HIV vulnerability and the adult survivor of childhood sexual abuse

The Influence of Violence Victimization on Sexual Health Behaviors and Outcomes

This study examines the implications of a history of personal violence on health and health behaviors. A secondary analysis of cross-sectional data involving adults (n = 214) from a semirural area in southern Louisiana between October 2008 and December 2010 was conducted to ascertain the association between a personal history of violence victimization and indicators of sexual health behaviors and outcomes: communication with sexual partners about HIV status, consistent condom use, and sexually transmitted infection (STI). While violence victimization is widely accepted as a risk factor for high-risk sex behavior, the mechanisms underlying violence victimization's influence on sexual health outcomes remain unclear. Bivariate analyses demonstrated a significant positive association between experience of physical abuse and lifetime history of STI. Surprisingly, respondents reporting lifetime physical violence were more than two times more likely to ask sexual partners about HIV status [odds ratio (OR) for physical attack = 2.23, 95% confidence intervals (CI) = 1.00-4.97; OR for physical injury = 4.60, 95% CI = 1.79-11.85]. Consistent condom use was not significantly associated with violence exposure in adjusted models. There was no evidence that communication with sexual partners mediated the relationship between experiences of violence and condom use. The link between personal history of violence and condom use may be mediated through alternative pathways beyond communication.

Caring for persons with early childhood trauma, PTSD, and HIV: a curriculum for clinicians

Access and adherence to medical care enable persons with HIV to live longer and healthier lives. Adherence to care improves quality of life, prevents progression to AIDS, and also has significant public health implications. Early childhood trauma-induced posttraumatic stress disorder (PTSD) is one factor that has been identified as an obstacle to adherence to both risk reduction and HIV care. The authors developed a 4-h curriculum to provide clinicians with more confidence in their ability to elicit a trauma history, diagnose PTSD, and address trauma and its sequelae in persons with HIV to improve adherence to medical care, antiretroviral medications, and risk reduction. The curriculum was designed to address the educational needs of primary care physicians, infectious disease specialists, psychiatrists, other specialists, psychologists, social workers, nurses, residents, medical students, and other trainees who provide care for persons infected with and affected by HIV.

Hypersexual behavior and HIV sex risk among young gay and bisexual men

Hypersexual behavior has been identified as a sexual risk correlate among gay and bisexual men (GBM). The Hypersexual Behavior Inventory (HBI) has been shown to be a reliable and valid measure of hypersexual behavior in clinical populations, yet it has not been used to assess hypersexual behavior in nonclinical samples. We examined the psychometric properties of the HBI with survey data recorded between December 2009 and March 2010 in a sample of young men (N = 366, M = 21.46 years old, SD = 1.95) who self-identified as gay (89%) or bisexual (11%) and assessed its association with unprotected receptive anal intercourse (URAI) partners and occasions. Using cross-sectional data of single, sexually active young GBM (YGBM), we used confirmatory factor analyses to test the HBI's three-factor structure. Using negative binomial regressions, we then tested the association between the HBI subscales and sexual risk. After accounting for covariates, we found that sexual control was a risk factor for URAI partners and occasions, and coping was found to be a protective factor for URAI occasions. In light of our findings, we discuss the importance of reexamining the theoretical assumptions of hypersexual behavior and propose HIV prevention strategies that may reduce young GBM's vulnerability to HIV infection.

HIV-infected men who have sex with men and histories of childhood sexual abuse: implications for health and prevention

A personal history of childhood sexual abuse (CSA) is prevalent and deleterious to health for people living with HIV (PLWH), and current statistics likely underrepresent the frequency of these experiences. In the general population, the prevalence of CSA appears to be higher in men who have sex with men (MSM) than heterosexual men, but there are limited data available for HIV-infected MSM. CSA is associated with poor mental and physical health and may contribute to high rates of HIV risk behaviors, including unprotected sex and substance abuse. CSA exposure is also associated with low engagement in care for PLWH. More information is needed regarding CSA experiences of HIV-infected MSM to optimize health and wellbeing for this population and to prevent HIV transmission. This article reviews the epidemiology, implications, and interventions for MSM who have a history of CSA.

The development and psychometric properties of the HIV and Abuse Related Shame Inventory (HARSI)

Shame has been shown to predict sexual HIV transmission risk behavior, medication non-adherence, symptomatic HIV or AIDS, and symptoms of depression and PTSD. However, there remains a dearth of tools to measure the specific constructs of HIV-related and sexual abuse-related shame. To ameliorate this gap, we present a 31-item measure that assesses HIV and sexual abuse-related shame, and the impact of shame on HIV-related health behaviors. A diverse sample of 271 HIV-positive men and women who were sexually abused as children completed the HIV and Abuse Related Shame Inventory (HARSI) among other measures. An exploratory factor analysis supported the retention of three-factors, explaining 56.7% of the sample variance. These internally consistent factors showed good test-retest reliability, and sound convergent and divergent validity using eight well-established HIV specific and general psychosocial criterion measures. Unlike stigma or discrimination, shame is potentially alterable through individually-focused interventions, making the measurement of shame clinically meaningful.

Transactional sex as a form of child sexual exploitation and abuse in Rwanda: implications for child security and protection

OBJECTIVE

To illuminate the different manifestations of transactional sexual exploitation and abuse among Rwanda's children in order to inform effective responses by policies, programs, and communities.

METHOD

Qualitative data was collected during April and May 2010. One-hundred and thirty-nine adults (56% female) and 52 children (60% female) participated in focus groups across three geographic locations in Rwanda. Eleven interviews were held with child protection stakeholders.

RESULTS

Interview and focus group participants reported how children, primarily girls, engaged in transactional sex as a survival strategy in response to situations of adversity including economic deprivation, difficulty accessing school, and social pressure.

CONCLUSIONS

Policy and programs should work to address the underlying social and economic determinants of transactional sexual exploitation through structural interventions that reduce gender inequalities to accessing school and securing basic needs. Further quantitative and qualitative research to better understand the complexities of this issue is warranted.

Visually storying living with HIV: bridging stressors and supports in accessing care

This paper examines how visual narratives may bridge relational understandings between people living with HIV/AIDS (PLWH/A) and future oral health care providers. Borrowing from literature in participatory visual methods such as photo elicitation and photovoice, we explored how PLWH/A visually choose to represent their daily lives. This study uses a grounded theory action-oriented approach in examining the thematic analysis of 257 photos and 12 related reflective participant journals. Ten collaborative themes emerged from the participants' analysis of their photos. These themes of social support, places, family, staff, group, recovery tools, transportation, friends, medications and food exhibited the indivisible characteristics of stressors and supports commonly found in accessing care. Further researcher reflections also found three meta-themes of stigmatization, maintenance of positive mental health and the development of pride in managing one's health. PLWH/A need to share these visual themes of supports and stressors with future dental providers so that they may hopefully acquire an understanding of chronic illness that is more personalized and relationship centered rather than merely numeric and detached.

Sexual Violence Victimization of Women

Sexual violence is a serious public health problem with devastating health-related consequences. In this article, the authors review the prevalence, characteristics, vulnerability factors for, and impacts of sexual violence victimization for women. Some key factors are reviewed that have been shown to increase vulnerability for victimization, including certain demographic characteristics, previous victimization, and use of drugs or alcohol. The impacts of rape and other sexual violence are described, including physical and sexual health; psychological, social, and societal impacts; as well as impact on risky health behaviors. The authors conclude with a discussion of the public health approach to sexual violence, primary prevention, the relevance of sexual violence research for health care practitioners, and recommendations for health care practice.

An evidence-based group coping intervention for women living with HIV and history of childhood sexual abuse

Women living with HIV/AIDS and a history of childhood sexual abuse often exhibit sexual trauma symptoms and elevated rates of HIV-risk behaviors. In this paper, we describe a coping skills group intervention that reduced traumatic stress and sexual-risk behavior in a recent randomized clinical trial. We focused on clinical issues that emerged among female participants receiving the intervention. Clinical observations showed that recognizing connections between trauma, psychological distress, and high risk behaviors was a new and powerful experience for many participants. Participants successfully applied psychoeducational material, expressing an increased sense of power and control over their relationships and behaviors as they developed more adaptive cognitive and behavioral skills. Women expressed high levels of satisfaction with the intervention. Recommendations for clinical practice are provided.

Psychosocial predictors of sexual HIV transmission risk behavior among HIV-positive adults with a sexual abuse history in childhood

Childhood sexual abuse (CSA) is associated with HIV sexual risk behavior. Although many psychosocial correlates of sexual risk among HIV-positive persons have been identified, studies predicting continued risk among HIV-positive adults with histories of CSA are limited. This cross-sectional study identified variables predictive of sexual transmission risk behavior among an ethnically diverse sample of 256 HIV-positive adults (women and men who have sex with men; MSM) with CSA histories. Participants were assessed for trauma symptoms, shame related to HIV and sexual trauma, substance use, coping style, and sexual risk behavior. Logistic regression analyses were conducted to identify variables predictive of unprotected sexual behavior in the past 4 months. Unprotected sex was significantly associated with substance use and trauma-related behavioral difficulties among women and men, and less spiritual coping among men. Unprotected sex with HIV negative or serostatus unknown partners was significantly associated with greater trauma-related behavioral difficulties, more HIV-related shame, and fewer active coping strategies. Thus, trauma symptoms, shame, coping style, and substance use were significantly associated with sexual risk behavior among HIV-positive adults with histories of CSA, with models of prediction differing by gender and partner serostatus. HIV prevention intervention for persons with HIV and CSA histories should address trauma-related behavioral difficulties and enhance coping skills to reduce sexual transmission risk behavior.

The effect of posttraumatic stress disorder on risk-taking propensity among crack/cocaine users in residential substance abuse treatment

BACKGROUND

The co-occurrence of posttraumatic stress disorder (PTSD) and substance use disorders (SUDs) has been found to be associated with a range of negative clinical outcomes (e.g., relapse, suicide, legal problems, HIV infection). However, less is known about the particular factors that may be placing individuals with a co-occurring PTSD and SUD diagnosis at risk for these outcomes. The construct of risk-taking propensity may hold particular promise.

METHODS

To investigate the relevance of risk-taking propensity to PTSD-SUD patients, differences in risk-taking propensity were examined among 90 crack/cocaine dependent patients in residential substance abuse treatment with (n=20) or without (n=70) a current PTSD diagnosis. Risk-taking propensity was assessed using an established behaviorally based measure, the Balloon Analogue Risk Task (BART).

RESULTS

Crack/cocaine dependent patients with PTSD exhibited significantly greater levels of risk-taking propensity than patients without PTSD, and this difference remained significant even when controlling for the presence of comorbid psychiatric disorders and current psychotropic medication use. No evidence was found for a different pattern of change in risk-taking propensity from the beginning to the end of the task as a function of PTSD status.

CONCLUSIONS

Although preliminary, results suggest the need to further investigate risk-taking propensity as a factor that may be associated with the negative clinical outcomes observed among crack/cocaine users with PTSD.

Trauma, mental health, distrust, and stigma among HIV-positive persons: implications for effective care

Individuals living with HIV often have complicated histories, including negative experiences such as traumatic events, mental illness, and stigma. As the medical community in the United States adapts to managing HIV as a chronic disease, understanding factors such as these negative experiences that may be associated with poorer adherence to treatment regimens, greater HIV risk behavior, and lower patient quality of life becomes critical to HIV care and prevention. In less wealthy nations, these issues are also critical for addressing quality of life as well as medication adherence in the areas where antiretroviral therapies are being made available. This article presents a review of the literature regarding the following psychosocial factors as they relate to HIV/AIDS in the US and globally: traumatic events; mental illness, including depression, anxiety, and posttraumatic stress disorder; lack of trust in the healthcare system and government; and experiences of stigma among individuals with HIV disease. These factors have been found to be prevalent among individuals with HIV/AIDS, regardless of gender or race/ethnicity. Traumatic events, mental illness, distrust, and stigma have also been linked with poorer adherence to medication regimens and HIV risk behavior.

Effects of a coping intervention on transmission risk behavior among people living with HIV/AIDS and a history of childhood sexual abuse

OBJECTIVES

To examine the effect of a 15-session coping group intervention compared with a 15-session therapeutic support group intervention among HIV-positive men and women with a history of childhood sexual abuse (CSA) on sexual transmission risk behavior.

DESIGN

A randomized controlled behavioral intervention trial with 12-month follow-up.

METHODS

A diverse sample of 247 HIV-positive men and women with histories of CSA was randomized to 1 of 2 time-matched group intervention conditions. Sexual behavior was assessed at baseline; immediately after the intervention; and at 4-, 8-, and 12-month follow-up periods (5 assessments). Changes in frequency of unprotected anal and vaginal intercourse by intervention condition were examined using generalized linear mixed models for all partners, and specifically for HIV-negative or serostatus unknown partners.

RESULTS

Participants in the HIV and trauma coping intervention condition decreased their frequency of unprotected sexual intercourse more than participants in the support intervention condition for all partners (P < 0.001; d = 0.38, 0.32, and 0.38 at the 4-, 8-, and 12-month follow-up periods, respectively) and for HIV-negative and serostatus unknown partners (P < 0.001; d = 0.48, 0.39, and 0.04 at the 4-, 8-, and 12-month follow-up periods, respectively).

CONCLUSION

A group intervention to address coping with HIV and CSA can be effective in reducing transmission risk behavior among HIV-positive men and women with histories of sexual trauma.

The Cedar Project: a comparison of HIV-related vulnerabilities amongst young Aboriginal women surviving drug use and sex work in two Canadian cities

BACKGROUND

In Canada, Aboriginal women and youth continue to be overrepresented amongst new cases of HIV, and are considered at increased risk for sex and drug-related harm. Young women involved in sex work are particularly vulnerable. The purpose of this study is to determine HIV-related vulnerabilities associated with sex work amongst young Aboriginal women in two Canadian cities.

METHODS

This study is based on a community-based cohort of Aboriginal young people (status and non-status First Nations, Inuit and Métis) between the ages of 14 and 30 who used injection or non-injection illegal drugs (street drugs) in the previous month. Participants lived in Vancouver, Canada, or Prince George, a remote, northern Canadian city. Between October 2003 and July 2005, 543 participants were recruited by word of mouth, posters, and street outreach. A baseline questionnaire was administered by Aboriginal interviewers, and trained nurses drew blood samples for HIV and HCV antibodies and provided pre- and post-test counselling. This study included 262 young women who participated at baseline. Analyses were conducted to compare socio-demographics, drug use patterns, injection practices, sexual experiences, and HIV and HCV prevalence between young women who reported being involved in sex work in the last 6 months (n=154) versus young women who did not (n=108). Logistic regression was used to identify factors independently associated with recent sex work involvement.

RESULTS

Both sexual violence and drug using patterns were found to be markedly different for women having recently been involved in sex work. Multivariate analysis revealed daily injection of cocaine (AOR=4.4; 95% CI: 1.9, 10.1 and smoking crack (AOR=2.9; 95% CI: 1.6, 5.2) in the previous 6 months, and lifetime sexual abuse (AOR=2.5; 95% CI: 1.4, 4.4) to be independently associated with sex work.

INTERPRETATION

Harm reduction and treatment programs that address historical and lifetime trauma amongst Aboriginal people and prioritize emotional and physical safety for young Aboriginal women involved in sex work are required.

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.

Outcomes from a group intervention for coping with HIV/AIDS and childhood sexual abuse: reductions in traumatic stress

Childhood sexual abuse is common among HIV-infected persons, though few empirically supported treatments addressing sexual abuse are available for men and women with HIV/AIDS. This study reports the outcome from a randomized controlled trial of a group intervention for coping with HIV and sexual abuse. A diverse sample of 202 HIV-positive men and women who were sexually abused as children was randomly assigned to one of three conditions: a 15-session HIV and trauma coping group intervention, a 15-session support group comparison condition, or a waitlist control (later randomly assigned to an intervention condition). Traumatic stress symptoms were assessed at baseline and post-intervention, with analysis conducted for the three-condition comparison followed by analysis of the two-condition comparison between the coping and support group interventions. Participants in the coping group intervention exhibited reductions in intrusive traumatic stress symptoms compared to the waitlist condition and in avoidant traumatic stress symptoms compared to the support group condition. No differences were found between the support group intervention and waitlist conditions. Tests of clinical significance documented the meaningfulness of change in symptoms.

Mental health and sexual risk behaviours in a South African township: A community-based cross-sectional study

OBJECTIVES

Despite the high prevalence of both mental illness and human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS) in developing countries, there are few data on the association between different forms of mental illness and sexual risk behaviours in resource-poor settings. The objective of this study was to examine the association between mental illness and HIV risk behaviours in a South African township.

STUDY DESIGN

A cross-sectional study was performed among 645 individuals living in households selected at random.

METHODS

A self-administered translated questionnaire investigated sexual risk behaviours [including sexual partners, condom use, casual sexual contacts, and sex in exchange for money, drugs or a place to stay (transactional sex)], depression (measured using the Center for Epidemiological Studies Depression Scale), alcohol abuse (from the Alcohol Use Disorders Identification Test), and post-traumatic stress disorder (based on the Life Event Checklist).

RESULTS

Of the 645 individuals who completed the survey, 33% reported depression, 17% reported alcohol abuse, and 15% reported post-traumatic stress disorder. After adjusting for demographic characteristics, the presence of any of these three conditions was strongly associated with experiences of forced sex [adjusted odds ratio (AOR) 2.53; 95% confidence intervals (CI) 1.60-4.02], transactional sex (AOR 2.88; 95% CI 1.29-6.48) and increased condom use (AOR 2.07; 95% CI 1.32-3.25).

CONCLUSIONS

These findings emphasize the substantial burden of mental illness in this setting, and its association with forced and transactional sex. The temporal nature of these associations is not always clear from this cross-sectional study, and additional prospective research is required. Public health interventions are needed to address the dual burden of HIV/AIDS and mental illness in this and similar settings.

Childhood trauma, sexually transmitted diseases and the perceived risk of contracting HIV in a drug using population

This cross-sectional study explored the association among childhood trauma, sexually transmitted diseases histories, and perceived risk of contracting AIDS in 358 women and 338 male drug users in San Antonio, Texas. Women addicts were less educated, more likely to be in a common-law relationship, living with someone of the opposite sex or separated, and had lower incomes in comparison to men addicts. Significant findings were that women with increasing severity of abuse (emotional, physical, and sexual) histories as measured by the Childhood Trauma Questionnaire had increasing numbers of sexually transmitted diseases and perceptions of contracting HIV. These findings have implications for future directions in HIV and sexually transmitted disease intervention programs.

Differences among sexually abused and nonabused youth living with HIV

Risk behaviors were compared between sexually abused and nonabused youth living with HIV (YLH). Abused YLH were significantly more likely to have attempted suicide, to have been admitted into an alcohol and/or drug treatment program, and to have engaged in crack cocaine use than were nonabused YLH and had a greater number of sexual partners. A significantly higher proportion of abused YLH had been incarcerated in contrast to nonabused youth. There were also significantly greater conduct problems among abused YLH. Finally, abused YLH had significantly higher scores on positive action and social-support coping styles than nonabused youth. Consistent with previous research, abused youth are at higher risk for a variety of negative outcomes and are also similar in many respects to sexually abused youth who are not HIV-positive. The high frequencies of two positive styles of coping among abused YLH were also observed.

Suicidal ideation and attempted suicide among women living with HIV/AIDS

The prevalence, timing, and predictors of suicidal ideation and attempted suicide were evaluated in a sample of 207 HIV-positive women in New York City. Twenty-six percent of the women reported attempting suicide since their HIV diagnosis. Of those who made an attempt, 42% acted within the first month after diagnosis and 27% acted within the first week. AIDS diagnosis, psychiatric symptoms, and physical or sexual abuse were significant positive predictors of both suicidal ideation and attempts. Contrary to expectations, having children and being employed were also significant positive predictors. Spirituality was significantly negatively associated with suicidal ideation only. These results suggest that suicide prevention measures should be implemented for HIV-positive women immediately after diagnosis. Specifically, interventions should target those with an AIDS diagnosis, psychiatric symptoms, an abuse history, children, or employment. The encouragement of spiritual connection seems to be a deterrent to suicidal thoughts and is a possible avenue for intervention.

Understanding the interface of HIV, trauma, post-traumatic stress disorder, and substance use and its implications for health outcomes

Many individuals living with HIV have been exposed to some type of traumatic event during their lives and may be living with symptoms of post-traumatic stress disorder (PTSD). A substantial number of these individuals are also likely to show evidence of a co-morbid substance use disorder (SUD). There is reason to believe that the co-occurrence of HIV and PTSD or co-morbid PTSD and SUD (PTSD/SUD) may predict poorer health outcomes. There are several pathways through which PTSD or PTSD/SUD might adversely impact the health of individuals living with HIV, including participation in negative health behaviours, low levels of adherence to antiretroviral medications, and/or a direct, deleterious effect on immune function. Psychological interventions are needed to treat PTSD and PTSD/SUD in HIV-positive individuals, and reduce the negative impact of these conditions on health outcomes. This article will explore data on the prevalence of trauma exposure, PTSD, and PTSD/SUD among individuals living with HIV, the pathways through which these conditions might affect health, possible interventions for PTSD and PTSD/SUD for individuals living with HIV, and methods for integrating care for individuals with these disorders. Future directions for research related to HIV, PTSD, and PTSD/SUD will also be discussed.

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.

HIV infection among female drug users in Northern Thailand

Reports on HIV infection and risk behaviors among female drug users in developing countries, particularly in Asia, are limited. In this study, we investigated HIV prevalence and risk factors for HIV infection among 200 women admitted for 21-day inpatient drug detoxification in Chiang Mai, Thailand. Volunteers completed a face-to-face interview using a structured interview, HIV pre-test counseling, specimen collection for HIV and STD tests, and were provided test results and HIV post-test counseling 1 week later. Two-third of participants (68%) were ethnic minorities with no formal education. Overall, 14 (7%) were HIV positive: 25% among 28 heroin injectors and 4.1% among 172 opium or methamphetamine smokers (p<0.001). History of drug injection and sexual abuse were associated with HIV infection. HIV prevention strategies for drug-using women in Thailand should consider both harm reduction strategies for drug use and promoting safer sex measures in a culturally appropriate context.

Factors related to childhood sexual abuse among gay/bisexual male Internet escorts

This exploratory investigation examined the relationship between childhood sexual abuse (CSA) and related psychosocial characteristics and sexual behaviors among 46 gay/bisexual male escorts who advertise via the Internet. More than a quarter of men (28.3%) reported some history of CSA. Men reporting CSA were more likely to be from an ethnic minority group, identify as bisexual, have a primary male partner, and were less likely to identify an anal receptive ("bottom") sexual role preference. Men with a history of CSA were more likely to report unprotected sex with work-related partners, increased internalized homophobia, and decreased adolescent isolation. Interventions designed for male escorts with a history of CSA should emphasize safer sex strategies with work partners and reducing internalized homophobia.

The state of science: violence and HIV infection in women

Violence and human immunodeficiency virus (HIV) are two critical public health problems affecting the lives of millions of women today. The purpose of this article is to review the state of science that exists in linking the phenomena of violence and HIV infection in women. The history and scope of violence and HIV infection is presented. Theoretical models for the phenomena of violence and abuse against women and HIV risk behavior reduction are explored. The literature review consists of 44 research articles that examine risk factors for violence and HIV, violence associated with HIV/AIDS disclosure, history of violence and HIV/AIDS, forced or coercive sex and HIV/AIDS, and violence associated with HIV self-protection conduct. Implications for nursing practice and nursing research are presented.

Self-reported health in HIV-positive African American women: the role of family stress and depressive symptoms

This prospective study examined the association between stressful life events and self-reported health in 72 inner-city, low-income African American women with HIV. Depressive symptoms were examined as a potential mediator of this association. Findings indicated that family stressors predicted deterioration in self-reported health status over the 15-month assessment period. Additionally, the association between family stress and self-reported physical health was mediated by depressive symptoms such that the strength of the association between family stress and self-reported health was no longer statistically significant after depressive symptoms were entered in the model. This study suggests a potentially important target for prevention and intervention efforts aimed at enhancing the quality of life of women with HIV.

HIV prevention in the Hispanic community: sex, culture, and empowerment

To address the serious HIV epidemic in the Hispanic community in the United States, the underlying causes of the epidemic must be addressed. Marginalization, including homophobia, poverty, and racism, as well as cultural factors such as machismo and sexual silence disempower people, making HIV prevention difficult. This article reviews evidence for the impact of marginalization and cultural factors on HIV risk and proposes a cycle of disempowerment. Three examples of empowerment interventions developed specifically for Hispanics (targeting heterosexuals, women, and gay men) are presented, and how these interventions address disempowerment is discussed. One intervention is used to illustrate principles of developing culturally appropriate interventions.

Childhood trauma and adult prostitution behavior in a multiethnic heterosexual drug-using population

A cross-sectional study of the association between severity of childhood trauma and adult prostitution behaviors was conducted among 676 heterosexual drug addicts in San Antonio, Texas. Three hundred and fifty eight women and 338 men taking part in a national multisite program for AIDS prevention research completed the Childhood Trauma Questionnaire as part of a comprehensive risk behavior assessment. Women addicts in the sample were less educated, more likely to be in a common-law relationship, living with someone of the opposite sex or separated, and had lower incomes in comparison to men addicts. Among male subjects,higher educational levels and older age were positively associated with prostitution activities. Single female subjects were three times more likely to engage in selling sex than married subjects. Single women with higher incomes were more likely to be prostituting than single women with lower incomes. Black women reporting severe degrees of emotional abuse, emotional neglect, or physical neglect were more likely to engage in prostitution behavior than Hispanic or white women with similar levels of trauma. Black men with a history of childhood physical abuse were more likely to use prostitutes than Hispanic or white men.

Acknowledging posttraumatic stress effects on health. A nursing intervention model

Many people in our society have been exposed to overwhelming trauma, including abuse and assault. Posttraumatic stress can persist and become a chronic disorder, with behavioral and physiologic alterations affecting health across the lifespan. Often the etiologic role of trauma in a health problem remains undiscerned and unacknowledged. Acknowledging the effects of trauma is a caring intervention in itself, and it can lead to more effective healthcare and better relationships with patients. This article describes the process of acknowledging the effects of trauma in clinical reasoning, in dialogue with the patient, and in planning care and interventions.

Abuse, Social Support, and Depression Among HIV-Positive Heterosexual, Bisexual, and Lesbian Women

SUMMARY A nonprobability sample of HIV-positive mostly African American and Puerto Rican women in New York City were surveyed regarding abusive experiences, social support, and depressive symptoms. Seventy-five percent reported experiencing physical or sexual abuse at some point in their lives. Multiple regression analyses controlling for relevant sociodemographic variables indicated that child physical and sexual abuse and adult sexual abuse were significantly associated with depressive symptomatology (i.e., CES-D scores). HIV-related social support had a significant negative correlation with CES-D scores but did not have a moderating impact on the effects of physical or sexual abuse. Lesbian/bisexual women reported higher rates of lifetime sexual and physical abuse than heterosexual women. However, there were no differences between the groups in total CES-D scores. Lesbian/bisexual women had significantly greater support from friends and groups/organizations than the heterosexual women. The implications of the findings for future research and the provision of services for HIV-positive women are considered.

Posttraumatic stress disorder in women attending human immunodeficiency virus outpatient clinics

This study examined posttraumatic stress disorder (PTSD) in human immunodeficiency virus (HIV)-positive women seeking medical care. Specifically, we examined traumatic life events, psychiatric treatment, social support, and demographic characteristics in relation to level of PTSD symptoms. We recruited and obtained informed consent from 47 ethnically diverse HIV-positive women from two HIV outpatient clinics in a county medical system. Forty-one of these women provided complete data on measures assessing demographics, traumatic life events, PTSD symptoms, social support, and psychotherapy/medical history. Analysis of the data demonstrated that a high percentage (42%) of the HIV-positive women were likely to meet criteria for full current PTSD, and an additional 22% for partial PTSD. Of the women likely with full PTSD, 59% were not receiving any psychiatric treatment, and of those likely with partial PTSD, 78% were not receiving any psychiatric treatment. Also, women reported having experienced a mean of 12 traumatic life events. As hypothesized, the level of PTSD was significantly related to the number of life events experienced (rs = 0.52, p < 0.001), and to perceived social support from friends (rs = - 0.34, p < 0.02) and family (rs = - 0.29, p < 0.05). Given the high percentages of women who were found to have experienced traumatic life events and high levels of PTSD symptoms, it seems important to assess and treat PTSD in women with HIV/acquired immune deficiency syndrome (AIDS).

Understanding the psychodynamics of non-adherence to medical treatment in persons with HIV infection

We present this medical-psychiatric case discussion to illustrate the psychodynamic aspects of nonadherence in a woman with AIDS. Our patient sustained severe, repeated abandonment and brutal emotional, physical and sexual trauma throughout her early and later childhood and adult life. Her care was considerably complicated by the sequelae of trauma including difficulty with trust and posttraumatic stress disorder. The additional problem of HIV dementia compounded the patient's nonadherence to treatment. We present a multidisciplinary biopsychosocial approach that enabled the patient to engage in both medical and psychiatric care.

Does a history of trauma contribute to HIV risk for women of color? Implications for prevention and policy

OBJECTIVES

We investigated history of abuse and other HIV-related risk factors in a community sample of 490 HIV-positive and HIV-negative African American, European American, and Latina women.

METHODS

Baseline interviews were analyzed, and logistic regressions were used to identify predictors of risk for positive HIV serostatus overall and by racial/ethnic group.

RESULTS

Race/ethnicity was not an independent predictor of HIV-related risk, and few racial/ethnic differences in risk factors for HIV were seen. Regardless of race/ethnicity, HIV-positive women had more sexual partners, more sexually transmitted diseases, and more severe histories of abuse than did HIV-negative women. Trauma history was a general risk factor for women, irrespective of race/ethnicity.

CONCLUSIONS

Limited material resources, exposure to violence, and high-risk sexual behaviors were the best predictors of HIV risk.

Untangling the impact of sexual abuse on HIV risk behaviors among youths in foster care

This study investigates the interrelationships among childhood sexual abuse, other types of child maltreatment, emotional and behavioral problems, and HIV risk behaviors in a sample of 167 adolescents, aged 15-19, participating in an independent living preparation program in one midwestern county. Thirty-three percent of the youths identified as white and 67% as youths of color. The sample was almost evenly split by gender (51% male and 49% female). Thirty-five percent of the youths (n = 59) reported some form of sexual abuse; 21 reported unwanted touching, with no unwanted intercourse, and 38 reported unwanted intercourse. Multivariate analyses demonstrated a significant relationship between the severity of sexual abuse and youths' recent HIV risk behaviors, after accounting for the contribution of other childhood trauma and emotional and behavioral problems. The findings support the need for HIV prevention programs targeting sexually abused youths.

The employee victim of violence: recognizing the impact of untreated psychological trauma

The impact of psychological trauma in the workplace often goes unaddressed. The untreated aftermath of these critical incidents may manifest itself in various states of anxiety, depression, substance use disorders, and even subsequent violence by the victims. This paper reviews common presentations of untreated traumatic events and provides suggestions for outreach to untreated employee victims as well as basic prevention strategies to reduce the risk of additional episodes of violence and enhance safety in health care facilities, including long-term care (LTC) and special-care units (SCU) for dementia patients.

Barriers to and Facilitators of HIV–STD Behavior Change: Intrapersonal and Relationship-Based Factors

This article draws on clinical, cognitive, and health psychology literature to explore a range of barriers to sexual risk behavior change. It is divided into 5 sections, each of which presents obstacles and solutions to address them. The first 4 sections are organized around antecedent factors commonly addressed in models of risk behavior. Barriers related to effective information, risk perception, attitudes and intentions, and behavioral skill acquisition are discussed. The 5th section focuses on barriers related to the psychological and social context of sexual encounters, factors relatively underexplored in traditional approaches to risk reduction. It is believed that future intervention programs will be strengthened by incorporating a more integrative and comprehensive approach to intrapersonal and interpersonal aspects of sexual behavior.

A model to explain the relationship between sexual abuse and HIV risk among women

This paper presents a model developed to advance the understanding of the relationship between sexual abuse and HIV risk among women. It is proposed that the relationship is mediated by many of the long-term sequelae of sexual abuse. The process of mediation is believed to occur through various causal pathways propelled by specific underlying mechanisms that increase the likelihood of HIV risk. The following causal pathways are proposed: (1) initiation of and/or increasing reliance on drug use as a method of coping with the sexual abuse experience, (2) problems with sexual adjustment related to sex risk taking, and (3) psychopathology (e.g. depression) which increases the likelihood of an individual participating in HIV risk behaviours. These hypothesized pathways are based on the characteristics and behaviours of individuals with histories of sexual abuse and do not take into account the influence of the individual's social environment. Increasingly, evidence suggests that understanding the social context of HIV risk is crucial to the development of preventive interventions. Therefore, a final pathway is explored which suggests that specific social network characteristics (e.g. network membership type, social support, and social isolation) influence HIV risk exposure opportunities among women with sexual abuse histories.

Determinants of sexual risk-taking among young HIV-negative gay and bisexual men

Data from a cohort of young HIV-negative gay and bisexual men were analyzed to identify determinants of sexual risk-taking at baseline. Gay/bisexual men aged between 18 and 30 completed a self-administered questionnaire including demographics, depression, social support, substance use, and consensual versus nonconsensual sex. Risk-takers were defined as those who had unprotected anal sex with casual male sex partners in the previous year; non-risk-takers were defined as those who reported consistent condom use during anal sex with all male partners in the previous year. Logistic regression was used to identify independent predictors of sexual risk-taking. Of 439 men studied, risk-takers had less education, a higher depression score, less social support, and were more likely to report nonconsensual sex and recreational drug use relative to non-risk-takers. Independent predictors of sexual risk-taking were low education, nitrite use, low social support (adjusted odds ratio [AOR]=1.65; 95% CI, 1.04-2.59), and nonconsensual sex experienced as a youth or adult (AOR=1.85; 95% CI, 1.15-2.96). Young gay/bisexual men reporting nonconsensual sex, low social support, or nitrite use were significantly more likely to have recently had unprotected anal sex with casual partners. HIV prevention programs aimed at young gay/bisexual men should include sexual abuse counselling and foster community norms supporting safer sex practices.

Social network characteristics as mediators in the relationship between sexual abuse and HIV risk

Recent research suggests that sexual abuse may be a potent risk factor for engaging in HIV risk behaviors for women. This relationship is likely mediated by the long term sequelae of sexual abuse. One plausible causal pathway posits that specific social network characteristics increase HIV risk exposure opportunities. This is premised on the belief that previous sexual abuse predisposes some women to become members of risk networks characterized by deviant behaviors and that HIV risk occurs in the context of these networks. One hundred and thirty women opiate users were systematically recruited from methadone maintenance and syringe exchange programs in New York City. The women participated in a one hour interview and provided information on drug use and frequency, HIV drug and sex risk behaviors, social network characteristics, and sexual abuse histories. Univariate and logistic regression techniques were used to test the relationship between sexual abuse and increased HIV risk as mediated by social network characteristics. Previous sexual abuse was strongly related to all social network characteristics examined. Moreover, these network characteristics appeared to affect patterns of drug use in identifiable ways. Social isolation was the only network characteristic associated with both HIV drug and sex risk behaviors. However, although a history of sexual abuse was significantly associated with five of the seven specific HIV risk behaviors examined, the relationship between sexual abuse and HIV risk behaviors remained unchanged when social network characteristics were included in the statistical model. Overall, the results suggest that a sexual abuse experience or its aftermath influence behavior far into the future. However, the results of this study did not show social network characteristics mediating the relationship between sexual abuse and HIV risk. Rather, previous sexual abuse and social network characteristics appear to be independent contributors to HIV risk behaviors for women.

Sexual addiction: many conceptions, minimal data

Sexual addiction has received increasing attention in the past decade. We review existing literature on (a) competing conceptualizations of this syndrome as constituting an addictive, obsessive-compulsive, or impulse control disorder; (b) symptomatology and progression; (c) etiological models; and (d) treatment approaches. Based on this review, we conclude by identifying questions requiring resolution via empirical investigation.

Suicidal behavior and sexual/physical abuse among street youth

OBJECTIVE

To examine the relationship between home life risk factors and suicide attempts among homeless and runaway street youth recruited from both shelters and street locations in Denver, CO; New York City; and San Francisco, CA.

METHOD

Street youth 12-19 years old (N = 775) were recruited by street outreach staff in Denver, New York City and San Francisco in 1992 and 1993 and interviewed. Cross-sectional, retrospective data were analyzed to examine the relationship between suicide attempts and antecedent home life variables. Logistic regression was used to identify factors predicting suicide attempts.

RESULTS

Forty-eight percent of the females and 27% of the males had attempted suicide. The mean number of suicide attempts was 6.2 (SD = 12.9) for females and 5.1 for males (SD = 7.6). Among females, 70% reported sexual abuse and 35% reported physical abuse. Among males, 24% reported sexual abuse and 35% reported physical abuse. Sexual and physical abuse before leaving home were independent predictors of suicide attempts for females and males. Other home life factors hypothesized to be risk factors for suicide attempts were not significant. Interaction terms were not significant. Among street youth who were sexually or physically abused in this sample, the odds of attempting suicide were 1.9 to 4.3 times the odds of attempting suicide among those not sexually or physically abused.

CONCLUSIONS

Interventions attempting to reduce risky behaviors in this population must include assessments of suicidal behaviors as well as components for assisting youth in dealing with the behavioral and emotional sequelae of physical and sexual abuse.

Influence of sexual abuse on HIV-related attitudes and behaviors in adolescent psychiatric inpatients

OBJECTIVE

To investigate the associations between sexual abuse and human immunodeficiency virus (HIV)-related attitudes and behaviors of adolescents with a psychiatric disorder.

METHOD

HIV-related knowledge, attitudes, and behaviors were examined by self-report assessment of adolescents admitted to a psychiatric hospital (N = 100). A subsample (n = 30) completed a role-playing exercise regarding HIV-preventive behavior that was scored for the degree of effective communication by raters blind to the subjects' abuse history.

RESULTS

HIV-related risk behaviors were prevalent, including unprotected sexual intercourse (67%) and multiple partners (27%) among the sexually active (71% of the total). Also frequent were alcohol and drug use (25%) and sharing cutting instruments (22%) among those engaged in self-cutting behavior (62%). The 38% of the sample identified as having a history of sexual abuse indicated significantly poorer self-efficacy concerning condom use than their peers. Abused females scored significantly lower on the self-efficacy of condom use scale and reported significantly more frequent alcohol use than nonabused females (p = .003). A hierarchical multiple regression that controlled for consistency of condom use and tolerance of people with acquired immunodeficiency syndrome found that abuse history uniquely accounted for 16% of the variance in condom use self-efficacy. Analysis of the videotaped role-play found that abused adolescents were significantly less competent and had more difficulty in effective communication than their peers (p = .003).

CONCLUSION

A history of sexual abuse is associated with impaired safe sexual decision-making and HIV-preventive communication skills, even in this already at-risk group. This study also underscores the importance of actively addressing these issues in the context of clinical care.

The relationship of sexual abuse and HIV risk behaviors among heterosexual adult female STD patients

Some effects of sexual abuse, for example, heightened sexual activity, are also risk factors for infection with the human immunodeficiency virus (HIV). Moreover, Social Cognitive theory suggests that the reduced self-esteem and increased sexual arousal that can result from abuse might alter self-efficacy for performing a behavior and expected outcomes of the behavior, making adoption of preventive behavior more difficult. Studies in the general population, adolescents, and male clients of sexually transmitted disease (STD) clinics, have found associations between childhood sexual abuse and HIV risk behaviors. This study was designed to measure: (a) whatever the association persists among female STD clinic clients; and (b) whether sexual abuse is associated with self-efficacy for condom use or condom use outcome expectations. Among the 83 female STD clinic clients studied, those sexually abused before age 18 had more sexual partners (p < .05), more positive hedonic outcome expectations for condom use (p < .01), and fewer positive partner-related outcome expectations for condom use (p < .05) than those never forced to have sex against their will. In summary, HIV risk behavior among female STD clients varies with childhood sexual abuse and Social Cognitive Theory suggests future directions for prevention.