Childhood sexual abuse in males and subsequent risky sexual behavior: A potential alcohol-use pathway☆
Introduction
Childhood sexual abuse (CSA) among males is not uncommon. Until recently, accurate prevalence rates have remained elusive—apparently because rates of abuse among boys have been masked by particularly low rates of abuse disclosure. Current estimates are that roughly 14% of males are sexually abused during childhood (Briere & Elliott, 2003). Unfortunately, this percentage may also be an underestimate due to continued low rates of disclosure.
While less robust than the research literature using female samples, there is ample evidence that male CSA is associated with a broad spectrum of detrimental sequelae (Holmes and Slap, 1998, Romano and De Luca, 2001). Increased alcohol consumption and elevated rates of sexual risk-taking have both been observed among various populations of male survivors of CSA (DiIorio et al., 2002, Hamburger et al., 2008, Paul et al., 2001). Additionally, increased alcohol consumption has independently and convincingly been associated with increased risky sexual decision-making (Cooper, 2002, George and Stoner, 2000). These two lines of independent but intersecting research findings—that CSA is associated with alcohol use and sexual risk-taking and that alcohol use is related to sexual risk-taking—suggest that alcohol is an important component in the path between CSA and subsequent sexual risk-taking. Using survey methodology, the current study investigated these possible linkages among CSA, alcohol use, and sexual risk-taking in a sample of adult heterosexual men from the community.
Multiple studies indicate a positive association between CSA and risky sexual practices (e.g., elevated number of sexual partners and unprotected intercourse) among adolescent and adult males (for a review, please see Purcell, Malow, Dolezal, & Carballo-Dieguez, 2004). CSA experiences seem to influence sexual risk-taking in an early and ongoing fashion. Studies have associated CSA with early consensual sexual initiation (Wilsnack, Vogeltanz, Klassen, & Harris, 1997) with one study reporting that male CSA survivors were younger at onset of sexual intercourse than female CSA survivors (Chandy, Blum, & Resnick, 1996). Among adolescent male survivors of CSA, elevated rates have been observed for number of sexual partners (Saewyc, Magee, & Pettingell, 2004) and inconsistent condom use (Brown, Lourie, Zlotnick, & Cohn, 2000). Among adult survivors, in addition to a greater number of sexual partners and inconsistent condom use (Bartholow et al., 1994, DiIorio et al., 2002, Holmes and Slap, 1998), CSA has also been associated with exchanging sex for drugs or money (e.g., Van Dorn et al., 2005), and using alcohol prior to or during sex (e.g., Senn, Carey, Vanable, Coury-Doniger, & Urban, 2006). Among both adolescent and adult male survivors, elevated rates of sexually transmitted infections (STIs) have been observed (Futterman et al., 1993, Holmes and Slap, 1998, Paul et al., 2001).
Published findings linking male CSA with sexual risk-taking have largely been based on samples drawn from populations with high STI risk indices (e.g., men who have sex with men [MSM], homeless populations, STI clinic patients). As such, it is not clear if these results generalize across all male survivors of CSA. The present study addressed this gap by investigating these relationships in a community sample of heterosexual men.
To date, Purcell et al. (2004) have suggested the only conceptual model tailored specifically for males to explain the link between CSA and subsequent risky sexual behavior. The model they proposed suggests that CSA exerts influence on the distal outcome (HIV-risk behavior) indirectly through its effect on more proximal outcomes that may serve as mediating variables. One of the proposed paths to risk-taking is through the use of substances, including alcohol. Alcohol use is a particularly important path to investigate given that some studies suggest that alcohol use among survivors of CSA may be of particular concern among males (e.g., Garnefski & Arends, 1998).
CSA in boys has been linked to increased and maladaptive alcohol use (DiIorio et al., 2002, Dube et al., 2005, Garnefski and Arends, 1998, Hamburger et al., 2008, Nagy et al., 1994, Senn et al., 2006, Wolfe et al., 2006). CSA may affect a person's drinking behavior beginning early in life. In a study of abused and non-abused boys aged 12–19, Garnefski and Arends noted that abused boys reported drinking nearly 3 times the amount of alcohol consumed by their non-abused counterparts. More recently, in an epidemiological study of survivors of childhood maltreatment, Hamburger et al. found that among male middle school and high school students, CSA was positively associated with preteen alcohol use. Further, the authors also reported that, when compared to those without a history of sexual abuse, these male survivors of CSA were 2.5 times more likely to report binge drinking (defined as consuming five or more drinks in a row).
While both male and female victims of CSA have shown elevated drinking levels, maladaptive adolescent drinking among CSA survivors may pose a unique risk for males. In 1996 a group of researchers reported that while female survivors of CSA reported consuming alcohol more frequently than male CSA survivors, the males were more likely than sexually abused females to consume five or more drinks during one episode and to drink before or during school (Chandy et al., 1996). Similarly, Garnefski and Arends (1998) reported a gender interaction such that both male and female survivors of CSA drank more than those without a history of CSA, but that the difference between the groups was significantly larger among males.
In addition to early drinking initiation and binge drinking early in life, CSA has been linked to increased alcohol consumption and related problems for men in mid-life as well. DiIorio et al. (2002), in a study of men ranging in age from 18 to 70 (mean age of 32), reported that men who experienced unwanted sexual activity during childhood were significantly more likely to report alcohol-related problems than men without histories of CSA. Using a population drawn from a managed care system in Southern California, a study of almost 8,000 men (mean age of 56) reported that men with a history of CSA had increased odds of reporting problems with alcohol. Further, the authors reported that victims of abuse that included intercourse were at increased odds for reporting problems with alcohol compared to men whose abuse experiences were limited to non-intercourse activities (Dube et al., 2005). This is in line with prior research that has linked increased severity of abuse with worsened outcomes (for a review, see Romano & De Luca, 2001). In sum, studies have consistently indicated that a history of CSA in boyhood is associated with elevated, maladaptive, and enduring patterns of drinking behavior.
Research has demonstrated a relationship between alcohol consumption and an array of risky sexual practices. This positive association has been demonstrated in research using both survey and experimental methods (for a review, see Cooper, 2002). Since Cooper's review, research has continued to support the alcohol-risky sex link. For instance, a recent study reported that heavy alcohol use was significantly associated with having multiple sex partners in the prior 12 months and was the single biggest risk factor for having experienced an unprotected sexual encounter while intoxicated (Kim, De La Rosa, Trepka, & Kelley, 2007). Fully 30.8% of those that reported heavy drinking also reported unprotected intercourse under the influence of alcohol. This compares to just 7.5% of participants that did not report heavy alcohol use, and suggests that the volume of alcohol consumption (versus drinking in general) may be an important alcohol-use dimension to incorporate conceptually. However, Kim et al. did not find that alcohol use was related to condom use behavior overall. This latter finding is in line with much of the event-level research (in which specific events are probed), which suggests added complexity in the association between alcohol consumption and overall condom use (Cooper, 2006). However, extending the finding of Kim et al.’s global association study, a 2007 event-level study of the relationship between alcohol consumption and unsafe sex among first-year college students reported significantly increased odds of having unsafe sex on days on which participants drank more than their average daily consumption (Neal & Fromme, 2007). Another recent event-level analysis found that while the link between alcohol use and condom use was only a trend, alcohol use was significantly related to a decrease in discussing “topics pertinent to safe sexual practices” (Goldstein, Barnett, Pedlow, & Murphy, 2007).
Well-designed laboratory experiments have corroborated event-level survey research indicating that alcohol intoxication fosters risky sexual decision-making (see review, Hendershot & George, 2007). For example, in multiple studies, alcohol's pharmacological effect has been shown to impair a person's ability to simultaneously attend to opposing cues (Steele & Josephs, 1990). Instead, alcohol seems to render a person disproportionately affected by the cues that are most salient. In the sexual domain, when instigatory cues such as sexual arousal and desire are more salient than inhibitory cues (e.g., not knowing a potential partner's sexual history), alcohol intoxication can increase a person's intention to take sexual risks (Davis et al., 2007, George et al., 2009, Stoner et al., 2008). Acute alcohol intoxication has also been experimentally shown to interfere with a person's ability to effectively negotiate condom usage (Maisto et al., 2002, Maisto et al., 2004). In sum, alcohol's association with sexual risk-taking, while not a simple relationship, is supported by substantial and diverse research findings.
To date, only one published study has examined the role of alcohol as a potential mediator in the relationship between CSA and later sexual risk-taking among males. Using a high-risk sample drawn from an STI clinic, Senn et al. (2006) reported that, among men, alcohol use during intercourse mediated the relationship between CSA and number of sexual partners in the past 3 months. CSA was associated with number of episodes of unprotected sex, but this relationship was not mediated by alcohol use during intercourse. Additionally, alcohol use did not mediate CSA's effects on risk-taking behaviors among women in the sample. The finding that gender moderated the mediated relationship again suggests that alcohol use is an especially meaningful component in this relationship for men and highlights the need for more research in this domain using a variety of samples. In line with most of the published research on CSA, Senn et al. defined CSA history dichotomously (present vs. absent). However, because abuse severity has been associated with worse outcomes, taking severity of abuse into account may allow for a more thorough understanding of these relationships. The present study incorporated abuse severity in the categorization of abused participants.
The present study aimed to extend previous work by examining the relationships among CSA, alcohol use, and risky sexual decision-making among males by sampling an understudied population. Instead of consisting of homeless men, MSM, or men recruited from a clinical setting, our sample was comprised of heterosexual men recruited from the general community. This population of men have risk indices that are presumably lower than the aforementioned populations, but are an important demographic to understand; a fact that is underscored by the increasing rate of sexually contracted HIV infections among heterosexual women (Centers for Disease Control and Prevention, 2007). Additionally, rather than dichotomize CSA, the present study defined CSA on a continuum of severity.
The present study addressed 3 hypotheses. First, it was hypothesized that severity of CSA would be directly associated with increases in risky sexual practices. Second, it was hypothesized that severity of abuse experience would be positively associated with alcohol use. Furthermore, we predicted that CSA severity would be associated with earlier use of alcohol and that alcohol use would endure over time. Last, it was hypothesized that severity of CSA would influence risky sexual behavior indirectly via an alcohol-use pathway. The hypothesized model is shown in Fig. 1.
Section snippets
Participants
Single heterosexual men (n = 280) were recruited from the greater Seattle area via ads in local weekly newspapers, the University of Washington student newspaper, and flyers posted at the university, nearby community colleges, and other social environments. Ads and flyers stated that the study was about “social drinking and decision-making.” Inclusion requirements consisted of being (a) between the ages of 21 and 35, (b) interested in dating an opposite sex partner, (c) not currently in a steady,
Rates of childhood sexual abuse
Precisely a fifth of our sample of heterosexual men reported CSA that included physical contact (n = 56). Of the men that reported contact CSA, 26 reported that their most severe experience was fondling, 11 men reported that their most severe experience consisted of oral sex (performing or receiving), and 19 men reported experiences that included intercourse (penetrative or receptive).
Model specification
Bivariate correlations among the measured variables appear in Table 2. The measured variables were all related to
Discussion
The present study examined relationships among history of childhood sexual abuse, risky sexual behavior, and an alcohol-use pathway that may connect these two phenomena. The goal of this study was to extend prior research linking CSA to sexual risk-taking by using a community sample of heterosexual men, using a continuous definition of CSA based on severity, and by taking more alcohol-use variables into account. In the present study, severity of CSA was directly and indirectly, through its
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