Adolescent sexual trauma screening is urged for HIV-infected women
Adolescent sexual trauma screening is urged for HIV-infected women
1 in 2 women with HIV have sexual abuse history
Childhood sexual abuse appears to be a common experience among American women who are infected with HIV, and the trauma resulting from this abuse could have a negative impact on HIV treatment unless it is addressed specifically, according to a recent study of HIV-infected women of various ethnic backgrounds.
"We looked to see what predictors of HIV serostatus were the most salient for women," says Gail Wyatt, PhD, associate director of behavior sciences at the University of California-Los Angeles (UCLA) AIDS Institute. "And a number of studies have reported that ethnic minority women are at greater risk for HIV," Wyatt says. "But when we looked at predictors for risk for HIV-positive women, we looked at demographic statistics, and we found that a history of child sexual abuse was more likely to predict HIV serostatus than ethnicity."
UCLA researchers found that among a community sample of 490 women, those who were HIV-positive were significantly more likely to report having had a pattern of child sexual abuse.1
HIV-positive women were recruited from HIV and service agencies, flyers, radio and print advertisements, personal contacts, and a random sample of women who were HIV-negative were recruited with random-digit dialing and 1990 U.S. census track data.1 "If you had at least one incident of sexual abuse before age 18, you were twice as likely to be HIV-positive as were women with no history," Wyatt says.
"These findings have implications because we have normally talked about high-risk behavior that is current or in the recent past for a person who is at risk for being infected or who is infected," Wyatt notes. "This was one of the first studies that documented that not only do current practices have to be discussed," she says, "but also experiences in life that could have happened long ago that might have been equally traumatic, if not more so."
The study found that one in two HIV-positive women had a history of childhood sexual abuse, compared with one in three women among those who were HIV-negative, she says. This abuse involved rape and other nonconsensual sexual trauma before the age of 18, and the study found that the typical age gap between the victim and perpetrator was five years, Wyatt says.
"This is a common occurrence, and the findings stress the need for HIV providers to ask about past histories of sexual trauma and not to just ask traditional questions about the woman’s current partner and the last three months of sexual activity," she explains. "There are many experiences in one’s life that can influence what we do today."
The UCLA research highlights a little discussed problem with treating women who are HIV-positive. Unless an HIV clinic provides psychosocial support or unless a clinician builds rapport and specifically asks female patients about sexual abuse in their past, their history of sexual trauma may never be identified.
Often, a woman who has experienced sexual abuse will engage in self-destructive behavior that both contributed to the HIV risk and that causes her to sabotage her antiretroviral therapy treatment.
"This is a pattern of self-destructive behavior of people who do not know how to do self-care," explains Ellen Kahn, MSW, director of Lesbian Health Services for the Whitman-Walker Clinic in Washington, DC. Kahn had worked with HIV/ AIDS patients for 11 years. As women who have these histories of sexual abuse begin to receive psychosocial treatment, they begin to value themselves more and are more likely to adhere to their medication regimens and attend support groups, as well as change their self-destructive behaviors of abusing drugs and alcohol, she says.
"Your expectation as a medical provider is that people will understand what it means to be HIV-positive and that they’ve invested in their treatment and will be cooperative," Kahn says. "But it’s few and far between that you can get a patient who will comply."
Other studies also have shown a relationship between sexual abuse and high-risk sexual and drug behavior, says Denise Paone, EDD, a researcher who was formerly the associate director of research at the Chemical Dependency Institute of Beth Israel Medical Center in New York City. "Most studies show there is definitely a high prevalence of sexual abuse histories in childhood among women who use drugs, and that was also true in a study that I conducted," she says. "It’s also true that women who have sexual abuse histories often go into sex work, and that puts them at higher sexual risk if they’re not using condoms."
When Paone was conducting focus groups a few years ago, she often had women, who were sex workers and injection drug users, in her groups talk about how they were going to get off of their drugs, but whenever they thought about quitting, they’d remember their past trauma. "They’d recreate that behavior and other high-risk situations," Paone says.
Years of doubt and depression take a toll
It’s not that women go directly from childhood sexual abuse to drug use and sexual risk taking, but they may spend years of being depressed, feeling as though they were at fault and are worthless, and this sort of emotional impairment makes them more susceptible to self-medication through drugs and devaluing their bodies and self-worth, she explains.
"I think child sexual abuse as a risk factor for HIV exposure among men and women needs to be looked at a lot more in research," says Claire Siverson, LCSW, who is a clinical social worker with the Women’s Specialty Program and University of California-San Francisco (UCSF) Medical Center and is a psychotherapist, who works with sexual abuse survivors, in private practice. "A lot of women with a sexual abuse history have problems with risk taking and inaccurate perceptions of risk, and then as a clinician, I have to gently confront some denial and misperceptions about sexual risk and safety," Siverson says.
Since childhood sexual abuse is so common and may negatively impact HIV treatment, it’s probably a good idea to screen new HIV patients, as well as at-risk populations, for such abuse. "We screen for this all the time," says Andy Epstein, RN, MPH, nurse manager for Cambridge (MA) Hospital’s Zinberg Clinic. "There is a large social-service component to our patient care," he says. "Thirty-four percent of our folks are injection drug users, and we know injection drug use is connected to early abuse."
A majority of women seen by the Zinberg Clinic have had some form of abuse in their past, and many have long histories of abuse, as well as mental health problems, homelessness, and addiction, Epstein says. "Once it’s identified that they have mental health issues, they are seen by a psychiatrist and followed up by a social worker," he says. "We take care of the physical and mental health aspects, and we have a nurse practitioner who specializes in medical adherence."
A woman’s history of sexual abuse might be identified at the intake session with a social worker or nurse, or it might take the woman a few visits longer before she is comfortable disclosing her past history, Epstein says. "We have close ongoing relationships with our patients, so people feel comfortable talking with us about these issues," Epstein adds.
Trust is a crucial component of identifying and treating HIV-infected women who have a history of sexual trauma, Siverson notes. "If you’re someone who has survived sex abuse or any kind of trauma, trust is already shaky because the person who did this against you has betrayed your trust," she says. "Some women have medicated their pain and abuse with drugs, and I have to find out first if they are using before I can do any work with them and before I am able to demonstrate that I’m trustworthy," she adds. "Once I’m able to establish that trust, the women tend to find it a relief to be able to unload the years of pain that they’ve stored inside, and their shame and guilt."
Ironically, it might be the very fact of a positive HIV test to wake these women up to how their self-destructive behaviors and their need for good health care, Siverson adds.
One factor that contributes to building that trust is that the clinic’s staff reflect the client population with professionals who are of Puerto Rican, Haitian, and Brazilian cultural backgrounds, Epstein says. "We have a multilingual and multicultural staff," he says. "Social workers do financial counseling and also have a therapeutic relationship with patients and see them in ongoing therapy to work with them through the abuse issues."
Other ways to screen for sexual trauma among HIV-infected women is to include a question about past sexual abuse on an assessment form because some women might be more comfortable with this sort of impersonal reporting method, Siverson says.
Siverson suggests that clinicians also may ask these questions in person, perhaps making a neutral and open-ended statement, such as: "A lot of women with HIV have been hurt in the past, either physically or sexually, and it’s very understandable to feel that nobody really cares or that your life is not worth saving when it comes to taking your medications and taking care of your HIV, and I wonder if you’ve ever felt like that?"
Reference
1. Wyatt GE; Myers HF; Williams JK, et al. Does a history of trauma contribute to HIV risk for women of color? Implications for prevention and policy. Am J Public Health 2002; 92(4):660-665.
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