Guided LGBTQ-affirmative internet cognitive-behavioral therapy for sexual minority youth's mental health: A randomized controlled trial of a minority stress treatment approach

OBJECTIVE

LGBTQ-affirmative cognitive-behavioral therapy (CBT) addresses the adverse impacts of minority stress. However, this treatment has rarely been tested in randomized controlled trials with LGBTQ youth and never using an asynchronous online platform for broad reach. This study examined the feasibility, acceptability, preliminary efficacy, and multi-level stigma moderators of LGBTQ-affirmative internet-based CBT (ICBT).

METHOD

Participants were 120 LGBTQ youth (ages 16-25; 37.5% transgender or non-binary; 75.8% assigned female at birth; 49.2% non-Latino White) living across 38 U.S. states and reporting depression and/or anxiety symptoms. Participants were randomized to receive 10 sessions of LGBTQ-affirmative ICBT or only complete 10 weekly assessments of mental and behavioral health and minority stress; all completed measures of psychological distress, depression, anxiety, suicidal thoughts, alcohol use, and HIV-transmission-risk behavior at baseline and 4 and 8 months post-baseline; 20 LGBTQ-affirmative ICBT participants completed a qualitative interview regarding intervention acceptability.

RESULTS

Participants randomized to LGBTQ-affirmative ICBT completed, on average, 6.08 (SD = 3.80) sessions. Participants reported that LGBTQ-affirmative ICBT was helpful and engaging and provided suggestions for enhancing engagement. Although most outcomes decreased over time, between-group comparisons were small and non-significant. LGBTQ-affirmative ICBT was more efficacious in reducing psychological distress than assessment-only for participants in counties high in anti-LGBTQ bias (b = -1.73, p = 0.001, 95% CI [-2.75, -0.70]). Session dosage also significantly predicted reduced depression and anxiety symptoms.

CONCLUSIONS

LGBTQ-affirmative ICBT represents a feasible and acceptable treatment. Future research can identify more efficacious approaches and modalities for engaging LGBTQ youth, especially those living under stigmatizing conditions, who might benefit most.

Intimate Partner Violence Survivors' Daily Experiences of Social Disconnection, Substance Use, and Sex with Secondary Partners

Women who have experienced intimate partner violence (IPV) are disproportionately likely to engage in sexual risk behavior, including sex with a secondary partner (i.e., sex partners outside their primary relationship). Social disconnection has been identified as a social determinant of health that may enhance understanding of sex with a secondary partner. This study extends past research by using an intensive longitudinal design consisting of multiple daily assessments to examine event-level associations between women IPV survivors' social disconnection and sex with a secondary partner concurrently (i.e., during the same aggregated assessment) and temporally (i.e., social disconnection during one assessment predicting sex with a secondary partner in a subsequent assessment) over a 14-day period, in consideration of physical, psychological, and sexual IPV, and alcohol and drug use. Participants (N = 244) were recruited from New England through 2017. Results from multilevel logistic regression models indicate that women who experienced greater social disconnection on average were more likely to report sex with a secondary partner. However, after including IPV and substance use in the model, the strength of this relationship was attenuated. Sexual IPV emerged as a between-person predictor of sex with a secondary partner in temporally lagged models. Results provide insight into the relationships between daily social disconnection and sex with a secondary partner among IPV survivors, particularly regarding the effects of substance use and IPV both concurrently and temporally. Taken together, findings emphasize the importance of social connection for women's well-being and highlight the need for interventions that enhance interpersonal connectedness.

Domestic Violence Housing First Model and Association With Survivors' Housing Stability, Safety, and Well-being Over 2 Years

Importance

Intimate partner violence (IPV) is a leading cause of homelessness and a serious threat to public health and well-being.

Objective

To determine whether the Domestic Violence Housing First (DVHF) model improves safety, housing stability, and mental health over 2 years.

Design, Setting, and Participants

This longitudinal comparative effectiveness study interviewed IPV survivors and reviewed their agency records. All unstably housed or homeless IPV survivors entering domestic violence (DV) services were eligible to participate in the study, ensuring capture of typical variability in service delivery (eg, some survivors would enter services when agencies had the capacity to provide DVHF and others would receive services as usual [SAU]). Clients from 5 DV agencies (3 rural and 2 urban) referred by agency staff in a Pacific Northwest state of the United States were assessed between July 17, 2017, and July 16, 2021. Interviews were conducted in English or Spanish at entry into services (baseline) and at 6-, 12-, 18-, and 24-month follow-up visits. The DVHF model was compared with SAU. The baseline sample included 406 survivors (92.7% of 438 eligible). Of the 375 participants retained at the 6-month follow-up (92.4% retention), 344 had received services and had complete data across all outcomes. Three hundred sixty-three participants (89.4%) were retained at the 24-month follow-up.

Intervention

The DVHF model has 2 components: housing-inclusive advocacy and flexible funding.

Main Outcomes and Measures

Main outcomes included housing stability, safety, and mental health, which were assessed using standardized measures.

Results

Of the 344 participants (mean [SD] age, 34.6 [9.0] years) included in the analyses, 219 (63.7%) received DVHF and 125 (36.3%) received SAU. Most participants identified as female (334 [97.1%]) and heterosexual (299 [86.9%]). Two hundred twenty-one participants (64.2%) were from a racial and ethnic minority group. Longitudinal linear mixed-effects models showed that receiving SAU was associated with greater housing instability (mean difference, 0.78 [95% CI, 0.42-1.14]), DV exposure (mean difference, 0.15 [95% CI, 0.05-0.26]), depression (mean difference, 1.35 [95% CI, 0.27-2.43]), anxiety (mean difference, 1.15 [95% CI, 0.11-2.19]), and posttraumatic stress disorder (mean difference, 0.54 [95% CI, 0.04-1.04]) compared with receiving the DVHF model.

Conclusions and Relevance

Evidence in this comparative effectiveness study suggests that the DVHF model was more effective than SAU in improving the housing stability, safety, and mental health of survivors of IPV. The DVHF's amelioration of all of these interconnected public health issues-relatively quickly and with long-term continuance-will be of substantial interest to DV agencies and others working to support unstably housed IPV survivors.

Domestic violence survivors' housing stability, safety, and well-being over time: Examining the role of domestic violence housing first, social support, and material hardship

Intimate partner violence remains a significant public health issue and survivors often need various forms of support to achieve safety. The increased likelihood of experiencing housing instability and homelessness among survivors has led to an uptake in domestic violence agencies implementing housing-based interventions, such as Domestic Violence Housing First (DVHF), to address survivors' needs. The present study expands on prior research supporting the effectiveness of DVHF to examine situational factors that moderate the outcomes associated with this model among 406 survivors seeking services from domestic violence agencies located in the Pacific Northwestern region of the United States. Using latent profile analysis, participants were grouped into three latent classes: (a) "high abuse/instability," (b) "still affected," and (c) "doing better." Latent transition analysis was used to estimate the probability that participants would transition into a different latent class over time with social support (SS), material hardship, and receipt of DVHF services included as model predictors. Receipt of DVHF predicted improvements in survivors' safety, housing stability, mental health, and well-being, such that receiving DVHF was associated with higher odds of survivors transitioning into the "doing better" class. Social support and material hardship also emerged as significant factors predicting class membership, such that higher levels of social support and financial stability predicted membership in the "doing better" class. Additionally, social support and financial stability appeared to augment receipt of DVHF services, with DVHF being more strongly associated with positive outcomes among participants who also had high levels of social support and lower levels of material hardship. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Impact of the Domestic Violence Housing First Model on Survivors' Safety and Housing Stability: Six Month Findings

Intimate partner violence (IPV) is a leading cause of homelessness, yet little evidence exists about effective strategies to assist IPV survivors as they work to avoid homelessness while freeing themselves from abuse. An ongoing demonstration evaluation is examining if and how one promising model assists IPV survivors in obtaining safe and stable housing over time. The Domestic Violence Housing First (DVHF) model involves providing IPV survivors with mobile advocacy and/or flexible funding, depending on individual needs, in order to attain these goals. We hypothesized that those receiving DVHF would experience greater housing stability and less re-abuse compared to survivors receiving services as usual. The current study evaluated the short-term efficacy of the DVHF model with a sample of 345 homeless or unstably housed survivors who sought services and who completed in-person interviews shortly after contacting the DV agency, as well as six months later. Those who received the DVHF model showed greater improvement in their housing stability compared to those receiving services as usual, as well as decreased economic abuse. Both groups experienced a sharp decline in all forms of abuse. The Domestic Violence Housing First model shows promise in helping unstably housed DV survivors achieve safe and stable housing. Study findings have implications for DV agencies as well as those funding such services. Understanding which interventions work best for which survivors is critical to ensuring that service providers are effectively working toward long-term housing stability and well-being for IPV survivors and their children.

Intimate Partner Violence Fear-11 Scale: An Item Response Analysis

Objective

Victims of intimate partner violence (IPV) often fear their intimate partners and the abuse they perpetrate against them. Fear in the context of IPV has been studied for decades yet, we lack a rigorously validated measure. The purpose of this study was to comprehensively evaluate the psychometric properties of a multi-item scale measuring fear of an abusive male partner and/or the abuse he perpetrates.

Method

We used Item Response modeling to evaluate the psychometric properties of a scale measuring women's fear of IPV by their male partner across two distinct samples: 1) a calibration sample of 412 women and 2) a confirmation sample of 298 women.

Results

Results provide a detailed overview of the psychometric functioning of the Intimate Partner Violence Fear-11 Scale. Items were strongly related to the latent fear factor, with discrimination values universally above a = 0.80 in both samples. Overall, the IPV Fear-11 Scale is psychometrically robust across both samples. All items were highly discriminating and the full scale was reliable across the range of the latent fear trait. Reliability was exceptionally high for measuring individuals experiencing moderate to high levels of fear. Finally, the IPV Fear-11 Scale was moderately to strongly correlated with depression symptoms, posttraumatic stress symptoms and physical victimization.

Conclusions

The IPV Fear-11 Scale was psychometrically robust across both samples and was associated with a number of relevant covariates. Results support the utility of the IPV Fear-11 Scale for assessing fear of an abusive partner among women in relationships with men.

Impact of the Domestic Violence Housing First Model on Survivors' Safety and Housing Stability: 12-Month Findings

Intimate partner violence (IPV) is a widespread and devastating phenomenon resulting in a myriad of long-term consequences for survivors and their children. IPV victimization not only has negative health and economic consequences, it has also been linked to homelessness and housing instability. In response, the Domestic Violence Housing First (DVHF) model is being used in some domestic violence (DV) agencies to help survivors attain safe and stable housing. The model includes using individualized advocacy and/or flexible funding to help survivors meet these goals. Using a longitudinal, quasi-experimental design, the current study involved conducting interviews with survivors and examining agency records to investigate the effectiveness of this model. We hypothesized that survivors who received DVHF would experience less re-abuse and greater housing stability over 12 months compared to those who received services as usual (SAU). The sample included 345 IPV survivors who had been homeless or unstably housed when they approached one of five DV programs for help. Interviews were spaced 6 months apart (when survivors first sought services as well as 6 months and 12 months later). Longitudinal analyses showed that survivors who received the DVHF model reported greater improvements in housing stability at both the 6-month and 12-month time points compared to those receiving SAU. At the 12-month time point, survivors who had received DVHF reported decreased physical, psychological, and economic abuse, as well as the use of their children against them as a form of abuse. This study adds to a growing body of evidence supporting this model's effectiveness and adds to our understanding of factors impacting the long-term housing stability and safety for IPV survivors.

The impact of COVID-19 on the safety, housing stability, and mental health of unstably housed domestic violence survivors

Using data from an ongoing longitudinal study, we examined the impact of the COVID-19 stay-at-home orders on a racially diverse population of unstably housed domestic violence (DV) survivors over time. Specifically, we examined survivors' safety, housing stability, and mental health before, during, and after the onset of COVID-19, and how demographic, social, and familial factors attenuated or exacerbated the effect of the stay-at-home orders. Approximately 300 participants were initially interviewed after they sought services from a DV agency, and then again, every 6 months over 2 years. COVID-19 stay-at-home orders occurred midway through the completion of this multi-year study. Longitudinal mixed effects models were estimated to examine the impact of COVID-19 on the safety, housing stability, and mental health of survivors over time. We also examined models with several time-varying (e.g., employment, income, social support, and number of children) and time-invariant (baseline outcome scores, racial/ethnic identity, education, and disability status) control variables. Results revealed that safety, housing stability and mental health were improving for study participants before the onset of the COVID-19 pandemic but plateaued after the stay-at-home orders were issued. Experiences of abuse, housing instability, and mental health symptomatology did not worsen as a result of the COVID-19 stay-at-home orders. Notably, social support and housing services emerged as important predictors of outcomes, such that participants who received housing-related services and greater social support reported less abuse, less housing instability, and lower mental health distress. COVID-19 temporarily disrupted the positive trajectory unstably housed DV survivors were experiencing in regard to safety, housing stability and mental health. These findings provide critical insight into the importance of service access during and after global catastrophes. Additional resources and support may be helpful in assisting survivors to return to their pre-pandemic recovery and growth trajectories.

Examining contextual influences on the service needs of homeless and unstably housed domestic violence survivors

Domestic violence (DV) is a leading cause of homelessness for women, yet many DV agencies are just beginning to focus on helping clients stabilize their housing situations. The purpose of this study was to better understand the contexts and service needs of unstably housed and homeless DV survivors, to promote more efficient and successful service matching from DV agencies. We examined whether DV survivors could be grouped by particular features, histories, and contextual factors, and how these group differences impacted what they needed from DV agencies. The sample included 406 homeless and unstably housed DV survivors who had recently sought DV services. Latent class analysis supported the identification of four distinct classes: (1) highest disadvantages service seeker, (2) moderate disadvantages-criminal legal system service seeker, (3) moderate disadvantages service seeker, and (4) lower disadvantages service seeker. Additionally, we were able to profile each class, and test the types of services survivors in each class needed from agencies.

Evaluation in the Real World: Decision Points and Rationales in Creating A Rigorous Study Designed to Convey Ecologically Valid Findings

Rigorously evaluating community-based interventions for multiply marginalized populations is fraught with challenges under the best of circumstances. This manuscript describes the methodology chosen to evaluate an innovative model designed to help survivors of intimate partner violence obtain safe and stable housing. We justify the choice of evaluation design from a community psychology perspective and detail why we believe the multi-method, multi-source design, that also focuses on social context, will maximize ecological validity and, therefore, propel the scale-up of the intervention if it is found to be effective. Longitudinal data are being collected from program recipients over time, the advocates who worked with them, agency service records, and monthly documentation of agency resources on hand that can impact services provided. Special attention is focused on capturing contextual information that can impact program success. While randomized control trials are still too often heralded as "the gold standard" for measuring intervention effectiveness, we maintain that the current design, which was developed in partnership with key community stakeholders, holds more promise when evaluating many community-based programs.

Gendered powerlessness in at-risk adolescent and young women: an empirical model

In the United States, youth aged 13-24 comprised approximately 21% of new HIV infections in 2017; 13% of these infections occurred among women, the majority of whom (86%) acquired HIV through heterosexual contact (Centers for Disease Control and Prevention. 2019a. HIV and youth. Retrieved from https://www.cdc.gov/hiv/group/age/youth/index.html, Centers for Disease Control and Prevention. 2019b. HIV among women. Retrieved from https://www.cdc.gov/hiv/group/gender/women/index.html). We fit and validated a developmentally appropriate empirical model of Connell's Theory of Gender and Power (Connell, R. W. 1987. Gender and power: Society, the person and sexual politics. Stanford, CA: Stanford University Press, Connell, R. W. 2013. Gender and power: Society, the person and sexual politics. Hoboken, NJ: John Wiley & Sons) in a sample of young women and assessed whether gendered powerlessness reflected a multidimensional higher-order latent factor, as the theory implies. Anonymous computer-assisted interviews were administered to at-risk, sexually active young women (N = 1,101). Factor analyses and structural equation modeling were used to determine the dimensionality of gendered powerlessness. Associations with condom use were examined to validate the model. We fit a three-component model of gendered powerlessness, but not a higher-order latent factor. We observed that high scores on two dimensions of gendered powerlessness - cathexis and sexual division of power - were associated with lower likelihood of condom use. Our three-component model helps elucidate the role that components of gendered powerlessness play in young women's health behaviors and underscores the need for measures tailored to young women at high risk of contracting HIV.

Improving Timely Linkage to Care among Newly Diagnosed HIV-Infected Youth: Results of SMILE

Delayed linkage to care deprives youth living with HIV of the benefits of HIV treatment and risks increased HIV transmission. Developing and testing linkage-to-care models that are capable of simultaneously addressing structural and individual obstacles are necessary to attain national goals for timely linkage of newly diagnosed youth to care. We assessed an integrated, multi-pronged strategy for improving youth's timely linkage to care carried out in eight adolescent medicine clinical trials units (AMTUs) in the USA. In phase I, the intervention strategy paired intensive medical case management with formalized relationships to local health departments, including granting of public health authority (PHA) to four of the AMTUs. In phase II, local coalitions run by the AMTUs to address structural changes to meet youth's HIV prevention and HIV testing needs began to advocate for local structural changes to improve timely access to care. Results of an ARIMA model demonstrated sustained decline in the average number of days to link to care over a 6-year period (ARIMA (1,2,1) AIC = 245.74, BIC = 248.70, p < .01)). By the end of the study, approximately 90% of youth linked to care had an initial medical visit in 42 or fewer days post-diagnosis. PHA improved the timeliness of linkage to care (b = - 69.56, p < .05). A piecewise regression suggested the addition of structural change initiatives during phase II made a statistically significant contribution to reducing time to linkage over and above achievements attained via case management alone (F (3,19) = 5.48, p < .01; Adj. R² = .3794). Multi-level linkage-to-care interventions show promise for improving youth's timely access to HIV medical care.

Ecological Barriers to HIV Service Access among Young Men who have Sex with Men and High-Risk Young Women from Low-resourced Urban Communities

Using an ecological perspective, we sought to elucidate the perceived barriers preventing HIV service access among two groups of U.S. youth (ages 12-24) disproportionately affected by HIV, men who have sex with men and high-risk women. We content analyzed interviews with 318 key informants to identify distinct service barriers. The 29 barriers informants named were organized into six categories (service-seeking demands, stigmas, knowledge and awareness, service quality, powerful opposition, and negative emotions). Findings suggest that barriers impacting access to HIV prevention, testing, and linkage-to-care services are remarkably similar and point to the need for comprehensive approaches to improving youth's access services that address both individual-level barriers and extra-individual barriers simultaneously. Findings can be used to guide future research, programming and interventions to reduce the disproportionate spread of HIV among US youth.

Anticipated HIV Stigma and Delays in Regular HIV Testing Behaviors Among Sexually-Active Young Gay, Bisexual, and Other Men Who Have Sex with Men and Transgender Women

Young gay, bisexual and other men who have sex with men (YGBMSM) and young transgender women are disproportionately affected by HIV/AIDS. The success of biomedical prevention strategies is predicated on regular HIV testing; however, there has been limited uptake of testing among YGBMSM and young transgender women. Anticipated HIV stigma-expecting rejection as a result of seroconversion- may serve as a significant barrier to testing. A cross-sectional sample of YGBMSM (n = 719, 95.5%) and young transgender women (n = 33, 4.4%) ages 15-24 were recruited to participate in a one-time survey. Approximately one-third of youth had not tested within the last 6 months. In a multivariable model, anticipated HIV stigma and reporting a non-gay identity were associated with an increased odds of delaying regular HIV testing. Future research and interventions are warranted to address HIV stigma, in order to increase regular HIV testing among YGBMSM and transgender women.

Youth health outcomes from the Connect-to-Protect Coalitions to prevent adolescent HIV infections

We assessed the relationships among HIV-related social and behavioral outcomes resulting from an adolescent-focused HIV structural change initiative in eight urban sites operating Connect to Protect (C2P) coalitions. Over a 4-year period, annual cross-sectional panels of adolescents (N = 2,248) completed an audio-computer-assisted interview, providing data on satisfaction with their communities as adolescent-supportive environments, internalized HIV stigma, lifetime HIV-testing, lifetime sexual risk-taking, and number of sexual partners in the prior year. We used structural equation modeling to estimate hypothesized links between time since coalition mobilization to our social and behavioral outcomes. Over the 4 years, adolescents perceived their communities to become more supportive (p < .05). Positive perceptions of community support were associated with lower lifetime HIV sexual risk (p < .05). The effect of time on risk behavior was mediated by perceptions of community support. Stigma was unchanged over time. Stigma had damaging effects on risk behavior, effects which were also mediated by perceptions of community support. Special efforts are needed to address the deleterious effect of HIV stigma on high-risk urban adolescents.

Structural and Community Change Outcomes of the Connect-to-Protect Coalitions: Trials and Triumphs Securing Adolescent Access to HIV Prevention, Testing, and Medical Care

Connect to Protect (C2P), a 10-year community mobilization effort, pursued the dual aims of creating communities competent to address youth's HIV-related risks and removing structural barriers to youth health. We used Community Coalition Action Theory (CCAT) to examine the perceived contributions and accomplishments of 14 C2P coalitions. We interviewed 318 key informants, including youth and community leaders, to identify the features of coalitions' context and operation that facilitated and undermined their ability to achieve structural change and build communities' capability to manage their local adolescent HIV epidemic effectively. We coded the interviews using an a priori coding scheme informed by CCAT and scholarship on AIDS-competent communities. We found community mobilization efforts like C2P can contribute to addressing the structural factors that promote HIV-risk among youth and to community development. We describe how coalition leadership, collaborative synergy, capacity building, and local community context influence coalitions' ability to successfully implement HIV-related structural change, demonstrating empirical support for many of CCAT's propositions. We discuss implications for how community mobilization efforts might succeed in laying the foundation for an AIDS-competent community.

Evaluating Testing Strategies for Identifying Youths With HIV Infection and Linking Youths to Biomedical and Other Prevention Services

IMPORTANCE

Most human immunodeficiency virus (HIV)-infected youths are unaware of their serostatus (approximately 60%) and therefore not linked to HIV medical or prevention services. The need to identify promising and scalable approaches to promote uptake of HIV testing among youths at risk is critical.

OBJECTIVE

To evaluate a multisite HIV testing program designed to encourage localized HIV testing programs focused on self-identified sexual minority males and to link youths to appropriate prevention services after receipt of their test results.

DESIGN, SETTING, AND PARTICIPANTS

Testing strategies were evaluated using an observational design during a 9-month period (June 1, 2015, through February 28, 2016). Testing strategies were implemented by 12 adolescent medicine HIV primary care programs and included targeted testing, universal testing, or a combination. Data were collected from local youth at high risk of HIV infection and, specifically, sexual minority males of color.

MAIN OUTCOMES AND MEASURES

Proportion of sexual minority males and sexual minority males of color tested, proportion of previously undiagnosed HIV-positive youths identified, and rates of linkage to prevention services.

RESULTS

A total of 3301 youths underwent HIV testing. Overall, 35 (3.6%) of those who underwent universal testing in primary care clinical settings, such as emergency departments and community health centers, were sexual minority males (35 [3.6%] were males of color) compared with 236 (46.7%) (201 [39.8%] were males of color) who were tested through targeted testing and 693 (37.8%) (503 [27.4%] were males of color) through combination efforts. Identification of new HIV-positive cases varied by strategy: 1 (0.1%) via universal testing, 39 (2.1%) through combination testing, and 16 (3.2%) through targeted testing. However, when targeted tests were separated from universal testing results for sites using a combined strategy, the rate of newly identified HIV-positive cases identified through universal testing decreased to 1 (0.1%). Rates of new HIV-positive cases identified through targeted testing increased to 49 (6.3%). Youths who tested through targeted testing (416 [85.1%]) were more likely to link successfully to local HIV prevention services, including preexposure prophylaxis, compared with those who underwent universal testing (328 [34.1%]).

CONCLUSIONS AND RELEVANCE

The findings suggest that community-based targeted approaches to HIV testing are more effective than universal screening for reaching young sexual minority males (especially males of color), identifying previously undiagnosed HIV-positive youths, and linking HIV-negative youths to relevant prevention services. Targeted, community-based HIV testing strategies hold promise as a scalable and effective means to identify high-risk youths who are unaware of their HIV status.

Anogenital and Physical Injuries in Adolescent Sexual Assault Patients: The Role of Victim-Offender Relationship, Alcohol Use, and Memory Impairment

Prior research has documented high rates of anogenital and physical injuries among adolescent sexual assault patients. Although a number of factors related to rates of injury detection in adolescents have been identified, there may be additional features of the assault that are disclosed in the patient history that could be important indicators of injury risk. The purpose of the current study was to expand this literature by examining whether factors that are salient in sexual assaults committed against adolescents-victim-offender relationship, substance use, and memory impairment-are associated with documented anogenital and physical injury rates. Results indicated that victim-offender relationship, substance use, and assault memory are significantly related to the number of anogenital injuries and, particularly, the number of physical injuries detected in adolescent sexual assault patients. These results highlight the importance of a comprehensive patient history, including assessment of alcohol and drug use and memory impairment, to guide the medical forensic examination.

The Effects of Children on the Process of Recovery in Oxford Houses

The effects of children on the process of substance use recovery for adults living in Oxford Houses is explored in two qualitative studies. Oxford Houses are self-run, community-based residential homes for small groups of adults who live together and support each other's efforts to recover from drug and/or alcohol addiction. In the first study, telephone interviews were conducted with 29 adults who were living in Oxford Houses that allowed children to live in the house with their parent. Results suggest that having children in the house supported a positive living environment for the recovery of house members. In the second study, telephone interviews were conducted with an additional 15 mothers who lived in Oxford Houses. These interviews focused on the effects of the mothers' addiction and recovery on their relationships with their children. This study found that most parents acknowledged the negative effects of their addiction on their relationship with their child and the effects of their recovery on improving those relationships.