arrest charge. Felony defendants in large urban counties, 2009—statistical tables, NCJ 243777.
         Prison term served, state and federal, years, M
      Combined state and federal prison term served calculated as the average term served in state and federal prison weighted by the number of prisoners at the state and federal level.
      6.4
      Calculated from data elsewhere in the table.
          State prison term, rape offense, years, M6.6
      U.S. Department of Justice
      Table 1.3. Mean state prison sentence and estimated time to be served in prison, by offenses, 2004. Bureau of Justice Statistics, state court sentencing of convicted felons, statistical tables, NCJ 217995.
          Annual state prisoners, rape offense, n160,900
      U.S. Department of Justice
      Table 14. Estimated sentenced prisoners under state jurisdiction, by offense and sex, race, and Hispanic origin, December 31, 2012. Survey of inmates in state correctional facilities. Bureau of Justice Statistics, National Prisoner Statistics Program, National Corrections Reporting Program.
          Federal prison term, sex offense, years, M4.5
      U.S. Department of Justice
      Table 6.58.2003. Time served to first release by Federal prisoners by offense, United States. Compendium of Federal Justice Statistics, NCJ 210299.
          Annual federal prisoners, sex offense, n13,524
      U.S. Department of Justice
      Table 6.0023.2013. Prisoners under the jurisdiction of the Federal Bureau of Prisons by adjudication status, type of offense, and sentence length, selected years 1990-2013. Federal Bureau of Prisons, State of the Bureau.
        Term served on parole, all offenses, years, M
      Parole defined in source as a period of conditional supervised release in the community following a prison term.
      1.8
      U.S. Department of Justice
      Table 6. Rate of parole exits, by type of exit, 2008–2013. Probation and Parole in the United States, NCJ 248029.
       Discount rate for annual spending after Year 1, %3.0
      Assumed.
      Estimated proportion of victims that have a perpetrator convicted, %
      Proportion of rape perpetrators that are convicted calculated as the estimated proportion of total rape offenses known to law enforcement annually (i.e., 5.4%) multiplied by the number of cleared forcible rape offenses annually (i.e., 41%), multiplied by the proportion of forcible rape offenses resulting in a conviction annually (i.e., 68%).
      1.4
      Calculated from data elsewhere in the table.
       Annual offenses known to law enforcement, forcible rape, n108,612
      U.S. Federal Bureau of Investigation
      Table 7. Offense analysis: Rape—revised definition. Crime in the United States 2013.
       Annual offenses known, rape, as % of 2010 rape victims reported in NISVS
      Estimated proportion of annual rape offenses known to law enforcement calculated as the number of annual forcible rape offenses known to law enforcement (i.e., 108,612) divided by the estimated annual number of rape victims (i.e., 1,929,000 + 219,000). DOJ, U.S. Department of Justice; FBI, U.S. Federal Bureau of Investigation; NISVS, National Intimate Partner and Sexual Violence Survey; USD, U.S. dollars.
      5.4
      Calculated from data elsewhere in the table.
       Annual cleared offenses, rape, as % of known offenses41
      U.S. Federal Bureau of Investigation
      Table 25. Percent of offenses cleared by arrest or exceptional means, rape—revised definition.
       Annual offenses resulting in conviction, forcible rape, as % of annual cleared offenses68
      U.S. Department of Justice
      Table 21. Adjudication outcome for felony defendants in the 75 largest counties, by most serious arrest charge. Felony defendants in large urban counties, 2009—statistical tables, NCJ 243777.
      Note: Costs are 2012 USD.
      a Unit cost refers to per offense or person in the corrections population.
      b Calculated from data elsewhere in the table.
      c Unpublished NISVS 2010–2012 data from the U.S. Centers for Disease Control and Prevention.
      d Annual cost of corrections spending attributable to sexual violence refers to the lifetime discounted cost of convicted perpetrators that annually enter the corrections system, calculated as the discounted lifetime cost of corrections per perpetrator ($78,603) multiplied by the estimated number of sexual violence perpetrators that are convicted (1.4% of 1,929,000 + 219,000).
      e Total corrections population refers to individuals in prison, jail, probation, parole.
      f Corrections spending per sexual violence perpetrator calculated as average annual spending per person in the corrections population (i.e., $11,641) multiplied by the total estimated corrections duration per sexual violence perpetrator (i.e., 7.4 years), with annual costs after the first year discounted to present value by 3%.
      g Total estimated corrections duration per sexual violence perpetrator calculated as the sum of parole, prison, and probation terms.
      h Sentence type does not sum to 100% (excludes 3% of convicted perpetrators not sentenced to incarceration or probation; no further disposition data available).
      i Combined state and federal prison term served calculated as the average term served in state and federal prison weighted by the number of prisoners at the state and federal level.
      j Parole defined in source as a period of conditional supervised release in the community following a prison term.
      k Assumed.
      l Proportion of rape perpetrators that are convicted calculated as the estimated proportion of total rape offenses known to law enforcement annually (i.e., 5.4%) multiplied by the number of cleared forcible rape offenses annually (i.e., 41%), multiplied by the proportion of forcible rape offenses resulting in a conviction annually (i.e., 68%).
      m Estimated proportion of annual rape offenses known to law enforcement calculated as the number of annual forcible rape offenses known to law enforcement (i.e., 108,612) divided by the estimated annual number of rape victims (i.e., 1,929,000 + 219,000).DOJ, U.S. Department of Justice; FBI, U.S. Federal Bureau of Investigation; NISVS, National Intimate Partner and Sexual Violence Survey; USD, U.S. dollars.

      Analysis

      The marginal probability of selected outcomes was multiplied by associated unit costs to estimate the per-person lifetime cost of rape, separately for men and women. The sex-specific, per-person estimated cost of rape was multiplied by the estimated number of men and women with lifetime experience of rape to estimate the total U.S. lifetime economic burden of rape. Government costs were assessed as the sum of criminal justice and adoption costs, plus the estimated government share of all medical spending (i.e., 59.8%).
      • Woolhandler S.
      • Himmelstein D.U.
      Paying for national health insurance—and not getting it.

      Results

      The present-value, per-victim estimated lifetime cost of rape was $122,461, or $3.1 trillion for all victims, based on 23 million U.S. women and 2 million men with lifetime experience of rape (Table 1). The per-victim cost was $122,278 for women and $124,631 for men, representing outcome differences (e.g., pregnancy), as well as differences in the proportion of victims by sex affected by particular outcomes (Table 1). The economic burden estimate included $1.2 trillion (39% of total) in medical costs; $1.6 trillion (52%) in lost work productivity among victims and perpetrators; $234 billion (8%) in criminal justice activities; and $36 billion (1%) in other costs, including victim property loss or damage. Government sources pay nearly one third (or $1 trillion) of the total lifetime economic burden (Table 1).

      Discussion

      The per-victim lifetime cost of rape ($122,461) can be interpreted as the cost averted for each potential victim who avoids rape. The per-victim estimate could change given new information about victim outcomes or unit costs. Barring substantial changes to the per-victim cost estimate, the lifetime economic burden of rape estimate ($3.1 trillion) will remain relatively stable; this estimate reflects the per-victim cost multiplied by the number of U.S. adults with lifetime experience of rape, and such a large population experiences modest incremental demographic changes. The estimated number of victims with rape experience in the past 12 months had a minor impact on the economic burden through the criminal justice and fatalities estimates. The economic burden represents costs over victims’ lifetimes. Though the authors do not know what proportion of victims in the previous 12 months (an estimated 1,929,000 women
      • Breiding M.J.
      • Smith S.G.
      • Basile K.C.
      • Walters M.L.
      • Chen J.
      • Merrick M.T.
      Prevalence and characteristics of sexual violence, stalking, and intimate partner violence victimization— National Intimate Partner and Sexual Violence Survey, United States, 2011.
      and 219,000 men [unpublished data]) were first-time victimizations, applying this study’s per-victim cost estimate to that annual number of victims yields an approximate annual economic burden of $263 billion.
      The per-victim estimate is the minimal identifiable cost of rape. This study did not include non-monetary elements, sometimes presented as intangible costs—a monetized version of victims’ pain and suffering.
      • McCollister K.E.
      • French M.T.
      • Fang H.
      The cost of crime to society: new crime-specific estimates for policy and program evaluation.
      • Yang J.
      • Miller T.R.
      • Zhang N.
      • LeHew B.
      • Peek-Asa C.
      Incidence and cost of sexual violence in Iowa.
      Previous studies have estimated the per-offense cost of rape and sexual assault to be $87,000 (1993 USD) to $240,776 (2008 USD) (or approximately $130,775 to $263,772 as 2014 USD

      U.S. Bureau of Economic Analysis. Table 1.1.4: Price indexes for gross domestic product. www.bea.gov/itable/. Published December 22, 2015. Accessed December 28, 2015.

      ), of which 80% to 95% were intangible costs.
      • McCollister K.E.
      • French M.T.
      • Fang H.
      The cost of crime to society: new crime-specific estimates for policy and program evaluation.
      • Miller T.
      • Taylor D.
      • Sheppard M.
      Costs of Sexual Violence in Minnesota.
      • Miller T.R.
      • Cohen M.A.
      • Wiersema B.
      Victim Costs and Consequences: A New Look.
      • Yang J.
      • Miller T.R.
      • Zhang N.
      • LeHew B.
      • Peek-Asa C.
      Incidence and cost of sexual violence in Iowa.
      Recognizing victims’ pain and suffering is unquestionably important, but must be weighed against the conceptual and computational challenges of monetizing pain and suffering.
      • Day T.
      • McKenna K.
      • Bowlus A.
      The economic costs of violence against women: an evaluation of the literature expert brief compiled in preparation for the Secretary-General’s in-depth study on all forms of violence against women.
      Costs to victims’ and perpetrators’ friends and families, and costs of other forms of sexual violence (e.g., being made to penetrate or sexual coercion) were not included. NISVS estimates do not include the currently institutionalized population, though would capture experiences among the previously institutionalized. Health outcomes that could be linked to specific attributable costs were included, though activity limitations, gastrointestinal symptoms, high cholesterol, HIV risk factors, non-specific pain, overweight, and urinary problems have higher prevalence among sexual violence victims.
      • Smith S.G.
      • Breiding M.J.
      Chronic disease and health behaviours linked to experiences of non-consensual sex among women and men.
      • Link C.L.
      • Lutfey K.E.
      • Steers W.D.
      • McKinlay J.B.
      Is abuse causally related to urologic symptoms? Results from the Boston Area Community Health (BACH) Survey.
      • Paras M.L.
      • Murad M.H.
      • Chen L.P.
      • et al.
      Sexual abuse and lifetime diagnosis of somatic disorders: a systematic review and meta-analysis.
      Many lost productivity unit estimates included only employed respondents, and valued respondents’ productivity using the human capital approach (i.e., lost wages). This approach, though commonly used, undervalues lost productivity overall and undervalues female losses, in particular, because women are often paid less than men. Many lost productivity estimates did not include mortality. Long-term lost productivity among rape victims not diagnosed with any of the analyzed outcomes was not included.
      Discounting assumed victims’ age at first rape was 18 years, which underestimates/overestimates costs among victims with first rape at age <18 years/>18 years. If one instead applies the average age of rape victimizations among adolescents and adults—27 years
      Age Patterns of Victims of Serious Violent Crime, July 1997, NCJ-162031.
      —the estimated cost per victim decreases modestly to $119,277, with a population economic burden still exceeding $3 trillion. Too few reference study estimates included measures of dispersion for a meaningful probabilistic sensitivity analysis (Appendix Tables 1 and 2, available online). Based on available data, the authors have not included the medical cost of follow-up visits for sexually transmitted infection testing that takes place after an initial medical visit for rape treatment. Identifiable double counting of costs includes the following: HIV costs appear in both sexually transmitted infection and illicit drug use unit costs, and some costs for anxiety and drug and alcohol dependence are included in the depression unit cost (Appendix Tables 1 and 2, available online). Substance use constitutes approximately a quarter of the per-victim cost; crime costs are a major component of contributing unit costs for substance abuse, and a small portion (<1%) of those unit costs included research and prevention activities related to alcohol and drugs.
      • Sloan F.
      • Ostermann J.
      • Picone G.
      • Conover C.
      • Taylor D.
      The Price of Smoking.
      • Sacks J.J.
      • Gonzales K.R.
      • Bouchery E.E.
      • Tomedi L.E.
      • Brewer R.D.
      2010 national and state costs of excessive alcohol consumption.
      • Bouchery E.E.
      • Harwood H.J.
      • Sacks J.J.
      • Simon C.J.
      • Brewer R.D.
      Economic costs of excessive alcohol consumption in the U.S., 2006.
      • Bouchery E.E.
      • Harwood H.J.
      • Sacks J.J.
      • Simon C.J.
      • Brewer R.D.
      Economic costs of excessive alcohol consumption in the U.S., 2006.
      U.S. Department of Justice
      The economic impact of illicit drug use on American Society.
      U.S. DHHS
      Results from the 2007 National Survey on Drug Use and Health: national findings (NSDUH Series H-34, DHHS Publication No. SMA 08-4343).
      Some reference studies focused on outcomes exclusively among adults who experienced childhood rape (Appendix Table 1, available online). The cost of some lifetime experiences was inferred from available annual cost data (Appendix Table 3, available online), which implicitly assumes an accurate distribution of patients at all stages of a particular outcome (i.e., acute, recurring, remission) in reference studies’ annual estimates.

      Limitations

      This study is notably limited by inexact timelines related to rape occurrence during victims’ lifetimes, number of rape incidents per victim, number of victims per perpetrator, onset of attributable health outcomes, and treatment of those outcomes. This study’s estimates are per victim, rather than per victimization, which certainly underestimates consequences among some victims and the acute costs associated with victimization.
      • Tjaden P.
      • Thoennes N.
      Full report of the prevalence, incidence, and consequences of violence against women: findings from the National Violence Against Women Survey.
      Another major limitation is that this study assumed that rape is the cause of victims’ higher observed prevalence of health-related conditions, although the status of these conditions as risk factors for, correlates with, or outcomes of sexual violence is complex.
      • Kilpatrick D.G.
      • Acierno R.
      • Resnick H.S.
      • Saunders B.E.
      • Best C.L.
      A 2-year longitudinal analysis of the relationships between violent assault and substance use in women.
      Future analysis of longitudinal data identifying sexual violence and health outcomes might address these issues, along with issues related to timing of rape exposure and the effects of multiple victimizations.

      Conclusions

      Despite limitations, this study’s economic burden estimate included more comprehensive information on victims’ lifetime mental and physical health than previous estimates. This study incorporated new national surveillance data from NISVS indicating rape affects many times more individuals than other sources have suggested previously. These findings can inform evaluations of interventions to prevent sexual violence, identifying cost-effective approaches to eliminate rape and its substantial impact on public health.

      Acknowledgments

      Authors acknowledge Michelle Berlin, Kathryn McCollister, and Manon Ruben for their contributions to a literature review of the health consequences and costs of sexual violence victimization conducted to support this study through Centers for Disease Control and Prevention contract 200-2012-F-53476 to Quality Resource Systems Inc. Authors acknowledge Jenna Truman and Lynn Langton at the U.S. Department of Justice, Bureau of Justice Statistics, for assistance with data from the National Crime Victimization Survey. Authors acknowledge Bruce A. Lawrence at the Pacific Institute for Research and Evaluation for unpublished cost estimates of medical treatment (emergency department and hospitalization) for rape.
      The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.
      Cora Peterson led the study design and interpretation of results, conducted data analysis, drafted and edited the manuscript, and approved the final manuscript as submitted. Sarah DeGue conceptualized the study design, led a literature review to inform the analyses, assisted with interpretation of results, edited the manuscript, and approved the final manuscript as submitted. Curtis Florence assisted with the study design and interpretation of results, edited the manuscript, and approved the final manuscript as submitted. Colby Lokey assisted with the study design and interpretation of results, assisted with a literature review to inform the analyses, edited the manuscript, and approved the final manuscript as submitted.
      No financial disclosures were reported by the authors of this paper.

      Supplementary material

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