This next set of questions asks about your experiences SINCE AGE 13 and up through the present time. Some of the questions are very similar so please read them VERY CAREFULLY.
The following questions concern sexual experiences that you may have had. We know that these are personal questions, so we do not ask your name or other identifying information. Each question appears in a bold type. After each question you will seea statement labeled a through e. Please circle a number
after each of these letters to indicate how many times that that particular sexual experience has occurred under each circumstance described. Your answers are completely confidential. We hope that this helps you to feel comfortable answering each question honestly.
Sexual Experiences
How many times since
age 13
20. I gave someone oral sex* or someone performed oral sex on me after:
*Oral sex means contact between the mouth and either the penis or the female genital area.
a. They told lies, made promises about the future they knew were
untrue, threatened to end the relationship or spread rumors. 0 1 2 3 or more b. They used strong arguments and continual pressure or showed
displeasure (got angry). 0 1 2 3 or more
c. I drank alcohol and/or used drugs until I was incapacitated and
couldn’t object or consent. 0 1 2 3 or more
d. They threatened some degree of physical harm. 0 1 2 3 or more e. They used some degree of physical force such as holding
me down or ripping my clothes off. 0 1 2 3 or more
21. Someone inserted their penis*, their fingers, or an object (such as
a dildo, bottle, or candle) into my vagina after:
*Even if the penetration was very slight and he did not ejaculate (cum) a. They told lies, made promises about the future they knew were
untrue, threatened to end the relationship or spread rumors. 0 1 2 3 or more b. They used strong arguments and continual pressure or showed
displeasure (got angry). 0 1 2 3 or more
c. I drank alcohol and/or used drugs until I was incapacitated and
couldn’t object or consent. 0 1 2 3 or more
d. They threatened some degree of physical harm. 0 1 2 3 or more e. They used some degree of physical force such as holding
me down or ripping my clothes off. 0 1 2 3 or more
IF YOU DID EXPERIENCE ANY OF THE INCIDENTS LISTED IN 20 AND 21, HAVE YOU EVER TOLD ANYONE ABOUT IT? (Please circle an answer)
APPENDIX A continued
How many times since
age 13
22. Someone inserted theirpenis*, their fingers or an object (ex. a dildo, bottle, or candle) into my anus (butt) after:
*Even if the penetration was very slight and he did not ejaculate (cum)
a. They told lies, made promises about the future they knew were
untrue, threatened to end the relationship or spread rumors. 0 1 2 3 or more b. They used strong arguments and continual pressure or showed
displeasure (got angry). 0 1 2 3 or more
c. I drank alcohol and/or used drugs until I was incapacitated and
couldn’t object or consent. 0 1 2 3 or more
d. They threatened some degree of physical harm. 0 1 2 3 or more e. They used some degree of physical force such as holding
me down or ripping my clothes off. 0 1 2 3 or more
23. Someone attempted to have oral sex with me, or attempted to make me have oral sex with them when I indicated I didn’t want to, but it did not happen.
a. They told lies, made promises about the future they knew were
untrue, threatened to end the relationship or spread rumors. 0 1 2 3 or more b. They used strong arguments and continual pressure or showed
displeasure (got angry). 0 1 2 3 or more
c. I drank alcohol and/or used drugs until I was incapacitated and
couldn’t object or consent. 0 1 2 3 or more
d. They threatened some degree of physical harm 0 1 2 3 or more e. They used some degree of physical force such as holding
me down or ripping my clothes off. 0 1 2 3 or more
24. Someone attempted to insert their penis, their fingers, or an object (such as. a dildo, bottle, or candle)into my vagina after I indicated that I didn’t want them to, but it did not happen.
a. They told lies, made promises about the future they knew were
untrue, threatened to end the relationship or spread rumors. 0 1 2 3 or more b. They used strong arguments and continual pressure or showed
displeasure (got angry). 0 1 2 3 or more
c. I drank alcohol and/or used drugs until I was incapacitated and
couldn’t object or consent. 0 1 2 3 or more
d. They threatened some degree of physical harm. 0 1 2 3 or more e. They used some degree of physical force such as holding
me down or ripping my clothes off. 0 1 2 3 or more
IF YOU DID EXPERIENCE ANY OF THE INCIDENTS LISTED IN 22, 23, OR 24, HAVE YOU EVER TOLD ANYONE ABOUT IT? (Please circle an answer)
APPENDIX A continued
IF YOU DID EXPERIENCE ANY OF THE INCIDENTS LISTED IN 25, HAVE YOU EVER TOLD ANYONE ABOUT IT? (Please circle an answer)
YES NO
How many times since
age 13
25. Someone attempted to insert their penis, their fingers, or an object (such as. a dildo, bottle, or candle) into my anus after I indicated that I didn’t want them to, but it did not happen.
a. They told lies, made promises about the future they knew were
untrue, threatened to end the relationship or spread rumors. 0 1 2 3 or more b. They used strong arguments and continual pressure or showed
displeasure (got angry). 0 1 2 3 or more
c. I drank alcohol and/or used drugs until I was incapacitated and
couldn’t object or consent. 0 1 2 3 or more
d. They threatened some degree of physical harm. 0 1 2 3 or more e. They used some degree of physical force such as holding