Although childhood maltreatment is associated with a number of adverse health outcomes, its relationship to STD risk is unclear. We found that among females in a nationally representative sample, physical neglect during childhood was associated with almost a doubling of the odds of testing positive for an STD in young adulthood. We also observed that physical neglect, physical abuse, supervision neglect and sexual abuse were associated with elevated odds of self-reported recent STD among females even in analyses with stringent controls for socioeconomic and demographic characteristics. The fact that these associations were rendered nonsignificant after adjustment for a history of other types of maltreatment suggests substantial overlap among maltreatment experiences, but is still consistent with prior research19,22
showing that maltreatment is associated with elevated subsequent self-reported STD risk.
The pattern of results in our models predicting self-reported STDs—the outcome most commonly used in prior research—differed substantially from the pattern in our models predicting test-identified STDs. A number of factors may explain these discrepancies. Self-reported STD measures significantly underestimate actual prevalence35,36
—particularly the prevalence of asymptomatic infections.16
Furthermore, several studies have documented inconsistencies in self-reported measures of sexual health. Most recently, an analysis of the National Survey of Adolescent Males found that more than 90% of respondents who ever reported an STD recanted that report in later waves.36
Additionally, the test-identified STD measure may capture current infections among asymptomatic individuals who think that their risk of infection is low and are therefore unlikely to seek testing. However, the absence of associations between other forms of maltreatment and test-identified STDs does not support this possibility and is consistent with findings from other studies using test-identified measures.37
Although the two STD measures used in our analysis are not fully comparable, our findings suggest that the exclusive use of self-reported STD measures—particularly in analyses that do not adequately adjust for socioeconomic characteristics or that use clinic-based or otherwise select samples—may overstate the association between child maltreatment and STD risk.
The association between physical neglect and STD risk in young females is consistent with a growing body of research suggesting that—like physical and sexual abuse—childhood neglect poses a considerable threat to subsequent health, and may even have unique associations with certain outcomes. For example, physical neglect appears to be more strongly predictive of internalizing symptoms (e.g., depression, anxiety and social withdrawal) during childhood than other types of maltreatment.38,39
Early neglect also disrupts the formation of secure attachments to caregivers and may lead to low expectations of support and nurturance within relationships.40
Such attachment disturbances may increase the likelihood of involvement with high-risk sexual partners, although we were unable to test this hypothesis with available data. To the extent that neglected individuals do not perceive these encounters as high-risk, they may forgo STD testing; as a result, analyses relying on self-reported measures alone may underestimate STD risk.
We observed notable sex differences in the association between physical neglect and test-identified STD status in young adulthood. After socioeconomic and demographic characteristics were included as controls, a history of childhood physical neglect was associated with elevated odds of a positive STD test result in young adulthood among females, but not among males. Several other studies have reported sex differences in the health-related consequences of maltreatment,22,41-43
but little information exists on the specific adaptations and developmental pathways that lead to these differences. One possibility is that our findings reflect differences in responses to stressful or traumatic life events. Females are generally more likely to exhibit internalizing, rather than externalizing, symptoms in response to stress,44,45
and internalizing symptoms have been linked to sexual risk behavior.46,47
Females’ vulnerability to experiencing internalizing symptoms—combined with the association between neglect and internalizing symptoms—may contribute to the sex differences we observed.
Strengths and Limitations
Our study offers a number of methodological improvements over past research. First, we employed a large probability sample that provides national estimates of the association between maltreatment and STD risk. Second, rather than relying exclusively upon self-reports of STD status, we also used a measure based upon results of laboratory tests for three common STDs. Finally, whereas much prior research has limited maltreatment exposure to sexual or physical abuse, we examined four types of maltreatment and, in the case of physical and sexual abuse, included exposure up to age 18. And we provided an estimate of the unique association between each maltreatment type and STD risk that is adjusted for exposure to the other types of maltreatment.
We also acknowledge several limitations regarding the interpretation of these findings. Maltreatment histories were based upon retrospective self-report; respondents may have been reluctant to disclose maltreatment histories or unable to recall them accurately. However, Add Health attempted to minimize underreporting by administering maltreatment questions via computer-assisted self-interviewing technology. While our analyses are strengthened by the inclusion of physical and sexual abuse up to age 18, these exposures were relatively rare; as a result, we could not assess whether the association between abuse and STD status varied by the developmental period during which abuse began or by the frequency of abuse. We also lacked data on the duration of abuse and therefore could not test whether the association between maltreatment and STD risk varied by duration and timing, as some studies have suggested.38,48
Additionally, the results of our interaction analyses should be interpreted with caution because data limitations prohibited us from evaluating interactions for less prevalent types of maltreatment and because of heterogeneity in our categories of race and ethnicity (particularly the “other” group).
Data limitations also constrained our choice of sexual risk behaviors. Condom use, age of sexual debut and number of partners in the last 12 months likely capture only a limited number of behavioral patterns that may differ between physically neglected respondents and others, but that likely contribute to increased STD risk in this population; indeed, they were only marginally associated with neglect exposure. Our failure to observe associations between physical neglect and number of sexual partners, in particular, is consistent with prior research suggesting that maltreatment is not positively related to number of partners,49
and—particularly in the case of sexual abuse—may even result in sexual aversion and avoidance.9
Given evidence that sexually active victims of child maltreatment report riskier sexual partners than others,26
information on the characteristics of respondents’ sexual networks—and the extent to which they are characterized by STD exposure—may be more useful than data on individual behaviors in explaining the association between neglect and STD status. This possibility is consistent with the sex differences we observed in the association between maltreatment and STD risk. Since women are biologically more vulnerable than men to contracting certain STDs, they may be more likely to become infected if they are involved in a high-risk sexual network.50
Our findings add to a large body of research documenting the broad range of negative psychosocial, physical and sexual health outcomes associated with exposure to maltreatment during childhood and adolescence. However, they also highlight the complexity of the relationship between maltreatment and subsequent STD risk with respect to biological sex, self-reported versus test-identified STD measures and type of maltreatment. Our findings focus attention on the understudied effects of physical neglect and underscore the need to consider childhood experiences that may contribute to elevated STD risk later in life. Additional research is needed to identify the behavioral, affective, social and cognitive consequences of childhood maltreatment (particularly with respect to physical neglect) that link this experience to STD acquisition. Better understanding of the mechanisms underlying this association—such as involvement with high-risk sexual partners and exposure to risky sexual networks—will allow health professionals and program planners working with maltreated youth to tailor interventions that will effectively promote sexual and reproductive health in this population.