To date, there has been very little research that explicitly compares factors that influence high risk behavior among women who have and have not experienced CSA (Noll, 2005
). This study involved a sample of women already at high risk for HIV infection, either directly (e.g., multiple sexual partners, injection drug use) or indirectly (e.g., injection drug-using partners). Over 40% of the sample reported having experienced sexual abuse during childhood, and participants reported having multiple additional risk factors including high rates of STIs, unprotected sex, and being intoxicated (i.e., under the influence of alcohol or drugs) during sex. For this study, we wanted to determine whether the subset of women who have experienced CSA engaged in even more risky behaviors than those who did not have such a history (Hypothesis 1). This hypothesis was partially supported. Those with a CSA history reported more STIs and more unprotected sex, but did not report greater frequency of being intoxicated during sex or a higher prevalence of HIV.
Next, we examined whether these two groups experienced different levels of relational power (Hypothesis 2). Contrary to our expectation, women with divergent abuse histories did not differ with regard to either relationship power or locus of control for STI acquisition. Given the preponderance of evidence linking CSA with powerlessness (Finkelhor & Brown, 1985
; Miller, 1999
; Thompson et al., 1997
), these null findings prompted us to consider other sociodemographic indicators of powerlessness, such as poverty. Indeed, post-hoc analyses revealed that there were more women who reported being both homeless and having experienced CSA than one would expect by chance alone. These findings suggest that a more comprehensive conceptualization of powerlessness, one which considers micro- and macro-systemic factors, might be warranted for women who have experienced CSA (Amaro & Raj, 2000
Our third hypothesis, that contextual factors such as sex work and the use of drugs or alcohol during sex will mediate the relationship between relationship power and sexual locus of control and unprotected sex for women with a history of CSA, but not for women without a history of CSA, was partially supported. Results from the path analyses suggest that locus of control and relationship power play an important role in sexual risk taking for women abused as children. That is, among women with CSA histories, those who had less relationship control had more frequent unprotected sex than similar women who had more relationship control. This finding underscores the difficulty women have with making healthy sexual decisions in the context of a relationship in which they have little power. Additionally, among those with a CSA history, external locus of control (in the relationship and in relation to STI acquisition) was associated with engaging in sex work. In turn, sex work was related to being intoxicated during sex and having more frequent unprotected sex for this group of women. Locus of control was only associated with frequency of unprotected sex through its relationship with engaging in sex work and being intoxicated during sex. In contrast, for women who were not abused during childhood, relationship control and locus of control for STI acquisition were not associated with sex work nor was locus of control associated, directly or indirectly, with frequency of unprotected sex.
Of course, this study relied on self-reports of CSA, using a cross-sectional design. We are limited in our interpretations with regard to causality as a result of these methodological constraints and it is likewise equally plausible to conclude that engaging in risky sexual behavior contributes to one's sense of not having personal control over sexual decision-making. Additionally, other factors not included in the model, such as intimate partner violence, socioeconomic factors (e.g., homelessness, lack of access to condoms or sexual health care, etc.), and attitudes toward safer sex behavior, possibly influence the mediated relationships between relationship control and locus of control with frequency of unprotected intercourse for women with histories of CSA. Some research indicates that the earlier CSA is experienced, the greater the chronicity and severity of abuse, and the more types of abuse that occur, the greater the likelihood of increased risk behavior during adulthood (Bensley et al., 2000
; Campbell, Sefl, & Ahrens, 2004
; Felitti et al., 1998
; Gore-Felton & Koopman, 2002
; Merrill, Guimond, Thomsen & Milner, 2003
) and the greater likelihood of revictimization (Classen, Palesh, & Aggarwal, 2005
; Roodman & Clum, 2001
). Our analyses would have been strengthened had we measured these characteristics of CSA more precisely. Future research should consider whether these contextual or relationship mediators play a role for those with greater or lesser severity of CSA experiences.
A related limitation is that the item we used to differentiate between those with and without a history of CSA asked women whether they had been sexually abused or raped. This definition is open to some interpretation and some participants may have included non-volitional or non-penetrative sexual acts in their interpretation of sexual abuse or rape, whereas others may not have included such acts. Also, the nature of this question requires that participants identified their unwanted childhood sexual experiences as sexual abuse (Kalmuss, 2004
), which suggests that the prevalence of CSA may have been even higher than what was reported here. More clearly defined items on a scale that gives differential weight to those incidents of abuse that differ by onset, chronicity, severity, and type would enhance the ability to understand the differential effects of these complex components.
Despite these limitations, the findings underscore the strong association between locus of control and sexual health decision-making among poor, urban women at high risk for STI infection. Our findings suggest that engaging in sex work and being intoxicated during sex mediates the relationship between control and risky sexual behavior for women with CSA histories, and that being intoxicated during sex mediates the relationship between sex work and risky sexual practices for those who have not experienced CSA; both findings have implications for STI prevention. Programs targeted at high risk women should also include an educational component in which topics such as maladaptive coping strategies (e.g., using drugs to dissociate, particularly in the context of sex work) are discussed. This focus would bring awareness to the ways in which contextual factors can impede one's desire or ability to protect oneself from STIs. These interventions should acknowledge the role alcohol and drugs can play in coping with feelings of powerlessness and how substance use and abuse can put women at increased risk, particularly in terms of sexual revictimization for those with CSA histories. Of course, some of these women may be limited in the degree to which they can exercise sexual control and many rely on sex work for subsistence. However, others may not realize the extent to which they assume an external locus of control and may benefit from a discussion of the ways in which engaging in particular behaviors compounds their risk of HIV infection.
Our data indicate that CSA experiences were slightly higher for this high risk sample than for other populations (Bensley et al., 2000
; Elze et al., 2001
). Inasmuch as the experience of sexual abuse during childhood is such a common reality, particularly among women who are marginalized by poverty and other contextual realities that reify diminished power expectations, interventions aimed at reducing sexual risk might do well to incorporate content related to victimization and its relationship with adult risky sexual behaviors. Further, what we have conceptualized as sexual risk taking might be better viewed as revictimization, particularly in a context of diminished relational locus of control. That is, women with a limited sense of personal control might unwillingly engage in risky sexual behavior, particularly in the context of drugs and prostitution (Whyte, 2006
). This is an important question that demands further research attention. Moreover, if early victimization predicts revictimization (e.g., Fleming, Mullen, Sibthorpe, & Bammer, 1999
), better surveillance of CSA is necessary in order to target interventions that attenuate adult risk. Interventionists need to find effective ways to empower girls prior to their involvement in adult sexual relationships. Although there is no “magic bullet,” having an explicit conversation about the realities of victimization in general and sexual victimization and revictimization in particular as well as helping young women identify their “bottom line” with regard to sexual activity could prove helpful (Sterk, 2002
This research represents an attempt to clarify the pathways by which adult sexual risk occurs for high risk women with and without a history of CSA. More research is needed to further examine the differences between these groups, particularly as they might better inform intervention efforts. Examination of other contextual factors, such as experiences of racism and sexism, will also be important for women in high risk urban contexts in which drug use, sex work, and poverty pervade. Moreover, research models that incorporate measures of resilience may also help inform positive, self-esteem-enhancing interventions in order to impact relationship and sexual locus of control among these populations.