The findings support substantial portions of the theoretical model, with important differences observed between secondary and primary partner models. In the present study, primary and secondary sexual relationships represent broad distinctions in types of close relationships. By definition, primary relationships involve a greater degree of commitment and love than secondary relationships (Peplau & Cochran, 1981
; Shannon & Woods, 1991
). Secondary sexual relationships encompass a more diverse range of sexual partnerships; although not a universal, they tend to be more transitory, and to involve more occurrences of high-risk sexual behavior (Buchanan, Poppen, & Reisen, 1996
; Dudley, Rostosky, Korfhage, & Zimmerman, 2004
; Dufour et al., 2000
; Molitor, Facer, & Ruiz, 1999
; Paul, Stall, Crosby, Barrett, & Midanik, 1994
). MSM who engage in secondary sexual relationships often have large numbers of sexual partners which, in turn, will significantly impact HIV/STI spread in the population.
The findings point to two over-arching but inter-related pathways (e.g., both pathways include effects on interpersonal skills) linking CSA and high-risk behavior for men in secondary sexual relationships: 1) CSA-Motivation-Scripts-Skills-Risk Behavior, and 2) CSA-Motivation-Coping-Risk Appraisal-Skills-Risk Behavior. For men in primary relationships, there was only one over-arching pathway that includes CSA-Motivation-Coping-Risk Appraisal- Risk Behavior processes.
Why this difference in the primary versus secondary partner models? If sexual trauma potentially inhibits primary relationship formation, then we might suspect there is something different about men with CSA histories who are able to form primary vs. secondary relationships. Either their CSA history was less traumatic, or the sexual victimization was associated with other developmental experiences that enhanced emotional and psychological resilience (e.g., see Bonanno, 2004
). For instance, they may have differential histories with respect to ameliorative or restorative relationships [e.g., supportive parent(s)]. Although we did not investigate restorative factors, we can examine for differences in functioning by relationship type through examination of men with CSA histories who reported only primary partners vs only secondary sexual partners. We conducted exploratory analyses at the level of observed variables ; these analyses, because of sample size, are limited to univariate statistics (t-/F-tests, Chi Square). We hypothesized that men in primary relationships, either because they had ameliorative experiences or less traumatic CSA experiences, would differ from men in secondary relationships in terms of having less interpersonal-anger, being less sexually preoccupied/compulsive, having lower depressive mood scores, reporting less use of escape avoidance coping and more use of adaptive coping, being more “other-directed,” having better interpersonal skills and less acceptance of violent behavior.
We limited this analysis to men with CSA histories who were only in primary (n = 57) vs. only in secondary (N = 105) sexual relationships in the past year to provide the most straightforward comparison for illustrative purposes. Although they did not differ on CSA severity (i.e., they had comparable sexual trauma histories based on the measures employed in this study), men in primary relationships were significantly less angry (on either anger scale; ps < .03), had lower depressive mood scores (p < .05), were less sexually preoccupied/compulsive (ps < .01) and more likely to be “other-directed” (p < .01). Men in primary versus secondary relationships were also less likely to be heavy drinkers (one index of behavioral escape avoidance), or use cognitive escape avoidance strategies (ps < .02; no significant differences in dissociation, denial, heavy drug use, or defensive avoidance were found). In terms of their sexual relationships, men in primary vs. secondary relationships had significantly more negative attitudes concerning the use of force in sexual relationships, and were better able to regulate sexual encounters towards positive outcomes for both themselves and their sexual partners (ps < .02). These findings suggest that men with CSA histories who are in primary relationships are socially and psychologically functioning better than those in exclusively secondary relationships. Analyses including men with CSA histories who had both primary and secondary sexual partners (n = 78) were similar to the prior results on key measures. In addition, men in primary relationships were significantly more likely to have used adaptive coping strategies for both instrumental and emotional issues (ps < .001). This result is consistent with the idea that men in primary relationships may have had a more extensive history of seeking and utilizing help for their CSA-related problems. Further, men with primary partners, regardless of the degree of sexual exclusivity in their relationships, have interpersonal characteristics and problem-solving oriented coping skills that may enhance the capacity to maintain intimate partnerships.
Motivation pathways: Affective motives
We examined four CSA-Motivation pathways: affective (depressive mood), interpersonal-affective (anger), interpersonal-approval seeking (”other-directedness”), and sexual motivations. The effects of CSA severity on affective motivation was robust across models, while CSA links to other motivational factors were less consistent. In both models, greater CSA severity was significantly associated with higher levels of affective distress (depressiveness), and greater affective distress (depressive mood) was, in turn, significantly related to more frequent use of behavioral and cognitive escape avoidance coping. This CSA-Affective(depression)-Coping pathway eventuates in high-risk sex in both secondary and primary partner models. The present findings support earlier work linking depression and high-risk behavior, and further suggests that prior inconsistencies in the literature linking affective conditions to high-risk sex may be due to not taking CSA histories and coping into account (see (O'Leary et al., 2003
; Paul et al., 2001
). Recently, Bancroft and Vukadinovic (Bancroft et al., 2003
) found that adults with dysphoric mood (depression, anxiety) frequently had extreme problems controlling aspects of their sexual behavior (e.g., excessive cruising, excessive masturbation). They suggest an explanatory model involving affect-motivation, inhibition control, and self-regulatory failure that has parallels in our model of MSM with CSA histories.
Motivation pathways: Interpersonal-affective and affective motives
CSA severity was significantly related to interpersonal-affective motivation (interpersonal-anger) in the secondary partner model, but not the primary partner model. As noted previously, these findings may reflect the possibility that people with anger management problems have difficulty developing or maintaining intimate close relationships. Greater interpersonal-anger, in turn, was related to less frequent use of adaptive coping and greater use of cognitive escape avoidance coping strategies (but unrelated to behavioral escape avoidance coping). This CSA-Anger-Coping pathway eventuates in subsequent effects on risk appraisal, interpersonal sexual skills, and ultimately high-risk sexual behavior. Moreover, there is a significant pathway from interpersonal-affective motivation through sexual scripts to interpersonal sexual skills (see discussion of scripts and skills below) that also impacts high-risk sex. Thus, interpersonal-anger affects high-risk sex through multiple pathways involving coping and other interpersonal processes. Lastly, we note that, although there is not a significant CSA-interpersonal-affective pathway in the primary partner model, interpersonal-affective motivation (interpersonal-anger) is still an important consideration in primary relationships in that it affects coping mechanisms which, in turn, influence risk appraisals and high-risk sex.
Motivation pathways: Sexual motives
Sexual motivations were involved in nonsignificant CSA-pathways in both models. Our sexual motivation factor was composed of measures of sexual preoccupation and compulsivity. In a recent report, O’Leary et al., (2003)
also found that CSA was unrelated to sexual compulsivity among MSMs. Preoccupation and compulsiveness are not, however, the only sexual motivations to consider. Bancroft et al. (2003)
found that the ability to inhibit sexual arousal may affect engaging in high-risk sex. That is, it is not that men with a CSA history are necessarily more sexually compulsive or preoccupied than men without such histories, but they may have less control over their sexual reactions in harmful sexual situations. CSA experiences could facilitate this type of developmental response in adulthood since the child-victim is in fact unable to control either the sexual interaction or, at times, his own body’s physical responses to being sexually stimulated.
Motivation pathways: Social desirability motive
We examined the role of interpersonal-approval seeking, specifically “other-directedness,” as a mediator of the CSA-risk behavior relationship. Our construal of approval seeking in terms of “other- versus self-directedness” differentiates a personality characteristic, related to one’s orientation to the social world, from the methodological meaning of the motive. Highly “other-directed” persons may be more concerned about the desires of others than their own best interests (i.e., eager to please). Highly “inner-directed” persons may, alternatively, be more unconventional, and unconcerned about what others think, and therefore may have poor social skills relevant to developing good social relationships. The CSA literature indicates that a history of CSA may lead to being more “other-directed” (i.e., concerned about the opinions of others), and, therefore, less influenced by threats to self. However, we did not find this to be the case. In the primary partner model, CSA severity was unrelated to “directedness.” In contrast, there was a significant CSA-approval seeking pathway for men with secondary partners that included coping strategies, risk appraisal and, subsequently, high-risk behavior. The primary partner findings may reflect the possibility that men in primary relationships have greater mutuality in their relationships For men in secondary relationships, the results indicated, contrary to predictions, that men with greater CSA severity were more “inner-directed” (lower need for social approval). That is, CSA trauma may result for some men in a preoccupation with self to the exclusion of other’s feelings. When coupled with high levels of interpersonal anger, these conditions may elicit interpersonal problems that shorten relationships, and increase health risks by increasing the number of sexual partners.
Men who were more “inner directed” were also more sexually preoccupied/compulsive, were less frequent users of adaptive coping strategies, and more frequent users of cognitive escape avoidance coping. These findings are consistent with the interpretation that low need for approval scores indicate a self-preoccupation. For instance, men who are more self-absorbed may be less likely to use adaptive coping, which involves reaching out to others, and/or more likely to use internally oriented cognitive escape coping processes. Similarly sexual preoccupation/ compulsiveness may reflect self-absorption with sexual pleasure. We had hypothesized that in brief sexual encounters sexual motivations may have a stronger effect than interpersonal motivations on perceived risk. In longer-term relationships, wherein interpersonal goals of maintaining and enhancing the relationship may be more relevant, interpersonal motivations may be equal to or stronger than sexual motivations in influencing risk appraisals (Misovich et al., 1997
). We did not find support for this hypothesis. However we did not specifically measure motives associated with maintaining and enhancing one’s relationship with the primary/secondary sexual partners; a subject for future study.
The present work suggests a key, but complex role for coping strategies in the CSA-risk behavior models examined with respect to coping with affective, interpersonal-affective, and interpersonal-approval seeking motivations. Aside from predicted outcomes, the coping results revealed some unpredicted effects. In the secondary partner model, greater CSA severity was directly associated with less frequent use of behavioral escape avoidance coping. One explanation for this finding is that some men with severe CSA trauma are able to cope more frequently and/or successfully with cognitive strategies with less reliance on behavioral escape avoidance coping. This may be an outcome of the CSA trauma or a consequence of ameliorative factors. Victims of sexual abuse are typically placed by the perpetrator in a situation in which they are less able to physically do anything about the abuse, and, therefore, may rely more on cognitive coping strategies to escape. Therapy directed at reducing self-destructive behaviors, for instance, may also reduce behavioral escape avoidance coping. As noted, we do not have data on therapeutic histories. Finding that more frequent use of cognitive escape avoidance coping was associated with greater fear of HIV was unexpected. In some instances, this finding may be indicative of “corrective hindsight.” That is, one engages in a high risk activity partly because one is contemporaneously engaging in escape avoidance coping, but later (such as at the time of interview) one re-categorizes the behavior as high risk (“from a safe distance?). This result, however, may also reflect the effects of other coping strategies or motivational forces not assessed in the present study (e.g., spiritual coping, coping × anger interactions).
Sexual scripts, as discussed here, represent learned patterns of sexual interaction that guide sexual relationships and affect sexual pleasure. Although the scant literature on these topics suggests that either highly aggressive or passive scripts might develop from CSA histories, the present results indicated that it was the more aggressive sexual script that was associated with problematic behaviors. Sexual scripts were part of a significant CSA-Motivational pathway that influenced sexual skills; more aggressive scripts were significantly related to poorer interpersonal sexual skills. This result may reflect the fact that the measures of interpersonal skills assessed here imply a level of caring or nurturing that may be absent when one is following an aggressive sexual script. Sexual aggression does not lead to mutuality in sexual outcomes unless one’s partner is masochistic. More aggressive scripts were found to be influenced by higher levels of interpersonal-anger. CSA driven interpersonal-anger may lead to the development of aggressive scripts as a means of satisfying both one’s sexual needs and expressing anger towards the original perpetrator (symbolically speaking).
Sexual skills are essential to healthy sexual outcomes in most models of sexual health behavior. With respect to CSA trauma, however, the import of sexual skills to risk behavior was primarily relevant in the secondary sexual partner relationship. This may reflect the higher functioning of men in primary relationships. It may also reflect the possibility that in primary relationships, where mutuality is high, the simple desire to protect one another from harm may be sufficient to achieve healthy goals without assertiveness and communication skills being necessary. In secondary relationships, mutuality and nurturance may be lower, and therefore, something more is needed to ensure harm reduction. In the secondary sexual partner model, interpersonal sexual skills directly impact, independent of risk appraisals, high-risk sexual behavior; lower skills are related to higher risk sexual activity. Interpersonal skills are influenced by CSA severity via interpersonal-anger and sexual script pathways (greater anger and more aggressive scripts are associated with poorer skills). Coping and risk appraisals also impact sexual skills. More frequent use of adaptive coping and less use of cognitive escape avoidance coping are associated with better skills, and higher levels of risk appraisal stimulate better skill performance. These results are theoretically consistent and underscore the role of emotional and cognitive processes in facilitating healthy sexual behavior via enhanced skill development.
Risk appraisal pathways
Risk appraisals have a direct impact on risk behavior in both models (and an indirect effect in the secondary partner model via skills), and as expected, such appraisals are influenced by coping processes (as discussed previously). Given the cross-sectional nature of our study, and as pointed out by Weinstein and Nicoloch (1993)
, we were somewhat fortunate to have found a theoretically consistent relationship between risk appraisals and risk behavior (lower concern associated with greater risk behavior). Because of the reciprocal nature of this relationship one could also observe the opposite relationship in a cross-sectional study. The obtained result is more often found in populations in the early stages of an epidemic, which is consistent with the observation that MSM are entering a new epidemic phase facilitated paradoxically, in part, by better treatments (Huebner et al., 2004
). The current findings suggest that risk appraisals play a key role in the CSA trauma model and future work should focus on factors that may assist men with a history of sexual trauma in making accurate appraisals.
Because motivational and coping factors are key mediating components of CSA and high-risk sexual behavior, and their effects are further mediated through interpersonal processes (scripts, interpersonal sexual skills), then we conclude that prevention strategies focusing exclusively on skill building may more often fail for MSM with more severe CSA histories. Indeed, most HIV relevant cognitive-behavioral prevention programs tend to focus on sexual skills and situation specific elements within the sexual interaction.
Indeed CSA poses considerable challenge for HIV prevention. As Briere (2004)
has pointed out, treatment for CSA-related problems may not be an effective way of preventing HIV risk in the general population. However, there may be many MSM CSA survivors currently in therapy that may be helped with reducing their HIV risk by addressing HIV-relevant risk factors, such as those described herein (e.g., cognitive-behavioral treatments for improving coping strategies, affect regulation, and interpersonal skills; substance abuse interventions) (e.g., Briere, 2004
; Chin, Wyatt, Vargas Carmona, Burns Loeb, & Myers, 2004
). Further, our results suggest that sexual histories may be useful as markers for identifying MSM CSA-survivors with more wide ranging problems (i.e,. men with secondary sexual partners to the exclusion of primary relationships). Moreover, the success of short-term HIV prevention programs may be increased by focusing on MSM CSA survivors in primary relationships. In addition, increased attention may be given through secondary education efforts directed at evaluating and augmenting therapist skills in addressing the sexual relationships of MSM CSA patients. We would note, however, that men with poor histories of seeking help from others may be less inclined to sustain therapeutic contact even if initiated. Paul et al., (2001)
have recommended case-management approaches to help facilitate sustained therapeutic contact. Aside from men in therapy, broader population-approachs may include developing public health campaigns that help normalize disclosure of CSA histories and facilitate treatment seeking. Similar “destigmatizing campaigns” have been made with respect to AIDS and other stigmatized health conditions (e.g., erectile dysfunctions).
We limited our analysis in several ways. First, we do not include previously studied personality, cognitive, and social factors that may influence the antecedents or outcomes of risk appraisal or enactment (e.g., self-efficacy beliefs; HIV knowledge; perceived health cues; social networks; other life-stresses). Many of these variables either have hypothesized pathways that are already represented by variables we examined, or have pathways that may not be relevant to a history of CSA. Furthermore, the small number of men in any one ethnic minority group in our study prohibits detailed analyses of subculture issues. Despite these limitations, the empirical model we examined includes key mediators of CSA and HIV sexual risk behavior that may be amenable to intervention efforts.
As with all research based on retrospective assessments of developmental events, recall error is a common concern. However, a number of studies have found that many CSA victims have reasonably reliable recall of their CSA experiences, and that retrospective assessments of CSA characteristics have consistent and reliable relationships to adult outcomes of relevance to research on HIV sexual risk behavior (Jinich et al., 1998
; Johnsen & Harlow, 1996
; Loferski et al., 1992
; Paul et al., 2001
; Whitmire et al., 1999
). An additional challenge is one of statistical power. Even though CSA is a highly prevalent developmental trauma among MSM, one needs large sample sizes to test the types of models examined in the current investigation. In this regard, we did not have sufficient power to model distinct partnership groups beyond secondary and primary partnership models. Men with both primary and secondary partners appear from our univariate analyses to be somewhere between men with only primary partners and those with only secondary partners with respect to many of the independent variables. As such, we included this group in both models for purposes of analysis, therefore the differences between models may be more extreme than represented here. Further, our theoretical work has not evolved sufficiently to predict what key interactions should be examined beyond relationship type (i.e., an interaction is inferred in our strategy of breaking analyses into two relationship models).
For practical reasons the factors in the present study have limited representation. For instance, the affective factor does not include assessments of anxiety. Anxiety, like depression, may have differential relationships to risk appraisals and enactment of safe sex (e.g., see Bancroft, Janssen, Strong & Vukadinovic, 2003
). For instance, Miller (1999)
has observed that post-traumatic stress syndrome (PTSD) may contribute to a decrease in risk behavior. That is, PTSD may motivate hyper-vigilance that enhances appraisals of risk and, consequently, avoidance of sexual situations because they all “appear” dangerous. In addition, the role of affective motives in high-risk sex may be more complex than the current model illustrates. For instance, severe depression may reduce motivation for seeking sex. Future work should explore the influence of more severe mental health problems among CSA victims in relation to sexual health risks. Guilt (e.g., survivor guilt), jealousy, and other relationship/sex relevant emotions would also be logical candidates for study. Other avenues for investigation with respect to the sexual motivation factor and social desirability factor have been discussed. The role of adaptive coping could be expanded to encompass the broader set of considerations associated with social support (e.g., network limitations). In addition, help-seeking and professional care experiences would, from our prior discussion, be relevant areas for future study.
Models were tested that explored potential mediators of CSA and adult sexual health, notably HIV/STI related risk behaviors. The secondary sexual partners model was the most complex with multiple pathways leading from CSA to high-risk sex. The primary sexual partners model was less complex with only one significant over-arching pathway observed linking CSA to high-risk sex. Explanations for these differences by partnership type are discussed and detailed discussion of specific pathways is provided.