NIMH Multisite HIV Prevention Trial Group. A test of factors mediating the relationship between unwanted sexual activity during childhood and risky sexual practices among women enrolled in the NIMH Multisite HIV Prevention Trial

Adverse Experiences in Childhood and Sexually Transmitted Infection Risk From Adolescence Into Adulthood

BACKGROUND

Childhood maltreatment, particularly sexual abuse, has been found to be associated with sexual risk behaviors later in life. We aimed to evaluate associations between a broad range of childhood traumas and sexual risk behaviors from adolescence into adulthood.

METHODS

Using data from Waves I, III and IV of the National Longitudinal Study of Adolescent to Adult Health (Add Health), we used logistic regression to estimate the unadjusted odds ratio (OR) and adjusted OR (AOR) for associations between 9 childhood traumas and a cumulative trauma score and three sexual risk outcomes (multiple partnerships, sex trade involvement, and sexually transmitted infection [STI]) in adolescence, young adulthood, and adulthood. We also examined modification of these associations by gender.

RESULTS

Associations between cumulative trauma score and sexual risk outcomes existed at all waves, though were strongest during adolescence. Dose-response-like relationships were observed during at least 1 wave of the study for each outcome. Violence exposures were strong independent correlates of adolescent sexual risk outcomes. Parental binge drinking was the only trauma associated with biologically confirmed infection in young adulthood (AOR, 1.46; 95% confidence interval [CI], 1.01-2.11), whereas parental incarceration was the trauma most strongly associated with self-reported STI in adulthood (AOR, 1.70; 95% CI, 1.11-2.58). A strong connection was also found between sexual abuse and sex trade in the young adulthood period (AOR, 2.17; 95% CI, 1.43-2.49).

CONCLUSIONS

A broad range of traumas are independent correlates of sex risk behavior and STI, with increasing trauma level linked to increasing odds of sexual risk outcomes. The results underscore the need to consider trauma history in STI screening and prevention strategies.

Pilot Test of an Integrated Sexual Risk Reduction Intervention for Women with a History of Childhood Sexual Abuse

HIV and childhood sexual abuse (CSA) are intersecting public health problems for women. We pilot tested an integrated sexual risk reduction intervention for women with a history of CSA that addressed both the consequences of CSA [based on the Traumagenic Dynamics (TD) framework] and the antecedents of sexual risk behavior (based on the Information-Motivation-Behavioral Skills [IMB] model). Women with a history of CSA who were attending a public STI clinic (n = 84) were randomly assigned to a five-session integrated TD/IMB (experimental) group intervention or to a time-matched IMB-guided sexual risk reduction (control) group intervention. Preliminary findings indicated that women in the integrated TD/IMB intervention reduced their average number of episodes of unprotected sex with a primary partner, their alcohol use, and their likelihood of being in a violent relationship, relative to women in the IMB-only group. Our findings suggest that sexual risk reduction interventions that address both the consequences of CSA and the antecedents of sexual risk behavior may be efficacious in reducing sexual risk behavior among women who were sexually abused.

Development and Refinement of a Targeted Sexual Risk Reduction Intervention for Women With a History of Childhood Sexual Abuse

Childhood sexual abuse (CSA) is associated with sexual risk behavior in adulthood. Traditional sexual risk reduction interventions do not meet the unique needs of women who have been sexually abused. In the current paper, we describe the four-stage process we followed to develop and refine a targeted sexual risk reduction intervention for this population. First, initial quantitative work revealed that the intervention should address how maladaptive thoughts related to traumatic sexualization, trust, powerlessness, and guilt/shame (traumagenic dynamics constructs) influence current sexual behavior. Second, qualitative interviews with 10 women who reported a history of CSA (M age = 34 years; 90% African American) as well as current sexual risk behavior provided support for targeting maladaptive thoughts associated with these traumagenic dynamics constructs. Third, based on the qualitative and quantitative results, we developed a 5-session, group-delivered intervention to address the maladaptive thoughts that occurred as a result of CSA, as well as the cognitive-behavioral determinants of sexual risk behavior. This intervention drew heavily on cognitive behavioral techniques to address cognitions associated with CSA and the links between these cognitions and current sexual risk behavior. Techniques from trauma-based therapies, as well as motivational techniques, were also incorporated into the intervention. Finally, we refined the intervention with 24 women (M age = 33 years; 79% African American), and assessed feasibility and acceptability. These women reported high levels of satisfaction with the intervention. The resultant intervention is currently being evaluated in a small, randomized controlled trial.

Intervening in the HIV/AIDS Crisis: The Role of Black Psychologists

Over the prior 2 decades, HIV and AIDS have ravaged the Black community. This article summarizes the epidemiologic, social, and psychological impact of HIV/AIDS on individuals and affected subpopulations in the Black community. An overview is then provided of prevailing research on psychological and mental health issues in HIV/AIDS-related prevention and care that highlights key issues of concern to Black psychologists and areas in which Black psychologists are well positioned to make important contributions to the field. In conclusion, specific suggestions for Black psychologists to become more involved in work on HIV/AIDS are provided.

Types and Characteristics of Childhood Sexual Abuse: How Do They Matter in HIV Sexual Risk Behaviors Among Women in Methadone Treatment in New York City?

BACKGROUND

Childhood sexual abuse (CSA) is often considered an important distal factor in HIV sexual risk behaviors; however, there are limited and mixed findings regarding this relationship among women experiencing substance use problems. In addition, research with this population of women has yet to examine differences in observed CSA-HIV sexual risk behaviors relationships by CSA type and characteristics.

OBJECTIVES

This study examines relationships between CSA coding, type, and characteristics and HIV sexual risk behaviors with main intimate partners among a random sample of 390 women in methadone treatment in New York City who completed individual interviews with trained female interviewers.

RESULTS

Findings from logistic regression analyses indicate that CSA predicts substance use with sexual activity, with variations by CSA coding, type, and characteristics; however, the role of CSA is more limited than expected. Having a main partner with HIV risk mediates some relationships between CSA and drinking four or more drinks prior to sex. Intimate partner violence is the most consistent predictor of sexual risk behaviors. Other salient factors include polysubstance use, depression, social support, recent incarceration, relationship characteristics, and HIV status.

CONCLUSIONS/IMPORTANCE

This study contributes to understanding of relationships between CSA and HIV sexual risk behaviors and key correlates associated with HIV sexual risk behaviors among women in methadone treatment. It also highlights the complexity of measuring CSA and its association with sexual risk behaviors and the importance of comprehensive approaches to HIV prevention that address psychological, relational, situational, and substance use experiences associated with sexual risk behaviors among this population.

Risk factors of repeated infectious disease incidence among substance-dependent girls and boys court-referred to treatment

BACKGROUND

A small portion of Americans account for a disproportionate amount of the incidences of sexually transmitted infection observed over a short period of time. Studies with adults have begun to characterize this population, yet there is very little data on adolescent sexually transmitted infection repeaters (STIR). This study explores characteristics associated with STIR among 102 girls and 93 boys (aged 14-18) court-referred for residential treatment.

METHODS

Background characteristics, substance use disorders, risky and interpersonal behaviors, and history of sexually transmitted infections were collected at intake using valid and reliable instruments. A negative binomial logistic regression was performed to determine the background, risky behaviors, and social patterns associated with adolescent STIR.

RESULTS

Approximately two out of three adolescents (62%) did not use contraception the last time they had sex, and 15% had at least one sexually transmitted infection recorded in their medical chart. Sexually transmitted infection repeaters entered treatment with higher rates of cocaine abuse (13%) than youth without multiple infections (3%, p < 0.05). History of sexual abuse, having sex with a person who said no, higher exhibitionism, and social estrangement increased the odds of adolescent STIR. Main effects of exhibitionism and social estrangement on increased odds of STIR were more pronounced for sexually abused adolescents.

CONCLUSIONS

The findings suggest a need for incorporating HIV education during residential treatment to improve health outcomes and intervention strategies that further connectedness for youth and victims of sexual abuse.

Strategies and outcomes of HIV status disclosure in HIV-positive young women with abuse histories

Young women with HIV and histories of physical and/or sexual abuse in childhood may be vulnerable to difficulties with disclosure to sexual partners. Abuse in childhood is highly prevalent in HIV-positive women, and has been associated with poorer communication, low assertiveness, low self worth, and increased risk for sexual and other risk behaviors that increase the risk of secondary transmission of HIV. HIV disclosure may be an important link between abuse and sexual risk behaviors. Qualitative interviews with 40 HIV-positive young women with childhood physical and/or sexual abuse were conducted; some women had also experienced adult victimization. Results suggest that HIV-positive women with abuse histories use a host of strategies to deal with disclosure of HIV status, including delaying disclosure, assessing hypothetical responses of partners, and determining appropriate stages in a relationship to disclose. Stigma was an important theme related to disclosure. We discuss how these disclosure processes impact sexual behavior and relationships and discuss intervention opportunities based on our findings.

Victimization and sexual risk behavior in young, HIV positive women: exploration of mediators

In this study we explore associations between child and adult victimization and sexual risk behavior in 118 young, HIV positive women. Prior research has demonstrated associations between victimization and engagement in sexual risk behavior. Victimization sequelae can include disrupted assertiveness and communication, as well as increased association with risky partners, both of which are also linked with engagement in sexual risk behavior. Thus, we propose a model wherein victimization is linked to sexual risk behavior through two mediating pathways, sexual communication and affiliation with risky partners. We also examine the moderating effects of the presence of an anxiety or depressive disorder on the path from child to adult victimization. Results suggested that adult victimization was associated with unprotected sex with a main partner; however, this association was mediated by less sexual communication and having a risky partner. Trends toward significance were found for depression and anxiety as a moderator of the relationship between child and adult victimization. Child victimization did not have direct effects on unprotected sex. Implications for secondary prevention of HIV and healthy intimate relationships are discussed.

Exploring the role of child sexual abuse and posttraumatic stress disorder symptoms in gay and bisexual men reporting compulsive sexual behavior

OBJECTIVES

Compulsive sexual behavior (CSB) is an impairing yet understudied clinical phenomenon. The experience of child sexual abuse (CSA) has been implicated as an etiological factor in the development of some cases of CSB (Kuzma & Black, 2008); however, research regarding the role of CSA and related psychopathology in CSB symptomatology has been limited in the literature. The present study aimed to examine the uniqueness of the association of CSA with CSB as compared to other experiences of child maltreatment; the role of posttraumatic stress disorder (PTSD) symptomatology in CSB symptoms for individuals reporting CSA; and clinical differences between individuals with and without histories of CSA.

METHODS

Hypotheses were tested using data from a sample of 182 gay and bisexual men reporting CSB symptoms.

RESULTS

CSA prevalence was high in the tested sample (39%). CSA severity was a unique predictor of CSB symptoms, above child physical and emotional abuse, and poly-victimization status was not significantly related to CSB symptoms. Contrary to hypotheses, PTSD symptoms did not significantly mediate the role of CSA severity, although PTSD symptoms explained additional variance in CSB symptoms, with the final model accounting for over a quarter of the variance in CSB symptoms (27%). Finally, men with a history of CSA reported more CSB, depressive, and anxious symptoms than those without a history of CSA.

CONCLUSIONS

Findings from the present study support the hypothesis that CSA may be uniquely related to CSB symptoms, above other forms of child maltreatment, and indicate that men with a CSA history are likely to present more severe clinical comorbidities. Clinical implications and future research directions are discussed.

The effect of pre-existing affect on the sexual responses of women with and without a history of childhood sexual abuse

Women with a history of childhood sexual abuse (CSA) are at greater risk for experiencing sexual problems in their adult lives. Yet, little is known about the possible role of cognitive and affective mechanisms in the development of sexual arousal difficulties in this population. This study investigated the role of pre-existing affect (affect prior to exposure to sexual stimuli) on genital responses, subjective sexual arousal, and affect elicited during the presentation of erotic film excerpts in a community sample of 25 women with and 25 women without a history of CSA. The CSA group showed greater pre-existing negative affect and smaller genital responses to the erotic film stimuli compared to the NSA group. Findings support a moderating effect of CSA, in that pre-existing negative affect was associated with strength of genital responses in the NSA but not in the CSA group. The results did not support a mediation model of pre-existing negative affect as an explanation for smaller physiological sexual responses in the CSA group. Taken together, the findings suggest that pre-existing affect may be more relevant for women with no history of CSA and call for more research on factors implicated in impaired sexual responses in women with a history of CSA.

Sexual health in women reporting a history of child sexual abuse

OBJECTIVE

The present study examined the association between child sexual abuse (CSA) and sexual health outcomes in young adult women. Maladaptive coping strategies and optimism were investigated as possible mediators and moderators of this relationship.

METHOD

Data regarding sexual abuse, coping, optimism and various sexual health outcomes were collected using self-report and computerized questionnaires with a sample of 889 young adult women from the province of Quebec aged 20-23 years old.

RESULTS

A total of 31% of adult women reported a history of CSA. Women reporting a severe CSA were more likely to report more adverse sexual health outcomes including suffering from sexual problems and engaging in more high-risk sexual behaviors. CSA survivors involving touching only were at greater risk of reporting more negative sexual self-concept such as experiencing negative feelings during sex than were non-abused participants. Results indicated that emotion-oriented coping mediated outcomes related to negative sexual self-concept while optimism mediated outcomes related to both, negative sexual self-concept and high-risk sexual behaviors. No support was found for any of the proposed moderation models.

CONCLUSIONS

Survivors of more severe CSA are more likely to engage in high-risk sexual behaviors that are potentially harmful to their health as well as to experience more sexual problems than women without a history of sexual victimization. Personal factors, namely emotion-oriented coping and optimism, mediated some sexual health outcomes in sexually abused women. The results suggest that maladaptive coping strategies and optimism regarding the future may be important targets for interventions optimizing sexual health and sexual well-being in CSA survivors.

Mental health in Ecuadorian migrants from a population-based survey: the importance of social determinants and gender roles

PURPOSE

To describe the prevalence of and the risk factors for poor mental health in female and male Ecuadorian migrants in Spain compared to Spaniards.

METHOD

Population-based survey. Probabilistic sample was obtained from the council registries. Subjects were interviewed through home visits from September 2006 to January 2007. Possible psychiatric case (PPC) was measured as score of ≥5 on the General Health Questionnaire-28 and analyzed with logistic regression.

RESULTS

Of 1,122 subjects (50% Ecuadorians, and 50% women), PPC prevalence was higher in Ecuadorian (34%, 95% CI 29-40%) and Spanish women (24%, 95% CI 19-29%) compared to Ecuadorian (14%, 95% CI 10-18%) and Spanish men (12%, 95% CI 8-16%). Shared risk factors for PPC between Spanish and Ecuadorian women were: having children (OR 3.1, 95% CI 1.4-6.9), work dissatisfaction (OR 4.1, 95% CI 1.6-10.5), low salaries (OR 2.5, 95% CI 1.1-5.9), no economic support (OR 1.8, 95% CI 0.9-3.4), and no friends (OR 2.2, 95% CI 1.1-4.2). There was an effect modification between the nationality and educational level, having a confidant, and atmosphere at work. Higher education was inversely associated with PPC in Spanish women, but having university studies doubled the odds of being a PPC in Ecuadorians. Shared risk factors for PPC in Ecuadorian and Spanish men were: bad atmosphere at work (OR 2.4, 95% CI 1.3-4.4), no economic support (OR 3.5, 95% CI 1.3-9.5), no friends (OR 2.5, 95% CI 0.9-6.6), and low social support (OR 1.6, 95% CI 0.9-2.9), with effect modification between nationality and partner's emotional support.

CONCLUSIONS

Mental health in Spanish and Ecuadorian women living in Spain is poorer than men. Ecuadorian women are the most disadvantaged group in terms of prevalence of and risk factors for PPC.

Interventions for encouraging sexual behaviours intended to prevent cervical cancer

BACKGROUND

Human papillomavirus (HPV) is the key risk factor for cervical cancer. Continuing high rates of HPV and other sexually transmitted infections (STIs) in young people demonstrate the need for effective behavioural interventions.

OBJECTIVES

To assess the effectiveness of behavioural interventions for young women to encourage safer sexual behaviours to prevent transmission of STIs (including HPV) and cervical cancer.

SEARCH STRATEGY

Systematic literature searches were performed on the following databases: Cochrane Central Register of Controlled Trials (CENTRAL Issue 4, 2009) Cochrane Gynaecological Cancer Review Group (CGCRG) Specialised Register, MEDLINE, EMBASE, CINAHL, PsychINFO, Social Science Citation Index and Trials Register of Promoting Health Interventions (TRoPHI) up to the end of 2009. All references were screened for inclusion against selection criteria.

SELECTION CRITERIA

Randomised controlled trials (RCTs) of behavioural interventions for young women up to the age of 25 years that included, amongst other things, information provision about the transmission and prevention of STIs. Trials had to measure behavioural outcomes (e.g. condom use) and/or biological outcomes (e.g. incidence of STIs, cervical cancer).

DATA COLLECTION AND ANALYSIS

A narrative synthesis was conducted. Meta-analysis was not considered appropriate due to heterogeneity between the interventions and trial populations.

MAIN RESULTS

A total of 5271 references were screened and of these 23 RCTs met the inclusion criteria. Most were conducted in the USA and in health-care clinics (e.g. family planning).The majority of interventions provided information about STIs and taught safer sex skills (e.g. communication), occasionally supplemented with provision of resources (e.g. free sexual health services). They were heterogeneous in duration, contact time, provider, behavioural aims and outcomes. A variety of STIs were addressed including HIV and chlamydia. None of the trials explicitly mentioned HPV or cervical cancer prevention.Statistically significant effects for behavioural outcomes (e.g. increasing condom use) were common, though not universal and varied according to the type of outcome. There were no statistically significant effects of abstaining from or reducing sexual activity. There were few statistically significant effects on biological (STI) outcomes. Considerable uncertainty exists in the risk of bias due to incomplete or ambiguous reporting.

AUTHORS' CONCLUSIONS

Behavioural interventions for young women which aim to promote sexual behaviours protective of STI transmission can be effective, primarily at encouraging condom use. Future evaluations should include a greater focus on HPV and its link to cervical cancer, with long-term follow-up to assess impact on behaviour change, rates of HPV infection and progression to cervical cancer. Studies should use an RCT design where possible with integral process evaluation and cost-effectiveness analysis where appropriate. Given the predominance of USA studies in this systematic review evaluations conducted in other countries would be particularly useful.

Pathways from childhood abuse and neglect to HIV-risk sexual behavior in middle adulthood

OBJECTIVE

This study examines the relationship between childhood abuse and neglect and sexual risk behavior in middle adulthood and whether psychosocial factors (risky romantic relationships, affective symptoms, drug and alcohol use, and delinquent and criminal behavior) mediate this relationship.

METHOD

Children with documented cases of physical abuse, sexual abuse, and neglect (ages 0-11) processed during 1967-1971 were matched with nonmaltreated children and followed into middle adulthood (approximate age 41). Mediators were assessed in young adulthood (approximate age 29) through in-person interviews between 1989 and 1995 and official arrest records through 1994 (N = 1,196). Past year HIV-risk sexual behavior was assessed via self-reports during 2003-2004 (N = 800). Logistic regression was used to examine differences in sexual risk behavior between the abuse and neglect and control groups, and latent variable structural equation modeling was used to test mediator models.

RESULTS

Child abuse and neglect was associated with increased likelihood of risky sexual behavior in middle adulthood, odds ratio = 2.84, 95% CI [1.74, 4.64], p ≤ .001, and this relationship was mediated by risky romantic relationships in young adulthood.

CONCLUSIONS

Results of this study draw attention to the potential long-term consequences of child abuse and neglect for physical health, in particular sexual risk, and point to romantic relationships as an important focus of intervention and prevention efforts.

The long-term effects of childhood maltreatment experiences on subsequent illicit drug use and drug-related problems in young adulthood

OBJECTIVES

The objective of this study was to examine the associations between (a) childhood maltreatment (i.e., physical abuse, sexual abuse, and neglect) and subsequent illicit drug use and (b) childhood maltreatment and drug-related problems in young adulthood.

METHODS

Wave 1 and Wave 3 public-use data from the National Longitudinal Study of Adolescent Health were used. Logistic regressions, controlling for adolescent drug use and other important family and peer contextual processes, were estimated to determine the associations between (a) childhood maltreatment experiences and subsequent illicit drug use and (b) childhood maltreatment and drug-related problems in young adulthood.

RESULTS

Among the participants, 31.9% reported some form of childhood maltreatment. Childhood physical abuse was associated with a 37% (OR=1.37; 95% CI=1.04, 1.80) increase in illicit drug use during the 30 days prior to the Wave 3 survey, a 48% (OR=1.48; 95% CI=1.16, 1.89) increase in illicit drug use during the year prior to the Wave 3 survey, and a 96% (OR=1.96; 95% CI=1.40, 2.76) increase in drug-related problems in young adulthood. The latter two associations persisted even after controlling for illicit drug use in adolescence. Neglect among females was associated with a higher likelihood of past year illicit drug use in young adulthood (OR=1.31; 95% CI=1.002, 1.71). However, this association was not significant once the effect of illicit drug use in adolescence was statistically controlled for.

CONCLUSIONS

The present findings suggest that childhood maltreatment is related to subsequent illicit drug use and drug-related problems in young adulthood and that some of these associations differ by gender. Implications for preventive intervention are discussed.

Interpersonal violence: an important risk factor for disease and injury in South Africa

BACKGROUND

Burden of disease estimates for South Africa have highlighted the particularly high rates of injuries related to interpersonal violence compared with other regions of the world, but these figures tell only part of the story. In addition to direct physical injury, violence survivors are at an increased risk of a wide range of psychological and behavioral problems. This study aimed to comprehensively quantify the excess disease burden attributable to exposure to interpersonal violence as a risk factor for disease and injury in South Africa.

METHODS

The World Health Organization framework of interpersonal violence was adapted. Physical injury mortality and disability were categorically attributed to interpersonal violence. In addition, exposure to child sexual abuse and intimate partner violence, subcategories of interpersonal violence, were treated as risk factors for disease and injury using counterfactual estimation and comparative risk assessment methods. Adjustments were made to account for the combined exposure state of having experienced both child sexual abuse and intimate partner violence.

RESULTS

Of the 17 risk factors included in the South African Comparative Risk Assessment study, interpersonal violence was the second leading cause of healthy years of life lost, after unsafe sex, accounting for 1.7 million disability-adjusted life years (DALYs) or 10.5% of all DALYs (95% uncertainty interval: 8.5%-12.5%) in 2000. In women, intimate partner violence accounted for 50% and child sexual abuse for 32% of the total attributable DALYs.

CONCLUSIONS

The implications of our findings are that estimates that include only the direct injury burden seriously underrepresent the full health impact of interpersonal violence. Violence is an important direct and indirect cause of health loss and should be recognized as a priority health problem as well as a human rights and social issue. This study highlights the difficulties in measuring the disease burden from interpersonal violence as a risk factor and the need to improve the epidemiological data on the prevalence and risks for the different forms of interpersonal violence to complete the picture. Given the extent of the burden, it is essential that innovative research be supported to identify social policy and other interventions that address both the individual and societal aspects of violence.

Associations between childhood adversity and depression, substance abuse and HIV and HSV2 incident infections in rural South African youth

OBJECTIVES

To describe prevalence of childhood experiences of adversity in rural South African youth and their associations with health outcomes.

METHODS

We analyzed questionnaires and blood specimens collected during a baseline survey for a cluster randomized controlled trial of a behavioral intervention, and also tested blood HIV and herpes simplex type 2 virus at 12- and 24-month follow up; 1,367 male and 1,415 female volunteers were recruited from 70 rural villages.

RESULTS

Both women and men before 18 had experienced physical punishment (89.3% and 94.4%), physical hardship (65.8% and 46.8%), emotional abuse (54.7% and 56.4%), emotional neglect (41.6% and 39.6%), and sexual abuse (39.1% and 16.7%). Incident HIV infections were more common in women who experienced emotional abuse (IRR 1.96, 95% CI 1.25, 3.06, p=.003), sexual abuse (IRR 1.66 95% CI 1.04, 2.63, p=.03), and physical punishment (IRR 2.13 95% CI 1.04, 4.37, p=.04). Emotional neglect in women was associated with depression (aOR 1.82, 95% CI 1.15, 2.88, p=.01), suicidality (aOR 5.07, 95% CI 2.07, 12.45, p<.0001), alcohol abuse (aOR 2.17, 95% CI .99, 4.72, p=.05), and incident HSV2 infections (IRR 1.62, 95% CI 1.01, 2.59, p=.04). In men emotional neglect was associated with depression (aOR 3.41, 95% CI 1.87, 6.20, p<.0001) and drug use (aOR 1.98, 95% CI 1.37, 2.88, p<.0001). Sexual abuse was associated with alcohol abuse in men (aOR 3.68, 95% CI 2.00, 6.77, p<.0001) and depression (aOR 2.16, 95% CI 1.34, 3.48, p=.002) and alcohol abuse in women (aOR 3.94, 95% CI 1.90, 8.17, p<.0001).

PRACTICE IMPLICATIONS

Childhood exposure to adversity is very common and influences the health of women and men. All forms of adversity, emotional, physical and sexual, enhance the risk of adverse health outcomes in men and women. Prevention of child abuse need to be included as part of the HIV prevention agenda in sub-Saharan Africa. Interventions are needed to prevent emotional, sexual, and physical abuse and responses from health and social systems in Africa to psychologically support exposed children must be strengthened.

Experience of sexual abuse in childhood and abortion in adolescence and early adulthood

OBJECTIVE

The present study examined the associations between the experience of sexual abuse in childhood (CSA) and the number of abortions in adolescence and early adulthood.

METHOD

A 25-year prospective longitudinal study of the health, development, and adjustment of a birth cohort of 1,265 New Zealand children (630 females). Measures included assessments of experience of CSA using retrospective data gathered at ages 18 and 21, self-reported abortions from ages 15 to 25, measures of childhood socio-economic disadvantage, family stability, family functioning, experience of childhood physical abuse, and pregnancy in adolescence and early adulthood.

RESULTS

Severity of CSA experience was significantly (p<.01) associated with an increasing rate of abortions during ages 15-25. Adjustment of the association for potentially confounding factors from childhood reduced the magnitude of the association, but it remained marginally statistically significant (p<.10). However, controlling for the mediating effects of pregnancy risk in adolescence and early adulthood reduced the association between experience of CSA and abortion to statistical non-significance (p>.70).

CONCLUSIONS

The current study suggested that the association between experience of CSA and increased rates of abortion was mediated by the increased rates of pregnancy associated with CSA experiences. The results suggest a causal chain in which experience of CSA leads to increased rates of pregnancy, which in turn leads to increased rates of abortion.

Child abuse in young, HIV-positive women: linkages to risk

In this article we explore the lives of young women living with HIV who experienced physical and/or sexual abuse in childhood. Using a modified version of the Life Story Interview, 40 women recruited from HIV clinics in three different states participated in a qualitative interview. Interviews covered abuse experiences, cognitive and emotional consequences of abuse, coping strategies, and sexual behavior and relationships. Overall, these young women had complex abuse histories, often experiencing more than one type of abuse in the context of other difficult life events. Avoidance and substance use were frequently utilized as coping strategies for abuse-related distress. Young women reported sexual and relationship concerns, including avoidance of sex, sexual dysfunction, sex as a trigger for abuse memories, and difficulty establishing intimacy and trust. Relationships between abuse-related reactions and sexual risk behavior, as well as recommendations for interventions, are discussed.

Sexually transmitted diseases among adults who had been abused and neglected as children: a 30-year prospective study

OBJECTIVES

We examined associations between childhood abuse and neglect and the risk in adulthood for sexually transmitted diseases.

METHODS

In a prospective cohort design, we matched children aged 0 to 11 years with documented cases of abuse or neglect during 1967 to 1971 with a control group of children who had not been maltreated (754 participants in all) and followed them into adulthood. Information about lifetime history of sexually transmitted diseases was collected as part of a medical status examination when participants were approximately 41 years old.

RESULTS

Childhood sexual abuse increased risk for any sexually transmitted disease (odds ratio [OR] = 1.94; 95% confidence interval [CI] = 1.00, 3.77; P = .05) and more than 1 type of sexually transmitted disease (OR = 3.33; 95% CI = 1.33, 8.22; P = .01). Physical abuse increased risk for more than 1 type of sexually transmitted disease (OR = 3.61; 95% CI = 1.39, 9.38; P = .009).

CONCLUSIONS

Our results provided the first prospective evidence that child physical and sexual abuse increases risk for sexually transmitted diseases. Early screening and interventions are needed to identify and prevent sexually transmitted diseases among child abuse victims.

Gender-based violence and HIV: relevance for HIV prevention in hyperendemic countries of southern Africa

Gender-based violence (GBV) is common in southern Africa. Here we use GBV to include sexual and non-sexual physical violence, emotional abuse, and forms of child sexual abuse. A sizeable literature now links GBV and HIV infection.Sexual violence can lead to HIV infection directly, as trauma increases the risk of transmission. More importantly, GBV increases HIV risk indirectly. Victims of childhood sexual abuse are more likely to be HIV positive, and to have high risk behaviours.GBV perpetrators are at risk of HIV infection, as their victims have often been victimised before and have a high risk of infection. Including perpetrators and victims, perhaps one third of the southern African population is involved in the GBV-HIV dynamic.A randomised controlled trial of income enhancement and gender training reduced GBV and HIV risk behaviours, and a trial of a learning programme reported a non-significant reduction in HIV incidence and reduction of male risk behaviours (primary prevention). Interventions among survivors of GBV can reduce their HIV risk (secondary prevention). Various strategies can reduce spread of HIV from infected GBV survivors (tertiary prevention). Dealing with GBV could have an important effect on the HIV epidemic.A policy shift is necessary. HIV prevention policy should recognise the direct and indirect implications of GBV for HIV prevention, the importance of perpetrator dynamics, and that reduction of GBV should be part of HIV prevention programmes. Effective interventions are likely to include a structural component, and a GBV awareness component.

Disentangling the complex association between childhood sexual abuse and alcohol-related problems: a review of methodological issues and approaches

This review describes and evaluates methodological approaches aimed at unraveling the association between childhood sexual abuse (CSA) and later misuse of alcohol, which is complicated by the significant overlap between factors that elevate risk for CSA exposure and those that increase risk for problem alcohol use. We critique methods used to distinguish direct effects of CSA events on alcohol-related outcomes from the effects of risk factors frequently present in families in which CSA exposure occurs (e.g., parental alcohol-related problems). These methods include measurement and adjustment for potentially confounding factors and the use of co-twin designs. The findings across methodological approaches provide support for a CSA-specific risk for alcohol misuse, despite the significant contribution of family background factors to overall risk, but much work remains to be done before a comprehensive model for this association can be proposed. Additional directions for research, including the incorporation of measured genes and the use of longitudinal designs, are proposed to further efforts to model the pathways from CSA to alcohol-related problems.

Childhood and adolescent sexual abuse and subsequent sexual risk behavior: evidence from controlled studies, methodological critique, and suggestions for research

Childhood and adolescent sexual abuse (CSA) is associated with a wide variety of adverse psychological and health outcomes, including negative sexual health outcomes. In this paper, we review the literature investigating the relation between CSA and subsequent sexual risk behaviors among men and women. Previous research has found a relatively consistent association between CSA and higher rates of sexual risk behaviors, particularly sex trading, more sexual partners, and an earlier age of first intercourse. However, there are a number of limitations to this research, including lack of a consistent definition of CSA, failure to investigate gender as a moderator, and possible confounding of the CSA experience with some of the sexual behavior outcome variables. Further, although there appears to be an association between CSA and later sexual risk behavior, researchers have not established whether this association is causal. Suggestions for future research and implications for clinical practice are discussed.

History of childhood sexual abuse and HIV risk behaviors in homosexual and bisexual men

OBJECTIVES

We examined the prevalence and frequency of childhood sexual abuse and their association with sexual risk among a sample of gay and bisexual men. Methods. Cross-sectional data were collected by survey from randomly selected gay and bisexual men who attended the 1997 and 1998 Minneapolis/St. Paul Gay, Lesbian, Bisexual, and Transgender Pride Festivals. Data included demographics, sexual activity, history of childhood sexual abuse, HIV status, history of sexually transmitted infection, use of sex-related drugs (such as crack, cocaine, Ecstasy, amyl nitrate, crystal methamphetamine, and Special K), and history of exchanging sex for payment. Results. childhood sexual abuse was reported by 15.5% of the survey respondents (n = 134). Those who reported experiencing abuse regularly were more likely to (1) be HIV positive, (2) have exchanged sex for payment, and (3) be a current user of sex-related drugs. Neither unsafe sex nor sexually transmitted infections were associated with childhood sexual abuse.

CONCLUSIONS

These findings show that more than 1 in 7 gay and bisexual men in a non-clinical, festival-based setting were victims of childhood sexual abuse and that childhood sexual abuse was associated with alarmingly high rates of men who were HIV infected and antecedent risk behaviors.

The effects of childhood trauma on sex trading in substance using women

This article presents a model developed to understand the relationship between childhood victimization, perpetration of violence, and later cocaine dependence and adult sex trading among drug using women. A cohort of heavy drinking and drug using women (N=594) recruited for two on-going community based HIV prevention studies in St. Louis City was analyzed to evaluate this association using path analysis. The women were stratified into two groups: sex traders and non-sex traders. Sex traders were more likely than non-sex traders to report being forced to kiss or touch someone in a sexual way before age 15 (35% vs. 22%), being kissed or touched in a sexual way by others when they did not want to be (42% vs. 31%), and being forced to have sexual intercourse (30% vs. 21%). Sex traders were more likely than non-sex traders to use a weapon or threaten someone with a weapon (29% vs. 18%) and physically hurt others on purpose before age 15 (9% vs. 5%). Path analysis confirmed that childhood victimization had a significant and direct association with both adult cocaine dependence and sex trading. However, the association between childhood perpetration and adult sex trading was mediated by cocaine dependence. This analysis concludes that childhood victimization was the strongest predictor of cocaine dependence and sex trading in adulthood.

Childhood sexual abuse, relationship satisfaction, and sexual risk taking in a community sample of women

Childhood sexual abuse (CSA) has been proposed to influence both women's adult sexual risk behaviors and the quality of their intimate relationships. Among a household sample of women (n = 732), good fit was obtained for a model in which CSA predicted Wave 1 male partner sexual risk and aggression characteristics, resulting in lower relationship satisfaction, and ultimately in higher numbers of Wave 2 sexual partners. The model was generally replicated among women who entered new relationships at Waves 2 and 3. Partner sexual risk characteristics also were associated with women's risk of sexually transmitted infection from current partner. Elevated sexual risk behaviors among CSA survivors reflect difficulty in establishing stable and safe relationships and may be reduced by interventions aimed at improving intimate relationships.

Association of violence victimization with inconsistent condom use in HIV-infected persons

The association of violence victimization with current condom use in HIV-infected persons was examined in this cross-sectional study. The HIV-Alcohol Longitudinal Cohort (HIV-ALC) recruited HIV-infected participants with a history of alcohol problems. Interviews assessed violence histories and current sexual behaviors. Of the 349 participants (79% men), 38% reported inconsistent condom use and 80% reported a violence history. Lifetime sexual violence was reported by 40% and lifetime physical violence (without sexual violence) by 40%. Participants reporting lifetime sexual violence had greater odds of inconsistent condom use than participants without any history of violence. A history of childhood sexual violence was also associated with greater odds of inconsistent condom use than participants without a history of childhood sexual violence. A history of sexual violence may in part explain HIV-infected persons' greater risk for transmitting HIV through high-risk sexual behaviors.

Predictors of sexual risk behaviors among adolescent mothers in a human immunodeficiency virus prevention program

PURPOSE

The purpose of this study was to determine the following: (1) whether adolescent mothers in a human immunodeficiency virus (HIV) prevention program had significantly greater perceived self-efficacy and perceived behavioral control to use condoms, and more favorable outcome expectancies and subjective norms regarding condom use than those in a health education control group, 3 months after intervention; and (2) the impact of the 3-month postintervention theoretical variables on intentions to use condoms at 3 months and sexual risk behaviors at 6 months.

METHODS

Structural equation modeling with latent variables was used to assess the influence of theoretical variables and treatment condition using data from 496 participants (78% Latinas, 18% African-Americans) who completed questionnaires at baseline and at 3- and 6-month follow-up evaluations.

RESULTS

Substantial improvements were shown by both groups, with a slight advantage for the HIV prevention group, on all theoretical variables between pretest and the follow-up evaluations. In the predictive model, the intervention group reported significantly fewer sex partners. By using intentions to use condoms as a mediator, greater self-efficacy, hedonistic beliefs, positive subjective norms, and less unprotected sex predicted intentions to use condoms, which, in turn, predicted less unprotected sex. Lower subjective norms modestly predicted multiple partners. Significant indirect paths mediated through intentions to use condoms were observed.

CONCLUSIONS

These data support a relationship among several constructs from social cognitive theory and the theory of reasoned action, and subsequent sexual risk behaviors. HIV-prevention programs for adolescent mothers should be designed to include these theoretical constructs and to address contextual factors influencing their lives.

Educational attainment but not literacy is associated with HIV risk behavior among incarcerated women

PURPOSE

To identify the educational factors associated with HIV risk behaviors among incarcerated women.

METHODS

We evaluated a cohort of female detainees at The Rhode Island Adult Correctional Institute between July and September 2004. Among the 423 women who participated in the study, 55% did not have a high school diploma, 29% had < or = 8th grade reading capacity, 32% had a learning disability, 37% had problem drinking, and 61% (257/423) reported HIV risk behavior.

RESULTS

In multiple logistic regression, participants who had completed high school had the lowest likelihood of HIV risk behavior (adjusted odds ratio [OR] 0.35, 95% confidence interval [CI] 0.12-1.00). There was no association between participants? literacy level and HIV risk behavior (adjusted OR 2.02, 95% CI 0.83-4.92).

CONCLUSIONS

Correctional education programs to reduce HIV risk behavior should focus on those with low educational attainment irrespective of literacy skills.

Low-income African American women's attempts to convince their main partner to use condoms

In this cross-sectional study the authors examine condom use attempts and condom use among 305 high-risk, low-income African American women who reported having a main partner. Women who had recently attempted to convince their main partner to use condoms were almost 10 times more likely to have recently used condoms with their partner than women who had not made an attempt. Among the subsample of 116 women who had recently made a condom use attempt with their main partner, having a history of childhood abuse and having one's main partner raise infidelity questions in response to the condom use attempt were negatively associated with recent condom use with this partner. Findings provide initial insights into the importance of women's condom use attempts, as well as subgroups of women who may encounter special challenges convincing their main partner to use condoms.

Sex on television and its impact on american youth: background and results from the RAND Television and Adolescent Sexuality study

Many policy makers and parents have called for stricter regulation of television, fearing that the sexual content in this medium spurs adolescent sexual activity. Media theory and research over the last few decades are consistent with this notion but fall short of answering the question of whether television content is causally related to adolescent sexual behavior. This article briefly reviews this earlier work and discusses the results of several new studies based on the RAND Television and Adolescent Sexuality data set. Practitioners should discuss television use and television portrayals of sex with adolescents, and help youth to identity and avoid any adverse effects the media might have on their sexual development and sexual behavior.

A meta-analysis of the relationship of child sexual abuse to HIV risk behavior among women

OBJECTIVE

This study is a meta-analysis of the literature exploring the relationship between child sexual abuse (CSA) and HIV risk behavior among women. Four outcome variables were tested: unprotected sex; sex with multiple partners; sex trading; and adult sexual revictimization.

METHOD

Forty-six studies met the inclusion criteria and were included in the analysis, and separate meta-analyses were performed for each of the four dependent variables described above.

RESULTS

Using the correlation coefficient r as an effect size estimate, results indicate an average effect size of .05 for the unprotected sex meta-analysis (N = 16 studies), .13 for the sex with multiple partners meta-analysis (N = 23 studies), .12 for the sex trading meta-analysis (N = 23 studies), and .17 for the adult sexual revictimization meta-analysis (N = 21 studies). We conducted a test of three potential moderator variables (source of sample, definition of CSA based on type of contact, and definition of CSA based on maximum age of victim). Results did not support the hypothesis that these three variables explain a significant amount of variability in effect sizes with one exception: Studies that define CSA more broadly to include adolescent victims (e.g., victims up to 17 years of age) had larger and more homogenous effect sizes for the sex trading meta-analysis than those that defined CSA as having occurred at younger ages.

CONCLUSIONS

These findings suggest a small positive relationship between CSA and subsequent HIV risk behavior among women that varies as a function of how CSA and HIV risk behavior are operationalized.

Child Sexual Abuse and Number of Sexual Partners in Young Women: The Role of Abuse Severity, Coping Style, and Sexual Functioning

The authors proposed and tested a model describing distinct pathways through which childhood sexual abuse (CSA) may lead to relatively low or high numbers of sexual partners in adulthood. Path analyses were conducted on survey responses of young female US Navy recruits who reported CSA (N=547). Use of avoidant strategies to cope with CSA was expected to produce higher levels of sexual problems and fewer heterosexual sex partners, whereas use of self-destructive coping strategies was expected to result in more dysfunctional sexual behavior and more heterosexual sex partners. As predicted, the effect of CSA on number of sex partners was largely mediated by coping strategies and dysfunctional sexual behavior.

Gender differences in the context of sex exchange among individuals with a history of crack use

Although sex exchange among crack users is associated with risky sexual behavior, research suggests that there is a subgroup of crack users who do not engage in high-risk sex exchange. The purpose of this study is to understand differences among individuals with a history of crack use who have and have not engaged in sex exchange; and to better understand gender differences in the context of sex exchange. The study sample included 148 male (64.2% reported sex exchange) and 149 female heterosexual individuals with a history of crack use (59.1% reported sex exchange). Results suggest that HIV prevention interventions should incorporate gender specific information related to sex exchange for heterosexual crack users. Future research is needed to address the gap in understanding the transition into sex exchange practices for heterosexual male and female drug users.

Women, sex, and HIV: social and contextual factors, meta-analysis of published interventions, and implications for practice and research

This article is focused on examining social and contextual factors related to HIV-risk behavior for women. Specifically, this article has three main purposes: to review the literature on selected social and contextual factors that contribute to the risk for the heterosexual transmission of HIV and AIDS, to review and conduct a meta-analysis of HIV-prevention interventions targeting adult heterosexual populations, and to suggest future directions for HIV-prevention intervention research and practice. Results suggest that the HIV-prevention interventions reviewed for this article had little impact on sexual risk behavior, that social and contextual factors are often minimally addressed, and that there was a large gap between research and the practice of HIV-prevention intervention.