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Learn More. Childhood sexual abuse CSA is associated with a wide range of negative outcomes. This study investigated the relation between CSA and sexual risk behavior in patients recruited from an STD clinic. Alcohol use for men, and drug use for women, mediated the relation between CSA and the of partners in the past three months; intimate partner violence mediated the relation between CSA and the of episodes of unprotected sex in the past three months for women.

These document the prevalence of CSA among patients seeking care for an STD, and can be used to tailor sexual risk-reduction programs for individuals who were sexually abused. Rates of CSA appear to be even higher in population sub-groups, such as pregnant adolescent females e. CSA has been associated with a variety of adverse sequelae, including engaging in risky sexual behaviors. Individuals who were sexually abused as children report an earlier age of first consensual intercourse e.

Individuals who were sexually abused as children also are more likely to have engaged in commercial sex work e. Individuals who were sexually abused as children are more likely to have an incident STD e. Miller proposed a conceptual model to explain the link between CSA and later risky sex. Miller hypothesized that CSA le to sexual risk behaviors through four mechanisms: a using substances to cope with the abuse; b mental illness due to the abuse; c riskier social networks; and d poorer sexual adjustment. Focusing on men who were sexually abused as boys, Purcell, Malow, Dolezal, and Carballo-Diequez hypothesized that CSA may influence later sexual risk behaviors through mediating variables such as substance use, psychological distress, sexual dysfunction, and revictimization.

Portions of the conceptualizations provided by Miller and Purcell et al. That is, empirical research has linked CSA with each of these proposed mediators, including alcohol e. Further, each of these proposed mediators have been associated with risky sexual behavior; thus, there is evidence of the substance use—risky sex link [e.

Building on these conceptual and empirical foundations, we propose a conceptual framework in which CSA le to increased alcohol and drug use, partner violence, and depression; these variables, in turn, increase the likelihood of sexual risk behavior.

Thus, even though the association between CSA and substance use, mental health, and partner violence is well-documented, most studies have focused on the latter as outcomes of CSA, rather than as potential mediators of the relation between CSA and risky sexual behavior. The current study advances prior research by examining the mediation of the CSA—risky sexual behavior link.

In addition, we hypothesize that the role that these potential mediating variables play will differ for males and females. The majority of studies of CSA have sampled only men or women, precluding gender comparisons. However, findings from several studies indicate that the relation between CSA and potential mediators i.

For example, studies have found that CSA is associated with: a greater alcohol use for women, but not for men Brown et al. These different patterns of association suggest that gender may be an important moderator of the CSA—risky sexual behavior relationship. In summary, the purposes of this study were to determine: a rates of CSA among patients at a public STD clinic; b whether CSA is associated with sexual risk behavior in this population; c what variables mediate the proposed relation between CSA and sexual risk behavior; and d whether these mediating variables function in the same way for men and women.

We hypothesized that: a CSA would be associated with elevated sexual risk behavior; b alcohol use, drug use, partner violence, and depression would mediate the relation between CSA and sexual risk behavior; and c the effect of the mediating variables would differ by gender. Eligibility criteria for the RCT included: age 18 or older; HIV negative; not seen at the clinic in the past 3 months; willing to participate in a standard clinic visit, including an HIV antibody test; and engaged in sexual risk behavior in the past 3 months.

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Sexual risk behavior was defined as one of the following: having sex with more than one person; being diagnosed with an incident STD in the past 3 months; having a partner who had sex with other people; having a partner who injected drugs; having a partner who was diagnosed with an incident STD in the past 3 months; or having a partner who is HIV positive. Exclusion criteria included using a condom every time with every partner in the past 3 months. On average, participants were Patients were called from the waiting room by registration and escorted to a private exam room by a trained Research Assistant RA.

The RA explained the purpose of the study, and obtained verbal permission to ask a brief series of screening questions to determine eligibility. The study was explained to all patients; patients were informed that all data would be confidential, and protected by a Federal Certificate of Confidentiality. Those who agreed to participate ed an informed consent form, provided contact information, and were asked to complete a calendar of important events over the past 3 months, to help them more accurately respond to survey questions asking about thoughts and behaviors.

All participants then completed an Audio Computer-Assisted Self-Interview ACASIa computerized survey that allowed participants to hear a question being read aloud over headphones as they saw the question on the computer screen. Four sample questions were completed, to familiarize participants with the different response types on the survey. All procedures were approved by the IRBs of the participating institutions. The ACASI survey included measures of demographic characteristics, health behaviors, and psychosocial functioning.

For the present study, we used measures that assessed childhood sexual abuse, alcohol use, drug use, intimate partner violence, depression, and sexual behavior. Participants indicated their sex male or femalerace recoded as minority vs. Caucasianand education re-coded as high school or less vs. To assess CSA, we used items adapted from Finkelhor Participants indicated which sexual activities e. For the current study, participants were included in the CSA group if they reported having oral, vaginal, or anal sex before age 13 with someone 5 or more years older, before age 17 with someone 10 or more years older, or before age 17 where force or coercion was used, consistent with research including both graded age difference and use of force in the definition of CSA Finkelhor, Items assess frequency of drinking and binge drinking, and frequency of alcohol-related problems.

For the first eight items, scores for each item ranged from 0 to 4; for the last 2 items, a score of 0, 2, or 4 was given, following the instructions in Babor, de la Fuente, Saunders, and Grant Anchors and midpoints varied for each item. Participants who responded that they never had a drink containing alcohol, and, when probed further, reported not having an alcoholic drink in the past year, were given a score of 0 for all AUDIT items, consistent with established procedures.

Internal consistency for the sample was. The DAST is a item instrument assessing drug use and drug-related problems. Participants indicated whether or not yes or no they experienced a series of problems related to drug use e. Yes responses were summed to calculate the total DAST score; one item was reverse-scored, so that yes responses were associated with drug use problems. Participants who reported not using drugs in the past year other than for medical reasons were ased a score of 0 for all DAST items.

Internal consistency reliability for the sample was. Participants rated, on a 5-point scale, how often in the past 3 months they drank or used drugs before sex Carey et al. Participants were asked these questions separately for a steady partner defined as a husband or wife, boyfriend or girlfriend, or a sexual partner the participant really cared aboutother i. To obtain a summary score for drinking drug use before sex, ratings of drinking drug use before sex were averaged across the three partner types. Three items assessed partner violence.

First, participants were asked if they had been hit, kicked, punched, or otherwise hurt by someone in their lifetime. Second, if they answered yes, they were asked whether the violence was perpetrated by a sexual partner adapted from Feldhaus et al. Third, participants were asked whether a partner ever threatened to hurt or kill them, or prevented them from engaging in a variety of activities adapted from Cohen et al. If the participant responded affirmatively to either of the last two questions, they were considered to have experienced partner violence.

The CES-D measures depressive symptoms in the general population. Scores on the CES-D correlate with other self-report measures of depression and with clinical ratings of depression Radloff, Two items were reverse scored. Items developed and tested in studies Carey et al. Participants reported the of male and of female sexual partners in their lifetime and in the past 3 months, the of times they exchanged sex for money or drugs, and the of times they were treated for an STD. Responses were dichotomized for the items assessing sex trading and STD treatment.

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To investigate the frequency of sex, participants were asked to report the of times they had vaginal and anal sex with and without a condom in the past 3 months with their steady partner, with their other female partners, and with their other male partners.

In addition, participants were asked about their most recent sexual experience, including whether this episode was with a steady or other partner; whether they had vaginal sex and, if so, whether a condom was used; and whether they had anal sex and, if so, whether a condom was used. Responses to the most recent sexual experience items indicated whether participants used a condom at last vaginal or anal intercourse dichotomouswhether participants whose last sexual experience was with a steady partner used a condom dichotomousand whether participants whose last sexual experience was with a non-steady partner used a condom dichotomous.

To determine whether CSA was associated with later risky sexual behaviors, we used linear regressions for continuous outcomes, and logistic regressions for dichotomous outcomes. To determine which variables mediated the relation between CSA and sexual risk behavior, we conducted a path analysis, with and without mediational paths, to evaluate whether the strength of the direct association between CSA and sexual risk behavior was reduced when mediators were included. In addition, the Sobel test determined which variables mediated the relation between CSA and sexual risk behavior.

Mediators were allowed to correlate with each other. Demographic variables that were related to both CSA group and the outcome variable were included in the models. To determine whether the mediational relations between CSA and risky sex differed by gender, a multi-group path analysis was conducted, with the model described earlier estimated separately for men and women. Sobel tests were conducted to determine which variables acted as mediators for men and for women.

To determine whether moderated mediation occurred i. Demographic correlates of CSA group and outcome variable determined separately for men and women were included in the models. Preliminary analyses determined whether those who were sexually abused as children CSA group and those who were not sexually abused as children non-CSA group differed on demographic variables i.

Given these associations, subsequent regression analyses controlled for race and education. CSA and non-CSA groups differed on several sexual behavior outcomes, after controlling for relevant demographic covariates see Table 1 ; raw data reported.

Because condom use can differ by partner type, the of episodes of unprotected sex with steady and with other partners was investigated. Condom use at last intercourse with an outside partner did not differ. Not only did the two groups differ in sexual behavior, they also differed in biologic outcomes. An abuse no vs. This term was not ificant in any of the regressions. To determine which variables mediated the relation between CSA and the of sex partners, a path analysis was conducted on the entire sample see Figure 1.

The demographic covariates race or education were not related to either abuse status or the of partners in the past 3 months; therefore, no covariates were included in the model. Because the model was just identified i. Correlations between mediators not included in path diagram. The variables partially mediated the relation between CSA and the of partners.

When no mediational paths were included, the standardized path coefficient for the relation between CSA and the outcome was. The co-occurrence of alcohol and sex, history of drug use problems DASTand the co-occurrence of drug use and sex were all associated with both CSA and the of sexual partners in the past 3 months. A second path analysis was conducted to determine which variables mediated the relation between CSA and the of episodes of unprotected sex in the past 3 months. However, the relation between CSA and the of episodes of unprotected sex was weak for the sample as a whole; without mediational paths included, this standardized path coefficient was.

To determine whether the relations between CSA, the mediators, and risky sex differed for men and women, multi-group path analyses were conducted. Path coefficients first were allowed to vary across men and women; this model was compared to a model in which path coefficients associated with a particular mediator were constrained to be equal for men and women.

For these models, race minority vs. As depicted in Figure 3the standardized path coefficient from CSA to the of sexual partners for women was. In path analyses where only one mediator at a time was considered, the co-occurrence of drug use and sex for men, and DAST for both men and women, also mediated the relation between CSA and the of partners.

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