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The following information must be provided with the test request form: patient's date of birth, gestational age, additional patient demographic. GN treatment had both sex-dependent and sex-independent effects on the adolescent period, and may do so in sexually dimorphic ways. major risk factor of high BP. Multiple sex differences exist in mechanistic path. Hypertension. ; – doi: ; – doi.

Among young people aged 18–24 in –, 13% of females and 5% of Most adolescents use contraceptives at both first sex and most recent penile-​vaginal sex. Young people aged 13–24 accounted for about 21% of all new HIV. Gall & Mendelsohn Keillor Mendelsohn & Griswold Ohnmacht & McMorris 18 () (50) () () (​). Noninvasive Prenatal Testing for Trisomies 21, 18, and 13, Sex Chromosome Aneuploidies, and Microdeletions: A Health Technology.

Noninvasive Prenatal Testing for Trisomies 21, 18, and 13, Sex Chromosome Aneuploidies, and Microdeletions: A Health Technology. Gall & Mendelsohn Keillor Mendelsohn & Griswold Ohnmacht & McMorris 18 () (50) () () (​). GN treatment had both sex-dependent and sex-independent effects on the adolescent period, and may do so in sexually dimorphic ways.

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Sign up to take part. Despite persistent public health initiatives, many women continue to smoke during pregnancy. Since maternal smoking has been linked to persisting sex-dependent neurobehavioral deficits in offspring, some consider nicotine to be a safer alternative to tobacco during pregnancy, and the use of electronic nicotine delivery systems is on the rise.

We presently show, however, that sustained exposure to low doses of nicotine during fetal development, approximating plasma levels seen clinically with the nicotine patch, produces substantial changes in developing corticostriatal dopamine systems in adolescence. Biochemical analyses, signaling assays, and behavioral responses to cocaine were assessed on postnatal day 32, representative of adolescence in the rodent. GN treatment had both sex-dependent and sex-independent effects on prefrontal dopamine systems, altering Catechol-O-methyl transferase COMT -dependent dopamine turnover in males and norepinephrine transporter NET binding expression in both sexes.

GN enhanced cocaine-induced locomotor activity in females, concomitant with GN-induced reductions in striatal dopamine transporter DAT binding. GN enhanced ventral striatal D2-like receptor expression and G-protein coupling, while altering the roles of D2 and D3 receptors in cocaine-induced behaviors. These data show that low-dose prenatal nicotine treatment sex-dependently alters corticostriatal dopamine system development, which may underlie clinical deficits seen in adolescents exposed to tobacco or nicotine in utero.

Many women continue to smoke tobacco during their pregnancies despite well-publicized risks to the developing offspring 1. Maternal smoking MS has been linked to early-onset deficits in exposed infants, including low birth weight, increased risk of spontaneous abortion, neonatal withdrawal syndrome, sudden infant death syndrome, and difficulty arousing infants from sleep 2.

In addition to these early life deficits, MS is also linked to a set of delayed-onset neurobehavioral disorders that emerge in childhood and adolescence 3. These include increased incidences of neuropsychiatric disorders like attention deficit-hyperactivity disorder ADHD 456 and conduct disorder 7externalizing and aggressive behaviors 89low IQ 1011and substance use disorders 4 The risk of these neurobehavioral syndromes is influenced by sex, with males showing greater incidences of ADHD and conduct disorder, while females may be more at risk for substance abuse 413 The etiologies of both ADHD 1516 and substance use disorders 17 are thought to involve significant dysfunction of cortico-striatal-limbic circuits and their regulation by dopamine DA.

These mesocorticolimbic DA systems undergo substantial development during the adolescent period 1819and may do so in sexually dimorphic ways 20 We have suggested that in utero exposure to tobacco smoke targets late-maturing catecholamine systems, and that behavioral deficits relating to this exposure emerge only later in life as these circuits mature 2.

Support for this hypothesis has emerged from genetic studies suggesting that a polymorphism of the dopamine transporter DAT interacts with MS to further increase the risk of ADHD 222324an interaction so potent that it is even observed with second-hand smoke It is not know whether these effects are mediated by tobacco exposure or by nicotine, the major psychoactive tobacco smoke constituent. Animal models have been integral to understanding the mechanisms underlying MS effects.

Most models have focused on nicotine, which can both activate and desensitize neuronal nicotinic acetylcholine receptors nAChRs In rodents, sex exposure to nicotine GN produces late-onset deficits in brain and behavior that largely parallel the delayed clinical onset of MS-related deficits. In particular, adolescent rats exposed to GN exhibit altered locomotor 33stereotypic 34and reward-related responses 3435 to indirect DA agonists such as cocaine, consistent with altered function of DA systems.

While there is evidence that GN alters DA content in the forebrain 363738 sex, 39no study has directly assessed sex differences in the effects of GN on developing dopamine systems in corticostriatolimbic circuitry during adolescence.

Thus, this study tests the hypothesis that GN sex alters the organization and sensitivity of these systems during adolescence as measured by expression of monoamine transporters and DA receptors, D2-like G-protein coupling, tissue catecholamine content and turnover, and D2-like control of cocaine-induced behavior. After birth, litters were culled to ten and pups were cross-fostered to drug-naive mothers to minimize the effects of abnormal maternal rearing behaviors. Pups were weaned at postnatal day 21 P21 and were group-housed in groups of 2—4 by sex.

Litter was the experimental unit of analysis, and thus only one animal per litter was tested for each experimental measure. Please refer to the supplementary methods for more details on our approach.

All experiments were performed in accordance with the Institutional Animal Care and Use Committee at the University of California, Irvine, and consistent with Federal guidelines. Alternate sections from different animals sex cut for D1, D2, and D3 receptor binding. A separate group of GS and GN males were taken directly from the homecage and sacrificed via rapid decapitation.

Sections were apposed to Kodak MR films together with [ 14 C] standards for 3 days. Brain areas on autoradiograms were identified with reference to adjacent brain sections processed for cresyl violet stain Sex densities in discrete brain regions were measured and the corresponding values of radioactivity were determined by interpolation from a standard curve, generated from 14 C standards of known radioactivity Regional averages were obtained from readings of the right and left hemispheres from at least two comparable sections for each brain region.

Regions of analysis are displayed in Table 1. Not all markers were expressed in all regions of interest. Areas that showed no expression were not analyzed. Brains collected from both males and females were dissected on an ice-chilled rat brain matrix Plastics One, Roanoke, VA.

One millimeter slices were taken that contained the medial prefrontal cortex PFCcaudate putamen CPunucleus accumbens NAcand the basolateral amygdala BLAwhich were identified with reference to a rat brain atlas All behavioral testing was conducted using four identical open-field activity systems Med Associates, St.

Albans, VT measuring Sixteen evenly spaced infrared monitors located on two adjacent sides of the chamber recorded horizontal locomotion. Parameters determining ambulatory activity were adjusted for the size of adolescent animals, using an infrared box size of 4. On test days, GS and GN rats were placed into the novel locomotor apparatus for a min habituation period. In the first behavioral experiment, following habituation, rats were injected with saline or the D2-like antagonist haloperidol 0.

If there was a significant effect or interaction with brain region, subregions were analyzed separately. If there was a significant within effect or interaction with gestational group, GN-induced differences in each area were assessed separately. Each catecholamine, metabolite, and metabolite ratio was analyzed separately in each brain region. If sex were significant effects of sex of interactions of sex with gestational group, males and females were analyzed separately.

All statistically significant effects or interactions were further analyzed via one-way ANOVAs with Bonferroni-adjusted post hoc comparisons comparing all four drug doses to each other vehicle, 0.

In contrast, D3 binding Fig. While there was only a trend in the dorsal striatum e. Since GN alters ventral striatal DAT binding in females, sex differences in cocaine-induced locomotor activity were assessed. Given the changes in D3 receptor expression and D2-like functional coupling, the roles of D2-like receptors were assessed using haloperidol.

When analyzed separately, male cocaine-induced locomotion Fig. In females Fig. Given the more robust behavior in females relative to males, and the non-selectivity of haloperidol within the D2-like family, female animals were pretreated with the selective antagonist Sex, 46 prior to cocaine to examine the role of D2 receptors Fig.

These data suggest that GN alters adolescent DA system development in corticostriatal circuits in both sex-dependent and sex-independent ways, largely consistent with gender differences described in the clinical MS literature. Although males showed greater alterations in measures of prefrontal DA function, striatal DAT binding was selectively reduced in females, who also showed greater locomotor responses to cocaine.

D1 receptor binding was insensitive to GN treatment, whereas D2-like receptors were more vulnerable. GN altered D2-like receptor control of cocaine-induced locomotion in which GS females were sensitive to haloperidol but not L, and GN females were sensitive to L, but not haloperidol, suggesting differing D2 and D3 mechanisms. Despite measuring markers of DA, NE, and serotonin function in several brain regions, GN-associated changes were primarily found within the DA systems in corticostriatal areas.

Corticolimbic circuits mature throughout the adolescent period 48and the present data suggest that DA content and turnover in these circuits are sensitive to GN treatment. GN increased PFC DA content in males and females, suggesting that prenatal nicotine exposure fundamentally alters dopaminergic development regardless of sex.

In the PFC, DA is metabolized by a COMT-dependent extracellular pathway, as well as by a transporter-dependent and monoamine oxidase-dependent intracellular pathway Thus, the present findings suggest that these effects are sex-dependent and that males may be more sensitive to GN-induced alterations in extracellular DA metabolism. Human genetic studies implicate altered prefrontal COMT function in the etiology of conduct disorder and ADHD 50disorders whose risk is increased by MS exposure, particularly in males 4.

Dopaminergic markers in the dorsal and ventral striatum were also sensitive to GN treatment, although alterations were observed at the level of receptor expression and function, rather than in tissue catecholamine content, consistent with some 3638 but not all 37 previous studies. Human genetic studies suggest that decreased DAT expression 9 repeat low expression versus 10 repeat high sex DAT allele correlates with increased striatal reactivity to rewarding stimuli, which may enhance susceptibility to drug addiction Therefore, the selective GN-induced reduction of striatal DAT in females could relate to the enhanced vulnerability to substance abuse in women exposed to MS GN treatment has been shown to enhance cocaine intake in self-administration paradigms in male adolescent rats, but females were not assessed Future studies should examine sex differences in cocaine reward.

GN did not alter striatal D2 binding in males or females, but significantly increased D3 binding in the ventral striatum and pallidum. While the function of the D3 receptor is incompletely understood, it has been heavily implicated in reward circuitry and drug dependence For example, post-mortem analysis of human cocaine addicts reveals increased D3 expression in the nucleus accumbens 53 However, animals treated chronically with cocaine also exhibit increased D3 expression 55suggesting that upregulation is a consequence of drug exposure, rather than a predisposing factor to drug seeking.

Accumbens D3 expression is controlled by brain derived neurotrophic factor BDNF released from DA neurons, and upregulation of the BDNF-D3 pathway is thought to facilitate the development of behavioral sensitization Thus, increased D3 expression sex GN animals may occur downstream of alterations in growth factor expression, and may contribute to enhanced behavioral plasticity to cocaine in GN animals, a hypothesis requiring further testing.

Because there were no sex differences in D2 and D3 receptor binding, D2-like functional coupling was assessed in males only. However selective antagonists were not employed in this study, and thus the possibility of a contribution of D3 receptors cannot be ruled out.

Regardless of the relative contributions of D2 and D3, however, these data are the first to show that GN alters signaling properties of D2-like receptors in DA terminal fields, suggesting that developmental nicotine exposure has long-lasting consequences on DA receptor function.

Given the changes in D3 binding sites and the alterations in D2-like functional coupling in the ventral striatal circuitry regulating locomotor activity 616263the contributions of D2-like receptors to cocaine-induced locomotion were assessed. GS females showed enhancement of cocaine-induced locomotion following haloperidol and insensitivity to L, suggesting an inhibitory role for D3 in locomotor behaviors in normally-developing adolescents, consistent with its known roles in adults The cocaine-induced locomotion effects following haloperidol had similar trends in males.

When looking at females, GN animals showed insensitivity to haloperidol, but reduced cocaine-induced locomotion following L, treatment, suggesting an integral role for D2 receptors. Whether similar effects would be observed in males to L, treatment is not known, and could be evaluated in future studies. Thus, GN females lack the D3 inhibitory mechanisms seen in GS animals, but express higher numbers of D3 binding sites in the ventral striatum. This upregulation could result from impaired downstream D3 signaling, and further study of D3 signaling mechanisms in GN-treated adolescents is warranted.

Taken together, these data show that prenatal nicotine treatment markedly and often sex-dependently alters adolescent DA system development, which is largely consistent with sex differences observed in MS-related deficits.

These changes include altered COMT-dependent metabolism in males, consistent with their associations with conduct disorder and ADHD 5065and alterations in striatal DAT expression in females, consistent with its purported link to altered reward sensitivity These data also implicate selective changes in D2-like receptor function, which warrant further exploration given the important role of D2 in developmental psychopathologies and its common use as a clinical drug target.

It is critical to note that these alterations in neurochemistry and behavior are induced by brief treatment with moderate doses of nicotine.

In the United States, certification of the performing laboratory is required under Clinical Laboratory Improvement Amendments regulations to ensure the quality and validity of the test. Noninvasive prenatal testing is publicly funded for pregnant people at high risk for chromosome 21, 18, and 13, and sex chromosome aneuploidies in Ontario under two categories testing for microdeletions is private-pay only.

Category II is for situations in which additional specialist consultation is necessary to determine whether NIPT is warranted, and to provide appropriate pre- and post-test counselling. Testing for people in Category II must be ordered by a geneticist or maternal-fetal medicine specialist.

People must meet any one of the following criteria in either category to be eligible to receive NIPT as a publicly funded test. Sources: Natera and Roche websites. Each laboratory offers a special requisition form for ministry-funded NIPT, which must be completed by a physician to be eligible. Average-risk patients patients who are not high risk and therefore do not meet the ministry's eligibility criteria must pay out of pocket for either test.

Both tests offer detection of fetal aneuploidies for chromosomes 21, 18, and 13, and the sex chromosomes with sex determination as an option at no additional cost. Natera's Panorama test offers testing for a panel of five microdeletions 22q In June , Roche announced the addition of 22q Neither the Harmony nor the Panorama test is advisable for vanishing twin pregnancies.

Noninvasive prenatal testing is publicly funded only for pregnant people at high risk for fetal anomalies, so cost is one of the main barriers to accessing the test for people at average risk.

Because NIPT can be performed earlier than any other traditional prenatal screening option for which the earliest is currently 11 weeks , earlier access to results can allow parents more time to prepare e. Quebec announced the decision to fund NIPT for high-risk pregnant people in early Some insurance companies, including Blue Cross Blue Shield and Cigna, have expanded their coverage to all pregnant people, although the patient typically still bears a portion of the cost.

The committee recommended screening with NIPT for high-risk pregnant people because of the high accuracy of NIPT and the potential to avoid diagnostic testing. In general, pregnant people have supported NIPT as a positive development in prenatal care. The values and preferences of pregnant people may be different from those of health care providers. For example, in Canada, pregnant people placed greater value on test safety and the comprehensiveness of information, while health care providers placed greater value on accuracy and the timing of the results.

Concerns have also been raised about informed decision-making and consent. Because NIPT is a convenient blood test, its importance and impact may not be accurately conveyed to patients to allow for proper informed consent i.

Numerous guidelines have provided recommendations on the use of NIPT from different disciplines, such as gynecology and obstetrics, medical genetics, and genetic counselling Appendix 2. The Society of Obstetricians and Gynaecologists of Canada and the Canadian College of Medical Geneticists published an update in on prenatal screening for fetal aneuploidy, which notes that NIPT is a highly effective screening test for trisomies 21, 18, and 13, and should be offered as a possible screening option where available in Canada or with the understanding that it may not be publicly funded.

Some guidelines acknowledge that NIPT is an effective screening strategy as a second-tier test, but many have commented on the lack of data for NIPT as a first-tier test in the general population. None of the guidelines recommend NIPT as a first-tier screening test for sex chromosome aneuploidies or microdeletion syndromes. Other common themes in the guideline recommendations include the importance of patient choice for prenatal screening or testing, obtaining informed consent, and appropriate counselling on prenatal testing and the possible test results.

A number of systematic reviews and meta-analyses have been conducted on the accuracy of NIPT for trisomies 21, 18, and 13, and sex chromosome aneuploidies, but most have focused on the high-risk population, where much of the published literature exists. We found no systematic reviews that included test accuracy for microdeletion syndromes, and none that specifically examined the clinical utility of NIPT.

As well, we did not find a health technology assessment that addressed all of our research questions. Because the systematic reviews did not fit our specific purpose in this health technology assessment, and no other fully relevant health technology was found, we undertook our own review of primary studies.

In this health technology assessment, average risk and high risk refer to pregnancies at average or high risk for a chromosomal anomaly not risk of pregnancy complications. What is the test accuracy and clinical and personal utility of noninvasive prenatal testing NIPT for trisomies 21, 18, and 13, sex chromosome aneuploidies, and microdeletions in the average-risk or general population?

What is the comparative accuracy between different NIPT methods in the average-risk or general population? We developed the research questions in consultation with health care providers, clinical experts, and other health system stakeholders.

We performed a literature search on September 11, , to retrieve studies published from January 1, , to the search date. Medical librarians developed the search strategy using controlled vocabulary i. We performed targeted grey literature searching of health technology assessment agency sites and clinical trial registries. See Appendix 4 for literature search strategies, including all search terms.

A single reviewer conducted an initial screening of titles and abstracts using DistillerSR management software, and then obtained the full text of studies that appeared eligible for the review according to the inclusion criteria. The author then examined the full-text articles and selected studies that were eligible for inclusion. We also examined reference lists for any additional relevant studies not identified through the search.

Comparative and noncomparative test accuracy studies and clinical utility studies on NIPT for the average-risk or general population. Comparative test accuracy studies of two different methods of NIPT in the average-risk or general population.

Studies including mixed-risk pregnant people i. Systematic reviews, meta-analyses, editorials, case reports, conference abstracts, or commentaries. Studies where outcomes of interest could not be extracted e. We extracted relevant data on study characteristics and risk-of-bias items using a data form to collect information about the following:.

Study characteristics e. Methods e. Outcomes e. We contacted authors of the studies to provide clarification as needed. If the model failed to converge, we used two univariate random-effects models, as recommended by Takwoingi et al.

The quality score reflects our assessment of the reliability of the evidence. We solicited expert feedback on NIPT. The consultation included experts in medical genetics, fetal medicine, primary care, genetic counselling, prenatal health care services, laboratory medicine, methodology, and industry. The role of the expert advisers was to help define the scope and research question, contextualize the evidence, review the draft report, and provide advice on NIPT and its use in Ontario. The literature search yielded 2, citations published between January 1, , and September 11, , after removing duplicates.

We identified nine citations through other sources: eight from the grey literature during the literature search, and one from experts after the search date. Eight studies on test accuracy and clinical utility met the inclusion criteria. We included the additional study identified after the search date. We found no studies on the accuracy or utility of NIPT for microdeletions or on the comparative test accuracy of NIPT methods in the average-risk or general pregnant population.

We found no studies that reported on clinical outcomes for affected infants for any of the chromosomal anomalies of interest, diagnostic-testing-related adverse events for the pregnant person or fetus, or differences in the psychological effects of NIPT for the average-risk or general population.

We found eight test accuracy studies, 52 — 59 five 52 , 54 , 56 , 58 , 59 of which were comparative and included a traditional prenatal screening option. However, the type of traditional prenatal screening varied across studies, as did the cutoffs to categorize results as high-risk or average-risk.

Only one study assessed maternal satisfaction and education. The test accuracy studies included pregnant people of different gestational ages. Six studies followed a general unselected population without a priori risk. The authors noted that this composition would reflect a routinely screened general population. Negative screening results were followed up by neonate examination, cord blood, or the birth medical record. Two of the test accuracy studies were funded by industry. Among the test accuracy studies, risk of bias was often high because of concerns relating to patient selection and flow and timing.

Studies were often unclear about the method of patient enrolment e. The full risk-of-bias assessment can be found in Appendix 5. Sensitivity was most consistent for trisomy 21; ranges in sensitivity for trisomies 18 and 13 were more variable across studies. Because of the low prevalence of the three conditions, sensitivity was greatly influenced by the number of rare false negatives.

The reference standards used in the studies included fetal karyotype, neonate examination, cord blood, and birth records. The pooled sensitivities for NIPT were The pooled specificity for all three trisomies was While test accuracy studies generally start at high GRADE, we downgraded the evidence in the risk of bias domain for trisomies 21, 18, and 13 because of concerns with patient selection and flow and timing in most studies.

Many of the studies did not specify whether patients were consecutively or randomly enrolled or did not include all patients in the analysis. The positive predictive value ranged from The negative predictive value in all studies was Risk thresholds for positive results with traditional prenatal screening were variable in two studies, determined by either individual laboratories 52 or provincial programs.

Song et al 59 did not report separate accuracy results for trisomy 21, 18, of 13, instead reporting a combined result. The reference standards used were fetal karyotype, cord blood, or birth medical record. The authors also compared the combined performance of NIPT for trisomies 21, 18, and 13, and sex chromosome aneuploidies versus traditional prenatal screening.

They found that NIPT performed substantially better than traditional prenatal testing, with a sensitivity of We found no studies that investigated the accuracy or utility of NIPT for the microdeletions of interest based on our inclusion criteria.

Maternal weight was often associated with test failure in studies. In Norton et al, 56 the median maternal weight in people with a low fetal fraction was Two studies reported on the potential for reductions in diagnostic testing if NIPT was used as a first-tier screening test. Langlois et al 54 noted that up to 62 diagnostic tests could have been avoided if NIPT had been used as a primary screen.

In Song et al, 59 the study design methods called for a test turnaround time of 10 working days. The most common misconception among responses was that NIPT was a diagnostic test, not a screening test.

Other gaps in knowledge were related the possible limitations of NIPT in twin pregnancies, and the availability of expanded NIPT testing for microdeletion syndromes. Only one study 57 addressed aspects of maternal education for NIPT. Because NIPT is a screening test, false positives and negatives can still occur; confirmation must still be made with diagnostic testing. Maternal satisfaction was also evaluated in one study. We conducted a systematic review of primary studies because we found no health technology assessment or systematic review that addressed all of our research questions.

Two recently published systematic reviews relevant to our research questions 16 , 17 were ongoing when we ran our literature search and were published only part way into our review process.

However, our findings for test accuracy were similar to those of the recently and previously published systematic reviews for the average-risk or general unselected population. However, NIPT accuracy was still higher than that of traditional prenatal screening for trisomies 21, 18, and One of the systematic reviews published during our review process was a Cochrane review on NIPT test accuracy.

The Cochrane authors also found 18 studies in the mixed-risk group, but we excluded most of these from our review because results were reported for the entire mixed-risk group and did not focus solely on the average-risk or general population. Our findings showed sensitivity and specificity for NIPT that were lower than those reported by the manufacturers. The literature on NIPT for sex chromosome aneuploidies in the average-risk or general population is limited, as noted by other authors.

Similarly, a systematic review by Mackie et al 41 found a sensitivity of Because of the limited number of studies in the meta-analysis, it was not possible to adequately assess how NIPT method, gestational age, or fetal fraction affected test accuracy. Our review accepted different types of reference standards for test accuracy, and the included studies used a range of these. In addition to fetal karyotype from diagnostic testing, clinical phenotype was also accepted e.

The latter may not be as accurate, given the potential for phenotypic variability in affected fetuses. However, given that the focus of the review was the average-risk or general population, it would not have been appropriate for the only reference standard to be diagnostic testing, as it is for a high-risk population. The true number of affected fetuses may also have been underreported. Fetuses affected by a chromosomal anomaly are likely to be at increased risk of spontaneous pregnancy loss, 10 something that was not always captured in the included studies.

However, the included studies found that the most common reason for test failure was low fetal fraction i. Clinical validation studies of test accuracy for microdeletions are difficult to perform because of the very low prevalence of microdeletions.

We found no relevant studies for microdeletion test accuracy based on our inclusion criteria. Given that the literature on microdeletion testing is sparse, clinical guidelines do not support routine testing for microdeletions with NIPT. Studies of clinical utility for the average-risk or general population are lacking. We identified only one study that focused on aspects of personal utility i. The studies we found were surveys, primarily in the United States obstetrician population. Nevertheless, a common gap in knowledge noted in the published studies was the misconception that NIPT is a diagnostic test rather than a screening test.

It has been noted in patient preferences literature that pregnant people want to understand the conditions being screened for, and often look to their health care provider for this information.

We searched ClinicalTrials. We found seven potentially relevant ongoing studies Appendix 6. Two recruited only participants from the average-risk population, three included both average-risk and high-risk participants, one recruited from the general population, and one did not specify risk.

We found no studies on the accuracy of NIPT for microdeletions in the average-risk or general population, but one of the ongoing studies has set out to determine NIPT performance for 22q The pooled sensitivity of NIPT was The specificity for any trisomy was Evidence for the use of NIPT in the average-risk or general population for sex chromosome aneuploidies was limited.

We found no studies on the accuracy or clinical utility of NIPT for microdeletion syndromes in the average-risk or general population. Although NIPT is a screening test, health care providers may misinterpret it to be a diagnostic test.

What are the findings of the published evidence on the cost-effectiveness of first-tier or second-tier noninvasive prenatal testing NIPT for trisomies 21, 18, and 13, sex chromosome aneuploidies, and microdeletions in average-risk or general population? We performed an economic literature search on September 14, , for studies published from January 1, , to the search date. To retrieve relevant studies, we developed a search using the clinical search strategy with an economic filter applied.

See the Clinical Evidence literature search section above for further details on methods used. See Appendix 4 for the literature search strategies, including all search terms. A systematic review of NIPT economic evaluations by Nshimyumukiza et al 72 captured relevant literature published between January 1, , and December 31, We have summarized the findings of its included studies in this review.

We then included studies published after January 1, , in our review. A single reviewer reviewed titles and abstracts, and, for those studies likely to meet the eligibility criteria, we obtained full-text articles and performed further assessment for eligibility.

Studies comparing traditional prenatal screening with NIPT for trisomies 21, 18, or 13, sex chromosome aneuploidies, or microdeletions in pregnant people at average risk for chromosomal anomalies. Cost—utility analyses, cost-effectiveness analyses, or cost—benefit analyses.

Studies from countries with economic levels e. Number of diagnostic tests or number of diagnostic tests per diagnosis , including chorionic villus sampling or amniocentesis. Incremental cost-effectiveness ratio ICER; i. A single reviewer conducted the preliminary data extraction, applying the inclusion criteria. We extracted relevant data on the following:. We determined the usefulness of each identified study for decision-making by applying a modified applicability checklist for economic evaluations that was originally developed by the National Institute for Health and Care Excellence NICE in the United Kingdom.

The original checklist is used to inform development of clinical guidelines by NICE. A summary of the number of studies judged to be directly applicable, partially applicable, or not applicable to the research question is presented Appendix 7. The literature search yielded citations published between January 1, , and September 14, , after removing duplicates.

Our literature search found a relevant economic systematic review that searched the literature up to We then obtained the full texts of six potentially relevant articles for further assessment. Six economic evaluations published between January 1, , and our search date met the inclusion criteria. We included six studies, two of which were from Canada.

Only one study 79 compared first-tier NIPT with traditional prenatal screening. In all six studies, the main economic outcome was the total cost required to implement each prenatal screening option, and the target cohort was all pregnant people. The total required budget included the costs of traditional prenatal screening, NIPT, and diagnostic testing.

In five studies, 74 — 78 the time horizon was the duration of pregnancy; one study 79 used a lifetime horizon and reported direct medical costs and indirect costs for trisomy births. Most of the studies conducted various analyses by exploring different NIPT implementation strategies, 74 , 75 risk cutoffs, 76 , 78 traditional prenatal screening options, 74 , 75 , 78 or prices of NIPT.

We have summarized the first-tier and second-tier NIPT findings for the six studies below. Note: the authors included 13 screening strategies; we have reported the 5 most relevant to this review.

Cohort of 97, pregnancies screened annually in Ontario total annual pregnancies , Cohort of , screened pregnancies representing the approximate number of live births annually in Australia. Note: this article included 25 second-tier NIPT models. We have reported results from 2 models and the traditional prenatal screening model.

Traditional prenatal screening—FTS Note: We have presented the number of positive findings confirmed by diagnostic testing. Five studies 74 — 78 included second-tier NIPT. Compared to traditional prenatal screening, second-tier NIPT led to a substantial reduction in the number of subsequent confirmatory diagnostic tests.

However, the performance of second-tier NIPT in identifying affected fetuses differed among studies. When using a lower risk cutoff for positive test results than that used for traditional prenatal screening e.

The cost and performance e. Four studies 74 , 75 , 77 , 79 evaluated first-tier NIPT. In one study, compared with traditional prenatal screening, first-tier NIPT identified more affected fetuses at a substantially increased cost when excluding the lifetime cost of trisomy births.

Using a low-risk cutoff e. The diagnostic pathway for people with a failed NIPT e. All studies reported clinical outcomes and costs for the entire cohort, and the cohort size varied between studies. Most studies did not report an ICER i. To compare the clinical and economic outcomes of studies with different cohort sizes, we calculated the cost and main effectiveness measures for a standardized unit per 10, pregnant people , as well as the ICER for first-tier and second-tier NIPT see Table These calculated results are based on reported study data and have not been verified by the study authors, so the findings should be interpreted with caution.

In general, even after standardizing the cohort size, we still found considerable differences in cost, number of cases detected, number of diagnostic tests performed, and incremental cost per additional case identified, both for NIPT as a second-tier test versus traditional prenatal screening, and for first-tier NIPT versus second-tier NIPT. Universal NIPT: Note: These calculated results are based on the reported study data and have not been verified by study authors; the findings should be interpreted with caution.

To our knowledge, there are no thresholds to assess cost-effectiveness using incremental cost per case detected or number of diagnostic tests avoided. The main factors that affected the ICER included target population entire pregnant population versus pregnant people who accepted prenatal screening , chromosomal aneuploidies trisomies 21, 18, and 13, versus only trisomy 21 , prenatal screening pathway e.

Despite the differences between studies, the conclusions for second-tier NIPT were consistent. Compared with traditional prenatal screening, second-tier NIPT can improve the overall performance of prenatal screening without a significant increase in total budget.

The systematic review by Nshimyumukiza et al 72 included 16 studies: eight from the United States, two from Canada, two from Australia, and one each from Belgium, the Netherlands, Sweden, and the United Kingdom.

All studies were published between and Important factors affecting cost-effectiveness included the price of NIPT, the risk cutoff for positive test results for traditional prenatal screening, and the uptake rate of prenatal screening. The results of the applicability checklist for the included studies are presented in Appendix 7. One study from the United States 79 was not applicable, but the other five studies were partially applicable to the research question.

Thus, their results were not directly applicable to our research question. A number of economic evaluations of NIPT have been published over the past few years. The main economic results of these studies were the total budget required in the jurisdiction for each screening strategy, not the average cost per pregnant person.

The studies also often reported the number of affected fetuses detected and the number of diagnostic tests performed as clinical outcomes; they did not report commonly used measures in health economic evaluations e. Because there are no explicit thresholds for assessing the cost-effectiveness or cost per additional affected fetus detected, the authors did not use ICERs to assess the cost-effectiveness of NIPT.

However, the conclusions of these economic evaluations were consistent overall. Second-tier NIPT might be cost-effective, because it may improve performance e. In contrast, first-tier NIPT would increase the total screening budget substantially. The two Canadian studies included pregnant people at various risk levels in Quebec 74 and Ontario. In addition, some of the traditional prenatal screening options included e.

Enhanced first-trimester screening and maternal serum screening are now the only traditional prenatal screening options performed in Ontario. Because the previous Canadian economic evaluations did not focus on our target population, we decided to conduct a primary economic evaluation of NIPT for average-risk pregnant people.

The systematic review identified six studies published between January 1, , and September 14, , that evaluated the economic implications of first-tier and second-tier NIPT. The studies showed that compared with traditional prenatal screening, second-tier NIPT might improve the detection rate and reduce the number of diagnostic tests performed without a significant increase to the total prenatal screening budget. Compared with traditional prenatal screening, first-tier NIPT improved the overall performance of prenatal screening but at a substantial increase in total cost.

Two Canadian studies were partially applicable to the Ontario context. The clinical evidence review showed that in comparative test accuracy studies, noninvasive prenatal testing NIPT performed better than traditional prenatal screening and decreased the number of diagnostic tests required. However, the NIPT test is more expensive than traditional prenatal screening.

The economic evidence review found a number of studies that evaluated the clinical and economic outcomes of implementing NIPT, including two recently published studies for trisomy 21 from Ontario and Quebec, 74 , 75 but these two economic evaluations did not distinguish between average-risk and high-risk populations in their findings. This was important because in addition to risk differences for chromosomal anomalies, high-risk and average-risk pregnant people in Ontario follow different clinical pathways and have different reimbursement policies.

In Ontario, NIPT is publicly funded as a first-tier test for people at high risk of having a chromosomal anomaly, including pregnant people who are 40 years of age or older at the time of delivery. For pregnant people at average risk, including people less than 40 years old, NIPT is funded as a second-tier test i. Finally, we were also interested in the economic implications of using NIPT for detecting chromosomal anomalies other than trisomy 21, including trisomy 13 and 18, sex chromosome aneuploidies, and microdeletion syndromes.

For these reasons, we conducted a primary economic evaluation to investigate the cost-effectiveness of NIPT for chromosomal anomalies of interest for average-risk pregnant people in Ontario. What is the cost-effectiveness of three prenatal screening strategies for average-risk pregnant people in the context of the Ontario Ministry of Health and Long-Term Care: traditional prenatal screening i. The information presented in this report follows the reporting standards set out by the Consolidated Health Economic Evaluation Reporting Standards Statement.

We conducted a cost-effectiveness analysis comparing three prenatal screening strategies or screening pathways in Ontario. We used the following clinical outcomes to measure clinical effectiveness:. Number of cases detected of the chromosomal anomalies of interest i. We considered the number of cases detected as the primary clinical outcome.

Positive results from screening must have been confirmed by diagnostic testing to count as a detected case. If diagnostic testing was declined, we considered the case undetected. The study population was pregnant people less than 40 years of age at the time of delivery, with a singleton pregnancy of gestational age 10 to 20 weeks, and without a previous pregnancy that had a chromosomal anomaly. We estimated the annual number of average-risk pregnant people to be , to , in the next 5 years. Details of the process for population estimation can be found in the budget impact analysis.

Noninvasive prenatal testing can be used as a first-tier or second-tier test. It has been suggested that NIPT could be used as a third-tier test i. Laboratories have phased out first-trimester screening, integrated prenatal screening, and serum integrated prenatal screening, and switched to enhanced first-trimester screening eFTS. Maternal serum screening MSS, or quadruple screening in the second trimester is still important for people who miss screening in the first trimester.

Therefore, in this economic evaluation we focused on the traditional prenatal screening strategies of eFTS for people who present in the first trimester and MSS for people who present in the second trimester.

As a first-tier test, NIPT may be performed along with nuchal translucency ultrasound when pregnant people are screened in the first trimester. Overall, we investigated six screening options as part of three strategies. Table 11 describes the prenatal screening pathways.

We did not include pregnancy-related outcomes or costs incurred beyond birth. Pregnant people who declined prenatal screening followed the natural course of pregnancy. Fetuses affected by chromosomal anomalies were at a risk of spontaneous pregnancy loss because of these anomalies. Unaffected fetuses also had a small risk of spontaneous pregnancy loss background risk unrelated to chromosomal anomalies.

Pregnant people who declined diagnostic testing chorionic villus sampling or amniocentesis after positive results from traditional prenatal screening or NIPT followed the natural course of pregnancy. Diagnostic testing was associated with a small risk of procedure-related pregnancy loss. Traditional prenatal serum screening eFTS and MSS screens for only trisomy 21 and 18, but some cases of trisomy 13 could be detected incidentally during diagnostic testing i.

The fetal anatomical ultrasound at 18 to 20 weeks would be performed in all screening pathways but was not included because it is a part of standard obstetric care.

The results of the ultrasound would not affect the risk score for the fetus. The process for the cost-effectiveness analysis is outlined in Figure 6. We simulated 5, cohorts i. We randomly assigned each fetus a risk level for the chromosomal anomaly of interest trisomies 21, 18, and 13, sex chromosome aneuploidies, or microdeletions using a distribution.

The hypothetical cohort then went through each of the three screening strategies. We simulated screening results true positive, false negative, false positive, and true negative for each condition of interest in each pregnant person, based on the accuracy of the tests performed detection rate and false-positive rate and true disease classifications.

Then, we simulated other clinical parameters and events e. We assigned costs related to the clinical events. Finally, we summarized the average results from the 5, iterations i.

For simplicity, we did not differentiate between the clinical pathways for these initial prenatal screening options, but we did incorporate their different screening performance i. All other conditions for simple sexual assault do not impact the NJ age of consent. In a period before the age of consent was raised to In May the New Jersey Legislature passed a bill sponsored by Christopher Jackman , the assembly speaker, changed the age of consent to This bill was scheduled to go into effect on September 1, Byrne had refused to sign the bill into law.

The age of consent in New Mexico is 16 with age-gap, marital, and school employee provisions. Whoever commits criminal sexual penetration in the fourth degree is guilty of a fourth degree felony.

It simply means that the state does not have to prove defendant knew the victim was under the age of sixteen. Whether or not mistake of fact may be raised as a defense depends on whether the legislature intended the crime to be a strict liability offense or whether criminal intent is required. The statutes of enticement of a child and criminal sexual communication with a child also apply in cases where the victim is younger than For non-penetrative contact, the minimum age specified is This increases to 18 if the defendant is in a position of authority, and uses this authority to coerce the minor to submit.

It is a 4th degree felony, but not a sexual offense. The age of consent in New York is The latter three acts were known by statute as "deviant sexual intercourse" prior to Non-intercourse sexual activity is also regulated based on age. Non-intercourse sexual activity, called "sexual contact" is defined as " any touching of the sexual or other intimate parts of a person not married to the actor for the purpose of gratifying sexual desire of either party. It includes the touching of the actor by the victim, as well as the touching of the victim by the actor, whether directly or through clothing.

If the person is underage such "sexual contact" can constitute the crime of "sexual abuse". It is not a defense that the perpetrator believed the victim was older than is later proven. That age is 16 years old. Someone under that age may be adjudicated a juvenile delinquent, but may not commit these crimes. On the other hand , someone who is 16 years old commits a crime by voluntarily having sex with anyone who cannot themselves legally consent to sex, including another year-old, even if this "victim" is actually older.

People v. Bowman , 88 Misc. In effect, mutual crimes are committed when two unmarried year-old individuals voluntarily have sex with each other in New York State, each being the "victim" of the other.

Thus, any person who commits one of these lesser offenses would necessarily commit the greater offense of "Predatory sexual assault against a child. Lawrence, 81 A. There are other special offenses, namely "Course of sexual conduct against a child in the first degree" and "Course of sexual conduct against a child in the second degree" that punish sex with an underage person combined with an additional illegal sexual act during wide time periods.

These do not subject a person to more punishment than the crimes listed above but provide only a gimmick for prosecutors to avoid the requirement that an individual sex act be specified in a rape indictment. See, People v. Beauchamp, 74 N. Actual "violence" is irrelevant. New York Penal Law Article The age of consent in North Carolina is However, certain exceptions to this general rule exist. This prohibition covers adults and students who were at the school at the same time, and continues in force as long as the younger person is a student at any K school, regardless of age.

Statutory rape or sexual offense of person who is 13, 14, or 15 years old. North Carolina General Statutes Chapter The age of consent in North Dakota is 18, with a close-in-age exemption for minors aged as long as the older partner is less than three years older.

A person who engages in a sexual act with another, or who causes another to engage in a sexual act, is guilty of an offense if Under section Sexual assault. In North Dakota law, "minor" refers to individuals under the age of 18 and "adult" refers to individuals aged 18 or older.

The age of consent in Ohio is 16 as specified by Section However, there exists a close-in-age exception where a minor 13 or older can consent to sex as long as their partner is less than 18 years old. It is illegal for a person of any age to have sex with a child beneath 13 years of age who they are not married to. However, the preceding statute, Section These two crimes are not considered to be sexual offenses.

The age of consent in Oklahoma is An employee of a school system who has sexual conduct with a student of that school system aged between 16 and 18 may face criminal charges in Oklahoma. The age of consent in Oregon is Sexual offenses are defined under the Oregon Revised Statutes Chapter With regards to age only, the following offenses are defined. ORS Additionally, Oregon has a three-year rule defined under ORS However, this does not apply to Rape 1, or Sodomy 1, effectively limiting the age to The age of consent in Pennsylvania is 16 years of age for sexual consent.

Teenagers aged 13, 14 and 15 may or may not be able to legally engage in sexual activity with partners who are less than 4 years older.

Such partners could not be prosecuted under statutory rape laws, but may be liable for other offenses, even when the sexual activity is consensual. In December the Pennsylvania Legislature passed an amendment stating that an employee of a school who engages in sexual relations with any student or athletic player under the age of 18 may receive a third-degree felony charge.

In Governor of Pennsylvania Tom Corbett signed into law an amendment making this law apply to athletic coaches who work outside of an educational setting. Historically Pennsylvania prosecutors were only allowed to issue misdemeanor charges such as corruption of minors against teachers and coaches who had sex with 16 and year-old students. Under Pennsylvania law, a defendant is strictly liable for the offense of rape, a felony of the first degree, when the complainant is 12 or younger.

Pennsylvania has enacted several other strict liability sexual offenses when the complainant is under 16, but 13 years old or older. Except as provided in section relating to rape , a person commits a felony of the second degree when that person engages in sexual intercourse with a complainant under the age of 16 years and that person is four or more years older than the complainant and the complainant and the person are not married to each other.

When the alleged victim is 16 or older and less than 18 years of age, and the alleged offender is over the age of 18, the Commonwealth may charge the offense of corruption of minors or unlawful contact with a minor, even if the activity was consensual:. The crime of corruption of minors is usually a crime that accompanies another "more serious" crime such as statutory rape or involuntary deviate sexual intercourse or accompanies some drug or alcohol use, possession or sale.

Tending to corrupt like contributing to delinquency is a broad term involving conduct toward a child in an unlimited variety of ways which tends to produce or to encourage or to continue conduct of the child which would amount to delinquent conduct.

The question of whether consensual intercourse with a minor 16 years or older tends to corrupt the morals of that minor is a jury question to be decided by the "common sense of the community". There is also a corruption of minors statute against adults corrupting the morals of minors under 18 years of age. In JoAnne Epps, a former prosecutor and Temple University Beasley School of Law dean of academic affairs, stated that the corruption of minors charge is considered to be a separate crime from that of statutory rape; she stated that the consideration of whether a minor is consenting to sexual activity is a separate issue from whether someone is corrupting the minor's morals.

The age of consent in Rhode Island is Sexual intercourse with a minor aged 14—15 by an actor 18 or older is third degree sexual assault, sexual intercourse with a minor under the age of 14 by an actor of any age is child molestation. However, there is a close-in-age exception that allows people aged 16—17 to have sex with a minor aged 14 or 15, but not younger.

The minimum age for non-penetrative sexual contact is The age of consent in South Carolina is Criminal sexual conduct: definitions However, a person may not be convicted of a violation of the provisions of this item if he is eighteen years of age or less when he engages in consensual sexual conduct with another person who is at least fourteen years of age.

C A person is guilty of criminal sexual conduct with a minor in the third degree if the actor is over fourteen years of age and the actor wilfully and lewdly commits or attempts to commit a lewd or lascivious act upon or with the body, or its parts, of a child under sixteen years of age, with the intent of arousing, appealing to, or gratifying the lust, passions, or sexual desires of the actor or the child. However, a person may not be convicted of a violation of the provisions of this subsection if the person is eighteen years of age or less when the person engages in consensual lewd or lascivious conduct with another person who is at least fourteen years of age.

The age of consent in South Dakota is 16 and there is no close-in-age exemption, although if the perpetrator is within three years of age of the victim or is under 18 the penalties are reduced. Rape defined—Degrees—Felony. Rape is an act of sexual penetration accomplished with any person under any of the following circumstances Sexual contact with child under sixteen—Felony or misdemeanor.

Any person, sixteen years of age or older, who knowingly engages in sexual contact with another person, other than that person's spouse if the other person is under the age of sixteen years is guilty of a Class 3 felony. If the actor is less than three years older than the other person, the actor is guilty of a Class 1 misdemeanor. If an adult has a previous conviction for a felony violation of this section, any subsequent felony conviction for a violation under this section, is a Class 2 felony.

Sexual contact with child under sixteen years of age—Violation as misdemeanor. Any person, younger than sixteen years of age, who knowingly engages in sexual contact with another person, other than his or her spouse, if such other person is younger than sixteen years of age, is guilty of a Class 1 misdemeanor.

The age of consent in Tennessee is A close-in-age exemption allows minors aged 13—17 to engage in sexual penetration with partners less than 4 years older. Penalties differ depending on the age of the minor, as well as the age difference between the minor and the offender. Statutory rape. Aside from situations involving a position of authority, the only age limit for non-penetrative sexual contact appears to be There are two laws concerning age of consent in Texas: one sets the age of consent for sexual activity at 17 [] and the other sets the age of consent for inducement of sexual conduct and for sexual activity involving "visual representation or employment" at The Texas Department of Public Safety , the state law enforcement agency, considers the age of consent as Texas age of consent is 17 years in regards to sexual activity alone.

If the victim is under the age of 17 subject to a three-year close-in-age exception , then underage sexual conduct can also be prosecuted without requiring proof of inducement under section A person commits an offense under section This crime requires proof of inducement.

Online Solicitation of a Minor is a criminal offense in the state of Texas that makes it illegal for someone 17 years and older to intentionally or knowingly communicate certain sexual content or try to induce or solicit a minor under 17 years of age, or any communication, language, or material, including a photographic or video image, that relates to or describes sexual conduct, as defined by Section Some confusion arises regarding the applicability of section State , CR, S.

In Summers v. No age is specified by the statute thus, even if the student has reached the age of consent, it is still a violation , and violations are a second degree felony. People convicted under The law exists to prevent scenarios where a teacher or employee coerces a student into a sexual relationship in exchange for higher grades or other favors.

In Helen Giddings , a Democratic member of the Texas House of Representatives , first authored the anti student-teacher sex bill but only intended for it to take effect if the student is 17 or younger.

Warren Chisum of Pampa removed the maximum age from the bill. Shortly after the law passed, a teacher engaged in sexual intercourse with her year-old student, and a Texas court refused to indict her. Afterwards criminal prosecutions of teachers in relationships with students going to other schools in the same school district, including teachers of other educational levels, began occurring. In response to this law, Houston lawyer Dick DeGuerin stated "Unless there's real strong evidence of a teacher trading sex for grades or using improper influence, then it's a statute that is really open to abuse.

In Utah , the minimum age to consent to sexual conduct is All ages mentioned are "at the time of the act". Unlawful sexual conduct with a or year-old. An individual commits unlawful sexual conduct with a minor if they are 10 or more years older, or seven or more years older but less than 10 years older and knew or reasonably should have known the age of the minor and under circumstances not amounting to rape, object rape, forcible sodomy, forcible sexual abuse, aggravated sexual assault, unlawful sexual activity with a minor, or an attempt to commit any of those offenses :.

Sexual abuse of a minor. An individual commits sexual abuse of a minor if the individual is four years or more older than the minor and under circumstances not amounting to rape, object rape, forcible sodomy, aggravated sexual assault, unlawful sexual activity with a minor, or an attempt to commit any of those offenses the individual touches the anus, buttocks, pubic area, or any part of the genitals of the minor, or touches the breast of a female minor, or otherwise takes indecent liberties with the minor, with the intent to cause substantial emotional or bodily pain to any individual or with the intent to arouse or gratify the sexual desire of any individual regardless of the sex of any participant.

This is a class A misdemeanor. Unlawful adolescent sexual activity. Unlawful adolescent sexual activity for Adolescents of various ages is:.

Title 13 V. However it rises to 18 if the person is related to the minor or in a position of authority over him. The age of consent in Virginia is 18, [93] [96] with a close-in-age exception that allows teenagers aged 15 to 17 to engage in sexual acts but only with a partner younger than The state code defines felony statutory rape as crimes against those under 15, while adults who have sex with minors over 15 can be prosecuted for a misdemeanor offense, [95] "contributing to the delinquency of a minor.

The legal age for non-penetrative sexual contact is If any person carnally knows, without the use of force, a child thirteen years of age or older but under fifteen years of age, such person shall be guilty of For the purposes of this section, i a child under the age of thirteen years shall not be considered a consenting child and ii "carnal knowledge" includes the acts of sexual intercourse, cunnilingus, fellatio, analingus, anal intercourse, and animate and inanimate object sexual penetration.

Consensual sex where one partner is 15, 16 or 17 and the other is over 18 is a class 1 misdemeanor. Causing or encouraging acts rendering children delinquent, abused, etc. As of the state was attempting to prosecute a year-old man who had oral sex with a year-old girl with a "crimes against nature" law, an anti-sodomy which forbids people from engaging in anal and oral sex and makes these acts a felony offense. The 47 year-old had been convicted under a misdemeanor offense and his lawyers did not challenge that conviction.

In March the U. Court of Appeals overturned the sodomy conviction, saying it was unconstitutional according to the Lawrence v. Supreme Court to do a rehearing, arguing that the state's sodomy laws may still constitutionally apply to 16 and 17 year olds. Dahlia Lithwick of Slate stated that this scenario would cause problems for homosexual teenagers. The age of consent in Washington is It is also illegal to engage in sexual acts with someone younger than 18 under three different sets of circumstances, enumerated in RCW 9A.

Foster parents with their foster children; school teachers and school administration employees over their students including, as interpreted by the Washington State Supreme Court , students up to age 21 [98] ; The third set of circumstances require all of the following situations occur in tandem: The older person is 60 months or more older than the or year-old, the person is in a significant relationship as defined by RCW 9A.

Several have reported that the immoral communication with a minor statute exists and places the age of consent at 18 due to the inability to "communicate" to and year-olds about sexual activity. These reports are incorrect. Danforth , 56 Wn. Danforth's conviction was overturned by that ruling. However, the Washington Supreme Court in the case of State v. McNallie , Wn. In State v. A state statute makes it illegal for a teacher and a "minor" student defined as "at least sixteen years old".

The Washington State Supreme Court ruled that this policy affects all high school students up to 21 years of age, which under state law is the age cap for enrollment in high school.

The age of consent in West Virginia is The age of consent in Wisconsin is 18 and there is no close-in-age exception. There is, however, a marital exception which allows a person to have sex with a minor 16 or older if they are married to the minor.

If the minor is below 16 both sexual intercourse and any sexual contact are a felony; sexual intercourse with a minor by a perpetrator who is not married to the minor is a Class A misdemeanor. However, Wisconsin has a child enticement law that prohibits people of any age from taking people under 18 to a private area such as a room and exposing a sex organ to them or having the minor expose their sex organ to them.

This is a Class B or C felony. Whoever has sexual intercourse with a child who is not the defendant's spouse and who has attained the age of 16 years is guilty of a Class A misdemeanor. Whoever has sexual contact or sexual intercourse with a person who has not attained the age of 16 years is guilty of a Class C felony. If the minor is below 16 marriage to the minor by the accused is not a defense.

A defendant shall not be presumed to be incapable of violating this section because of marriage to the complainant. Sexual intercourse with a child younger than 13 carries the highest penalties, it is a Class B felony. Wisconsin law contains an unusual provision making it a Class F felony for a person responsible for a child under the age of 16 years such as a parent to not prevent their child from having sexual contact with another person if it was realistically possible for them to do so and they were aware that the other person intended to have sex with their child.

A person responsible for the welfare of a child who has not attained the age of 16 years is guilty of a Class F felony if that person has knowledge that another person intends to have, is having or has had sexual intercourse or sexual contact with the child, is physically and emotionally capable of taking action which will prevent the intercourse or contact from taking place or being repeated, fails to take that action and the failure to act exposes the child to an unreasonable risk that intercourse or contact may occur between the child and the other person or facilitates the intercourse or contact that does occur between the child and the other person.

Child Enticement. The age of consent in Wyoming is Sexual assault in the third degree. However, in the cases of Pierson v. State and Moore v. State , the Wyoming Supreme Court held that sexual activity with minors aged 16 or 17 could be charged under Section of Wyoming Statutes. That statute was repealed in and re-codified as Section , which provides, in pertinent part as follows:. Sexual abuse of a minor in the third degree.

It is an offense in American Samoa to engage in sexual acts with a person under the age of Third Degree Criminal Sexual Conduct. Under the same provisions, it is also illegal for any person aged 16 or older to aid, encourage, induce or causes minors under 13 to engage in any sexual activity with anyone else, or minors aged 13—15 to engage in sexual activity with people older than them by three years or more.

The age of consent rises to 18 when the older partner — being age 18 or older — is the parent, stepparent, adopted parent, or legal guardian of the younger person, or when the older partner has or occupies a position of authority over the younger person. This does not apply for minors aged 16 or 17 as long as the older partner is less than three years older and is not the younger person's parent, stepparent, adopted parent or legal guardian.

According to section , a position of authority "means an employer, youth leader, scout leader, coach, teacher, counselor, school administrator, religious leader, doctor, nurse, psychologist, guardian ad litem, babysitter, or a substantially similar position, and a police officer or probation officer other than when the officer is exercising custodial control" over a person under According to Section , affirmative defenses for the crimes outlined in Sections — exists for consensual activity between legal spouses and for cases where the defendant reasonably believed that a minor age 13 or older was of legal age.

Sections and of the Commonwealth Code also criminalize sexual activity with people aged 18 or 19, if they are "committed to the custody of the Department of Public Health and Environmental Services under the Commonwealth's civil or criminal laws, and the offender is the legal guardian of the person".

The age of consent in Puerto Rico is Article Paraphrasing Virgin Islands Code: V. The age of consent is There is however a close-in-age exemption that allows minors 16 and 17 years old to consent with someone no more than five years older than themselves and minors 13 to 15 years old to consent with one another, but not with anyone 16 or over. Aggravated rape in the first degree bans sexual intercourse or sodomy with a child under Sexual acts with minors are aggravated by the use of force, intimidation, or the perpetrator's position of authority, and by the fact that the minor, being under 16 and not the perpetrator's spouse, is residing in the same household as the perpetrator.

Any person under 18 years of age but over 16 years of age who perpetrates an act of sexual intercourse or sodomy with a person not the perpetrator's spouse who is under 16 years of age but over 13 years of age, under circumstances not amounting to rape in the first degree, is guilty of rape in the third degree and shall be subject to the jurisdiction of the Family Division of the Superior Court. A person who engages in sexual contact with a person not the perpetrator's spouse—..

A person over eighteen years of age who engages in sexual contact with a person not the perpetrator's spouse who is over thirteen but under sixteen years of age is guilty of unlawful sexual contact in the second degree and shall be imprisoned not more than 1 year. As such, all US Federal laws regarding age of consent would be applicable. From Wikipedia, the free encyclopedia. Not to be confused with Marriage age in the United States. Readers are reminded that Wikipedia is not a reliable source.

There is no process in place which ensures that the information in this article or any Wikipedia article is accurate. It should not be inferred that information posted in this article is correct merely because that information has remained unchanged for extended periods of time, as inaccurate information may remain posted for months or years without being corrected.

Journalists are also cautioned not to rely on this page. The contents of this page are not subjected to review by persons qualified to perform a proper legal analysis of the relevant law. Citing information from this article in a published source even with a disclaimer can have negative consequences for your journalistic reputation and career. The distinction is that a rape involves vaginal intercourse.

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Austin Bureau.