Childhood Maltreatment and Adolescent Sexual Risk Behaviors: Unique, Cumulative and Interactive Effects
Marie-Eve Thibodeau and Francine Lavoie École de psychologie, Université Laval, Québec, Canada;
Martine Hébert and Martin Blais
Département de sexologie, Université du Québec à Montréal, Québec, Canada
Publié dans
Child Abuse & Neglect
Thibodeau, M.- E., Lavoie, F., Hébert, M., & Blais, M. (2017). Childhood Maltreatment and Adolescent Sexual Risk Behaviors: Unique, Cumulative and Interactive Effects. Child Abuse & Neglect. Advance online publication. doi: j.chiabu.2017.09.002
Résumé
Les mauvais traitements vécus en enfance sont associés aux comportements sexuels à risque. Par le passé, les chercheurs se sont généralement penchés sur une seule forme de mauvais traitements, ne leur permettant pas d’observer les interrelations entre les formes de mauvais traitements et leur influence sur les comportements sexuels à risque. Le but de cette étude est d’examiner les effets uniques, cumulatifs et interactifs de quatre formes de mauvais traitements (agression sexuelle, agression physique, négligence et exposition à la violence interparentale) sur les comportements sexuels à risque. L’échantillon comprend 1 940 adolescents sexuellement actifs (Mâge = 15,6; 60,8% filles) fréquentant les établissements scolaires du
Québec. Les résultats des régressions ont montré que toutes les formes de mauvais traitements étudiées sont associées à un plus grand nombre de partenaires sexuels, des contacts sexuels avec des inconnus, de l’échange de services sexuels et un plus jeune âge à la première relation sexuelle consensuelle. L’agression physique et l’exposition à la violence interparentale sont associées à un usage inconstant du condom, et l’agression physique est associée à un diagnostic d’infection transmissible sexuellement. En contrôlant pour toutes les formes de mauvais traitements vécus (effets uniques), les analyses ont montré que l’agression sexuelle, l’agression physique, la négligence et l’exposition à la violence interparentale sont associées spécifiquement à certains comportements sexuels à risque. Un plus grand nombre de formes de mauvais traitements vécus est associé à davantage de comportements sexuels à risque (effet cumulatif). Lorsque l’agression sexuelle n’est pas vécue, il y a un effet de la négligence sur le nombre de partenaires sexuels (effet interactif). En général, les associations entre les mauvais traitements et les comportements sexuels à risque étaient semblables pour les garçons et les filles. La relation entre des formes spécifiques de mauvais traitements et les comportements sexuels à risque peut être mal évaluée lorsque les autres formes de mauvais traitements ne sont pas contrôlées.
Mots-clés : agression sexuelle, mauvais traitements, cumul de mauvais traitements, comportements sexuels à
Abstract
Child maltreatment has been associated with sexual risk behaviors. Previous investigators have typically studied only one form of maltreatment, preventing them from exploring interrelations between forms of maltreatment and their impact on sexual risk behaviors. Thus, this study aims to examine the unique, cumulative, and interactive effects of four maltreatment forms (sexual abuse, physical abuse, neglect, and witnessing interparental violence) on sexual risk behaviors. The sample comprised 1,940 sexually active adolescents (Mage = 15.6; 60.8% girls) attending Quebec (Canada) high schools. Regression results showed
that all maltreatment forms were associated with having a higher number of sexual partners, casual sexual behavior, sex exchange, and a younger age at first consensual intercourse. Physical abuse and witnessing interparental violence were associated with inconsistent condom use, and physical abuse was associated with sexually transmitted infections. After controlling for other forms of maltreatment (unique effects), analyses showed that sexual abuse, physical abuse, neglect or witnessing interparental violence remained statistically associated depending on the sexual risk behavior. A greater number of forms of maltreatment was associated with more sexual risk behaviors (cumulative effect). When sexual abuse was not experienced, neglect was associated with a higher number of sexual partners (interactive effects). In general, associations between maltreatment and sexual risk behaviors were similar for both genders. The magnitude of the relationship between a specific form of child maltreatment and sexual risk behaviors may be inaccurately estimated when not controlling for other forms of maltreatment.
Introduction
Child maltreatment (CM) is now recognized as a major public health concern worldwide (Stoltenborgh, Bakermans-Kranenburg, Alink, & van Ijzendoorn, 2015; Tourigny, Hébert, Joly, Cyr, & Baril, 2008). CM is associated with multiple short-term and long-term effects, such as sexual risk behaviors (SRBs). Indeed, studies suggest that CM namely neglect, physical abuse, and sexual abuse is associated with a higher risk of sexually transmitted infections (STIs), a higher number of sexual partners, younger age at first intercourse, unprotected sex, sex exchange, and casual sexual behavior (Fergusson, McLeod, & Horwood, 2013; Negriff, Schneiderman, & Trickett, 2015; Norman et al., 2012; Senn & Carey, 2010; Ulloa, Salazar, & Monjaras, 2016). These findings are troubling, especially for adolescents who are in a period characterized by an increase in SRBs (Fergus, Zimmerman, & Caldwell, 2007). In fact, along with emerging adults, adolescents belong to the most at-risk group for STIs in the United States and Canada (Centers for Disease Control and Prevention, 2015; Government of Canada, 2014). The present study will examine the association between CM and adolescent SRBs while attempting to delineate the unique, cumulative, and interactive effects. We investigated two types of SRBs: nature of sexual partners (i.e., number of sexual partners, casual sexual behavior, and sex exchange) and sexual health risks (i.e., age at first consensual intercourse, condom use, and STIs). Some of these SRBs, such as having a casual sexual behavior, and sex exchange, are understudied among the adolescent population. Yet, an understanding of risk factors associated may inform prevention practices. Past studies that have investigated the consequences of CM have often been limited by their focus on one or two particular forms of CM, such as sexual abuse and physical abuse (Littleton, Radecki Breitkopf, & Berenson, 2007). Although these studies contributed greatly to our understanding of the independent effects of specific forms of CM on SRBs, they did not take into account other potential forms of CM experienced. Thus, results must be interpreted with caution, given that the scholarly literature shows that forms of violence rarely occur in isolation of others (Cyr et al., 2013; Finkelhor, Vanderminden, Turner, Hamby, & Shattuck, 2014; Higgins & McCabe, 2000; Tourigny et al., 2008). Finkelhor et al. (2009) found in a nationally representative survey in the United States that children experienced in their lifetime an average of 3.7 forms of victimization out of 26 (e.g., sexual abuse, physical abuse, property crime or witnessing interparental violence). Consequently, studies examining one or two forms of violence not only fail to provide information on the total effect of exposure to cumulative abuse but also lead to an overestimation of the consequences of a single form (Turner, Finkelhor, & Ormrod, 2010). For example, Senn and Carey (2010) found that sexual abuse, physical abuse, neglect, and psychological abuse were all independently associated with adult SRBs among women. However, when considering all forms of CM in the same analysis (unique effects), only sexual abuse significantly predicted SRBs. The present study will add to Senn and Carey (2010) study in three ways. First, it
rather than an adult clinical population. Second, our sample will include boys, in order to explore possible gender differences. Finally, while Senn and Carey (2010) only explored two types of SRBs (i.e., the number of sexual partner and unprotected sex), the present study will add the following: casual sexual behavior, sex exchange, age at first consensual intercourse, and STIs.
A recent literature review produced clear guidelines for future research on cumulative abuse (Scott-Storey, 2011). First, Scott-Storey highlighted the importance of controlling for other potential abuse that may have been experienced when predicting the consequences of a specific form of CM (testing unique effects). In fact, one of the two lines of thought influencing research on CM outcomes, the differential effects theory, posits that specific forms of CM are associated with specific outcomes (Davis & Petretic-Jackson, 2000; Senn & Carey, 2010). This model is supported by a large body of research that consistently shows, for instance, that sexual abuse is associated with SRBs (Senn, Carey, & Vanable, 2008). However, most of these studies did not adequately control for other forms of CM, restricting our ability to draw the conclusion that sexual abuse is uniquely associated with SRBs. Few studies have attempted to address this issue. Among these studies, Jones et al. (2010) have demonstrated that other forms of CM (i.e., physical and emotional abuse) contribute to the explanation of SRBs over and above the effect of sexual abuse. Though this study was one of the few on adolescents, it only explored age at first intercourse as a SRB. Negriff et al. (2015) investigated a wider range of CM (sexual, physical, emotional, and neglect) and of SRBs (e.g., condom use, age at first intercourse, number of sexual partners, casual sexual behavior). Nevertheless, the reliance on a clinical sample of adolescents hinders the generalization of results to the general population. Other studies demonstrated, but only for adult women, that physical abuse contributed to the explanation of SRBs over and above the effect of sexual abuse (Lacelle, Hébert, Lavoie, Vitaro, & Tremblay, 2012; Littleton et al., 2007). These results emphasize the importance of carrying out research to clarify the unique effects of different forms of CM on SRBs.
Next, the cumulative dose-response relationship between the number of forms of CM experienced and poorer physical and mental health outcomes cannot be ignored (Scott-Storey, 2011). A multitude of studies has demonstrated the cumulative effects of different forms of CM on health (Álvarez-Lister, Pereda, Abad, & Guilera, 2014) and women’ SRBs (Hahm, Lee, Ozonoff, & Wert, 2010; Rodgers et al., 2004). These findings are consistent with the second line of thought on CM outcomes: the general effect theory. This theory holds that increasing the number of forms of CM experienced is associated with more adverse outcomes (Davis & Petretic-Jackson, 2000; Senn & Carey, 2010). The general effect theory, unlike the differential effects theory, posits that there is no specific outcome associated with specific forms of CM. It has been supported by Arata, Langhinrichsen-Rohling, Bowers, and O'Brien (2007) and others in the contexts of physical abuse and sexual
abuse. However, Senn and Carey (2010) rejected this theory and concluded that the association between CM and adult SRBs is driven by sexual abuse, which is consistent with the differential effects theory.
Finally, Scott-Storey (2011) and Senn and Carey (2010) highlighted an important limitation to typical approaches examining CM. The first approach allows for the examination of the unique effects of particular forms of CM, and the second approach examines the cumulative effect of CM using a summary score of the number of forms of CM experienced. However, these approaches do not allow for the examination of the potential interactive effects of CM. The examination of interactive effects informs if some forms of CM are more strongly associated with greater involvement in SRBs and if specific forms of CM interact to result in greater involvement in SRBs. Some empirical studies have demonstrated that certain combinations of CM would be associated with worst outcomes. For example, Arata et al. (2007) found that a) the combination of sexual abuse and neglect, or b) the combination of sexual abuse, physical abuse and neglect, result in a greater number of sexual partners among adolescents. Other combinations (sexual abuse and physical abuse, or physical abuse and neglect) were not associated with a greater number of sexual partners than in the case of individuals without any forms of CM. Luster and Small (1997) found that female adolescents who experienced both sexual abuse and physical abuse reported more sexual partners than those who were not abused. Senn and Carey (2010) did not find an interaction between sexual abuse, physical abuse, psychological abuse, and neglect on the report of the number of sexual partners among their sample of adult women.
In sum, there is a need to simultaneously address the unique, cumulative, and interactive effects of CM. To the best of our knowledge, in studies addressing sexual health outcomes, only Senn and Carey (2010) have done so. Given that their sample included adult women with high rates of SRBs attending a publicly funded STI clinic, their results cannot be generalized to the general population. The present study will examine independent, unique, cumulative, and interactive effects with a large representative sample of girls and boys attending Quebec high schools. Our sample will allow for the investigation of a gender effect, which is largely encouraged in this field of study (Saunders, 2003; Scott-Storey, 2011). This study had five primary goals, including to determine: (1) whether forms of CM are associated with adolescent SRBs without controlling for other forms of CM (independent effects), (2) which forms of CM are uniquely associated with adolescent SRBs after controlling for other forms of CM, (3) whether experiencing more forms of CM is associated with greater involvement in adolescent SRBs (cumulative effect), (4) whether different forms of CM interact to result in greater involvement in SRBs, and (5) if there are gender differences in the association between CM and SRBs. Consistent with previous findings, it was hypothesized that all forms of CM would be associated with SRBs without controlling for other forms of CM (hypothesis 1) (Senn & Carey, 2010). In line with the differential effects theory, it was hypothesized that sexual abuse would be uniquely associated with SRBs (hypothesis 2)
greater involvement in SRBs (hypothesis 3) (Finkelhor et al., 2007), that combinations of sexual abuse and any other form of CM would be associated with greater involvement in SRBs (hypothesis 4) (Arata et al., 2007), and that the associations among CM and SRBs would be the same among girls and boys (hypothesis 5) (Fergusson et al., 2013).
Method
Participants
Data were drawn from the Quebec Youths’ Romantic Relationships (QYRR) survey. The QYRR survey targeted high school students enrolled in grades 10 through 12 in the province of Quebec, Canada. Participants were recruited using one-stage stratified cluster sampling of high schools. Schools were randomly selected from an eligible pool from the Quebec Minister of Education, Recreation and Sports. Self- administered questionnaires were completed in school in the fall of 2011. Six months later, participants were invited to participate in a second wave in school (Time 2). Written informed consent was obtained from each participant. The research ethic boards of the Université du Québec à Montréal approved this project. Further publications using this database are available at http://martinehebert.uqam.ca.
A total of 8,194 adolescents from 34 schools participated in the survey. The overall response rate, defined as the ratio of the number of students that accepted to participate to number of solicited students, was 99%. To obtain a representative sample of Quebec adolescents attending public high schools, schools first were classified into 8 strata according to their geographical area, status (public or private), teaching language (French or English) and socioeconomic deprivation index. Participants were given a sample weight in all analyses to correct biases relating to the nonproportionality of the school sample compared to the target population (Levy & Lemeshow, 2008). The weight was defined as the inverse of the probability of selecting the given grade in the respondent’s stratum in the sample multiplied by the probability of selecting the same grade in the same stratum in the population (N weighted = 6,540).
The analytical sample (N = 1,940) was restricted to sexually active adolescents aged 17 years or younger (60.8% girls). On average, adolescents were 15.6 years old (SD = .09), with 75.4% of the sample aged 15 to 16. A minority of the adolescents were 13 years old (0.1%) and 14 years old (11.4%). Most participants reported that their parents were native-born Quebecers (79.3%) and spoke French at home (91.8%). More than half of them indicated that they lived with their family of origin (55.0%). Sexually active adolescents selected in this study were more likely than non sexually active adolescents from the overall sample to have reported living with separated parents or others (2 (1) = 134.81, p < .001), having a mother with a high school
physical abuse (2 (1) = 25.19, p < .001), and having witnessed interparental violence(2 (1) = 20.49, p <
.001).
Measures
Child maltreatment
In line with recommendations in the literature (Scott-Storey, 2011), CM primarily was assessed with lifetime measures. Two items that were adapted from Quebec and American surveys assessed sexual abuse (Finkelhor, Hotaling, Lewis, & Smith, 1990; Tourigny et al., 2008). The first one assessed unwanted sexual touching: “Have you ever been touched sexually when you did not want to, or have you ever been manipulated, blackmailed, or physically forced to touch sexually?” The second one assessed unwanted sexual intercourse: “Excluding the sexual touching mentioned in the previous item, has anyone ever used manipulation, blackmail, or physical force, to force or obligate you to have sex (including all sexual activities involving oral, vaginal or anal penetration) with them? ” Participants had to indicate for each item whether they had experienced sexual contact with four different perpetrators (1 = Yes, 0 = No) (i.e., a member of their immediate or extended family, a sports trainer, a person outside their family that they knew [other than a boyfriend or girlfriend], and a stranger). Those who reported unwanted sexual touching or intercourse were coded as having experienced sexual abuse (1 = Yes, 0 = No).
Physical abuse was assessed by the following question: “Have you ever been physically hit by a member of your family?” (1 = Yes, 0 = No). The item was adapted from the Early Trauma Inventory – Short Form (Bremner, Bolus, & Mayer, 2007).
Neglect was assessed using four items adapted from The National Longitudinal Study of Adolescent Health (Hahm, Lee, Ozonoff, & Wert, 2010) and the Early Trauma Inventory – Short Form (Bremner, Bolus, & Mayer, 2007). Participants indicated at Time 2 how often they experienced each of the following experiences during their childhood (0 = Never to 4 = Six times or more): not take care of your basic needs (clean, food, clothing), leave you home alone when an adult should have been with you, ridicule or humiliate you, and treat you with coldness, indifference or in a way that you felt unloved. A continuous variable was created by computing a mean score ( = .71).
Witnessing interparental violence was assessed using four items adapted from the Revised Conflict Tactics Scale (Straus, Hamby, Boney-McCoy, & Sugarman, 1996). Participants were asked how many times they had witnessed their parents or caregivers engage in each of the four following violent behaviors toward one another (0 = Never to 3 =11 or more times): insult, swear, shout or yell, threaten to hit or destroy the other person’s belonging, push, shove, slap, twist the arm or throw something at the other person that could hurt,
and threaten with a knife or a weapon, punch or kick or slam the person against a wall. Respondents answered these four questions relating to violence by the father against the mother and violence by the mother against the father. A continuous variable was created by computing a mean score ( = .81).
Adolescent sexual risk behaviors
The nature of sexual partners was measured by the number of sexual partners and two risky sexual contexts (casual sexual behavior and sex exchange). The number of sexual partners was assessed using the following question “In your lifetime, with how many people have you engaged in consensual sexual relations with penetration (oral, vaginal or anal)?” Participants reported if they had consented to sexual contact in the past twelve months with a vague acquaintance, someone whom they met on the internet or a stranger (1 = Yes, 0 =
No). Participants who reported sexual contact with at least one of those sexual partners were categorized as
having had a casual sexual behavior. Participants indicated if they ever received something (money, drugs, alcohol, gifts, a place to stay or anything else) in exchange for sexual contact (sexual touching, oral, vaginal or anal sex) with someone other than a boyfriend or girlfriend (0 = Never to 3 = 11 or more times). As a result of the skewed distribution due to the infrequent occurrence of this behavior, a dichotomous variable was created (1 = Yes, 0 = No).
Adolescent sexual health risk was measured by age at first consensual intercourse, inconsistent condom use, and STIs. Participants responded to the following question: “How old were you when you engaged in consensual sexual relations with penetration (oral, vaginal or anal) for the first time?” Age at first consensual intercourse was used as a continuous variable, with younger age indicating higher risk. Inconsistent condom use was assessed on a 6-point scale with the following question: “Up until now, how many times have you used a condom when engaging in consensual sexual relations with penetration?” (1 = Never to 5 = All the
time). A dichotomous measure of inconsistent condom use was developed based on whether the participant
reported having had sexual relations with penetration without always using a condom (0 = Always use condom