Abstract

INTRODUCTION

Previous studies in the United States have found that the prevalence of childhood sexual abuse (CSA) among men who have sex with men (MSM) is significantly higher than those in the general male population. Using a probability sample of urban MSM, Paul et al¹ found that 20% of their sample reported CSA, whereas Lenderking et al² and Doll et al³ reported rates of 35.5% and 37%, respectively. In comparison, Finkelhor⁴ estimated that between 5% and 10% of men in the general population have experienced CSA and that at least 20% of women were sexually abused as a child. Although cross-study comparisons are hampered by differing definitions of CSA (eg, noncontact experience like indecent exposure versus contact experiences like kissing, fondling, or intercourse to whether or not the individual considered the experience to be abusive), high prevalence rates of CSA have been consistently documented in samples of MSM, with rates of CSA closer to those of heterosexual women than those of heterosexual men.¹

A predictive relationship between CSA and high-risk sexual behavior among MSM has been shown in a number of studies. Lenderking et al² found that MSM who were sexually abused as children were more likely to have an increased number of male partners across their lifetime and were more than twice as likely to have had unprotected receptive anal intercourse in the past 6 months relative to MSM who were not sexually abused. Paul et al¹ reported that MSM who experienced CSA were significantly more likely to engage in high-risk sex. In this study, men who experienced CSA 6 or more times (reported number of incidents without specifying same or new perpetrator) were nearly 2.5 times as likely to have unprotected insertive or receptive anal intercourse with a nonprimary partner and over 5 times as likely to do so with a serodiscordant male compared with those who experienced no CSA.¹ Jinich et al⁵ reported similar findings, with 21.4% of abused men engaging in unprotected anal intercourse with a nonprimary partner in the previous 12 months compared with 15.0% of those who were not abused in childhood. Examining a sample of MSM of a Puerto Rican ancestry living in New York City, Carballo-Diéguez and Dolezal showed that men who experienced CSA and participated unwillingly and/or felt hurt by the experience engaged in unprotected receptive anal sex at higher rates (56%) than those who experienced childhood sexual contact with an older partner but identified as willing and not hurt (42%). Likewise, the willing/not hurt group exhibited a higher risk profile than a control group, which experienced no childhood sexual contact with an older partner (22%).⁶ O’Leary et al demonstrated that MSM who were abused in childhood not only placed themselves at risk through sexual behavior but also put others at risk. Examining a sample of HIV-infected MSM in New York and San Francisco, they found that those with a history of CSA were significantly more likely than those without a history of abuse to have unprotected anal (UA) sex with partners of HIV negative or unknown serostatus (33% versus 20%).⁷

In addition to the association of CSA to later sexual risk taking, CSA has been shown to be associated with other negative effects later in life. For instance, in a review of the literature, Browne and Finkelhor⁸ reported fear, anxiety, depression, anger, hostility, aggression, and sexually inappropriate behavior as initial effects of CSA. Long-term effects reported frequently were depression and self-destructive behavior, anxiety, feelings of isolation and stigma, poor self-esteem, difficulty in trusting others, a tendency toward revictimization, substance abuse, and sexual maladjustment. Additionally, Boudewyn and Liem⁹ showed CSA to be predictive in both men and women of depression and self-destructive behaviors such as acts of self-harm, suicidal ideation, and suicide attempts. Moreover, severity of CSA (use of force, genital contact versus noncontact exposure) has been associated with greater severity of sequelae.⁸

In light of the noted association between CSA and risky sexual behavior, MSM who were sexually abused in childhood have been shown to have higher rates of HIV and other sexually transmitted infections (STIs) compared with those with no history of CSA.^2,3 Although these past studies have shown a cross-sectional association between higher rates of HIV and other STIs among MSM with a history of CSA, the current study is the first, multisite, longitudinal study to show the predictive association between a history of CSA and subsequent HIV infection among a large sample of HIV-uninfected MSM. We a priori hypothesized that MSM with a history of CSA would be more likely to engage in UA sex, more likely to engage in serodiscordant unprotected anal (SDUA) sex, more likely to become infected with HIV, and have a poorer response to a behavioral HIV risk reduction intervention because previous studies have suggested that coexisting psychopathologies or substance use disorders may interfere with HIV treatment effect. We further hypothesize that substance use, depression, self-efficacy, safer sex norms, and communication skills regarding sexual safety will mediate the relationship between CSA and (1) UA sex, (2) SDUA sex, and (3) HIV infection.

METHODS

RESULTS

Of the 4244 participants enrolled with baseline assessment of CSA, 1686 of the overall EXPLORE cohort (39.7%) reported a history of CSA. Additional characteristics of the overall EXPLORE cohort and main outcome analysis have been described previously.^10–12

DISCUSSION

This is the first study of which we are aware to demonstrate a predictive relationship between a history of CSA and higher rates of HIV infection among HIV-uninfected MSM, when controlling for study arm, study site, age at enrollment, education, and race/ethnicity. This finding extends previous research that has documented higher rates of CSA among HIV-infected MSM by identifying CSA as a risk factor for HIV infection in an HIV-uninfected sample of MSM. These findings are particularly noteworthy as no other study to date has documented this increased hazard ratio, particularly among a large-scale multisite sample of HIV-uninfected MSM enrolled in a longitudinal cohort study. In addition, MSM with a history of CSA were more likely to engage in UA sex and SDUA sex. These results corroborate findings from other studies of MSM. For example, in a study of over a thousand adult MSM, Bartholow et al²⁰ reported a significant association between CSA and HIV risk behavior.

Another pertinent finding from the current study is that among participants reporting CSA, the EXPLORE intervention had no effect in reducing HIV infection rates. It is not clear that this study had sufficient power to detect a significant effect; however, these findings provide good initial evidence that the presence of CSA history in MSM interferes with their ability to derive benefit from traditional HIV prevention interventions. This finding speaks to the importance of conducting postintervention analyses in intervention trials to understand why interventions do not work or for whom they do not work.

These findings are particularly relevant for HIV prevention efforts as the observed rates of CSA in this cohort were very high. The rate of CSA (39.7%) among the MSM in this study is similar to the rates found in other studies of MSM^1–3 but substantially higher than the rates found in the general male US population.⁴ This is particularly concerning due to the harmful consequences of CSA that have been demonstrated specifically in MSM, including mental health counseling and hospitalization, psychoactive substance use, depression, and suicidal thoughts or actions.

In this study, depression was significantly more prevalent among MSM with a history of CSA relative to those without. In addition, MSM with a history of CSA versus those without were more likely to use illicit substances and alcohol. These findings support the notion that sexual risk taking among MSM, particularly those with a history of CSA, is often occurring in the context of “intertwined syndemics.”²¹ The coexistent untreated depression and increased substance use that are often associated with sexual risk–taking behavior in this population need to be addressed in future HIV prevention interventions to decrease further infection, acquisition, or transmission of HIV and other STIs.

Notably, individuals with a history of CSA compared with those without reported (1) lower self-efficacy for adopting safer sex behaviors, (2) poorer communication skills regarding safer sex, and (3) lower social norms that favor safer sex.¹² The cognitive and behavioral consequences of CSA can affect many of the psychosocial variables that have been used to explain HIV risk taking. Three of the most common psychosocial models that have been employed to explain HIV risk–taking and/or HIV prophylactic behavior are the health belief model, the theory of reasoned action/planned behavior, and the social cognitive theory (ie, self-efficacy models).^22,23 Health belief models emphasize the role of perceived benefits and barriers to condom use and perceived vulnerability to and consequences of acquiring HIV.²⁴ In the theory of reasoned action/planned behavior,^25,26 health behavior, such as condom use, is a function of intentions to use condoms, and, in turn, intentions to use condoms are a function of variables such as attitudes and norms regarding HIV and condom use. Social cognitive models (ie, self-efficacy) explain condom use as a function of an individual’s knowledge about HIV, his or her expectancies about the outcomes of using condoms (ie, pleasure reduction versus disease prevention), and his or her own self-efficacy that he or she will be able to use a condom in different sexual situations.^27,28 These psychosocial models of HIV prophylactic behavior have been tested both cross sectionally and longitudinally in a variety of populations, including MSM, HIV-infected and HIV-uninfected individuals, and heterosexual men and women.²⁹ All these models include social and cognitive variables that can become distorted in individuals who have a history of CSA. CSA and the resulting negative emotions and negative beliefs about oneself, for example, can interfere with self-efficacy, perceived social norms about sexual risk taking, and the perceived costs and benefits of condom use and norms and attitudes.

Findings from this study suggest that the reasons why MSM continue to engage in risky sexual practices may differ depending on whether individuals experienced CSA or not. Analyses of the baseline EXPLORE data¹² demonstrated that the 4295 men enrolled in the study had widely divergent responses to the screening questions associated with sexual risk taking, and about 60 different patterns of responses were seen. For some of the men, unsafe sex was highly correlated with alcohol or other substance abuse, whereas for others, condoms decreasing sexual pleasure seemed more important and others reported low levels of self-efficacy and depression. The data in the present study suggest that the EXPLORE intervention, which included some skills building but was predicated on participants’ perceptions that they could change their behavior, might not have been robust enough to change patterns of internalized anger, depression, and lack of self-efficacy that may have been long standing in the participants who experienced CSA.^30–32 Future behavioral interventions for this group of at-risk MSM may need to incorporate counseling and skills building that address the traumatic memories and coping strategies that ensue after young men are abused, given the high prevalence of these childhood experiences and their role in potentiating sexual risk–taking behavior.

The pathways to sexual risk behavior in MSM are complex, particularly among MSM with CSA histories. Catania et al³³ examined mediators of the relationship between CSA and subsequent HIV risk taking among MSM using cross-sectional data and concluded that CSA contributes to the ongoing HIV epidemic among MSM by distorting or undermining critical motivational, coping, and interpersonal factors that, in turn, influence adult sexual risk behavior. Similarly, in this study, substance use, depression, lower self-efficacy for adopting safer sexual behaviors, poorer communication skills regarding safer sex, poorer safer sex norms, UA sex, and SDUA sex were found to significantly mediate the primary relationship between CSA and subsequent HIV infection, supporting our hypothesis that these mediators are in fact on the causal pathway. Future research could usefully examine the social, behavioral, and cognitive sequelae of CSA that contribute to adult sexual risk taking and increased risk for HIV infection. Specifying these pathways may also lead to the development of HIV prevention technology to specifically target the unique prevention needs of this at-risk group.

The limitations of this study include reduced generalizability to a wider population of MSM. Moreover, the enrollment criteria for EXPLORE may have biased this study toward the very high prevalence of CSA. This seems likely as the study excluded MSM who were in a mutually monogamous relationship. The primary exposure—having a history of CSA—relied on retrospective reports, as all other studies of MSM and CSA do, which may potentially introduce recall bias. In addition, interpretation of statistical significance of findings from subset analyses needs to be performed with caution, given the nominal nature of the computed P values and CIs.

Another limitation important to consider has to do with our operationalization of CSA using age differentials. Given that the long-term negative mental and physical health effects of CSA have been shown to be associated most robustly with high severity of trauma,¹ using age differentials alone to categorize CSA mixes those MSM who experienced less severe and more severe trauma and may occlude important differences that exist by type or severity of trauma. Future research is warranted to not only examine trauma by age but also explore differences along other dimensions of trauma including severity, type of CSA-associated sexual contact, number of contacts, and use of violence/threat of violence.

Furthermore, several unique conceptual issues are introduced when using age differentials to operationalize CSA for MSM in particular. Age discrepancy is often used to operationalize CSA such that the power dynamic in the sexual relationship between child or teen and older adult inherently constitutes abuse.^2,34,35 For young adolescent or teenage MSM, however, this approach may be problematic due to unique developmental challenges associated with being gay or bisexual or questioning that further complicate the relationship between age and power. For example, young MSM may have a difficult time finding sexual partners or romantic relationships with same-sex same-age peers, and the process of finding same-sex age-mates during adolescence may itself be risky in terms of facing harassment and violence from peers.^36–38 As a consequence, it is usual to find that many MSM report that some of their first sexual partners during adolescence included sexual encounters with older partners.^34,39 Thus, further data on consensual versus forced sexual encounters with older partners are important to consider for future studies.^33,34 Taken within this context of “normal” MSM adolescent development, therefore, it is possible that the current study overestimates the prevalence of CSA and that the statistical relationships between CSA and health outcomes may have been attenuated (ie, the relationships between CSA and mediators or outcomes may be stronger than the current study).

Finally, other developmental issues and stressors should be considered while interpreting findings. Sexual trauma is situated amid other developmental factors that may acerbate or confound the CSA–adult outcome relationships. For example, Friedman et al⁴⁰ examined the role of sexual orientation–related abuse during adolescence in relation to CSA and adult health outcomes, and Paul et al¹ examined the role of other types of childhood abuse (eg, physical abuse) that may co-occur with CSA. Thus, it is important to understand that for some MSM, we may be observing the broader effects of multiple developmental traumas/stressors on later life health outcomes and not just a singular traumatic event. Interventions with MSM with CSA histories should likewise consider the possible role of multiple developmental traumas/stressors in addressing HIV risk behavior.

Of note, despite the high rates of CSA in the sample, these data do not suggest anything causal regarding the association of abuse to later homosexuality. In fact, one interpretation of the existing data is that children may be more likely to be sexually abused or victimized because of the perception that they might be gay/homosexual. Regardless, this study did not collect or analyze data that would be able to confirm or reject this hypothesis in either direction. Furthermore, the majority of men in EXPLORE did not report any type of CSA, so there is little to suggest that CSA “causes” homosexuality, but rather, CSA makes MSM more likely to engage in HIV risk behaviors. Similarly, we did not collect data on adult revictimization in this study and hence cannot confirm or reject whether MSM with CSA histories were more or less likely to experience further abuse in adulthood.

HIV-uninfected MSM with CSA histories are at greater risk for HIV infection, report higher rates of HIV sexual risk behavior, and derive less benefit from prevention programs. The efficacy of HIV prevention interventions may be enhanced by incorporating treatment components designed to address the specific mental health concerns of individuals with a history of CSA.

ACKNOWLEDGMENTS

REFERENCES