July 11, 1994
ASSOCIATION BETWEEN HISTORY OF CHILDHOOD SEXUAL ABUSE
AND ADULT HIV-RISK SEXUAL BEHAVIOR
IN PUERTO RICAN MEN WHO HAVE SEX WITH MEN
Carballo-Diéguez, Alex, Ph.D.Dolezal, Curtis, Ph.D.
HIV Center for Clinical and Behavioral Studies
New York State Psychiatric Institute and Columbia University
This work was supported by the National Institute for Mental Health, grants RO3 MH47232 and 5-P50-MH43520.
Please address all correspondence to Dr. Alex Carballo-DiŽguez, New York State Psychiatric Institute, Unit 10, 722 West 168th Street, New York, NY 10032, USA. Phone number: (212) 960-2261. FAX: (212) 740-1774.
Running title: Sexual abused men and HIV risk.
Key words: Latino, Puerto Rican, HIV, homosexuality, sex abuse.
This study explored whether homosexually active men who were sexually abused in childhood are more likely to engage in HIV-risk sexual behavior than men who were not sexually abused. Participants were 182 adult men of Puerto Rican ancestry living in New York City who had had sex with other men or with men and women. Quantitative and qualitative methods of exploration were used.
Three groups were determined: 1) Abuse group (AB), formed by men who before age 13, had sex with a partner at least four years their senior and who felt hurt by the experience and/or were unwilling to participate in it; 2) Willing/not hurt group (W), consisting of men who had an older sexual partner before age 13 but did not feel hurt by the experience and were willing to participate; and 3) No-older-partner group (NOP). The results show that men in the AB group were significantly more likely than men in the NOP group to engage in receptive anal sex and to do so without protection. Men in the W group were ranked between the other two groups in terms of their unsafe behavior. Age and education were cofactors both for receptive anal sex and for unprotected receptive anal sex. It is concluded that given the need to improve HIV prevention among Puerto Rican men who have sex with men, sexual abuse in childhood may constitute a marker to identify men at increased risk.
Are homosexually active men who were sexually abused in childhood more likely to engage in HIV risk sexual behavior than men who were not sexually abused? The available literature on the long-term effects of child sexual abuse focuses mainly on women, not men (see reviews by Beitchman, Zucker, Hood, DaCosta, Akman and Cassavia, 1992, and Vander Mey, 1988). The comparatively smaller number of studies dealing with males have postulated that long term correlates of sexual abuse include problems in social adjustment, psychological disorders (anxiety, depression, and substance use), sexual dysfunction, confusion of sexual identity, inappropriate attempts to reassert masculinity, and recapitulation of the abusive experience (reviews by Beitchman et al., 1992, and Watkins and Bentovim, 1992). Only a few investigators have directly explored correlations between child sexual abuse and HIV-risk sexual behavior in adulthood.
Bartholow et al. (in press) conducted a study among 1001 adult homosexual and bisexual men attending sexually transmitted disease clinics in Chicago, Denver, and San Francisco. One third of the men (343) met the authors' criteria of sexual abuse during childhood or adolescence. Sexual abuse was significantly associated with HIV risk behavior including unprotected anal intercourse during adulthood. Furthermore, sexually abused men of Latin American origin were twice as likely as black or white men to engage in receptive anal intercourse with steady sexual partners.
Hirozawa, Givertz, Lemp, Nieri, Anderson, and Katz (1993, June) conducted a study in San Francisco and Berkeley, Ca, surveying 425 young men who have sex with men. They found that those who had a lifetime history of forced sex (N=174) were significantly more likely to have had unsafe anal sex in the six months prior to the interview than those without history of forced sex (N=251): 41% vs. 27% respectively.
Other investigators have tangentially alluded to the question posed at the beginning of this article. Zierler, Feingold, Laufer, Velentgas, Kantrowits-Gordon, and Mayer (1991) studied the effects of childhood sexual abuse on the HIV-risk sexual behavior of men and women, either self-referred or provider-referred, in the Rhode Island area. The authors found that men who reported a history of sexual abuse had a twofold increase in prevalence of HIV infection relative to non-abused men (90% CI = 1.0, 3.9). The increase was not explained by a history of intravenous drug use. The small sample size (only 12 of the men in the study had been sexually abused during childhood or adolescence) limits the significance of the results, and the fact that apparently not all male participants were homosexually active further constrains the bearing of these findings on our question.
Allers, Benjack, White, and Rousey (1993) report a case study of a 32-year-old HIV-positive bisexual white male presenting symptoms of chronic depression, revictimization, sexual compulsivity, and substance abuse. The authors attribute the adult symptomatology to childhood sexual abuse. Unfortunately, this being a single case study and given the insufficient information provided on it, it is difficult to substantiate a cause-effect link. In a prior article, two of these authors (Allers and Benjack, 1991) found that 42% of clients randomly selected from an Atlanta-based AIDS social service agency had histories of childhood sexual abuse. When sexually and physically abused participants were compared to non-abused participants, the first group was significantly more likely to report sexual compulsivity. The results of this study only partially address the question under investigation since the population studied included both men and women, and only some of the men were homosexually active.
In summary, although emerging evidence seems to point to a relationship between history of childhood sexual abuse and adult HIV-risk sexual behavior in homosexually active men, considerable gaps in our knowledge still remain. The issue merits further exploration to gain better knowledge of the factors associated with unsafe sexual behavior in this population and to apply this knowledge to prevention interventions. Moreover, since homosexually active minority men are at increased risk when compared to homosexually active Anglos (Diaz, Buehler, Castro, and Ward, 1993), the former should be prime targets for research efforts.
This report is based on a study conducted on a sample of homosexually active Puerto Rican men living in the New York metropolitan area. The study explored the association of self-reported childhood sexual abuse and the adult HIV-risk sexual behavior of the participants.
To be eligible for the study, men had to self-identify as Latino, Hispanic, or Puerto Rican; either be born in Puerto Rico or have at least one parent or two grandparents born in the island; be between 18 and 60 years of age; and have had sex with one or more men at least once during the year prior to the interview and ten times in their lifetime.
The procedures used to recruit this sample have been described elsewhere (Carballo-DiŽguez and Dolezal, 1994). In summary, the recruitment was done from both gay and non-gay identified sources; it was addressed to men who have sex with men (or with men and women), thus avoiding labelling study candidates as gay, homosexual, or bisexual; and it was carried out by bilingual and bicultural personnel from January, 1992 to March, 1993.
Both quantitative and qualitative methods of investigation were used. The quantitative assessment consisted of questionnaires on the participant's demographic characteristics, HIV status, history of childhood sexual activity, and the Sexual Practices Assessment Schedule (Carballo-DiŽguez, Exner, Gruen, and Meyer Bahlburg, 1990), among other assessment instruments. The qualitative assessment was done through observations at the recruitment sites, focus groups, and in-depth individual interviews. All interviews were held in the language preferred by the participant by interviewers fluent in both English and Spanish.
The qualitative analysis followed Patton's (1990) guidelines. All qualitative interviews were transcribed. The content of transcripts was then analyzed with the purpose of identifying and indexing the topics of interest. To increase validity and reliability, the coding and categorization of the material done by the first author was compared with that of two colleagues. Discrepancies were discussed and corrected. The narrative was then reviewed to delete unnecessary interjections or self-corrections that obscured it. Extreme care was paid to preserve the literacy of the text and the style of the speaker. The passages with common contents were indexed under a code and pooled together. The thematic pools were analyzed with the purpose of identifying recurrent patterns. Finally, Spanish interview excerpts that were to be used as vignettes were translated into English. Following Patton's advice with regards to the investigator's "get[ting] out of the way of the data to let the data tell its own story" (Patton, 1990), vignettes from interviews are used in this report for the presentation of qualitative results.
The quantitative data were entered in a mainframe and analyzed by means of SPSSX.
The participants in the study were 182 Puerto Rican men.
Age: The mean was 29.4 years, ranging from 19 to 59 years with a standard deviation of 7.
Race: Given three choices, 60% of the participants described themselves as "trigue–os" (brown skinned), 38% as white, and 2% as black.
Religion: Sixty four percent of the participants called themselves Catholic, 9% adhered to various Protestant denominations, 7% said they were agnostic or atheist, 3% followed Santer’a (a folk religion with Catholic and African roots), and the rest were labelled as "other." Out of four possibilities, ranging from "not at all" to "extremely," 46% stated they were "moderately" religious and 38% "slightly" religious.
Education: The mean of years of education was 13, ranging from 4th grade to graduate degree. Seven percent of the participants had not continue beyond 8th grade, and 59% had at least some college.
Income: The income distribution was skewed to the lower end of the scale, with a median of $16,000 per year.
Sexual self-identity: Based on the participant's self-identity, four groups were established: Gay (N=119, 65%), Bisexual (N=36, 20%), Drag Queen (N=8, 4%), and Straight (N=19, 10%). [For a full discussion on these contrasting types, see Carballo-DiŽguez and Dolezal, 1994].
Childhood sexual history
Participants were asked to remember their first sexual experience and to state whether it happened before their 13th birthday. Sexual experience was defined as sexual contact (manual-genital, manual-anal, oral-genital, genital-genital, or genital-anal) between the respondent and another person. Those who replied affirmatively were then asked if their sexual partner was four years their senior or more. Those who responded affirmatively were then asked about kinship with sexual partner, whether they had been willing participants in the sexual encounter, whether they had felt emotionally of physically hurt by the experience, and if they had told anybody about it. Those individuals who were either unwilling to participate or felt harmed by the experience were included in one group which we labelled "abuse" (AB). Those individuals who, before age 13, had sex with someone at least four years older but claimed to have done it willingly and without feeling hurt by the experience were included in a second group which we labelled "willing/not hurt" (W). A third group comprised individuals who did not have a sexual experience prior to age 13 or who had it with someone less than four years their senior. This last group was labelled "no-older-partner" (NOP). The distribution of participants in these three groups was: AB=32(18%); W=33(18%); NOP=117(64%).
To further explore the circumstances in which the childhood sexual event took place, we invited the initial recruits to attend a second interview. Ten (56%) out of the 18 men in the AB group who were reinterviewed reported having been anally penetrated, frequently recalling scenes of violence. A 31 year-old participant, describing how, at age 9, he was forced by his 16 year-old stepbrother to have sex with him, said:
We were in my bedroom and we were looking at television. At one point he just started playing with his genitals, locked my door, took his pants off, and told me I had to suck his dick.[...] Then he told me [to] turn over [and] lay on my stomach. And I remember his getting some lubricant and [...] penetrating me. It hurt. I started screaming. He had his hand over my mouth. I tried to [...] bite. After that I was bleeding. He told me I was going to be all right... not to tell anybody.
A 32 year-old participant reported:
I was five years old when I was sodomized [by] three boys in the neighborhood. I remember it as if it was yesterday and it still haunts me. I lived in the South Bronx... I was playing in the back yard and these three guys came up and they were like teasing me... The ball went into a corner, into an alley way, and I went to fetch the ball. I turned around and they were there... One of them grabbed me and held me down... The other one lowered his zipper and proceeded to, like, try to shove his penis in my mouth... I was trying to yell .. but in a situation like that it's like nothing comes out... The other one proceeded to try to penetrate my anus. And I kept on twitching back and forth and they're pulling my hair and holding me around my neck, and finally he penetrated me, and the pain was unbearable... It seemed like it went on for an eternity... After a while I just blocked myself out... After they left ... there were splatters of blood on the floor. I guess they must have just ripped me apart.
The W participants focused, in the qualitative interview, on their curiosity about the partner's genitals and the mixed feelings of enjoyment and guilt that they experienced. One reported, with a smile,
I lost my virginity at age 8.
The characteristics of the first sexual partners of the men in the AB and W groups were: in 58 (89%) cases a male, in 42 (65%) cases four to eight years older than the respondent, and in 29 (45%) cases a family member ranked from cousin (most frequent) to grandfather (least frequent), with brother or stepbrother, uncle, and father or stepfather in between.
Concerning disclosure, 67% of the respondents did not inform others of the event, generally out of fear of negative consequences. A 26 year-old participant stated:
I was so scared I was gonna get hit [...]. Like, when you are little, everybody talked about faggots, and I didn't want to be considered a faggot. People treat you real bad and stuff. I just kept it to myself. I figured nobody knows, you know, and it's better for me.
Some participants disclosed their memories for the first time during this study's interview. One participant stated:
[I thought] "If I say something I'm going to get beat up for it." Cause I was always getting beat up for minor things. I said, "If I tell this [back home], forget about it, they will kill me." So I never spoke about it until now. [It's] the first time in almost 20 years that I've told anybody.
Those who did inform an adult about the sexual episode reported quite frequently that adults either did not believe them or tried to hush them.
Adult sexual risk behavior
The Sexual Practices Assessment Schedule (Carballo-DiŽguez, Exner, Gruen, and Meyer-Bahlburg, 1990) explores the respondents' sexual practices with men and women during the 12 months prior to the interview. For the present report only those responses referring to anal and vaginal sex were considered.
Sex with men: By eligibility criteria, all men in the sample had had sex with men at least 10 times in their lives and at least one time in the year prior to the interview. The assessment showed that the participants had between 1 and 1,155 male partners during the prior year, with a median of 6. With respect to anal sex, 166 (91%) reported engaging in it; 152 (84%) penetrated and 116 (64%) were penetrated by their partners. Condoms were consistently used by 83 (55%) of the men who engaged in insertive anal sex and by half of those who engaged in receptive anal sex.
Sex with women: During the year prior to the interview, 51 (28%) participants had sex with both men and women. The median number of female partners was 2, ranging from 1 to 261. All 51 participants reported engaging in vaginal sex and 23 in anal sex. Only 18 (35%) of those who had vaginal sex and 10 (43%) of those who had anal sex with women consistently used condoms.
It is noteworthy that, during the year prior to the interview, 7 (37%) of the straight-identified men and 7 (20%) of the bisexually-identified men had sex exclusively with men, while 10 (8%) of the gay-identified had sex with men and women. Also, 5 (4%) of gay men always dressed in women's clothes but did not self-identify as drag queen or equivalent.
Association between childhood sexual history and adult sexual risk behavior
Logistic regression analyses were conducted to determine the relationship between childhood sexual history and adult sexual behavior of the participants. The dependent variable in the initial analysis was whether the men had engaged in receptive anal sex in the twelve months prior to the interview. Age, educational level, HIV status, and childhood sexual history were the independent variables.
INSERT TABLE 1 HERE
The results show (Table 1) that age, education, and HIV status were all significantly associated with anal receptive intercourse: younger men, more educated ones, and those who were HIV-positive were more likely to engage in receptive anal intercourse than their counterparts. In both univariate and adjusted analyses, childhood sexual history was significantly associated with receptive anal intercourse: AB participants were more likely, as adults, to engage in receptive anal intercourse than NOP participants.
Another logistic regression analysis was conducted to assess the relationship of the postulated variables with unprotected receptive anal intercourse. Only those men who had engaged in receptive anal sex were considered (see Table 2).
INSERT TABLE 2 HERE
The results show that those who had had unprotected receptive anal sex tended to be older, less educated, and to have a history of childhood sexual abuse.
Men in the AB group were more likely than those in the W group, who in turn were more likely than those in the NOP group, to have engaged in anal receptive sex and to have done so without protection (Table 3). Chi square analyses showed that these differences were significant at the .05 level for engaging in unprotected receptive anal sex, but only marginally significant for engaging in any receptive anal sex.
INSERT TABLE 3 HERE
This study targeted homosexually active Puerto Rican men. Those men who had been sexually abused in childhood were significantly more likely to engage in receptive anal intercourse as adults and to do so without protection than men who had had no older partner before age 13.
Why is this the case? The qualitative data collected in this study may offer a partial answer to this question. A 36-year-old participant related the following anecdote involving a younger brother:
One time some guy wanted to fuck him and shit, you know, my kid brother... At the time he was maybe 10 or 11, you know, I was maybe 15. I says, "Listen, tell me the truth: did you get fucked?" Because that would really hurt me -- he's my brother, he's a man, you know. I says "Anybody tries, man, you get a bat, you bat'em over the head... 'cause you're a man. You born a man and you gonna die a man... You protect your manhood, and you kill for that."
Within this paradigm, being sexually abused is failing to live up to society's expectations of manhood. It is a confirmation of weakness and powerless. In the words of Nielsen (1983),
A male ethic that promotes physical strength, self-reliance, and competitiveness may make it harder for boys to seek help when they are hurt, offended, or frightened.... By definition, to be a victim is not masculine.
Kempe and Kempe (1984) also state that being ineffectual in fighting back leaves the young male with serious doubts about his self-esteem and masculine identity.
It can be postulated that, being brought up in a Latin society where gender roles are radically dichotomized (Carballo-DiŽguez, 1989; Carrier, 1989; de la Cancela, 1986; Taylor, 1986), once robbed of his masculinity the abused boy felt there was only one other role to take, that of a woman. Since the gender script for women in Latin-American societies prescribes acquiescence with a man's desire (Burgos and D’az PŽrez, 1986), the abused boy grew up to be a man who cannot reject the sexual advance of another man and must ultimately succumb to him.
Another aspect of the abuse experience may be that the boy derived intimacy from the relationship with the abuser, especially if it was maintained over time. This may have led the boy to relate to others by exploiting his own sexuality (Nielsen, 1983) or to perceive his personal value as derived from sexual interactions (Cassese, 1993). In adulthood, this may result in his offering himself to others as an object of unrestricted pleasure without attention to self-protection.
It is important to note that two thirds of the boys who had sex with an older partner did not tell others about it. Fear, shame, and guilt, coupled with the assumption that they would not be believed, appear to act as important deterrents to disclosure for the participants of this study. These feelings have been reported by other researchers working with abused boys (Finkelhorn, 1987; Nielsen, 1983; Sauzier, 1989; Watkins and Bentovim, 1992). For example, Nielsen (1983) states,
a boy may not report because he feels guilty about having received money, presents, or pleasure in exchange for sexual activities. He may have been sworn to secrecy, or he may have been threatened with harm. Fearing something harmful will happen to an offender who is loved and respected is a common concern. A child may have been warned that he will be responsible for any bad things that happen to his family if he tells anyone.
As we read in the vignette of the 26 year-old participant, the fear of being labeled gay is very powerful. Furthermore, the boy may perceive that the adults around him may be unwilling to hear about the abuse experience. Nielsen (1983) writes that some parents may discourage reporting the incident wishing to avoid the possible stigmatization for their son and the family, but that this reaction can be destructive to the child, his view of himself, and his chances for resolving the trauma incurred as a result of the sexual experience.
Lack of disclosure of the abusive experience seems to occur in almost half of the cases (Sauzier, 1989). This could result in underreporting among the study participants. This issue should be seen as a limitation of the reported results.
Could the sexual abuse episode be just a product of the participant's imagination? Loftus (1993) discusses several sources, such as certain therapies and self help books, which may lead individuals to generate unauthentic memories of childhood sexual abuse, even to the point of self-incrimination in a felony. This is a serious problem in legal cases where the reality of an event is of paramount importance. For the purpose of HIV prevention, however, if believing oneself to have been sexually abused as a child results in HIV-risk sexual behavior in adulthood, it is inconsequential whether the event actually took place.
Could it be that men with high-risk sexual activity were more likely to recall sexual abuse as a "justification" of a socially undesirable behavior? We do not think that this was the case.
When we asked participants to state the three main reasons for not using protection during sex, they alluded to issues directly related to the adult sexual activity, such as dislike of condoms, being in love with their partner, or acting out of impulse (to be reported in forthcoming publication) rather than to historical events such as childhood sexual abuse. It is our belief that if the relationship between sexual abuse and HIV-risk sexual behavior is a causal one, the effect occurs outside the individual's awareness.
The analysis of the behavior of the men in the W group raises interesting questions. More W men than NOP men (but less than AB men) engage in receptive anal sex. If we consider those men who engage in receptive anal sex only, again more W than NOP (but less than AB men) do it without protection. The placement of the W group between the other two raises the hypothesis that the early sexual experience in itself may be associated with increased risk behavior. This issue requires further exploration.
The analysis of our data also showed an association between age and sexual behavior: younger men were more likely than older men to engage in receptive anal intercourse and to do so protected. One possible explanation could be based on generational differences: younger men grew up in a time when homosexuality was less in the closet and, though still stigmatized, less so than in prior decades. This may have led them to feel more open to experimenting with different forms of sexual pleasure and to be less concerned about adopting the stereotypical penetrative role. Likewise, these young men growing up in the age of AIDS may have always seen condoms as an integral part of anal intercourse. It may also be that older men who engaged in unprotected receptive anal intercourse in a pre-AIDS era have had more difficulty modifying their behavior.
Education seemed to relate to sexual behavior in a fashion similar to age: the more educated men were more likely than the less educated to engage in anal receptive behavior and more likely to use protection. It may be postulated that higher levels of education provide men with more freedom from stereotypical gender scripts and allow them to be versatile in their sexual behavior while at the same time improving their understanding of the risks of HIV transmission and helping them maintain safer sex practices.
Forty five percent of the males in this sample who had had an older sexual partner before age 13 reported that the partner was a family member. This percentage is higher than the 17% reported by Finkelhor (1979) in his survey of childhood sexual victimization among a sample of college students. The difference may be attributable to sample bias. Nevertheless, it merits further exploration.
History of childhood sexual abuse appears as a marker of likely increase in sexual risk behavior. AIDS educators should pay attention to the special needs that these individuals may present to be able to avoid risk behavior.
Other implications of this study transcend the area of HIV prevention. It is important to bring to the awareness of Puerto Rican families that young boys may be victims of sexual abuse, that this often happens within the family, and that it may have serious negative effects in the later emotional development of the individuals. Furthermore, Puerto Rican families should be encouraged to improve channels of communication with young boys so that they may trust that they will be heard if they disclose the occurrence of sexual abuse.
Further research on male child sex abuse among Puerto Ricans is required, especially concerning its possible long term effects on the behavior of the affected individuals. Since childhood sexual abuse frequently occurs in the context of dysfunctional families, close attention should be paid to other variables that may account for the observed outcomes.
The authors would like to thank Carlos V‡zquez, Jairo Pedraza, and Arthur Fox for the enthusiasm they put in their work as research assistants, and Roberta Leftenant for her administrative support. Most of all, they would like to thank all the study participants for their trust and cooperation.
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