In the United States, impoverished adolescents and young adults experience persistent high rates of sexually transmitted infections (STI) and incarceration.1,2 Youth who have been involved with the criminal justice system are more likely to be infected with an STI3,4 and to engage in STI risk behaviors.5,6 One explanation for the link between incarceration and STIs is related to sexual concurrency, or overlapping sex partners, a known driver of incident STI infections in a population.7 Although studies have found a correlation between incarceration and multiple sexual partners, there persists a lack of understanding of the mechanism by which these are linked. It has been suggested that this association is driven by an individual's proclivity toward risk.8 However, Khan and colleagues6 propose that arrest and incarceration disrupt sexual networks and facilitate multiple sexual partners. Although sex network disruption may be a necessary factor, there may be other factors that must also exist to cause sexual concurrency. One such factor may be the value men place on having sex and sexual relationships to validate themselves. There is a wide variation among men on the importance of sexual relationships in authenticating their gender identity. Gender identity is a culturally constructed process by which individuals develop a sense of gendered self, and it is heavily influenced by societal views of masculinity and femininity.9 At its extreme, masculinity is associated with sexual prowess, an emphasis placed on seductive capabilities or sexual ability, and having many sexual partnerships—characteristics associated with HIV/STI risk. Young men who place a high importance on multiple sexual relationships may be more likely to react to incarceration and destabilization of their social and sexual networks with new sexual relationships than those who place less importance on sexual relationships as a means of validation. It is age appropriate to move toward more stable, committed relationships over the course of adolescence and into young adulthood.10 Incarceration disrupts this normal developmental process, where intimacy and commitment are important, by removing individuals from their relationships. Adolescents who place a high importance on sex and sexual relationships may not put their efforts into rebuilding a relationship that has been interrupted by incarceration, but rather look for additional partners. At the individual level, incarceration may lead to the de-valuing of relationships and patterns of sexual concurrency.
Criminal justice involvement (CJI) is experienced disproportionately by young African American men.11 Therefore, young African American men are more likely to have their relationships disrupted than young white men. Concurrency has been found to be highly prevalent among African American men.12 Whitehead has placed this high prevalence in the historical sociocultural context of the United States in which the economic capacity of African American men was restricted, leading to an emphasis on sexual prowess as a means of expressing masculinity.9 Young African American men who place a high value on sex may be more likely to respond to incarceration with multiple sexual partners as a way of reinforcing their sexual prowess and strengthening their sense of gender identity after this period of confinement and isolation from social networks and romantic partners.9,13 It may be important to explore how sexual validation may explain racial differences in rates of concurrency.
The goals of this study were to examine the associations between CJI, sexual validation and engaging in sexual concurrency in a household sample of young men, and to examine differences by race. We hypothesized that the association between CJI and concurrency may, in part, be explained by the importance young men place on sex and sexual relationships (Fig. 1). We focused on young men because young men are most affected by the criminal justice system.
MATERIALS AND METHODS
A detailed description of methods has been published previously.14 Data were collected as part of a longitudinal household study conducted in Baltimore, Maryland, from February 2011 through May 2013. The target population consisted of African American and white, English-speaking, sexually active persons between the ages of 15 and 24 years who resided in Baltimore City. We used a stratified sampling design in which sampling strata were census block groups (CBG) to allow for oversampling in areas with high concentrations of the target population. Households were selected based on a probability-based sample of residential mailing addresses within each CBG. Households were randomly chosen to represent low and middle socioeconomic status (SES) neighborhoods with majority white or African American populations. Parent education was used as the indicator of SES, where high SES was defined as having a parent with a college education. Ninety-eight percent of CBGs in Baltimore were included in the sampling frame, with 2% excluded owing to no households or insufficient education data. Nonlinear optimization procedures were used to oversample addresses in CBGs with concentrations of white young adults and those with concentrations of parents with at least some college education.
To enable reliable estimation of the target population parameters, interview weights were calculated for all respondents. Household weights account for different selection probabilities due to the sampling allocation and for differential screening response propensities, and adjusted for the number of eligible persons per household, and subsampling of African American, no college (ie, low SES) households. Final interview weights were calculated by poststratifying preliminary weights to estimated target population totals by sex and race/ethnicity. Sampling strata were collapsed to allow for design-consistent estimation. The study was approved by the institutional review board of the Johns Hopkins Bloomberg School of Public Health.
All sampled households received a lead letter describing the study 2 weeks before the households were contacted for enumeration. Enumeration was conducted by telephone for households with available phone numbers (33%) or, if not, in person by trained research assistants. If age-eligible individuals lived within the household, eligibility screening was conducted. If more than 1 age-eligible person was present, 1 was randomly selected for screening. Parental/guardian-informed consent and adolescent-informed assent was conducted with individuals younger than 18 years and informed consent was conducted for individuals over 18 years. The study had a weighted acceptance rate of 73.5%. Consenting individuals were enrolled, and research assistants administered an audio computer-assisted self-interview in a private setting. The audio computer-assisted self-interview captured demographics and sexual histories, including individual- and partner-specific STI risk behaviors. For each sex partner named in the last 90 days, participants were asked to report on the same, or similarly specific, questions about their sex partners’ behavior.
Validation Through Sex and Sexual Relationships Scale
The Validation through Sex and Sexual Relationships (VTSSR) is a 12-item scale that assesses the importance placed on sex and sexual relationships. All VTSSR items were written to assess whether a person (1) feels validated by engaging in sexual activities or (2) perceives validation from their peers when they engage in sexual activities. The items (Table 1) are statements with 4-item Likert scale response options ranging from 1 (strongly agree) to 4 (strongly disagree). The scale previously demonstrated evidence of construct validity as hypothesized associations between higher-scale scores and risky sexual behaviors were observed among a sample of men from high poverty urban areas in Baltimore.15 The VTSSR showed high reliability in the current sample (Cronbach α = 0.91).
Criminal Justice Involvement
The CJI history was assessed by asking participants separately if they have ever spent time in jail, juvenile detention center, or correctional facility with response options of yes or no. A response of yes to any of these questions was then coded as having a history of CJI. Arrest history alone without time spent in jail or a correctional facility was not included in this measure.
For each sex partner named in the last 90 days, participants were asked about partner characteristics and partner-specific behaviors. Sexual concurrency was assessed by asking participants “Did you have sex (meaning ONLY anal or vaginal sex) with anyone else while you were seeing [current main partner]?” with response options of yes or no.
The poststratified weights were used in all analyses to ensure that gender and race domains were appropriately represented in the weighted estimates by adjusting to census totals. The VTSSR scale items were reverse coded for higher scores to represent higher sexual validation. To examine moderation, the VTSSR was dichotomized into high/low sexual validation based on the median split. Weighted logistic regressions were used to compare the difference in demographic, sexual, and behavioral characteristics between males who did and did not have a CJI history. Participant's age, race and high school dropout status were added into the multivariable analyses. Weighted logistic regression was used to test the association between CJI, sexual validation and sexual concurrency and for all stratified models. All analyses were performed using SAS v9.2.
Table 2 presents weighted means and percentages for male participants’ (N = 132) sociodemographic characteristics stratified by sexual validation. Participants were on average 20.2 (SD, 0.28) years old; 72.5% African American. The majority completed high school or General Education Diploma (52.3%), with a small percentage having dropped out of high school (8.7%). The mean (SD) age at first sex was 14.5 (0.2) years, and the majority (54.4%) reported having 2 or more sex partners in the preceding 6 months. Twenty-nine of 132 participants had a history of CJI. Almost 19% of participants with no CJI history had been arrested. There were no significant differences in participant characteristics by CJI history except for concurrency, which was more prevalent among those with a history of CJI (48.9 vs 20.2%, P = 0.03).
Young men in this study reported a mean (SD) [median] sexual validation (VTSSR) score = 23.7 (8.8) [22.5]) range, 12–48). Those who scored high on sexual validation had a higher prevalence of depressive symptoms, index concurrency, having 1 sex partner versus no sex partner in the past 6 months, as well as recent alcohol and marijuana use [Table 2]. Fifty-nine percent of African American men scored below the median on the VTSSR compared with 38.5% of white men, although the difference was not statistically significant (P = 0.12). Placing high value on sexual relationships was not associated with having a history of CJI (odds ratio [OR], 1.00; 95% confidence interval [CI], 0.94–1.07).
Table 3 presents the unadjusted and adjusted associations between CJI, sexual validation and concurrency. In bivariate analyses, every additional point on the sexual validation scale was associated with a 10% increased odds of engaging in sexual concurrency (OR, 1.10; 95% CI, 1.04–1.16). Similarly, having a history of CJI was strongly associated with sexual concurrency (OR, 3.69; 95% CI, 1.12–12.1). The magnitude of the association between sexual validation and concurrency increased after controlling for CJI, race, age, high school dropout, substance use, and mental health (OR, 1.14; 95% CI, 1.04–1.26), whereas CJI was no longer significantly associated with concurrency in the fully adjusted model (OR, 1.04; 95% CI, 0.20–5.33).
To examine the moderating role of sexual validation, we stratified the sample by sexual validation score (high vs low). As shown in Table 4, having a history of CJI was positively and significantly associated with sexual concurrency among those who scored high on sexual validation (N = 65) (OR, 9.18; 95% CI, 1.73–48.6); however, there was no statistically significant association between history of CJI and sexual concurrency among those who scored low on sexual validation (N = 65) (OR, 1.53; 95% CI, 0.23–10.3).
We examined the association between sexual validation and concurrency stratified by race (Table 5). An increase on the sexual validation scale was associated with an increased odds of engaging in sexual concurrency for both African American (OR, 1.12; 95% CI, 1.04–1.20) and white men (OR, 1.25; 95% CI, 1.05–1.48). However, the association between CJI and concurrency was modified by race. Among African American males, having a history of CJI was strongly associated with engaging in sexual concurrency (OR, 4.51; 95% CI, 1.20–16.9), whereas among white men, having a history of CJI was not associated with engaging in sexual concurrency (OR, 0.33; 95% CI, 0.03–3.79).
Understanding the importance young men place on sex and sexual relationships provides a critical link that has been missing from our understanding of the relationship between CJI and sexual concurrency. Consistent with what has been reported previously, we found a strong association between CJI and having concurrent sexual partners in this household sample of adolescent and young adult men.16 However, this association no longer held after accounting for the importance young men placed on sex and sexual relationships; providing unique insight into the mechanism by which incarceration and sexual concurrency are associated.
The VTSSR was created to assess whether a person feels validated or perceives validation from their peers when they engage in sexual activities, and to explore how sexual validation is related to STI risk.15 We found that young men who place great importance on sex and sexual relationships were much more likely to engage in sexual concurrency. In addition, our data supported our hypothesis that sexual validation plays an important role in concurrency for men who have been incarcerated. For young men who have been incarcerated, those who placed a high importance on sex and sexual relationships were more likely to engage in sexual concurrency, putting themselves and their partners at risk for HIV and other STI. Criminal justice involvement was not associated with concurrency among young men who scored low on sexual validation. Results from this study may help to explain the mixed findings on rates of young men’s risky sexual behavior after incarceration as we have shown heterogeneity in the value placed on sex and sexual relationships.17,18
Sexual validation was associated with concurrency in both African American and white youth, emphasizing the importance of addressing masculinity and gender role ideologies in the sexual domain for both groups. Men experiencing unfulfilled gender ideologies may focus on sex as a means of acquiring power because it may be more under their individual control than economic or political power.9 Despite there being no differences in sexual validation scores between White and African American youth, CJI was associated with concurrency only for African American youth. Gender role ideologies in the sexual domain are thought to be particularly salient for African American men living in impoverished communities because they have limited opportunity to achieve the standards of masculinity in economic and political domains.12,13,19 Because African American men are disproportionately involved in the criminal justice system,11 those who place a high value on sex and sexual relationships may be at increased risk of HIV and other STI.
It has been suggested that to create more effective STI interventions for at-risk individuals, it is important to identify the cultural and societal context in which individuals make sexual decisions.20 By understanding the importance young men place on sex, sexual relationships, and their perceived sexual norms, we have an improved understanding of the influence of these factors on their sexual behaviors. It should be noted that the prevalence of incarceration among whites in this sample was higher than expected from National data.21 These findings may indicate the broader context facing all youth in Baltimore. As discussed by LaVeist, “When whites are exposed to the health risks of a challenging urban environment their health status is compromised similarly to that of blacks, who more commonly live in such communities.”22 However, our findings have enduring implications on the disparities that result from differences in the perception of deeply held assumptions and limited opportunities internalized by youth who have been involved in the criminal justice system that have significant implications on health and health behaviors.23 Disadvantaged youth adapt to their environment.24 In the absence of economic and political opportunities, youth who have been disproportionately incarcerated are left with sexual opportunities to reclaim their gender ideologies and a sense of internal power.25 Developing a critical consciousness, or an awareness of social oppression, among CJI youth may be 1 intervention strategy that empowers young men to free themselves from feeling the need to overcompensate for the disempowering experience of CJI through sex.26
Although this study improves our understanding of the relationship between CJI and STI risk among young men, our findings should be interpreted in light of several limitations. This was a cross-sectional study and any associations cannot be inferred as causal relationships. These findings come from a relatively small sample of adolescent and young adult males, which resulted in wide confidence intervals and limited our ability to examine associations further within subgroups. Although findings may not generalize to rural or suburban populations, we expect that they are relevant for other urban populations. Our measure of CJI was limited in that it did not capture length or multiple experiences of incarceration, both opportunities for future research. Although the interview asked about experience with jail, juvenile detention center, or correctional facility separately, these outcomes were combined in the analysis due to small numbers; however, the type of facility may impact relationships differently. Further, we were not able to separate concurrent vaginal from concurrent anal sex, behaviors which can confer different types of STI risk. Finally, although we found that the mean VTSSR score for men in this sample was low relative to the range, we do not have additional samples for comparison. Widespread use of the VTSSR scale will help to establish relative values and to further validate the scale.
An increasing number of juveniles experience the criminal justice system, which poses significant public health problems, particularly for communities who experience a disproportionate rate of their youth in detention.27 Ascribing to less rigid gender ideologies and reducing the importance youth place on sex and having multiple sexual relationships may be a source of resilience.28 In addition to the need for policies that move away from the incarceration of youth,29 interventions designed to change the ideology of masculinity have been successful in other countries.13,30 Findings from this study suggest that similar approaches may be needed to reduce the importance young men place on sex over their own health.
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