Week 10 Discussion

SPECIAL SECTION: SEXUAL HEALTH IN GAY AND BISEXUAL MEN

Complexity of Childhood Sexual Abuse: Predictors of Current Post- TraumaticStressDisorder,MoodDisorders,SubstanceUse,andSexual Risk Behavior Among Adult Men Who Have Sex with Men

Michael S. Boroughs1,2 • Sarah E. Valentine1,2 • Gail H. Ironson3 • Jillian C. Shipherd4,5 •

Steven A. Safren1,2,6 • S. Wade Taylor6,7 • Sannisha K. Dale1,2, • Joshua S. Baker6 •

Julianne G. Wilner1 • Conall O’Cleirigh1,2,6

Received: 11 August 2014/Revised: 7 April 2015/Accepted: 10 April 2015/Published online: 10 July 2015

� Springer Science+Business Media New York 2015

Abstract Men who have sex with men (MSM) are the group

mostatriskforHIVandrepresentthemajorityofnewinfections

intheUnitedStates.Ratesofchildhoodsexualabuse(CSA)among

MSM have been estimated as high as 46%. CSA is associated

with increased risk of HIV and greater likelihood of HIV sexual

risk behavior. The purpose of this study was to identify the

relationships between CSA complexity indicators and mental

health, substance use, sexually transmitted infections, and HIV

sexual risk among MSM. MSM with CSA histories (n=162)

whowerescreenedforanHIVpreventionefficacytrialcompleted

comprehensive psychosocial assessments. Five indicators

ofcomplexCSAexperienceswerecreated:CSAbyfamilymember,

CSA withpenetration,CSA withphysicalinjury,CSA withintense

fear,andfirstCSAinadolescence.Adjustedregressionmodelswere

used to identify relationships between CSA complexity and

outcomes.ParticipantsreportingCSAbyfamilymemberwere

at 2.6 odds of current alcohol use disorder (OR 2.64: CI

1.24–5.63), two times higher odds of substance use disorder

(OR 2.1: CI 1.02–2.36), and 2.7 times higher odds of reporting

anSTIinthepastyear(OR2.7:CI1.04–7.1).CSAwithpenetration

wasassociatedwithincreasedlikelihoodofcurrentPTSD(OR

3.17: CI 1.56–6.43), recent HIV sexual risk behavior (OR 2.7:

CI 1.16–6.36), and a greater number of casual sexual partners

(p= 0.02). Both CSA with Physical Injury (OR 4.05: CI 1.9–

8.7) and CSA with Intense Fear (OR 5.16: CI 2.5–10.7) were

related to increased odds for current PTSD. First CSA in ado-

lescencewasrelatedtoincreasedoddsofmajordepressivedis-

order.Thesefindings suggest thatCSA,with one ormorecom-

plexities,createspatternsofvulnerabilitiesforMSM,includingpost-

traumaticstressdisorder,substanceuse,andsexualrisktaking,

and suggests the need for detailed assessment of CSA and the

development of integrated HIV prevention programs that address

mental health and substance use comorbidities.

Keywords Men who have sex with men (MSM) � Childhoodsexualabuse(CSA)�PTSD�HIV�Sexualorientation

Introduction

Childhood Sexual Abuse: Mental Health and Sexual

Health Consequences

Intheextantliterature,childhoodsexualabuse(CSA)hasemerged

asanon-specificriskfactorforarangeofnegativehealthandmen-

talhealthsequelaeinadults.Forinstance,CSAhasbeenassociated

withmentalhealthproblemssuchasdepressionandpost-traumatic

stress disorder (PTSD), as well as substance use disorders

(e.g., Browne & Finkelhor, 1986; Maniglio, 2010; Neu-

mann, Houskamp, Pollock, & Briere, 1996; Suvak, Brogan,

& Shipherd, 2012). In addition to mental health and substance

abuseproblems,CSAhasbeenassociatedwithsexualriskbehav-

ior,sexualdysfunction,andinterpersonaldifficulties(i.e.,impaired

& Conall O’Cleirigh [email protected]

1 Department of Psychiatry, Massachusetts General Hospital, One

Bowdoin Square, 7th Floor, Boston, MA 02114, USA

2 Department of Psychiatry, Harvard Medical School, Boston, MA,

USA

3 Department of Psychology, University of Miami, Coral Gables,

FL, USA

4 National Center for PTSD –Women’s Health Sciences, Division,

VA Boston Healthcare System, Boston, MA, USA

5 Department of Psychiatry, Boston University School of Medicine,

Boston, MA, USA

6 The Fenway Institute, Fenway Health, Boston, MA, USA

7 DepartmentofSocialWork,WheelockCollege,Boston,MA,USA

123

Arch Sex Behav (2015) 44:1891–1902

DOI 10.1007/s10508-015-0546-9

social cognitions, emotional lability, and poor interpersonal

relatedness) amongadults (e.g.,Neumann et al., 1996; Van

Bruggen,Runtz,&Kadlec,2006).Severalstudieshaverevealed

anassociationbetweenCSAandsexualriskvariablesincluding

unprotectedsex,sexwithmultiplepartners,andengaginginsex

trading among women (Arriola, Louden, Doldren, & Forten-

berry, 2005; Fargo, 2009; Gidycz, Coble, Latham, & Layman,

1993; Kaltman, Krupnick, Stockton, Hooper, & Green, 2005;

Suvak et al., 2012).

Childhood Sexual Abuse Among Gay, Bisexual,

and Other Sexual Minority Men

Although much of the extant literature has focused on the vic-

timizationofwomen,estimatesofCSAamonggayandbisexual

men reach as high as 47% (Arreola, Neilands, Pollack, Paul, &

Catania, 2008; Lenderking et al., 1997; Mimiaga et al., 2009;

O’Cleirigh, Safren, & Mayer, 2012). As a group, gay and

bisexual adults report more childhood psychological and phy-

sicalabusebyparentsandcaretakers(i.e.,familymembers)than

theirheterosexualsiblingsofthesamesex,andmoreCSA(Balsam,

Rothblum, & Beauchaine, 2005). In a study of young gay and

bisexual men (ages 15–22), 68% of the sample reported expe-

riencing verbal and physical violence victimization from family

members(Koblinetal.,2006).Agrowingbodyofresearchongay

and bisexual men’s health has revealed correlates of CSA that

parallel those first established among women. Specifically, gay

and bisexual men with CSA histories are more likely to expe-

riencenegativeemotional,cognitive,andinterpersonaloutcomes

as adults, including depression, suicidal ideation, substance abuse,

andsexualrisk-takingbehaviorcomparedtogayand bisexual men

withoutCSAhistories(Bartholowetal.,1994;Brennan,Heller-

stedt, Ross,& Welles,2007; Kalichman,Gore-Felton, Benotsch,

Cage, & Rompa, 2004; Lloyd & Operario, 2012; Relf, 2001b;

Stalletal.,2003).Further,theseearlyexperiencesofvictimization

appear to put gay and bisexual men at increased risk for subse-

quent experiences of violence and abuse in adulthood, including

increasedriskofvictimizationintheiradultromanticrelationships

(Balsam, Lehavot, & Beadnell, 2011; Balsam et al., 2005; Koblin

et al., 2006; Lalor & McElvaney, 2010).

Childhood Sexual Abuse in the Context of HIV Risk

and Prevention

Among gay, bisexual, and other men who have sex with men

(herein MSM for each of these groups), CSA history has been

consistently associated with increased risk for HIV acquisition

(Limetal.,2010;Lloyd&Operario,2012;Mimiagaetal.,2009;

O’Cleirigh et al., 2011; Stall et al., 2003). In addition, CSA has

been linked to a variety of sexual risk behaviors among MSM

including unprotected anal sex with a non-primary partner,

serodiscordant unprotected anal sex, sex with multiple partners,

and sex in exchange for money or drugs (Bartholow et al., 1994;

Brennan et al., 2007; Carballo-Diéguez & Dolezal, 1995;

Kalichman et al., 2004; Lenderking et al., 1997; O’Leary,

Purcell, Remien, & Gomez, 2003; Paul, Catania, Pollack, & Stall,

2001;Relf,2001a;Stalletal.,2003).Theexperienceofviolencein

MSM’sadultromanticrelationshipshasalsobeenassociatedwith

unprotected sex and HIV acquisition (Merrill & Wolfe,

2000; Nieves-Rosa, Carballo-Dieguez, & Dolezal, 2000; Relf,

Huang,Campbell,&Catania,2004).Thus,MSMareatincreased

risk of HIV acquisition both in primary and non-primary sexual

relationships.Inprimaryrelationships,MSMwithCSAhistories

are morelikelytoreport feelingunsaferequestingthattheir abu-

sive partners use barrier protection (Heintz & Melendez, 2006).

Preliminary evidence from HIV prevention trials suggests that

sexual risk reduction interventions may be less effective for

MSMwhohaveCSAhistories(Crepazetal.,2006;Mimiaga

et al., 2009; Safren, Reisner, Herrick, Mimiaga, & Stall, 2010).

Thesefindingssuggesttheneedforbetterunderstandingofthose

constructs linking CSA to sexual risk that may be achieved by

more nuanced assessment of CSA.

Assessment of Childhood Sexual Abuse

The correlation between CSA and HIV risk is well established

among MSM, although exact mechanisms remain unclear. One

of the main limitations of the current literature is that the way in

which CSA is operationalized (often as a binary indicator) dis-

counts the within-group heterogeneity of experiences. Defining

CSAinthiswaydilutesthelivedexperiencesofvictimsforwhom

CSAcanrepresentasingle-eventthatisincongruentwithinasur-

vivor’s context (‘‘an anomaly’’); or, CSA may represent just one

event in the context of pervasive interpersonal abuse and neglect

(‘‘the norm’’). In support of a more nuanced conceptualization of

CSA, previous researchers have highlighted the importance of

abusecharacteristicssuchasduration,ageoffirstexperience,use

ofthreatorharm,andabuseinvolvingpenetration,inunderstand-

ingpost-traumaticadjustment,includingcopingstyleandriskfor

mental health and substance abuse problems (Cloitre & Rosen-

berg, 2006; Merrill, Guimond, Thomsen, & Milner, 2003).

Inaddition, recent researchon the nuance of definingand char-

acterizing CSA experiences among MSM suggests that there may

be additional considerations when defining CSA for this popula-

tion. For instance, some researchers have taken a closer examina-

tionoftheconsequencesofchildhoodsexualexperiencewitholder

partners (i.e., partners prior to the age of 13 who are at least four

years older) among MSM (e.g., Arreola et al., 2008; Carballo-

Dieguez, Balan, Dolezal, & Mello, 2012). Carballo-Dieguez et al.

only define the subset of these experiences, namely, experiences

where the child felt emotionally or physically hurt as a result of

CSA.Carballo-Dieguezetal.suggestthatnotenoughattentionhas

been paid to the perceptions of survivors of the events, such as

whether or not men choose to label these childhood sexual expe-

riencesasabuse(Carballo-Dieguez&Dolezal,1995;seealsoRind,

Tromovitch, & Bauserman, 1998).

1892 Arch Sex Behav (2015) 44:1891–1902

123

AfewstudieshavefoundthatonlyMSMwhoperceivedforce

orcoercionaspartoftheirchildhoodsexualexperiencesreported

poor adjustment, including depression and suicidal ideation

(Arreola et al., 2008; Stanley, Bartholomew, & Oram, 2004).

Importantlythough,MSMwhoreportedchildhoodsexualexpe-

rienceswitholderpartners(withandwithoutforce/coercion) were

more likely to engage in HIV sexual risk behaviors compared to

MSM without these experiences (Arreola et al., 2008). It is also

importanttonoteherethattheseauthorsrelyonadultretrospective

perceptions experiences from childhood, and do not adequately

acknowledgehoweasilytheseperceptionscanbedistortedbypost-

traumatic sequelae, such as guilt or denial (for detailed summary

of this argument, see Dallam et al., 2001; Ondersma, Chaffin,

Berliners, Cordon, & Goodman, 1998). Althoughmostadults

who experienced CSA do not go on to have negative sequelae,

thisdoesnotmeanthatadult–childsexisnotharmfultochildren

(Dallam et al., 2001; Ondersma et al., 1998). Further, a recent

study on the labeling of CSA experiences, among HIV-positive

MSM, suggests that negative mental health sequelae are present

regardless of how the survivor labels the experience (Valentine

&Pantalone,2013).Despitewidedisagreementinthefield,these

findings highlight that it is important to distinguish between

forced/coercive sex and consensual sex when reporting findings

regarding childhood sexual experiences, and this is particularly

truewhendiscussingthechildhoodsexualexperiencesofMSM.

These nuances and characteristics are thought to represent

CSA complexities that warrant further study. Five dimensions,

orcomplexityindicators,wereinvestigatedinthisstudybecause

they may contribute to making the traumatic experience more

difficult given their association with greater disturbance and

impact upon functioning, and because they may predict distress

ordisturbanceintoadulthoodcomplicatingassessmentandtreat-

ment. Thus, we define complexity indicators as those character-

istics, supported by previous work, that influence negative health

outcomes and complicate assessment and treatment of sexual

trauma for MSM.

Thereiscurrentlynogoldstandardforthemeasurementof

CSAcomplexity,although researchersagreethatfrequencyand

intensity of abuse, current functioning, and context of CSA

matters when attempting to characterize post-abuse adjustment

(Casey & Nurius, 2005; Kaysen, Rosen, Bowman, & Resick,

2010; Loeb, Gaines, Wyatt, Zhang, & Liu, 2011; Zink, Klesges,

Stevens, & Decker, 2009). Given the evidence demonstrated in

theliterature,webelievethattheCSAcomplexityissignificantly

influential in risk for impaired mental health, substance use, and

sexualrisktaking.Theseoutcomesareofparticularinterestbecause

of their influence in the adult mental health and adult adjustment

particularly among MSM with CSA histories. However, depres-

sion (Koblin et al., 2006; Mustanski, Newcomb, Du Bois, Garcia,

& Grov, 2011; O’Cleirigh et al., 2013), PTSD (El-Bassel, Gilbert,

Vinocur, Chang, & Wu, 2011; Ibañez, Purcell, Stall, Parsons, &

Gómez, 2005; Reisner, Mimiaga, Safren, & Mayer, 2009), and

substance use (e.g., Skeer et al., 2012) have each independently

been identified as predictors of sexual risk for HIV among MSM

regardless of CSA history.

The relationship between CSA complexity indicators, sexu-

allytransmittedinfections,andHIVsexualriskbehaviormayalso

helptospecifyaspectsoftheCSAexperiencethatserveaspoten-

tiatorsoftheproximalrisksforHIVinfectionamongMSM.Thus,

thecurrentstudyexaminedtherelationshipsbetweenempirically

derivedindicatorsofCSAcomplexity(i.e.,CSAbyafamily

member, CSA with penetration, CSA with physical injury, CSA

withintensefear,orfirstCSAinadolescence)andadultfunction-

ing,includingmentalhealth,substanceuse,andsexualrisktaking

withanexpectationthatthecomplexityofCSAwillimpactthese

outcomes among MSM.

Method

Participants

Datawerecollectedasapartofacomprehensiveassessmentfrom

amulti-siterandomizedclinicaltrialfromHIV-uninfectedMSM

(n = 162) that reported sexual risk and had a history of CSA

beforeage17.ThestudysiteswerelocatedinBoston,MA,and

Miami, FL. The average age was M = 39.4, SD= 11.8 (range

19–67).Thesamplewas66.1%EuroAmerican,22.6%African

American,3.6%Asian/PacificIslander,3.6%NativeAmerican,

with 27.8% identifying as Latino distributed across racial cate-

gories. Sexual orientation was assessed resulting in a sample that

identified as 61 % gay, 27 % bisexual, 9 % unsure, and 3 %

heterosexual. The majority of the sample (81 %) experienced

multiple episodes of CSA before age 13, while 51% reported

experiencingsexualabusebetweenages13and17.Asignificant

minority (43%) of participants reported CSA across both age

ranges (see Table1).

Procedure

Recruitment

Recruitment was accomplished via outreach including at bars,

clubs, and cruising areas, community outreach, and advertising.

Recruitment for the study was done in conjunction with recruit-

ment for other, ongoing studies, and health promotion activities

todecreasestigmaandprotectindividualswhospokewithstudy

stafffrombeingidentifiedbyothersinthevenueassomeonewho

experienced sexual abuse in childhood.

Study Procedure

Following recruiting procedures, prospective participants were

screened by trained clinical staff via a structured questionnaire.

Arch Sex Behav (2015) 44:1891–1902 1893

123

Those who self-identified as HIV-negative were considered for

participation in the study, confirmed via rapid testing. All study

participantscompletedacomprehensivebaselineassessment

that included a thorough psychiatric evaluation, HIV and other

STItesting,andcomputer-basedpsychosocialassessments.Par-

ticipants responded to survey questions directly into a computer

because of the preponderance of studies that reveal that partici-

pants are more likely to disclosure sensitive information in this

manner (Des Jarlais et al., 1999; Metzger et al., 2000; Millstein,

1987;Navalineetal.,1994;O’Reilly,Hubbard,Lessler,Biemer,

& Turner, 1994; Turner et al., 1998; Wilson, Genco, & Yager,

1985).Inordertobeincludedinthestudy,participantshadto(1)

identify as a biological man who has sex with men age 18 or

older,(2)reportsexualcontactbeforetheageof13withanadult

oraperson5yearsolder,orsexualcontactbetweentheagesof13

and16inclusivewithaperson10yearsolder(oranyagewiththe

threatofforceorharm),(3)reportmorethanoneepisodeofunpro-

tected anal or vaginal intercourse within the past three months,

and (4) be HIV uninfected. Participants were excluded if all

episodesofunprotectedanalorvaginalintercourseoccurred

withonlyasingle,primary,HIV-negativepartner.Allprocedures

were IRB-approved.

Measures

Demographics

Theseincludedself-reportedage,race,ethnicity(independentof

racialcategory),income,relationship/maritalstatus,andedu-

cational attainment.

Assessment of Childhood Sexual Abuse

The parameters of CSA were assessed through a clinician-ad-

ministered interview adapted from previous work in HIV treat-

ment and prevention and used previously to assess sexual abuse

in a variety of medical populations (Leserman et al., 1997; Le-

serman, Li, Drossman, & Hu, 1998) including those HIV in-

fected(Lesserman,Ironson,&O’Cleirigh,2006).Theinterview

provided standardized questions that assessed sexual abuse

history comprised of 20 closed-ended questions predominantly

requiringyes/noanswers.CSAwasassessedacrosstwoageranges

0–12 years old and 13–16 years old. CSA is indicated in the

younger age range with any unwanted sexual contact report-

ed with someone 5 or more years older. In the older age range,

CSAwasindicatedifwithanysexualcontactreportedwithsome-

one 10years older or with some one of any age if there was the

threatofforceorharm.CSAwasindicatedifanyofthefollowing

occurred: genital touching, being touched, or penetrative inter-

course(i.e.,vaginaloranalpenetration).Thismeasureofunwanted

sexual contact was adapted from earlier research (Kilpatrick,

1992). All items on the measure asked about unwanted sexual

contact.Tomeetcriteriaforsexualabuse,theremustbeclearforce

or threat of harm for adolescents with a perpetrator less than 10

yearsolder;however,inchildren(\13years),thethreatofforceor harmisimpliedbya5-yearagedifferentialbetweenthevictimand

perpetrator.

CSA Complexity Indicators

Each of these CSA characteristics was coded dichotomously

indicating the presence or absence of the indicator.

Table1 Participant characteristics

Participant sample (N=162)

n %

Race Euro American 111 66.1

African American 38 22.6

Asian/Pacific Islander 6 3.6

Native American 6 3.6

Ethnicity Latino 45 27.8

Income \$10,000 per year 50 30.2 [$60,000 per year 30 18.6

Educational attainment Some High School 10 6.2

High School Diploma 40 24.7

Some College 58 35.8

College Graduate 27 16.7

Some Graduate or above 27 16.7

Relational status Partnered 50 30.4

Single 112 69.6

Age M (SD) 39.4 (11.8)

1894 Arch Sex Behav (2015) 44:1891–1902

123

CSA by Family Member Participants were asked to identify

theirrelationshiptotheperpetrator(s),withapositivecodeinthis

category if the participant reported any CSA perpetrated by a

parent, stepparent, guardian, brother, other family member, or

other adult living in the family home.

CSA with Penetration was indicated if the participant repor-

tedthatpenetrativesexoccurredasdescribedaboveduringeither

age range.

CSA with Physical Injury was assessed via one question that

asked‘‘during any of the abuse experiences did you suffer ‘no

physicalinjuries,’‘minorphysicalinjuries’(scrapesandbruises),

or‘majorphysicalinjuries’(injuriesrequiringmedicalatten-

tion).’’CSAwithphysicalinjurywasindicatedifminorormajor

physical injury was reported.

CSA with Intense Fear was assessed through the question

‘‘Duringthe worst episode were youafraidthatyoumightbe

killed or seriously injured.’’

First CSA in Adolescence Participants’ CSA experiences

were assessed within two age ranges, one prior to their 13th

birthday and the other from age 13 through age 16. Partici-

pants who reported their first CSA experience during the

older age range were coded in this category.

Post-Traumatic Stress Symptom Assessment

Structured Clinical Interview for DSM-IV Axis I Disorders

(SCID-IV; Spitzer, Gibbon, & Williams, 1997)

Only the section on PTSD was used to provide an independent

assessment of current PTSD diagnosis and symptoms.

Sexual Risk Assessment

HIV sexual risk behavior was defined as insertive or receptive

anal or vaginal intercourse without a condom with any casual

partner or with any primary partner who had not specifically

disclosed that he/she was HIV uninfected and reported a recent

(past 3months) negative HIV test result. The number of HIV

sexual risk acts in the previous 3months as defined above was

summeddichotomizedatthemeantoreflecthighandlowsexual

risk. As recent sexual risk was one of the inclusion criteria in

order to enroll inthe study, thisconstruct lacksvariabilityinthat

no one reported zero risk episodes. The data were also heavily

skewed at the upper end of the range. To account for these

characteristics in the distribution, the distribution of sexual risk

behaviorwasdichotomizedatthemeantodistinguishthosewith

higher levels of recent sexual risk behaviors.

Sexually Transmitted Infections

As part of the self-report assessment, participants were asked if

theyhadbeendiagnosedwithanSTI inthe past 12months.This

generated a dichotomous variable.

Distress Assessment

The Mini-International Neuropsychiatric Interview (M.I.N.I.;

Sheehan et al., 1998)

TheMINIisashortstructureddiagnosticinterviewthathasgood

reliabilityandvaliditythatiscomparabletotheStructuredClinical

InterviewforDSM-IV(SCID-IV)(Sheehanetal.,1998).This

assessmentwascompletedwitheachparticipantbyatrainedInde-

pendentAssessoratthebaselineevaluationtoprovideinformation

on the presence of major mental illness (e.g., untreated severe

mood disorders, psychotic disorders), which is one of the exclu-

sioncriteria,andassistwithprovidingdiagnosisofothermoodor

substanceusedisorders.MajorDepressiveDisorderwasscoredas

present for anyone meeting diagnostic criteria for major depres-

siveepisodeatanytimeupto2weekspriortothebaselineassess-

ment.AnySubstanceUseDisorderwasscoredaspresentforthose

meeting diagnostic criteria for either substance abuse or depen-

denceacrossanyofthesubstancecategoriesinthepast12months.

Similarly,anyAlcoholUseDisorderwasscoredaspresentforeach

participant who met diagnostic criteria for either alcohol abuse or

dependence in the past 12months.

Data Analysis

The demographics and background information provided in

Table 1 were generated through frequency counts, percent-

ages, and the calculation of means and standard deviations. The

interrelationships between the CSA complexity indicators were

examinedusingunadjustedlogisticregressions.Therelationships

between the CSA complexity indicators and the adult mental

health,substanceuse,andsexualhealthoutcomeswereestimated

using logistic regressions adjusted for age, race, education level,

andtheabsenceorpresenceofadiagnosisofcurrentPTSD.Cur-

rent PTSD was included as a covariate to identify the magnitude

and significance of these relationships over and above what is

contributed by PTSD. The magnitude and significance of these

relationships are provided by the odds ratios and the associated

95% confidence interval. In one instance, the outcome variable

wascontinuous,i.e.,numberofcasualsexualpartners,andlinear

regressionsmodelswereusedwiththeidenticalcovariatesusedin

the logistic regression models. For the continuous outcome, the

tstatistic,degreesoffreedom,andthepvalueassociatedwiththe

CSA complexity predictor are reported. For the models predict-

ing current PTSD, PTSD was omitted from the list of covariates.

Results

Background Characteristics

Thetotalnumberofsexualpartnersintheprevious3-monthperiod

wasM=7.9,Median=5(range1–50),andtheHIVstatusofmale

Arch Sex Behav (2015) 44:1891–1902 1895

123

andfemalesexualpartnerswasoftenunknown.Themajorityofthe

sample reported male sexual partners exclusively (68.7%), fol-

lowed by both male and female partners (29.5%), and just 1.8%

reported female sexual partners exclusively over the previous

3-month period.

Examination of Outcome Data

Each of the outcomes of interest was descriptively examined.

Given the full sample, sexual risk behavior was M=7.52, SD=

12.43 suggesting an average of 7–8 partners in the past 3month

period. For the other outcomes interest, a sizable number of par-

ticipantshadcurrentPTSD(46%),anymooddisorder(40%),or

any alcohol use disorder (36 %). A smaller number of par-

ticipants reported an STI (17 %).

Interrelationships Between CSA Complexity Indicators

The strongest relationships were observed between CSA with

physical injury and CSA with penetration (OR 11.8: CI 4.4–

31.8) and between CSA with physical injury and CSA with

intensefear(OR9.4:CI4.3–20.5).FirstCSAinadolescencewas

significantly associated with increased odds of CSA with pen-

etration(OR4.1:CI2.1–8.3),CSAwithphysicalinjury(OR3.0:

CI 1.4–6.6), and CSA with intense fear (OR 2.3: CI 1.2–4.7).

Allbuttwooftheindicatorsweresignificantlyrelatedtoeach

other.CSAwithpenetrationwasnotsignificantlyrelatedtoCSA

by family member and neither was first CSA in adolescence

significantly related to CSA by family member. The complete

matrix of these interrelationships is presented in Table2.

Relationships between CSA Complexity Indicators

and Psychological and Health/Risk in Adulthood

Those reporting CSA with physical injury had more than four

times higher odds (OR 4.05: CI 1.90–8.70) tobe diagnosedwith

current PTSD than those who reported no physical injury. CSA

withinjurywasnotsignificantlyassociatedwithanyoftheother

outcomes under investigation (See Table3a, b for full results).

Similarly, CSA with penetration was significantly associated

with more than three times higher odds of being diagnosed with

current PTSD (OR 3.17: CI 1.56–6.43). CSA with penetration

wasalsoassociatedwithnearlythreetimeshigheroddsofreport-

ing very high levels unprotected anal intercourse in the past 3

months (OR 2.72: CI. 1.16–6.36) and with a higher number of

casual sexual partners in the past 3months.

ThosereportingCSAbyfamilymemberhad2.6timeshigher

odds(OR2.64:CI1.24–5.63)ofbeingdiagnosedwithanalcohol

usedisorderandmorethantwicetheodds(OR2.1:CI1.02–4.36)

of being diagnosed with a current substance use disorder. CSA

byfamilymemberwasnotsignificantlyassociatedwithincreased

risk of current mood disorder, current PTSD, or increased sexual

riskforHIV.ThosereportingCSAwithphysicalinjuryhadnearly

threetimeshigheroddsinreportingasexuallytransmitteddisease

inthepastyear(OR2.7:CI1.04–7.10).ThosewhoreportedCSA

withintensefear(i.e.,fearofbeingkilledorseriouslyinjured)had

morethanfivetimeshigheroddsinmeetingdiagnosticcriteriafor

current PTSD than those who did not (OR 5.15: CI 2.5–10.7).

CSAwithintensefearwasnotsignificantlyassociatedwithanyof

the other adult outcomes. See Table3a, b for full results.

ThosewhoreportedfirstCSAinadolescencewerelesslikely

to meet criteria for major depressive disorder compared to those

who had first been abused during childhood. Despite its strong

relationshiptoallbutoneoftheotherCSAcomplexityindicators

first CSA in adolescence was not significantly related to any of

the other adult outcomes.

The reference group for each of these analyses is gay, bisex-

ual, other MSM with CSA histories, but who did not experience

each of the complexity indicators.

Discussion

This is the first study, of which we are aware, to link indices of

CSAcomplexitytoincreasedrisk for mental health,alcoholand

substance use disorders, and to increased risk for sexually trans-

mitted infections, and sexual risk for HIV, among adult MSM

overandabovewhatcanbeascribedtodiagnosticlevelsofPTSD.

Bothalcoholandothersubstanceusedisorderswerepredictedby

a history of CSA by family member. This category was also sig-

nificantly associated with a participant self-report of at least one

sexuallytransmittedinfectioninthepastyear.Thus,therelational

Table2 Interrelationships between CSA complexity indicators

CSA complexity

indicators

% (n) CSA with injury CSA with

penetration

CSA by family

member

CSA with intense

fear

First CSA

in adolescence

CSA with physical injury 31.1 (52) – 11.8 (4.4–31.8) 2.0 (1.01–3.9) 9.4 (4.3–20.5) 3.0 (1.4–6.6)

CSA with penetration 58.3 (98) – 1.4 (0.97–2.0) 6.1 (3.0–12.6) 4.1 (2.1–8.3)

CSA by family member 31.5 (53) – 1.95 (1.01–3.8) 0.6 (.30–1.2)

CSA with intense fear 41.7 (70) – 2.3 (1.2–4.7)

First CSA in adolescence 61.3 (103) –

Expressed as unadjusted Odds Ratio (95% Confidence Interval)

Odds ratios that are significant at p\.05 or less are indicated in bold

1896 Arch Sex Behav (2015) 44:1891–1902

123

complexity of CSA is linked with sexual risk taking resulting in

STIs. Because risk for the acquisition of HIV is increased while

infected with another STI, assessment and intervention address-

ingthiscomplexitywouldbebeneficialtoMSMwiththishistory.

Thus,evaluationoftheseCSAcomplexityindicatorscouldserve

twoimportantfunctions.First,assessmentoftheseindicatorsmay

prove to be key in adapting the most effective intervention, at the

individual level, to bring about positive behavioral change asso-

ciated with sexual risk reduction, moderation of substance use,

andimprovedmentalhealth.Second,atthepopulationlevel,there

is an impetus to address the public health crisis of HIV infection

rateswhichmaybereducedthroughtheindirecttreatmentofpast

trauma given its role in current adult risk behaviors. Therefore,

thesefindingssupportthenotionthatgayandbisexualmen’smen-

tal health should be addressed with empirically supported assess-

ment and interventions that need to be developed and tested to

support MSM’s sexual health with integrated programs that

include elements of sexual risk reduction and trauma treatment.

Current PTSD was predicted by three CSA complexity indi-

cators: CSA with penetration, CSA with physical injury, and

CSA with intense fear. These findings are consistent with other

studiesthatexaminedPTSDcomplexities(Gold,Feinstein,Skid-

more, & Marx, 2011; Johnson, Pike, & Chard, 2001; Kendall-

Tackett, Williams, & Finkelhor, 1993; McKibben, Bresnick,

Wiechman-Askay,&Fauerbach,2008).Together,currentPTSD

was predicted by CSA that included the complexities of pene-

tration, injury, or intense fear. Only CSA by family member was

not associated with current PTSD. The latter finding is unclear,

but perhaps repeated exposure to a family member that per-

petrated CSA reduces a variety of symptoms across the mul-

tipleclustersrequiredforadiagnosisofPTSD.Inaddition,itis

possiblethatthosewithfamilyperpetrationhadlifetimePTSD

but did not meet diagnostic criteria for current PTSD. Finally,

the only complexity of the five to predict current alcohol or

other substance use disorders was CSA by family member.

This may be a marker for‘‘self-medicating’’and influential in

explainingwhythosewiththiscomplexitydidnothavecurrent

PTSD.

OnlyfirstCSAinadolescencewasrelatedtolessthanhalfthe

likelihood of meeting diagnostic criteria for a major depressive

disorder. It is plausible that men who are sexually abused at an

older age are more resilient to the impact of the abuse on their

mood over time compared to those who are first abuse during

childhood.Thelackofsignificantrelationshipsbetweenageof

firstabuseandthestudyoutcomesissurprisinggivenitsstrong

relationship to the other complexity indicators. It is plausible

Table3 The relationship between (a) indices of CSA and psychological diagnoses and (b) indices of CSA and health/risk behaviors

(a) Indices of CSA and psychological diagnoses

CSA complexity measure Mental health/substance use diagnoses

Lifetime MDD Current PTSD a

Alcohol disorder Substance use disorder

OR 95% CI OR 95% CI OR 95% CI OR 95% CI

CSA with physical injury 1.42 0.39-1.93 4.05 1.90–8.70 1.55 0.70–3.44 0.84 0.38–1.87

CSA with penetration 0.87 0.41–1.84 3.17 1.56–6.43 0.91 0.43–1.95 0.79 0.37–1.65

CSA by family member 1.43 0.71–2.88 1.55 0.76–3.12 2.64 1.24–5.63 2.10 1.02–4.36

CSA with intense fear 1.83 0.83–4.07 5.16 2.5–10.70 1.06 0.48–2.29 0.52 0.24–1.15

First CSA in adolescence 0.41 0.18–0.93 1.38 0.70–2.85 0.94 0.43–2.04 0.86 0.40–1.85

(b) Indices of CSA and health/risk behaviors

CSA complexity measure Sexual health/risk

Any STI past year High sexual risk for HIV # of casual sex partners b

OR 95% CI OR 95% CI t (df) p

CSA with physical injury 1.50 0.51–4.42 1.02 0.45–2.30 1.18 (154) 0.24

CSA with penetration 1.49 0.53–4.11 2.72 1.16–6.36 2.39 (155) 0.02

CSA by family member 2.7 1.04–7.10 0.78 0.36–1.72 -0.39 (155) 0.70

CSA with intense fear 1.94 0.70–5.39 1.38 0.61–3.13 0.57 (155) 0.57

First CSA in adolescence 1.39 0.50–3.91 0.87 0.39–1.95 0.77 (155) 0.44

Oddsratiosand95%confidenceintervalarereportedforlogisticregressionmodelsadjustedforcovariatesage,race,education,andthepresenceorabsenceof

current PTSD

Odds ratios or t values that are significant at p\.05 or less are indicated in bold a In the models predicting current post-traumatic stress disorder, PTSD was omitted from the list of covariates

b The relationship with number of sexual partners was examined using linear regression models with the same covariates as the logistic regression models

Arch Sex Behav (2015) 44:1891–1902 1897

123

that the relationship between age of first CSA and impairment

and dysfunction in adulthood is complex with suggestions

from the broader literature that the proximity of CSA to pub-

erty may be particularly relevant (Bifulco, Brown, & Adler,

1991;Briere&Runtz,1990).Posthocanalysesexaminingage

of first abuse as a continuous variable, or estimated time from

puberty of first abuse did not generate additional significant

relationships.

No other CSA complexity indicators were related to major

depressive disorder. Although current PTSD was covaried in

these models (PTSDwas significantly related tomajordepres-

sive disorder in every model), the relationship between these

aspectsoftheCSA(withtheexceptionoffirstCSAinadoles-

cence) and major depressive disorder was not significant even

when PTSD was omitted from the regression models. This sug-

geststhatamongCSAvictimswhoareMSM,theothercomplexi-

ties assessed here (CSA by a family member, CSA with penetra-

tion,CSAwithphysicalinjury,andCSAwithintensefear)donot

contribute to increased risk for a current mood disorder. Alterna-

tively,theoverlappingsymptomsofMDDandPTSDmayaccount

forthisfindingparticularlyamongthoseMSMwithcurrentPTSD

whereasimilarsymptompresentationisbetteraccountedforby

post-traumatic stress.Thus,one opportunityforimprovedpsycho-

logical assessment among MSM would include improved differ-

ential diagnosis whenan individual presents with mood problems,

particularlywhentheseareatypicalandseeminglyunrelatedsymp-

tomsare present,e.g., those that are inthe hypervigilanceclus-

ter of PTSD.

Given the overrepresentation of MSM among those with

CSA histories, behavioral health care would improve if health-

careproviderschosetoconducttraumascreeningsforMSMthat

presentwithmoodproblems,orprovideappropriatereferralsfor

a comprehensive mental health evaluation. It is also plausible

that the adult mental health vulnerability realized because of a

history of CSA may be more apparent among the anxiety dis-

orders than mood disorders. Mood Disorders tend to be inter-

mittentandareoften,formany,aself-limitingillnessthatimproves

withorwithouttreatment.Therefore,futureinvestigationsmay

endeavortoexaminetheroleoflifetimemooddisturbancesrather

than a current mood problem. Additional hypotheses to explain

this finding should be a focus in future investigations. For exam-

ple,perhapsamooddisorder,asakeyoutcomeofinterest,wasnot

influenced by any of the included complexities because boys and

mentendtowardexternalizingratherthaninternalizingdiagnoses

(Ackerman, Newton, McPherson, Jones, & Dykman, 1998).

Inaddition tobeingassociatedwithcurrent PTSD,CSAwith

penetrationwasalsosignificantlyassociatedwithaproximalrisk

for HIV through its relationship with higher numbers of casual

sexual partners and greater risk of unprotected anal intercourse,

the latter of which is one of the most risky behaviors associated

with seroconversion. This finding suggests that a detailed

assessment of CSA history among MSM may identify proximal

conduits to sexual risk for HIV than can be addressed through

tailored HIV prevention interventions. Thus, simply identifying

those MSM with a past CSA history may prove to be an insuffi-

cient level of data with which to conduct the most effective treat-

mentofmultiplepsychiatriccomorbiditiesaswellasinterveneat

the level of behavioral health interventions to reduce sexual and

substancerisktaking.Instead,healthcareprovidersmightusestan-

dardizedstructuredassessments,suchasthoseusedinthisstudy,in

ordertoevaluatethenatureofCSAexperienceandthepotential

impact these variables have on risk behaviors and treatment

options.

RegardlessofwhetheracurrentPTSDdiagnosiswaspresent,

CSA complexity indicators improved the prediction of health

risk behaviors including an STI over the past year, HIV sexual

risk behavior, and the number of sexual partners. This finding

providesfurthersupportforathoroughevaluationofCSAamong

MSM to include assessment of these, and perhaps other, CSA

complexities.ThisinformationwouldpossiblycontributetoHIV

preventioninthecontextofinteractionsbetweenMSMandtheir

health providers.

A history of CSA appears to create a broad base of vul-

nerabilitiesforMSMthatarenotaccountedforbytheclinicalcon-

ceptualizationofPTSD,andthusmaybemissedbytraditionaltrau-

ma-focused assessment. These problems endure into adulthood.

This study examined mental health, substance use, and sexual

health across five complexity indicators from a childhood trau-

matic event. Each of these was associated with at least one di-

agnosedimpairment inadulthoodandthree proximal healthrisk

behaviors in adulthood. These findings begin to provide a foun-

dationforbothpublichealthinitiatives,andpsychosocialassess-

ment and intervention, to address a cascade of negative physical

and mental health problems in adulthood that stem from a child-

hood event. It is notable that across a variety of disorders, (e.g.,

substance use, alcohol, trauma history, or PTSD), each was in-

dependentlyrelatedtosexualriskbehaviorand/orincreasedrisk

for seroconversion (Bedoya et al., 2012; Chesney et al., 2003;

Mimiaga et al., 2009; Stall et al., 2003). With these additional

burdens,MSMmustalsonavigateadifficultcoursetodealwitha

history of CSA.

The consequent adult vulnerabilities that appear to be related

to the contextual aspects of CSA reported here are perhaps most

appropriately examined within the context of the theory of syn-

demic production (Stall et al., 2003) and the more recent exami-

nationsof these relationships(Dyer et al., 2012; Kurtz, Buttram,

Surratt, & Stall, 2012; Mimiaga et al., 2015; Mustanski, Garo-

falo,Herrick,&Donenberg,2007;Parsons,Grov,&Golub,2012).

This growing body of work suggests that developmental chal-

lenges associated with sexual minority status (including dispro-

portionate rates of CSA) contribute to multiple psychosocial vul-

nerabilitiesinadulthood(depression,substanceuse,intimatepart-

ner violence, sexual compulsivity, and others) and combine and

interact to generate health challenges for gay, bisexual, and other

menwhohavesexwithmen.Traditionally,CSAhasbeenincluded

asoneofthedriversofsyndemicproduction(e.g.,Stalletal.,2003).

1898 Arch Sex Behav (2015) 44:1891–1902

123

Ourfindings,thatcharacteristics(i.e.,complexities)ofCSAare

stronglyrelatedtoincreasedoddsofmeetingdiagnosticcriteriafor

current PTSD in adulthood and relationships between these char-

acteristicsandimpairment,independentofPTSD,allowustosug-

gestthatCSA-relatedPTSDisoneofthemechanismsofsyndemic

productionratherthanCSAitself.Moreaccurately,CSArepresents

adevelopmentalvulnerabilityforgay,bisexual,andothermenwho

have sex with men, which contributes to the mechanisms of syn-

demicproductionthatmayormaynotincludeadultpost-traumatic

stress responses.

It is interesting within this syndemic framework to note that

from a consideration of CSA alone, relationships to major psy-

chological,substanceuse,andsexualhealthimpairmentsemerge,

without reference to other developmental challenges and inde-

pendent of adult PTSD (which was covaried in these analyses).

These findings underscore the enduring, damaging, and often

devastating effects, across multiple areas of adult functioning, of

sexual trauma perpetrated on gay and bisexual young boys and

emerging adolescents.

Thehealthofgay,bisexual,andotherMSMisapublichealth

crisis(InstituteofMedicine,2011).ThisisregardlessoftheHIV

prevention efforts currently underway. Traditional HIV pre-

vention interventions are have been shown ineffective with MSM

with CSA histories (Mimiaga et al., 2009) and thus improving

accesstohealthcare,referralformentalhealthcare,andappropriate

and evidence-based assessment and diagnosis resulting in inte-

gratedinterventionsarecentralgoalsformultiplehealthdisciplines,

the NIH, and the community being served.

Some of the limitations of this study include the use of self-

report measures which have a variety of challenges. In order to

mitigatethislimitation,standardizedcliniciandiagnosticassess-

ments were used in addition to paper-and-pencil and computer-

based assessments. Although we were looking to address lon-

gitudinal relationships, including predicting factors associated

with childhood trauma and its impact on adult health and func-

tion, this was cross-section research. Our STI results were based

on self-report at study entry and therefore are subject to recall

bias. And finally, the data represent a restricted rage given that

only men with CSA together with recent sexual risk-taking be-

haviors were included in the study. This may limit generaliz-

ability, and also may leave some relationships undetected.

These findings, however, provide additional support for and

underscore the need for integrated behavioral health interven-

tionstoaddressHIVpreventionforMSMinthecontextofCSA,

andpossiblyother,trauma-relatedvulnerabilities.Thisincludes,

but is not limited to, current PTSD and substance use in the con-

textofsexualrisktaking.Fromaclinicalpracticepointofview,a

moredetailedassessmentofCSAisneededbeyondthepresence

orabsenceofthediagnosisofPTSD.Thisisespeciallyimportant

amongMSM.Thebenefitsofamoredetailedassessmentinclude

the identification of complexities that negatively influence both

physical and mental health outcomes.

Futuredirectionsinthisareaofresearchincludeadditional

work in adaptive psychosocial and integrated prevention inter-

ventions to protect the physical and mental health of the MSM

population. These interventions require studies using RCTs in

order to demonstrate efficacy, acceptability, sustainability, and

empirical support.

Acknowledgments Thisstudywas supportedbyaGrantfromtheNIMH (R01 MH095624) PI: O’Cleirigh; Author time (Safren) was supported, in

part, by Grant 5K24MH094214.

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