The sample was comprised of 70 women and 82 men with SMI. Participants ranged in age from 20 to 63 years (M = 38.61 ± 9.28) and were racially diverse (58% White, 27% Black, 11% Hispanic, 4% mixed/other). Most identified as heterosexual (85%) and had a high school education (80%). Reflecting their SMI status, the majority was single (66% never married, 28% divorced/separated, 1% widowed), was currently unemployed (82%), had a monthly income under $1000 (89%), and had a history of homelessness (80%). Primary psychiatric diagnoses were: 40% psychotic disorder (20% schizoaffective, 18% schizophrenia, 2% other) and 60% non-psychotic disorder (29% major depressive, 26% bipolar, 5% posttraumatic stress). Two thirds had a lifetime history of substance use disorder, and 47% met criteria within the past year. Ninety percent had one or more inpatient psychiatric hospitalizations (M = 7.03 ± 8.35), and 54% were hospitalized in the past year. All were currently receiving treatment for their SMI.
Almost all participants (93%) had at least one lifetime sex partner. The mean number of sex partners was 22.82 (SD = 36.37, range = 0–300); 37% of participants had 20 or more sex partners. One third (33%) had ever engaged in sex trading, and 36% had a history of sexually transmitted infection. Two participants reported that they were HIV-positive.
Prevalence, description, and correlates of childhood abuse
The prevalence of childhood sexual and physical abuse was 47% and 58%, respectively. The majority (70%) reported at least one type of abuse, and 32% reported both types of abuse. Women were more likely than men to have been sexually abused (63% vs. 33%, χ2(1) = 13.59, p < .001), but there was no gender difference for physical abuse (61% vs. 50%, χ2(1) = 2.00, p = 0.16). Men were more likely to report no childhood abuse (40% vs. 19%, χ2(1) = 8.40, p = .004). Whites were more likely to report a history of physical abuse (65% vs. 42%, χ2(1) = 7.65, p = .006), but there was no race difference for sexual abuse (51% vs. 41%, χ2(1) = 1.65, p = .20). There were no group differences on age, educational attainment, sexual orientation, or marital status (all p > .10).
There were also gender and race differences on adult victimization. Women were more likely to report adult sexual abuse (46% vs. 9%, χ2(1) = 27.36, p < .001) and adult physical abuse (43% vs. 24%, χ2(1) = 10.96, p = .001). Whites were more likely to report adult sexual abuse (33% vs. 16%, χ2(1) = 5.83, p = .016) but not adult physical abuse (49% vs. 35%, χ2(1) = 3.18, p = .08)
describes participants’ childhood abuse experiences. Among participants who reported childhood sexual abuse, 61% experienced repeated abuse occurring over a mean of 5.13 years (SD = 3.92). Women were more likely than men to have been repeatedly sexually abused, abused for longer duration, and abused by a family member. Among participants who reported childhood physical abuse, 68% reported repeated abuse occurring over a mean of 7.57 years (SD = 6.29). There were no gender differences in the frequency and duration of physical abuse, but women were more likely to have been physically abused by a partner.
Description of childhood abuse experiences among adults with SMI
compares participants with physical abuse only, sexual abuse only, physical and sexual abuse, and no abuse on lifetime substance abuse, adult victimization, and HIV sexual risk. There were overall group differences on all variables except substance abuse problem and cocaine use. When comparing participants with sexual abuse only versus physical abuse only, those with sexual abuse only were significantly more likely to have a lifetime drug use disorder (68% vs. 29%); otherwise there were no significant differences between these groups. In contrast, when comparing participants with any abuse versus no abuse, those with any abuse were significantly more likely to report adult physical abuse (48% vs. 30%), adult sexual abuse (33% vs. 9%), sex trading (40% vs. 24%), sexually transmitted infection (44% vs. 17%), and 20 or more sex partners (43% vs. 24%); however, there were no differences in substance abuse variables. These findings suggest that childhood sexual abuse may be a unique predictor of drug use disorder, but any childhood abuse (sexual and/or physical abuse) is a risk factor for adult victimization and lifetime HIV risk.
Effect of childhood abuse on lifetime substance abuse, adult victimization, and HIV sexual risk
We then tested the hypothetical model. All indicator loadings on the latent factors were greater than .50 (p < .001). Because race and gender were associated with both childhood and adult abuse, they were added as covariates. The model had adequate fit (χ2(37) = 50.22, p > .05; RMSEA = 0.049; CFI = 0.92; NNFI = 0.95). Inspection of modification indices suggested that controlling for the effects of race on drug abuse and HIV risk improved model fit. depicts this final structural model with path coefficients. This model had excellent fit (χ2(35) = 35.53, p > .05; RMSEA < 0.01; CFI = 1.00; NNFI = 1.00).
Structural equation model depicting paths and standardized estimates among childhood abuse, drug abuse, adult victimization, and HIV risk behavior (measurement error terms not shown).
shows the direct and indirect effects of all variables in the final model. Childhood abuse was directly (z = 2.03, p < .05) and indirectly (z = 2.28, p < .05) associated with HIV risk. Childhood abuse was directly associated with adult victimization (z = 2.04, p < .05), and adult victimization was directly associated with HIV risk (z = 2.89, p < .01). Childhood abuse was not directly associated with drug abuse (z = 1.72, p > .05), but drug abuse was directly and strongly associated with HIV risk (z = 4.44, p < .01). While the overall indirect effect of childhood abuse on HIV risk was significant, Sobel tests for mediation found that the individual indirect effects of drug abuse and adult victimization on HIV risk were not significant (t = 1.64, p = .10 and t = 1.71, p = .09, respectively), though the effects were in the expected direction.
Direct and indirect effects of childhood abuse on drug abuse, adult victimization, and HIV sexual risk
Multiple group comparisons indicated no significant difference in the models by gender (χ2(8) = 6.44, p > .05), indicating that the model did not differ significantly between men and women. There were also no differences between men and women for individual paths in the model (data not shown).