Rape has a substantial impact on the health of victims, including a broad spectrum of physical, psychologic, and social sequelae (1-3). The development of appropriate and effective rape-prevention programs is assisted by consistent collection of information about and by accurate estimation of the incidence of rape. In North Carolina, as in many other states, the only source of statewide and county-specific population-based data on rape incidence is the Uniform Crime Reporting Program (UCR), coordinated by the Federal Bureau of Investigation (FBI); however, these data may underestimate the actual incidence of rape (4,5) because they include only assaults that have been reported to police and that conform to the UCR definition of forcible rape *. To assess the usefulness of rape crisis centers (RCCs) as an additional potential source of data for determining the incidence of rape, in 1994 the Injury Control Section, North Carolina Department of Environment, Health, and Natural Resources (NC-DEHNR), surveyed RCCs in North Carolina, then compared estimates of the annual incidence based on RCC and UCR data for selected counties during 1989-1993. This report summarizes the results of the survey and comparative analysis.

A questionnaire developed by NC-DEHNR was mailed to each of the 52 RCCs operating in the state during 1994; each RCC served a single county or a group of adjoining counties. RCCs that did not respond to the initial mailing received an additional mailing and one telephone call. Of the 52 RCCs, 35 (67%) responded: 18 provided information about rape victims served in all 5 years of the study period and 13 for 1-4 years; three did not maintain client records with sufficient information for any of the years; and one did not begin serving clients until 1994 and was excluded. Responding and nonresponding RCCs had similar geographic distributions across the state, and similar proportions of both groups were located in predominantly rural counties.

Although the survey requested information about clients whose assaults met the UCR definition of forcible rape, approximately 70% (range: 19 {61%} of 31 RCCs in 1993 to 16 {76%} of 21 RCCs in 1990) of the RCCs were unable to distinguish UCR-defined rapes from other types of assaults. For these RCCs, NC-DEHNR used information provided by the North Carolina Council for Women (NCCW) for 1993 to estimate the proportions of clients whose assaults met the UCR definition of rape. NCCW provides partial funding to all RCCs in North Carolina and collects data from each RCC about the proportion of clients who experienced sexual assault, attempted rape, or marital rape (the combination of these three categories most closely matches the UCR definition of forcible rape). County-specific information about rapes during 1989-1993 was obtained from annual summaries of UCR data prepared by the State Bureau of Investigation. For comparisons of UCR- and RCC-based rape rates, county-specific UCR data were included only for counties served by participating RCCs. Women of any age were included in data from both RCCs and the UCR.

By year, UCR-based rates were 8%-14% higher than RCC-based rates for 1989 and 1990, while during 1991-1993, annual RCC-based rates were 15%-48% higher than UCR-based rates (Table_1). Analysis restricted to only the 18 RCCs that provided data for each of the 5 years was consistent with this pattern. Analysis restricted to only those RCCs that provided information about assaults meeting the UCR definition of forcible rape indicated that the corresponding RCC-based rates for 1989-1993 were 23%-136% higher than the corresponding UCR-based rates.

Reported by: TB Cole, MD, Injury Control Section; PD Morris, MD, Occupational and Environmental Epidemiology Section, Div of Epidemiology, North Carolina Dept of Environment, Health, and Natural Resources. Family and Intimate Violence Prevention Team, Div of Violence Prevention, National Center for Injury Prevention and Control; Div of Field Epidemiology, Epidemiology Program Office, CDC.

Editorial Note

Editorial Note: The findings in this report indicate the inconsistency of rape estimates in North Carolina between sources and over time. Similar discrepancies exist among various sources of national estimates of rape incidence, including the FBI's nationwide UCR (6) used in this report, the National Women's Study (7), and the National Crime Victimization Survey (8). Each of these sources employs different methods for defining rape and collecting information and yields different estimates of the magnitude of the problem (Table_2). The lack of a standard definition and the different methods for estimating the incidence of rape have constrained both the public health surveillance of this problem and comparisons across data sets. In particular, the determination of age-specific and sex-specific counts and rates would enable more valid comparisons over time and between population groups.

To consider issues related to the improvement of surveillance for rape, CDC recently convened separate meetings of experts about rape (state health department representatives, researchers, and rape-victim advocates) and state sexual assault prevention coordinators. These groups recommended

1. developing consistent definitions of rape -- varying interpretations and use of terms such as rape, completed rape, attempted rape, sexual assault, and child sexual abuse impede understanding and prevention of the problem.

2. determining the best sources for surveillance data for rape -- although potentially useful sources include records from hospitals, emergency departments, RCCs, other health and human service providers, the justice system, police departments, and population surveys, linkage of such sources would enable more precise estimation of the incidence of rape; confidentiality must be an essential component of any such surveillance system.

3. modifying and developing surveillance systems to capture at least the type of incident (e.g., rape or sexual assault), relationship between victim and perpetrator, sex of victim, and age of victim both at the time of the report and at the time of the incident (many victims report only after prolonged periods).

   The findings of this analysis in North Carolina and of the

comparison of national data sources document the effects of different data sources on estimates of the incidence of reported rape and suggest approaches for improving surveillance. In conjunction with advocates for rape victims and other groups, CDC is assisting in the development of standard public health definitions of rape and sexual assault that, when adopted, will enable comparability across data sources. Surveillance as an initial process in the public health approach will enable more accurate documentation of the magnitude of the problem and assist efforts to further identify the long-term physical and mental health consequences associated with rape.

References

1. Council on Scientific Affairs, American Medical Association. Violence against women: relevance for medical practitioners. JAMA 1992;267:3184-9.

2. Resick PA. The psychological impact of rape. Journal of Interpersonal Violence 1993;8:223-55.

3. Schwartz IL. Sexual violence against women: prevalence, consequences, societal factors, and prevention. Am J Prev Med 1991;7:363-73.

4. Von JM, Kilpatrick DG, Burgess AW, Hartman CR. Rape and sexual assault. In: Rosenberg ML, Fenley MA, eds. Violence in America: a public health approach. New York: Oxford University Press, 1991:95-122.

5. Koss MP, Gidycz CA, Wisniewski N. The scope of rape: incidence and prevalence of sexual aggression and victimization in a national sample of higher education students. J Consult Clin Psychol 1987;55:162-70.

6. Federal Bureau of Investigation. Uniform crime reports, 1990: crime in the United States. Washington, DC: US Department of Justice, Federal Bureau of Investigation, 1991.

7. Kilpatrick DG, Edmunds CN, Seymour AK. Rape in America: a report to the nation. Arlington, Virginia: National Victim Center, 1992.

8. Bureau of Justice Statistics. Criminal victimization in the United States, 1990: a national crime victimization survey report -- February 1992, NCJ-134126. Washington, DC: US Department of Justice, Office of Justice Programs, Bureau of Justice Statistics, 1992.

9. Kilpatrick DG, Resnick HS, Saunders B, Best CL. Measuring violent assaults against women: results from the National Women's Study. In: The American Society of Criminology 46th annual meeting: challenges of crime and social control -- 1994 program and proceedings. Columbus, Ohio: The American Society of Criminology, 1994.

10. Bachman R, Saltzman LE. Violence against women: estimates from the redesigned survey. Washington, DC: US Department of Justice, Office of Justice Programs, 1995. (Bureau of Justice Statistics special report no. NCJ-154348).

Defined as the carnal knowledge of a woman forcibly and against her will. Assaults or attempts to commit rape by force or threat of force are included; statutory rape (without force) and other sex offenses are excluded.

TABLE 1. Number and rate * of reported rapes + based on rape crisis center (RCC) data
and on the Federal Bureau of Investigation's Uniform Crime Reporting Program (UCR)
data -- North Carolina, 1989-1993
==================================================================================================
                            RCC                           UCR
          -------------------------------------     ---------------
Year      No. providing data &  No. Rapes  Rate     No. Rapes  Rate
-------------------------------------------------------------------
1989              18                529     64.3       571     69.4
1990              21                907     79.5      1032     90.5
1991              23               1322    106.4      1150     92.5
1992              26               1850    127.4      1247     85.8
1993              31               1954    115.7      1352     80.0
-------------------------------------------------------------------
* Per 100,000 women.
+ Defined as the carnal knowledge of a woman forcibly and against her will. Assaults or attempts
  to commit rape by force or threat of force are included; statutory rape (without force) and
  other sex offenses are excluded.
& Of 52 RCCs operating during 1994, 35 (67%) responded: 18 provided information about rape
  victims served in all 5 years of the study period and 13 for 1-4 years; three did not maintain
  client records with sufficient information for any of the years; and one did not begin serving
  clients until 1994 and was excluded.
==================================================================================================

TABLE 2. Descriptive features and data about rape from the National Women's Study (NWS), the National Crime
Victimization Survey (NCVS), the NCVS-Revised, and the Uniform Crime Reporting Program (UCR) -- United States
==========================================================================================================================================
                                                                          Estimated no.
                                                                          rapes during     Annual
Data source   Year(s)       Study type              Definition of rape     12 months      rape rate *
-----------------------------------------------------------------------------------------------------
NWS           Fall 1989-    Longitudinal phone      Sexual penetration      683,000       710 women
              Fall 1990     survey of national      with force, threat      completed     aged >=18
                            household               of harm, or                           years (9)
                            probability sample      nonconsent
                            of women

NCVS          1990          Ongoing series of       Carnal knowledge        130,260       60 persons
                            phone and in-person     with use or threat      completed     aged >=12
                            interviews with a       of force, or attempts   and           years &
                            national probability                            attempted
                            sample of households                            rapes +

NCVS-         1992-         Same as NCVS            Physical force or       172,400       160 women
Revised @     1993                                  psychologic             completed     aged >=12
                                                    coercion to engage      rapes         years **
                                                    in sexual
                                                    intercourse

                                                    No definition of        141,200       130 women
                                                    attempted rape is       attempted     aged >=12
                                                    given                   rapes         years **

UCR           1990          Ongoing                 Carnal knowledge        102,555       80 women
                            surveillance system     of a woman with         completed     of any age
                            based on data           force and against       and
                            reported to state and   her will, includes      attempted
                            local law               attempts and            rapes
                            enforcement             threats of force
                            agencies
-----------------------------------------------------------------------------------------------------
 * Per 100,000.
 + The NCVS presents these data combining rapes involving female and male victims of rape.
 & Rate for women: 100 per 100,000; rate for men: 20 per 100,000 but may be unstable because of too few cases.
 @ In the original NCVS, respondents were not specifically asked about rape experiences. After a series of questions about threats of
   beatings and threats of harm with knives, guns, and other weapons, respondents were asked, "Did anyone try to attack you in some
   other way?". The NCVS-Revised uses more direct rape screening questions, includes prompts about types of potential rapists (e.g.,
   strangers, casual acquaintances, and persons known well), and collects information on an array of sexual assaults in addition to rape
   (10).
** The early report on the NCVS-Revised presents data only about rapes involving female victims although data also were collected
   about male victims.
==========================================================================================================================================

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