Impact of Sexual Abuse on the HIV-Risk-Related Behavior of Adolescents in Intensive Psychiatric Treatment

The study participants (N=208) attended psychiatric day schools and residential programs; 84.2% (208 of 247) of the youths eligible for the study (between 13 and 18 years of age, not psychotic, and able to participate in school activities) were enrolled. The diagnostic range of patients was similar to that found in other therapeutic settings (33.2% [N=69] had impulse-control disorders, 29.8% [N=62] had depressive disorders, and 9.1% [N=19] had PTSD as their primary diagnosis). Those without a history of sexual intercourse (N=92) were dropped from subsequent analyses. Eighteen adolescents had clinical histories of abusive sexual experiences only during childhood, and 10 had been abused sexually only since age 13. Thirty-three subjects had histories of childhood sexual abuse both before and during adolescence. Scale scores (examined by means of analysis of variance) and behaviors (examined by means of chi-square analysis) of the three groups of abused adolescents were similar, so they were combined for subsequent analyses (N=61). After describing the study to subjects, written informed consent was obtained from a parent or guardian.

All participants completed measures of HIV-related knowledge, tolerance of individuals with HIV, perceived susceptibility to HIV, intention to prevent the transmission of HIV, condom self-efficacy, and HIV self-efficacy, which have shown excellent reliability and internal consistency (9, 10, 11). The Condom Self-Efficacy Scale (10) reflects the emotional context of condom use (e.g., “You use a condom when you’re upset”), while the HIV Self-Efficacy Scale (11) assesses practical skills (e.g., the ability to acquire and carry condoms). Assessed behaviors included history of sexually transmitted diseases, substance use, and frequency of purchasing and using condoms. Two subscales from the Weinberger Adjustment Inventory (12) measured impulse control and self-restraint. A measure of general attitudes not related to HIV risk (9) was completed.

There were no differences in age, ethnicity, or history of substance abuse between the adolescents with (N=61) and without (N=55) a history of sexual abuse (age: mean=15.13 years, SD=1.53; mean=15.05, SD=1.35, respectively) (ethnicity: 40 white, 74.1%; 39 white, 75.0%) (history of substance abuse: N=30, 49.2%; N=27, 49.1%). However, more of those with a history of sexual abuse were female (N=32 of 61, 51.5%) than were those without a history of sexual abuse (N=11 of 55, 20%) (χ²=12.98, df=1, p<0.001). Those with a history of sexual abuse were diagnosed with PTSD more often (N=16, 26.2%) than were those without such a history (N=2, 3.6%) (χ²=11.25, df=1, p<0.001), whereas adolescents without a history of sexual abuse were more often diagnosed with attention deficit hyperactivity disorder (N=16, 26.2%) than were those with such a history (N=4, 7.3%) (χ²=10.23, df=1, p<0.001). Otherwise, there were no diagnostic differences between the groups. (Note that some data were missing.)

A multivariate analysis of covariance controlling for gender found a significant difference in overall HIV-risk-related behaviors and attitudes between adolescents with and without a history of sexual abuse (F=2.79, df=9, 86, p<0.01). Univariate tests found that adolescents with a history of abuse scored significantly lower on knowledge of HIV, condom self-efficacy, and impulse-control scales compared to their peers (Table 1). Abuse was significantly associated with inconsistent condom use, failure to purchase condoms, and a history of sexually transmitted diseases.

To identify these associations with recent sexual behavior, a multiple logistic regression for inconsistent condom use examined simultaneously all significant variables (history of sexual abuse, condom self-efficacy, impulse control, and gender) (model χ²=14.87, df=4, N=108, p<0.01). Only a history of sexual abuse was found to be significantly associated with recent risky sexual behavior (adjusted odds ratio=3.06, 95% confidence interval=1.21–7.70) (Wald χ²=5.62, df=1, p=0.01).

This study found that adolescents with a history of sexual abuse were three times more likely than their peers to report inconsistent condom use, a finding not attributable to gender or diagnostic differences. Having a history of abuse was also significantly associated with having more sexually transmitted diseases, less impulse control, and less knowledge of HIV than adolescents without a history of abuse. Participants with a history of sexual abuse scored significantly lower on the Condom Self-Efficacy Scale, which measures the perceived ability to use condoms in difficult situations. This new finding suggests that even among adolescents in psychiatric treatment with high HIV-related risk, those who have experienced sexual abuse have greater difficulties enacting “safe” sexual behaviors than those who have not been sexually abused.

This study has limitations. It is possible that a history of sexual abuse may be associated with the severity of a psychopathology that was not measured. However, there were few diagnostic differences, as has been consistent with the results of other studies. The finding of less nonsexual impulse control among those with a history of abuse suggests difficulties with behavior control that perhaps are not reflected in diagnostic or general distress measures. In addition, the cross-sectional design precluded analysis of causal links between sexual abuse and HIV-related attitudes or sexual initiation.

Clinicians should consider a history of sexual abuse as a marker for current HIV-risk-related behaviors among adolescents with psychiatric impairment. Adolescents with a history of sexual abuse may have particular difficulty being assertive in sexual situations. Sexual abuse may lead to low self-esteem, powerlessness, and difficulty maintaining appropriate sexual boundaries. Because sexuality may revive traumatic memories and affect, simple behavioral rehearsal does not appear to be sufficient to induce assertiveness. Therapy is an opportunity to assist adolescents in reducing their anxieties (e.g., “He might leave me if I make him use a condom”) and restoring the self-efficacy (e.g., “I can control what happens when I have sex”) needed for a safer future.

Received Dec. 18, 1998; revisions received July 22, 1999, Oct. 19, 1999, Jan. 21, 2000, and March 13, 2000; accepted March 31, 2000. From Rhode Island Hospital. Address reprint requests to Dr. Brown, Child and Family Psychiatry, Rhode Island Hospital, 593 Eddy St., Providence, RI 02903; [email protected] (e-mail). Supported by NIMH grant MH-50416 and a grant from the Department of Psychiatry and Human Behavior, Brown University.