SEXUAL ABUSE CONTINUES TO be a problem that affects many adolescents.1,2 It is estimated that almost one third of female adolescents and approximately 10% of their male counterparts report being a victim of sexual abuse.3,4 One concern about sexual abuse is its association with health-compromising behaviors. Numerous reports suggest that adolescents who have been sexually abused are more likely to report drug and alcohol use, multiple sexual partners, early onset of consensual sexual activity, and engaging in unprotected sex or sex resulting in a pregnancy.5–11 Although much research has been done on the association between age of sexual abuse onset and problem behaviors, including sexual risk behaviors, results are not consistent.10,12 In some studies, earlier age at occurrence of abuse was associated with worse outcomes,9,13 whereas in others, there was no difference in outcome between early versus late age of onset.7,12 However, on the subject of whether the outcomes of sexual risk behaviors, particularly sexually transmitted diseases (STDs), are associated with the age of onset of sexual abuse, very little research has been done. The current study sought to examine whether onset of abuse at a younger age versus older age was associated with risk behaviors or being diagnosed with STDs.
Engaging in sexual risk behaviors raises the concern about acquiring STDs with their possible negative sequelae such as pelvic inflammatory disease, infertility, and cervical cancer.14,15 In view of the association between sexual abuse and sexual risk behaviors, it would be expected that victims of sexual abuse would be more likely to report or have a higher incidence of STDs compared with their nonabused peers. Although some studies have found this to be true,16–19 other researchers did not find sexual abuse to be predictive of acquiring STDs.20,21 Noell et al found that number of partners but not a history of abuse predicted STDs.21 What is not evident from these studies is whether there is an association between the age at which sexual abuse occurred and the acquisition of STDs. In several of these studies, victims who were abused before 18 years are classified under the broad heading of “childhood sexual abuse” without consideration of whether abuse occurred at the preadolescent age or after.
Sexual abuse occurring at a younger age during which social competence is evolving may influence a victim’s perception of social norms such that sexualized behaviors may be perceived as a means of engaging and interacting with others.9,13 This may set the stage for risky sexual behaviors that may put victims at increased risk of STDs. Because interventions are targeted at reducing STDs among adolescents, including those who are sexual abuse victims, there is a need to understand factors such as age of onset of abuse that may influence engagement in risky sexual acts predisposing them to STDs.15,22
Drawing from previous studies,4,6,19 the present analyses examined the relationship between the reported age when abuse began and onset of consensual sex, number of lifetime partners, number of partners in the past 6 months, and always using a barrier method for all sexual encounters. An added advantage of this study is the opportunity to investigate the association of onset of abuse with laboratory-confirmed tests of STDs. The hypothesis was that the earlier the age at which sexual abuse occurred, the more likely victims are to engage in behavior predisposing them to STDs as well as having a positive test for STDs.
The literature is inconsistent on whether a history of sexual abuse or number of partners predicts STD. The next set of analyses investigated whether the number of lifetime partners played a role in the association between history of abuse and current STD diagnosis. We hypothesized that the relationship between sexual abuse and STD diagnosis will be mediated by number of partners.
The data for this research were derived from the Minnesota STD Prevalence Study. This was a collaborative project between the Minnesota Department of Health (MDH) and the University of Minnesota conducted between January 2000 and September 2001. Using a self-administered questionnaire, demographic and behavioral information was collected from adolescents and young adults aged 12 to 24 years. The 2278 study participants were systematically sampled from 10 clinic sites that were selected from across the state based on geographic location and willingness of the site to participate. The sites included community clinics, college/school health services, family planning clinics, a homeless youth project clinic, and juvenile and adult detention centers. Forty-two percent of the total sample was female. Over half (59%) of study participants were in detention facilities. Urine-based DNA amplification tests (AVID ligase chain reaction assay) for chlamydia and gonorrhea and serology test for herpes simplex virus (HSV) 1 and 2 were conducted for all participants. All laboratory testing was carried out at the MDH central laboratory. Participants were given $15 gift certificates for taking part in the study. Informed consent was obtained from each participating individual. The University of Minnesota Institutional Review Board of the Human Subjects Committee gave approval for the original project and for these analyses.
The survey instrument contained a statement that defined “having sex” to include vaginal, oral, anal, and oral–anal contact. Following this statement, participants were then asked to answer yes or no to the following question, which was used to assess a history of sexual abuse: “As a child or teenager (18 years of age or younger), were you ever raped or forced to have sex with adults without your consent? This includes any kind of sex or other forced things like touching.” Those who endorsed a history of abuse were asked the age at which abuse first occurred. We dichotomized age at which sexual abuse first occurred into younger (≤10 years) and older (>10 years) age of onset. With adolescence stated in the literature to begin from age 10 to 11 years, 10 years was used as a cutoff age to distinguish abuse occurring in childhood (preadolescent age) and that occurring in adolescence.23,24 Making this distinction was based on studies reporting that abuse that occurred in childhood had a stronger impact on risky behaviors than that occurring in adolescence.9,13
Sexual behavior measures included age at which consensual sex first occurred, number of lifetime partners, number of partners in the last 6 months, and whether a barrier method was always used for all sexual encounters in the previous 6 months.
History/Prevalence of Sexually Transmitted Diseases.
Self-reported history of STD was assessed by asking participants to report whether they had ever had any of the following: chlamydia, gonorrhea, genital/anal warts, genital or anal herpes, syphilis, trichomonas, nonspecific urethritis, pelvic inflammatory disease, or another STD. Responses were coded yes/no. Endorsing at least 1 of these was coded as a positive history of STDs. The youth were also asked whether they had ever been told by a healthcare provider that they had an STD. STD diagnosis was assessed by a positive laboratory test for at least 1 of these diseases: urine test for chlamydia, urine test for gonorrhea, or serology test for HSV 1 and 2. These served as an objective measure for currently having an STD.
The independent variable for the analyses was a history of sexual abuse as a child or adolescent. The participants were categorized into 3 groups: never been sexually abused, sexually abused after age 10, and sexually abused at or before age 10 years. t test and chi-squared test were used to assess the bivariate association between sexual abuse and the following variables: age at time of study, age at first consensual sex, number of lifetime partners, number of partners in the previous 6 months, always used barrier method for all sexual encounters in the previous 6 months, self-reported history of STD, and positive laboratory test for STD. Bivariate analyses were stratified by gender because of differences in reports of abuse for males and females.
A series of logistic regression analyses stratified by gender were used to investigate whether there was a relationship between sexual abuse and STD diagnosis and whether number of lifetime partners mediated this relationship.25 To test this, we sought to establish that there was a relationship between sexual abuse and STD diagnosis using youth never sexually abused as the reference (first regression model). Because we were proposing number of partners as a mediator, it was initially established that sexual abuse was associated with number of lifetime partners. We then sought to establish that there was a relationship between number of partners and STD diagnosis (second regression model). The third model tested whether the relationship between sexual abuse and STD diagnosis was affected when number of lifetime partners was included as a control variable. The age of study participants at first consensual sex and race were potential confounders because they were found to be associated with sexual abuse and STD diagnosis. Consequently, they were included in all the regression models as control variables. A P value of <0.05 was used as the criteria for statistical significance.
Description of Sample
A total of 2175 adolescents who responded to the question asking about a history of sexual abuse and age at first abuse comprised the sample for the study. Females comprised 41.9% (n = 911) of the study population. A history of sexual abuse as a child or adolescent was reported by 311 respondents (14.3%). Approximately 50% of those who reported abuse were sexually forced after 10 years of age. Approximately 1 of every 4 adolescent girls (26.7%, n = 243) reported abuse and this was significantly different from the rate of abuse reported by their male counterparts (5.4%, n = 68) (chi-square [df = 2] = 221, P <0.0001). Almost 90% of those sexually forced after 10 years and 67.3% of those forced ≤10 years were female. There was no significant difference in the rates of abuse between respondents from urban and rural residences. There was also no statistical difference in the mean age of participants across the 3 groups at the time of the study. The descriptive characteristics of the study population by onset of sexual abuse are shown in Table 1.
More than 9 of 10 respondents reported ever having consensual sex, with prevalence of sexual experience significantly higher among those with a history of abuse. Thirty percent of the study participants always used a barrier method for all sexual encounters in the preceding 6 months. A self-reported history of STD and a positive test for STD was found for 28% and 54.5%, respectively, of all the young people studied.
Table 2 compares the sexual behaviors of male study participants by history and onset of sexual abuse. The mean age at first consensual sex across the 3 groups was similar. Being abused at a younger age was significantly associated with more lifetime partners compared with adolescents who were not abused (10.0 vs. 9.2 partners, respectively, P <0.01). Male adolescents abused at a younger age were significantly more likely to report more partners (3.7) in the previous 6 months compared with those who were not abused (2.3 partners) and those abused after 10 years (2.4 partners). Those who were abused after age 10 were not more likely than those never abused to have more partners, either over their lifetime or in the last 6 months. For boys, a history of sexual abuse irrespective of age at which abuse occurred was not significantly related to age at first consensual sex, always using a barrier method, self-reported history of STDs, and STD diagnosis.
The comparison of sexual behaviors by history and onset of sexual abuse among female respondents is shown in Table 3. Females with a history of sexual abuse regardless of age of abuse reported more recent and lifetime partners and were more likely to self-report a history of STD. Compared with those abused after 10 years, girls who were abused ≤10 years and those not reporting any abuse were significantly more likely to report that they always used a barrier method in all their sexual encounters in the previous 6 months. Those abused ≤10 years had similar rates of recent protected sexual encounters as those who where never sexually abused. Being a victim of abuse at or before 10 years was associated with higher rates of STD diagnosis compared with adolescents who were not abused.
The association between sexual abuse and STD diagnosis and the role played by number of partners in this relationship was explored using regression analyses (Table 4). Results of these analyses indicated that the odds of both males and females who were sexually abused at 10 years or younger having STD diagnosis were 2.5 times the odds of their nonsexually abused peers having STD diagnosis. No association was found between history of abuse after 10 years and STD diagnosis. Including number of lifetime partners in the analyses did not affect the association between being abused at or before 10 years and STD diagnosis.
Our study confirmed that sexual abuse as a child or adolescent was associated with sexual risk behaviors and STDs with some outcomes being worse if abuse occurred at a younger age. In this broad convenience sample of adolescents and young adults in clinical settings and correctional facilities, the rate of sexual abuse (14.3%) was slightly higher than the 10% reported for school-going adolescents in the same state,26 but the prevalence of sexual abuse among males and females was comparable to that reported by others.1,4,27,28 Consistent with previous research, females were more likely to report abuse compared with males.1,4,26–29
Adolescents abused ≤10 years initiated consensual sex at a younger age and had significantly more lifetime partners compared with those without a history of abuse. However, there was no difference in number of lifetime partners for those abused at an older age and those with no history of abuse. This is similar to findings by Rotheram-Borus et al, when they compared youths abused before and after 13 years of age.10 In contrast to their study, however, we also found that compared with not being abused at all and being abused after age 10, abuse at or before 10 years was significantly associated with having more partners in the previous 6 months. This latter finding is similar to Parillo et al’s results in which childhood abuse, but not abuse in adolescence, predicted recent number of partners.9
Overall, our study population had high rates of sexual activity compared with other studies.4,28,30 This may reflect sampling bias because our study population was a convenience sample drawn from attendees at family planning clinics and detained youth, among others. It is not unexpected to have attendees at such sites having higher rates of sexual activity than the general population. However, rates of sexual activity were the same among the 2 groups of sexually abused adolescent females but were significantly higher than that for the group without a history of abuse. These findings agree with a study of runaway adolescents who also had similar rates of sexual activity.10
Among those sexually abused after 10 years, the rate of always using a barrier method in recent sexual encounters was low but consistent with that found in Noell et al’s study.21 Also, in keeping with the literature,4,29 female adolescents who were sexually abused after age 10 in our study were significantly less likely to report using a barrier method for all recent sex sexual encounters compared with those without a history of abuse. It was surprising, however, to find that girls sexually abused at 10 years or younger were significantly more likely to report always using a barrier method for sex compared with those abused after 10 years and at a rate similar to those who were never sexually forced. This may reflect an increased perception of being at risk for the exposure and spread of STDs related to risky sexual behavior, notably having more recent partners, on the part of those abused at a younger age. Wilson and colleagues found that adolescent males who had multiple partners during the previous 6 months were more likely to have ever used condoms than those who had been celibate or monogamous.31 They suggested that being aware of their sexual risk behaviors, these youths took the precautions. In a study by O’Donnell et al, having more than 1 sexual partner in the past month and the perception of being at risk for STDs and HIV were associated with acquiring a condom.32
In agreement with previous reports,18,19,33 female adolescents in our study with a history of abuse were significantly more likely to report a history of STD and have a currently positive test for STD. There was no significant difference in rates between the 2 groups of abused adolescents. Further analyses using logistic regression showed that across gender, being sexually abused ≤10 years was significantly associated with STD diagnosis. This relationship was not mediated by number of lifetime partners. This is in contrast to other studies that found number of partners as opposed to a sexual abuse history being predictive of acquiring STDs.20,21
This study has several important limitations as well as strengths. The self-reported nature of most of the data leaves room for reporter bias. Also, convenience sampling limited generalizability of our findings. Unlike females, a history of sexual abuse made little difference in several sexual risk behaviors among males. This may be because very few male adolescents reported a history of abuse in our study population resulting in low power to detect differences. The cross-sectional nature of the study also precluded any inference of causality using our results. This study also has strengths worthy of mentioning, however. The laboratory-confirmed tests of STDs gave us an objective means of investigating the association between sexual abuse and STDs. The analyses also took into consideration the age of onset of abuse, making it possible to identify differences in outcome based on whether the abuse occurred at a younger versus older age.
In summary, our study confirms that a history of sexual abuse in childhood is associated with sexual risk behaviors. Our findings also show that although sexual abuse occurring at a young age is a big risk factor for STD, the number of partners does not explain why early sexual abuse is a risk factor for STD. Abuse occurring at a young age, a critical period for the development for social competencies, may have significant effects on developing social abilities, including the regulation and expression of sexual activity.13 As a consequence, victims may engage in sexual behaviors that can put them at risk for STDs, but to them, the sexualized behaviors may be perceived as a means of engaging and interacting with others. In the development of strategies to reduce STDs among adolescents, it is important to assess for a history of sexual abuse and, particularly if the abuse occurred at a preadolescent age, there is a need to address the impact the abuse may have had on the developing social repertoire of the victim. Interventions to reduce STDs among adolescents usually focus on preventive behaviors such as use of a barrier method and delaying sexual activity, and may not adequately address underlying issues that could impact the effectiveness of these methods. Youths who are sexually abused at a young age are at risk for behaviors that may increase their possibility of contracting STDs. It is important that they are identified early for intervention before sexual risk-taking behaviors becomes the norm for them. For adolescents presenting in healthcare centers for treatment of STDs, eliciting a history and age of onset of sexual abuse and addressing the trauma of the experience of the abuse may help to reduce STDs among those affected by abuse.
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