Abstract
Background
Social networks directly and indirectly influence STI risk. The objective was to explore associations between sex with a male recently released from incarceration and sexual risk and intimate partner violence (IPV) among African-American adolescent females.
Methods
Sociodemographic, psychosocial and sexual behavior data were collected at baseline, 6- and 12-months from African-American females, 15–21 years, participating in an HIV/STI prevention trial. Among 653 participants with ≥1 follow-up assessments, generalized estimating equations tested associations during follow-up between having a recently released partner and STI acquisition, sexual risk behaviors and IPV, adjusting for age, treatment assignment and corresponding baseline measure.
Results
Eighty-three (13.6%) participants had a recently released partner at 6-months and 56 (9.3%) at 12-months. Participants with a recently released partner were more likely to: have vaginal (AOR: 5.48), anal (AOR: 2.43) and oral (AOR: 1.51) sex, a casual partner (AOR: 1.66), sex while high/drunk (AOR: 1.57) or with a high/drunk partner (AOR: 2.27); use condoms inconsistently (AOR: 0.58); acquire Chlamydia (AOR: 1.80) and experience emotional (AOR: 4.09), physical (AOR: 2.59) or sexual abuse (AOR: 4.10) by a boyfriend. They had a greater number of sex partners, lower partner communication- and refusal-self-efficacy, were high/drunk during sex more frequently and used condoms during oral sex less frequently.
Conclusions
A recently released sex partner is associated with sexual risk and IPV among African-American adolescent females. Prevention programs should inform adolescents about potential risks associated with recently released partners as well as provide adolescents with skills to establish and maintain healthy sexual relationships.
Keywords: Adolescent, African-American, Incarcerated partner, Sexually transmitted infections, Sexual risk, Intimate partner violence
Introduction
Black adolescent females bear the greatest burden of both gonorrhea and Chlamydia among all age, gender and race categories in the United States.1 Perhaps contributing to the high rates of sexually transmitted infections (STIs) among young Black women is the disproportionately high incarceration rate of Black men.2,3 In 2009, the incarceration rate among Black males (4,749 inmates per 100,000 U.S. residents) was 6.7 times that of white non-Hispanic males and 2.6 times that of Hispanic males.4 Black men accounted for 40% of the population of men (n=2,096,300) in custody at prisons and jails during the one-day mid-year census in 2009.4 At mid-year in 2006, approximately 12% of Black males 24–29 years of age were incarcerated, as compared to 1.7% of white men the same age.5 Nationally, one-quarter to one-third of Black men will be incarcerated at some time in their lives.6,7
Sex with a partner with an incarceration history is a human immunodeficiency virus (HIV) and STI risk factor.8,9 Sex with a partner recently released from incarceration could increase risk via several pathways. Relative to the general population, incarcerated populations are more likely to be infected with HIV and STIs.10,11 Many men have multiple and concurrent sex partners, unprotected sex and sex while high or drunk soon after release from incarceration.10,12 Increased STI risk may occur via direct transmission, or partners recently released from incarceration may expose individuals to riskier social networks.13
Finally, men with an incarceration history may be more prone to violence, as incarceration is related to several intimate partner violence (IPV) perpetration risk factors (e.g., unemployment, economic stress, substance use, history of violence victimization and perpetration, low academic achievement).11,14–16 “Intimate partner violence” refers to “behavior within an intimate relationship that causes physical, sexual or psychological harm.”17 Intimate partners include current and former spouses and non-marital partners.18 IPV within dating relationships is often termed “dating violence”.19 Among adolescent females, dating violence is associated with increased sexual risk behavior, substance use and pregnancy.20 African-American women who have experienced sexual violence as youth have increased risk for: abortion, subsequent abuse as an adult, STIs, >2 lifetime STIs, early sexual debut and a greater number of lifetime sexual partners.21,22 IPV may result in HIV and STI transmission during forced sex or disempowerment to negotiate safer sexual practices, as suggested by the theory of gender and power.20,21,23 A history of dating violence is associated with increased fear about the consequences of condom negotiation and fear of talking to a partner about pregnancy prevention among African-American adolescent females.23 This peripheral path through partner communication is supported in the adult literature and among African-American adolescents.21,24,25
Despite high incarceration rates among young African-American men and high rates of sexual risk behavior among inmates following release, we are aware of no studies which have investigated the risks of having a male sex partner recently released from incarceration specifically among African-American adolescent females. Our objectives were to assess the associations between having sex with a male partner recently released from incarceration and STI acquisition, sexual risk behavior, psychosocial constructs related to sexual risk behavior and IPV among African-American adolescent females.
Methods
Study sample
From March 2002 to August 2004, 715 African-American adolescent females enolled in a HIV/STI prevention trial, completed baseline assessments and were randomized to study conditions, as previously described.26 Participants were recruited from 3 reproductive health clinics in Atlanta, Georgia. Eligibility criteria included self-identifying as African-American, age 15 to 21 years and vaginal intercourse in the past 60 days. Exclusion criteria included being married, currently pregnant or attempting to become pregnant. On a return visit to the clinic, adolescents completed informed consent procedures and baseline assessments and were randomized to trial conditions. Written informed consent was obtained from all participants, with parental consent waived for those younger than 18 years due to the confidential nature of clinic services. Of eligible adolescents, 84.4% enrolled in the study, completed baseline assessments and were randomized to study conditions. Participants were compensated $50 for travel and childcare to attend intervention sessions and complete assessments. The Emory University institutional review board approved all study protocols. This analysis reports on the 653 (91%) participants who completed at least one follow-up assessment post-intervention.
Study procedures
The study procedures have been described elsewhere.26 Briefly, the intervention (HORIZONS) consisted of 2 4-hour group HIV/STI prevention sessions, 4 15-minute telephone contacts to reinforce information presented in the group sessions and vouchers given to male sex partners to facilitate HIV/STI screening and treatment. Telephone contacts occurred 3–4 weeks and 10–12 weeks following the baseline and 6-month assessments. Participants randomized to the control condition attended a 1-hour group session to watch an STI/HIV prevention video followed by a group discussion. Participants received telephone contacts on the same schedule as participants randomized to the intervention condition but only to update locator information.
Data collection occurred at baseline and 6 and 12 months following completion of the group sessions and consisted of an audio computer-assisted self-interview (ACASI) and self-collected vaginal swabs. The ACASI assessed sociodemographics, sexual history, attitudes, and psychosocial constructs associated with STI/HIV–preventive behaviors. Identical questions were asked at each assessment. Following the ACASI, participants provided 2 self-collected vaginal swabs.27 One specimen was assayed for Chlamydia trachomatis and Neisseria gonorrhoeae, using the Abbott LCx Probe System (Abbott Laboratories, Abbot Park, Illinois).28–30 After discontinuation of this assay in September, 2002, all specimens were subsequently tested using the BD ProbeTec ET C trachomatis and N gonorrhoeae Amplified DNA assay (Becton Dickinson and Company, Sparks, Maryland).31 The second specimen was tested for Trichomonas vaginalis using a non-commercial real-time polymerase chain reaction assay.32 Participants with a positive STI test result received directly observable single-dose antimicrobial treatment and risk-reduction counseling per Centers for Disease Control and Prevention recommendations and were encouraged to refer sex partners for treatment. The County Health Department was notified of reportable STIs.
Measures
Sociodemographic Characteristics
School enrollment was assessed with, “Are you currently attending school?” (yes/no). Family aid index was assessed with a 4-item scale. Participants respond yes/no to “In the past 12 months, did you or anyone you live with receive any money or services from”: a) “Welfare (including TANF (Temporary Assistance to Needy Families) or SSI)?”; b) “food stamps?”; c) “WIC (Women, Infants and Children?” and d) “Section 8 housing (housing subsidies)?”.
Substance Use
Participants responded yes/no to, “In your lifetime, have you ever tried marijuana?” and “In your lifetime, have you ever tried alcohol?”.
Sex with a Recently Released Partner
Participants were asked, “In the past 6 months, have you had vaginal sex with a guy who you know has just been released from a jail, prison, or detention center?” (yes/no).
STIs
Participants were defined as having Chlamydia, gonorrhea or trichomoniasis at baseline if they tested positive for these infections. Participants were defined as acquiring Chlamydia, gonorrhea or trichomoniasis at the 6- or 12-month assessment if they had a positive test result following a negative test result or documented treatment with effective single-dose antibiotics at the preceding visit. A composite “any STI” variable was created to indicate infection with Chlamydia, gonorrhea and/or trichomoniasis.
Sexual Risk Behaviors
Age at first sex was assessed with, “How old were you the first time you willingly had vaginal sex?”. “In your entire life, how many guys have you had vaginal sex with?” assessed participants’ lifetime number of sex partners. We assessed the following risk behaviors in the 60 days prior to assessment: (a) vaginal sex (yes/no) (b) number of vaginal sex partners, (c) number of times had vaginal sex, (d) percent condom use during vaginal sex, (e) anal sex (yes/no), (f) number of anal sex partners, (g) number of times had anal sex, (h) percent condom use during anal sex, (i) oral sex (yes/no), (j) number of oral sex partners, (k) number of times had oral sex, (l) percent condom use during oral sex, (m) had sex while high or drunk (yes/no), (n) number of times had sex while high or drunk, (o) had sex with a partner who was high or drunk (yes/no) and (p) number of times had sex with a partner who was high or drunk. The dichotomous vaginal, anal and oral sex variables were created from the questions about the numbers of sex partners in the past 60 days. We assessed the frequency questions (number of partners, number of sex acts, percent condom use) only among participants who endorsed engaging in the behavior in the past 60 days. Percent condom use was calculated by dividing the number of times the participant reported using a condom by the total number of sex acts reported. We also assessed: (q) consistent condom use, defined as 100% use during vaginal sex in the 60 prior to assessment, (r) having a current boyfriend who has had concurrent sex partners during the relationship (yes/no) and (s) currently having a casual partner (yes/no).
Psychosocial Constructs
An 8-item scale measured fear of consequences of condom negotiation; a sample item was, “I have been worried that if I talked about using condoms with my boyfriend or sex partner he would threaten to leave me” (α=.84).33 Partner sexual communication self-efficacy was assessed with a 6-item index; a sample item was, “How hard is it for you to demand that he use a condom?” (α=.83).33 Partner sexual communication frequency was assessed with a 5-item index; a sample item was, “During the past 60 days, how many times have you and your boyfriend or sex partner(s) talked about how to prevent pregnancy?”33 Perceived peer norms supporting risky sexual behavior was measured using an 8-item index (α=.68). A sample item included “How many of your friends think that cheating on your partner is okay?”. Finally, refusal self-efficacy was assessed with a 7-item index (α=.84) ; a sample item was, “How sure are you that you would be able to say NO to having sex with someone you want to date again?”34
Abuse/IPV
All participants were asked whether they ever experienced emotional, physical and sexual abuse. Among participants at least 18 years of age, we assessed IPV perpetrated by a boyfriend or a casual partner in the 60 days prior to assessment. Participants were asked about abuse by a boyfriend or casual partner separately. Emotional abuse was assessed with, “In the past 60 days, have you been emotionally abused by [your boyfriend / a casual sex partner]?” Physical abuse was assessed with, “In the past 60 days, have you been physically abused (hit, punched, kicked, slapped, etc.) by [your boyfriend/ a casual sex partner]?”. Sexual abuse was assessed with, “In the past 60 days, has [your boyfriend/ a casual sex partner] made you have vaginal sex when you didn't want to?”
Adolescents less than 18 years of age were not surveyed about recent abuse due to concerns about the quality of the data to be obtained and so as not to deter their participation in the research given the research team’s responsibility to report recent abuse to minors to local authorities. All participants were offered referrals for needed services, and a clinical psychologist was available throughout the study to provide assistance to participants in the event they became distraught during research activities.
Data analysis
Descriptive statistics summarized selected baseline characteristics. We compared selected baseline characteristics according to participants’ reports of having a recently released partner in the six months prior to baseline assessment using t-tests and chi-square statistics. Generalized estimating equations tested unadjusted and adjusted associations during follow-up between STI acquisition, sexual risk factors and IPV (outcome measures) and having a recently released partner in the 6 months prior to the two follow-up visits. Adjusted models controlled for age at baseline, treatment assignment and the corresponding baseline measure of the outcome. Baseline values for percent condom use during anal sex were imputed for participants who reported anal sex during follow-up but not at baseline. The imputed values were set equal to mean percent condom use among participants who reported anal sex at baseline. Baseline values for percent condom use during oral sex were similarly imputed for participants who reported oral sex during follow-up but not at baseline. Statistical analyses were conducted using STATA version 11.1 SE (STATA Corp., College Station, TX).
Results
Sample characteristics
Eighty-three participants (13.6%) reported sex with a male partner recently released from jail, prison or detention at the 6-month assessment, and 56 participants (9.3%) reported a recently released partner at 12-months. Nineteen participants, 3.4% of participants with complete follow-up data, reported a recently released partner at both follow-up assessments. Table 1 presents selected baseline characteristics among study participants.
Table 1.
Selected baseline characteristics among the sample of African-American females 15–21 years of age who completed at least one follow-up visit
| Variable | Females (N=653), n (%) |
|---|---|
| Sociodemographic characteristics | |
| Age (years), mean (SD)‡ | 17.8 (1.7) |
| Currently in school | 434 (66.5%) |
| Family aid index, mean (SD) | 0.87 (1.0) |
| Substance use | |
| History of alcohol use | 555 (85.0) |
| History of marijuana use | 510 (78.1) |
| Lifetime sexual history | |
| Age at first sex (years), mean (SD)∞ | 14.6 (1.7) |
| Lifetime number of sex partners, mean (SD) § | 8.4 (19.3) |
| STIs | |
| Any STI | 177 (27.1) |
| Chlamydia | 107 (16.4) |
| Gonorrhea | 28 (4.3) |
| Trichomoniasis | 83 (12.7) |
| Sexual behavior in past 60 days | |
| Number of vaginal sex partners, mean (SD)§ | 1.5 (1.4) |
| Consistently used condoms Θ | 134 (25.8) |
| Had anal sex | 69 (10.6) |
| High/ drunk during sex§ | 203 (31.2) |
| Partner high/ drunk during sex§ | 285 (43.8) |
| Lifetime abuse | |
| History of emotional abuse | 394 (60.3) |
| History of physical abuse | 305 (46.7) |
| History of sexual abuse | 157 (24.0) |
| IPV in past 60 days† | |
| Emotionally abused by boyfriend∫ | 83 (24.1) |
| Physically abused by boyfriend∫ | 48 (14.0) |
| Sexually abused by boyfriend∫ | 8 (2.3) |
| Emotionally abused by casual partner∫ | 22 (6.4) |
| Physically abused by casual partner∫ | 18 (5.2) |
| Sexually abused by casual partner∫ | 6 (1.7) |
Assessed only for the 347 participants ≥18 years of age
Missing one response
Missing two responses
Missing three responses
Missing four responses
Missing 134 responses
Characteristics associated with having a recently released partner at baseline
Table 2 compares baseline characteristics according to participants’ reports of having a recently released partner in the 6 months prior to baseline assessment. Participants with a recently released partner were less likely to be enrolled in school (55.9% vs. 68.4%, p=0.014) were more likely to have ever tried marijuana (88.2% vs. 76.2%, p=0.007) and tended to be younger at first sex (14.3 vs. 14.6 years, p=0.050).
Table 2.
Comparison of baseline characteristics among African-American females 15–21 years of age according to their report of sex in the prior 6 months with a male partner recently released from incarceration
| Variable | Sex with a recently released partner (n=102) |
No sex with a recently released partner (n=551) |
p-value |
|---|---|---|---|
| Sociodemographic characteristics | |||
| Age (years), mean (SD) | 17.8 (1.6) † | 17.8 (1.7) | 0.387 |
| Currently in school, n (%) | 57 (55.9) | 377 (68.4) | 0.014 |
| Family aid index, mean (SD) | 0.86 (0.94) | 0.87 (1.03) | 0.894 |
| Substance use | |||
| History of alcohol use, n (%) | 89 (87.3) | 466 (84.6) | 0.486 |
| History of marijuana use, n (%) | 90 (88.2) | 420 (76.2) | 0.007 |
| Lifetime sexual history | |||
| Age at first sex (years), mean (SD) | 14.3 (1.6) | 14.6 (1.7)∞ | 0.050 |
| Lifetime number of sex partners, mean (SD) | 8.5 (12.0) | 8.4 (20.4) § | 0.950 |
Missing one response
Missing two responses
Missing four responses
Associations between having a recently released partner and STIs, HIV/STI risk factors and IPV
Table 3 presents unadjusted associations between having a recently released partner and STIs, selected HIV/STI risk factors and IPV during follow-up while Table 4 presents the adjusted associations. Controlling for potential confounders, participants with a recently released partner were more likely to acquire Chlamydia (AOR: 1.80, 95% CI: 1.14, 2.85) and any STI (AOR: 1.61, 95% CI: 1.06, 2.45). In the 60 days preceding follow-up visits, participants with a recently released partner were more likely to: have had vaginal (AOR: 5.48, 95% CI: 2.11, 14.22), anal (AOR: 2.43, 95% CI: 1.42, 4.19) and oral (AOR: 1.51, 95% CI: 1.05, 2.16) sex; have a casual sex partner (AOR: 1.66, 95% CI: 1.11, 2.49); have had sex while high/ drunk (AOR: 1.57, 95% CI: 1.02, 2.44) or with a high/ drunk partner (AOR: 2.27, 95% CI: 1.57, 3.27); use condoms inconsistently (AOR: 0.58, 95% CI: 0.35, 0.94) and experience emotional (AOR: 4.09, 95% CI: 2.11, 7.92), physical (AOR: 2.59, 95% CI: 1.23, 5.45) or sexual abuse (AOR: 4.10, 95% CI: 1.39, 12.13) by a boyfriend. Participants with a recently released sex partner had a greater mean number of vaginal (B*: 0.66, 95% CI: 0.21, 1.10) and anal (B*: 0.28, 95% CI: 0.05, 0.50) sex partners in the past 60 days, were high or drunk during sex more frequently (B*: 3.22, 95% CI: 0.88, 5.57) and used condoms during oral sex less frequently (B*: −0.11, 95% CI: −0.19, −0.03). They also had lower refusal self-efficacy (B*: −1.07, 95% CI: −1.95, −0.19) and partner communication self-efficacy (B*: −0.56, 95% CI: −1.09, 0.02). Participants with a recently released partner had less frequent sexual communication with their partners (B*: −0.70, 95% CI: −1.42, −0.02), although the association was only marginally statistically significant.
Table 3.
Unadjusted associations between having a sex partner who was recently released from incarceration and STIs, HIV/STI risk factors and IPV
| Logistic Regression Models | ||||
|---|---|---|---|---|
| Outcome | n | OR | 95% CI | p-value |
| STIs | ||||
| Any STI† | 647 | 1.66 | 1.10, 2.49 | 0.016 |
| Chlamydia† | 647 | 1.86 | 1.18, 2.93 | 0.007 |
| Gonorrhea | 647 | 1.84 | 0.84, 4.06 | 0.129 |
| Trichomoniasis | 647 | 1.36 | 0.76, 2.42 | 0.296 |
| Sexual Risk Behavior | ||||
| Boyfriend ever have concurrent partners during relationship, if have a boyfriend | 561 | 1.48 | 0.98, 2.23 | 0.065 |
| Currently have a casual partner† | 653 | 1.70 | 1.14, 2.52 | 0.009 |
| Vaginal sex† | 653 | 5.38 | 2.07, 14.01 | 0.001 |
| Consistent condom use, if had vaginal sex† | 579 | 0.51 | 0.34, 0.77 | 0.001 |
| Anal sex† | 653 | 2.45 | 1.46, 4.11 | 0.001 |
| Oral sex† | 653 | 1.52 | 1.13, 2.05 | 0.005 |
| High/ drunk during sex† | 653 | 1.57 | 1.02, 2.44 | 0.042 |
| Partner high/ drunk during sex‡ | 653 | 2.34 | 1.68, 3.26 | <0.001 |
| Intimate Partner Violence§ | ||||
| Emotionally abused by boyfriend‡ | 339 | 3.14 | 1.68, 5.89 | <0.001 |
| Physically abused by boyfriend‡ | 339 | 3.83 | 1.93, 7.60 | <0.001 |
| Sexually abused by boyfriend† | 339 | 4.28 | 1.48, 12.33 | 0.007 |
| Emotionally abused by casual partner | 339 | 2.63 | 0.89, 7.79 | 0.081 |
| Physically abused by casual partner | 339 | 1.78 | 0.35, 9.03 | 0.489 |
| Sexually abused by casual partner | 339 | 1.74 | 0.52, 5.78 | 0.370 |
| Linear Regression Models | ||||
| Outcome | n | B | 95% CI | p-value |
| Sexual Risk Behavior | ||||
| Number of vaginal sex partners, if had vaginal sex† | 618 | 0.69 | 0.24, 1.14 | 0.003 |
| Number of times had vaginal sex, if had vaginal sex | 478 | −0.29 | −3.43, 2.85 | 0.857 |
| Percent condom use during vaginal sex, if had vaginal sex | 579 | −0.08 | −0.16, 0.00 | 0.037 |
| Number of anal sex partners, if had anal sex† | 72 | 0.25 | 0.03, 0.47 | 0.028 |
| Number of times had anal sex, if had anal sex | 72 | −0.45 | −1.08, 0.17 | 0.154 |
| Percent condom use during anal sex, if had anal sex | 72 | 0.01 | −0.23, 0.25 | 0.949 |
| Number of male oral sex partners, if had oral sex | 328 | 0.72 | −0.04, 1.48 | 0.065 |
| Number of times had oral sex, if had oral sex | 328 | 1.73 | −0.24, 3.71 | 0.086 |
| Percent condom use during oral sex, if had oral sex† | 327 | −0.08 | −0.15, 0.00 | 0.039 |
| Number of times high/ drunk during sex, if >0‡ | 216 | 4.07 | 1.81, 6.33 | <0.001 |
| Number of times partner high/ drunk during sex, if >0 | 280 | 0.75 | −1.41, 2.92 | 0.495 |
| Psychosocial Constructs Associated With Sexual Risk Behavior | ||||
| Fear of consequences of condom negotiation | 653 | 0.73 | −0.10, 1.56 | 0.086 |
| Partner sexual communication self-efficacy | 653 | −0.52 | −1.11, 0.07 | 0.086 |
| Partner sexual communication frequency | 653 | −0.81 | −1.54, −0.07 | 0.032 |
| Perceived peer norms supporting risky sexual behavior† | 615 | 1.16 | 0.34, 1.98 | 0.006 |
| Refusal self-efficacy† | 653 | −1.24 | −2.09, −0.39 | 0.004 |
OR: odds ratio, CI: confidence interval, B: linear coefficient
p≤0.05
p≤0.001
Assessed only for participants ≥18 years of age at baseline
Table 4.
Adjusted associations between having a sex partner who was recently released from incarceration and STIs, HIV/STI risk factors and IPV
| Logistic Regression Models | ||||
|---|---|---|---|---|
| Outcome | n | AOR* | 95% CI | p-value |
| STIs | ||||
| Any STI† | 647 | 1.61 | 1.06, 2.45 | 0.026 |
| Chlamydia† | 647 | 1.80 | 1.14, 2.85 | 0.012 |
| Gonorrhea | 647 | 1.71 | 0.78, 3.76 | 0.178 |
| Trichomoniasis | 647 | 1.32 | 0.73, 2.39 | 0.364 |
| Sexual Risk Behavior | ||||
| Boyfriend ever have concurrent partners during relationship, if have a boyfriend | 560 | 1.50 | 0.98, 2.28 | 0.060 |
| Currently have a casual partner† | 653 | 1.66 | 1.11, 2.49 | 0.013 |
| Vaginal sex‡ | 653 | 5.48 | 2.11, 14.22 | <0.001 |
| Consistent condom use, if had vaginal sex† | 475 | 0.58 | 0.35, 0.94 | 0.029 |
| Anal sex‡ | 651 | 2.43 | 1.42, 4.19 | 0.001 |
| Oral sex† | 651 | 1.51 | 1.05, 2.16 | 0.026 |
| High/ drunk during sex† | 653 | 1.57 | 1.02, 2.44 | 0.042 |
| Partner high/ drunk during sex‡ | 653 | 2.27 | 1.57, 3.27 | <0.001 |
| Intimate Partner Violence § | ||||
| Emotionally abused by boyfriend† | 339 | 2.98 | 1.59, 5.60 | 0.001 |
| Physically abused by boyfriend† | 339 | 3.53 | 1.73, 7.21 | 0.001 |
| Sexually abused by boyfriend† | 339 | 4.10 | 1.39, 12.13 | 0.011 |
| Emotionally abused by casual partner | 339 | 2.78 | 0.91, 8.50 | 0.074 |
| Physically abused by casual partner | 339 | 1.60 | 0.35, 7.38 | 0.549 |
| Sexually abused by casual partner | 339 | 1.82 | 0.50, 6.61 | 0.361 |
| Linear Regression Models | ||||
| Outcome | n | B* | 95% CI | p-value |
| Sexual Risk Behavior | ||||
| Number of vaginal sex partners, if had vaginal sex† | 615 | 0.66 | 0.21, 1.10 | 0.004 |
| Number of times had vaginal sex, if had vaginal sex | 477 | −0.41 | −3.53, 2.71 | 0.798 |
| Percent condom use during vaginal sex, if had vaginal sex | 475 | −0.04 | −0.12, 0.05 | 0.426 |
| Number of anal sex partners, if had anal sex† | 72 | 0.28 | 0.05, 0.50 | 0.016 |
| Number of times had anal sex, if had anal sex | 72 | −0.48 | −1.10, 0.15 | 0.133 |
| Percent condom use during anal sex, if had anal sex | 72 | 0.05 | −0.17, 0.27 | 0.643 |
| Number of male oral sex partners, if had oral sex | 326 | 0.61 | −0.09, 1.30 | 0.086 |
| Number of times had oral sex, if had oral sex | 326 | 1.29 | −0.80, 3.39 | 0.226 |
| Percent condom use during oral sex, if had oral sex† | 325 | −0.11 | −0.19, −0.03 | 0.006 |
| Number of times high/ drunk during sex, if >0† | 215 | 3.22 | 0.88, 5.57 | 0.007 |
| Number of times partner high/ drunk during sex, if >0 | 280 | 0.06 | −2.10, 2.22 | 0.955 |
| Psychosocial Constructs Associated With Sexual Risk Behavior | ||||
| Fear of consequences of condom negotiation | 653 | 0.52 | −0.31, 1.35 | 0.219 |
| Partner sexual communication self-efficacy† | 653 | −0.56 | −1.09, −0.02 | 0.042 |
| Partner sexual communication frequency | 653 | −0.70 | −1.42, 0.02 | 0.058 |
| Perceived peer norms supporting risky sexual behavior | 606 | 0.60 | −0.17, 1.37 | 0.129 |
| Refusal self-efficacy† | 653 | −1.07 | −1.95, −0.19 | 0.017 |
AOR: adjusted odds ratio; CI: confidence interval; B: adjusted linear coefficient
All models adjusted for age, treatment assignment and corresponding baseline measure
p≤0.05
p≤0.001
Assessed only for participants ≥18 years of age at baseline
Discussion
Among African-American adolescent females in our study, having a male sex partner who was recently released from jail, prison or detention was associated with increased STI acquisition, increased sexual risk behavior, psychosocial constructs related to sexual risk behavior and abuse by a boyfriend. To our knowledge, this is the first study to examine the associations between having a recently released male sex partner and both sexual risk and IPV and the first study to explore these topics specifically among African-American adolescents.
Adolescents with a partner recently released from incarceration were more likely to acquire Chlamydia, which is a leading cause of infertility and facilitates HIV transmission.27 Adolescents may have been infected by their recently incarcerated partner or as a result of exposure to new social networks supporting risk-taking. Adolescents with a recently released partner reported increased sexual risk behavior and decreased refusal self-efficacy, a correlate of inconsistent condom use.35 For males and females, incarceration may lead to or be a proxy for involvement in networks with high HIV and STI prevalence and risk behaviors.3,11,13 HIV prevalence in prison populations is 6–10 times higher than in the general population.36 It has been estimated that 14% of all individuals with HIV in the United States were released from a correctional facility in 2006.37 Especially given high rates of sexual risk behavior following release, incarcerated individuals may serve as a bridge between higher and lower sexual risk groups.3
Nationally, IPV rates are especially high among African-American and younger women.38 Among African-American women 15–24 years, IPV is the primary reason for premature death from homicide and nonfatal injury.39 Outside of studies involving men incarcerated for domestic violence and small qualitative studies, we are unaware of any studies which have explored associations between IPV victimization and having a partner with an incarceration history. In our study, African-American adolescent females with a sex partner recently released from incarceration were 2–4 times as likely to experience IPV perpetrated by a boyfriend, although we were unable to determine if the recently incarcerated partner was the perpetrator. Dating violence is related to fear of condom negotiation and sexual communication with one’s partner.23 In our study, having a partner recently released from incarceration was significantly associated with lower partner sexual communication self-efficacy and marginally associated with lower partner sexual communication frequency. The experience of IPV associated with having a recently incarcerated partner could potentially impact sexual risk in future relationships, as fear of abuse may prevent individuals from negotiating condoms and engaging in HIV/STI risk reduction in future relationships.24
Strengths and Limitations
Our study is subject to a number of limitations. First, subjects were participating in an HIV/STI prevention intervention trial, and, thus, the findings may not be fully generalizable, although our study achieved high recruitment and retention rates.26 We might expect that our ability to detect associations with having a sexual partner recently released from incarceration would be reduced given that the intervention aimed to reduce STI incidence, however, we found a number of significant findings related to both outcome and potential mediating variables.
We had limited information about the recently incarcerated sexual partner. We were unable to determine whether the incarcerated partner was a boyfriend or casual or new partner. We did not have information about length of or reason for incarceration, type of correctional facility or the participant’s incarceration history. We are limited in our ability to make inferences about causality. Importantly, we were unable to determine if the recently incarcerated partner was the IPV perpetrator, nor if sexual risk behaviors were practiced with the incarcerated partner. We are unable to exclude the possibility that young African-American women who practiced riskier behaviors or experienced IPV might have been more likely to select recently incarcerated partners. We are also unable exclude the possibility that increased risk behavior and STI acquisition occurred during the partner’s incarceration. Additionally, although community incarceration and STI prevalence rates are correlated through a variety of hypothesized mechanisms,40 we were unable to control for neighborhood of residence or community-level factors.
In addition, IPV was assessed retrospectively using self-reported yes/no questions. Thus, we could not determine when specific episodes of abuse occurred or the frequency, severity or duration of abuse. A more thorough assessment based on an extensive survey or face-to face interview may be useful for more accurately assessing and characterizing abuse. Also, given our extreme definition of sexual violence, females not reporting sexual violence per our definition may have experienced other forms of sexual abuse. Lastly, we were able to assess associations between IPV and having a recently released partner only among participants at least 18 years of age; the degree to which these findings apply to younger participants is unknown.
Despite these limitations, our study has several unique strengths. Our study focuses on a highrisk population of African-American adolescent females in a setting with exceptionally high incarceration rates among Black men. In addition, we demonstrated over-time associations between having a recently incarcerated sexual partner and STI acquisition using biologic end points. We also presented associations with sexual risk behavior, psychosocial constructs related to risk and IPV, demonstrating how having a recently incarcerated partner may lead to increased risk both in the short- and long-term.
Implications
Many participants in our study had sex with a partner recently released from incarceration. Although STI and HIV rates are high among incarcerated populations, routine screening and treatment in correctional settings is far from universal. Our findings highlight the potential impact HIV/STI prevention and treatment efforts in correctional settings may have on the general community.
HIV/STI prevention programs should heighten African-American adolescent females’ awareness of potential risks associated with a recently released sex partner. Interventions should provide young women with skills and strategies to identify, establish and maintain healthy sexual relationships. Of particular importance is enhancing young women’s self-efficacy to negotiate safer sexual practices with their partners. Such intervention approaches should also seek to raise awareness regarding the prevalence of IPV in adolescent relationships and connect adolescents in abusive relationships with available services. Screening for IPV as part of sexual health services or via HIV/STI prevention interventions can also facilitate appropriate referrals. Ultimately, multi-faceted sexual health interventions provide a unique opportunity to empower young African-American women with the confidence and skills to establish and maintain healthy relationships, free of IPV, and practice safer sexual behaviors.
Acknowledgements
Supported by grants from the National Institutes of Mental Health (5R01MH070537) and Emory Center for AIDS Research (P30A1050409). Jennifer L. Brown was supported by K12GM000680 from the National Institute of General Medical Sciences. Jessica M. Sales was supported by K01MH085506 from the National Institute of Mental Health.
Footnotes
Publisher's Disclaimer: This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final citable form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
Conflicts of interest and financial disclosures: None reported
Registration: The study is registered at www.clinicaltrials.gov (NCT00633906).
Implications and contribution: Among African-American adolescent females, sex with a male recently released from incarceration is associated with sexual risk and intimate partner violence (IPV). Despite high incarceration rates among African-American men, this is the first study to investigate both sexual risk and IPV among young African-American females with a recently released partner.
Contributor Information
Andrea Swartzendruber, Department of Behavioral Sciences and Health Education, Rollins School of Public Health, 1518 Clifton Rd., Atlanta, GA 30322, 404-384-3718 (phone), 404-591-7939 (fax), alswart@emory.edu.
Jennifer L. Brown, Department of Behavioral Sciences and Health Education Rollins School of Public Health.
Jessica M. Sales, Department of Behavioral Sciences and Health Education Rollins School of Public Health.
Colleen C. Murray, Department of Behavioral Sciences and Health Education Rollins School of Public Health.
Ralph J. DiClemente, Department of Behavioral Sciences and Health Education Rollins School of Public Health.
References
- 1.Centers for Disease Control and Prevention. Sexually Transmitted Disease Surveillance 2009. Atlanta: U.S.: Department of Health and Human Services; 2010. [Google Scholar]
- 2.Thomas JC. From slavery to incarceration: Social forces affecting the epidemiology of sexually transmitted diseases in the rural south. Sex Transm Dis. 2006;33(7 Suppl):S6–S10. doi: 10.1097/01.olq.0000221025.17158.26. [DOI] [PubMed] [Google Scholar]
- 3.Adimora AA, Schoenbach VJ, Doherty IA. HIV and African Americans in the southern United States: Sexual networks and social context. Sex Transm Dis. 2006;33(7 Suppl):S39–S45. doi: 10.1097/01.olq.0000228298.07826.68. [DOI] [PubMed] [Google Scholar]
- 4.West HC. Prison inmates at midyear 2009—statistical tables [NCJ 230122] Washington, DC: Bureau of Justice Statistics, Office of Justice Programs, US Department of Justice; 2010. [Google Scholar]
- 5.Beck AJ, Harrison PM. Prison and jail inmates at midyear 2005 [NCJ 213133] Washington, DC: Bureau of Justice Statistics, Office of Justice Programs, US Department of Justice; 2006. [Google Scholar]
- 6.Hattery A, Smith E. Incarceration: A tool for racial segregation and labor exploitation. Race, Gender and Class. 2008;15(2):79–97. [Google Scholar]
- 7.Bonczar TP, Beck AJ. [NCJ-160092]. Lifetime likelihood of going to state or federal prison. Washington, DC: U.S. Department of Justice; 1997. [Google Scholar]
- 8.Barry PM, Kent CK, Klausner JD. Risk factors for gonorrhea among heterosexuals--San Francisco, 2006. Sex Transm Dis. 2009;36(2 Suppl):S62–S66. doi: 10.1097/OLQ.0b013e31815faab8. [DOI] [PubMed] [Google Scholar]
- 9.Khan MR, Epperson MW, Mateu-Gelabert P, Bolyard M, Sandoval M, Friedman SR. Incarceration, sex with an STI- or HIV-infected partner, and infection with an STI or HIV in Bushwick, Brooklyn, NY: A social network perspective. Am J Public Health. 2011 doi: 10.2105/AJPH.2009.184721. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 10.Khan MR, Doherty IA, Schoenbach VJ, Taylor EM, Epperson MW, Adimora AA. Incarceration and high-risk sex partnerships among men in the United States. J Urban Health. 2009;86(4):584–601. doi: 10.1007/s11524-009-9348-5. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 11.Freudenberg N. Jails, prisons, and the health of urban populations: A review of the impact of the correctional system on community health. J Urban Health. 2001;78(2):214–235. doi: 10.1093/jurban/78.2.214. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 12.MacGowan RJ, Margolis A, Gaiter J, et al. Predictors of risky sex of young men after release from prison. Int J STD AIDS. 2003;14(8):519–523. doi: 10.1258/095646203767869110. [DOI] [PubMed] [Google Scholar]
- 13.Adimora AA, Schoenbach VJ. Social context, sexual networks, and racial disparities in rates of sexually transmitted infections. J Infect Dis. 2005;191(Suppl 1):S115–S122. doi: 10.1086/425280. [DOI] [PubMed] [Google Scholar]
- 14.Centers for Disease Control and Prevention. [Accessed March 30, 2011];Intimate partner violence prevention, risk and protective factors. Available at: http://www.cdc.gov/ncipc/dvp/ipv/ipv-risk_protective.htm.
- 15.Smith AE. African American men and intimate partner violence. J Afr Am St. 2008;12:156–179. [Google Scholar]
- 16.Pettit B, Western B. Mass imprisonment and the life course: Race and class inequality in U.S. incarceration. Am Sociol Rev. 2004;69(2):151–169. [Google Scholar]
- 17.World Health Organization. [Accessed October 26, 2011];Intimate partner and sexual violence against women. Available at: http://www.who.int/mediacentre/factsheets/fs239/en/
- 18.Saltzman LE, Fanslow JL, McMahon PM, Shelley GA. Intimate Partner Violence Surveillance: Uniform definitions and recommended data elements, Version 1.0. Atlanta (GA): National Center for Injury Prevention and Control, Centers for Disease Control and Prevention; 1999. [Google Scholar]
- 19.Centers for Disease Control and Prevention. [Accessed October 26, 2011];Teen dating violence. Teen dating violence. Available at: http://www.cdc.gov/ViolencePrevention/intimatepartnerviolence/teen_dating_violence.html.
- 20.Silverman JG, Raj A, Mucci LA, Hathaway JE. Dating violence against adolescent girls and associated substance use, unhealthy weight control, sexual risk behavior, pregnancy, and suicidality. JAMA. 2001;286(5):572–579. doi: 10.1001/jama.286.5.572. [DOI] [PubMed] [Google Scholar]
- 21.Wingood GM, DiClemente RJ. Child sexual abuse, HIV sexual risk, and gender relations of African-American women. Am J Prev Med. 1997;13(5):380–384. [PubMed] [Google Scholar]
- 22.Wyatt GE. The relationship between child sexual abuse and adolescent sexual functioning in Afro-American and white American women. Ann N Y Acad Sci. 1988;528:111–122. doi: 10.1111/j.1749-6632.1988.tb50854.x. [DOI] [PubMed] [Google Scholar]
- 23.Wingood GM, DiClemente RJ, McCree DH, Harrington K, Davies SL. Dating violence and the sexual health of black adolescent females. Pediatrics. 2001;107(5):E72. doi: 10.1542/peds.107.5.e72. [DOI] [PubMed] [Google Scholar]
- 24.Wingood GM, DiClemente RJ. The effects of an abusive primary partner on the condom use and sexual negotiation practices of African-American women. Am J Public Health. 1997;87(6):1016–1018. doi: 10.2105/ajph.87.6.1016. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 25.Sales JM, Salazar LF, Wingood GM, DiClemente RJ, Rose E, Crosby RA. The mediating role of partner communication skills on HIV/STD-associated risk behaviors in young African American females with a history of sexual violence. Arch Pediatr Adolesc Med. 2008;162(5):432–438. doi: 10.1001/archpedi.162.5.432. [DOI] [PubMed] [Google Scholar]
- 26.DiClemente RJ, Wingood GM, Rose ES, et al. Efficacy of sexually transmitted disease/human immunodeficiency virus sexual risk-reduction intervention for African American adolescent females seeking sexual health services: A randomized controlled trial. Arch Pediatr Adolesc Med. 2009;163(12):1112–1121. doi: 10.1001/archpediatrics.2009.205. [DOI] [PubMed] [Google Scholar]
- 27.Smith K, Harrington K, Wingood G, Oh MK, Hook EW, 3rd, DiClemente RJ. Self-obtained vaginal swabs for diagnosis of treatable sexually transmitted diseases in adolescent girls. Arch Pediatr Adolesc Med. 2001;155(6):676–679. doi: 10.1001/archpedi.155.6.676. [DOI] [PubMed] [Google Scholar]
- 28.Carroll KC, Aldeen WE, Morrison M, Anderson R, Lee D, Mottice S. Evaluation of the Abbott LCx ligase chain reaction assay for detection of Chlamydia trachomatis and Neisseria gonorrhoeae in urine and genital swab specimens from a sexually transmitted disease clinic population. J Clin Microbiol. 1998;36(6):1630–1633. doi: 10.1128/jcm.36.6.1630-1633.1998. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 29.Smith KR, Ching S, Lee H, et al. Evaluation of ligase chain reaction for use with urine for identification of Neisseria gonorrhoeae in females attending a sexually transmitted disease clinic. J Clin Microbiol. 1995;33(2):455–457. doi: 10.1128/jcm.33.2.455-457.1995. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 30.Lee HH, Chernesky MA, Schachter J, et al. Diagnosis of Chlamydia trachomatis genitourinary infection in women by ligase chain reaction assay of urine. Lancet. 1995;345(8944):213–216. doi: 10.1016/s0140-6736(95)90221-x. [DOI] [PubMed] [Google Scholar]
- 31.Van Der Pol B, Ferrero DV, Buck-Barrington L, et al. Multicenter evaluation of the BDProbeTec ET system for detection of Chlamydia trachomatis and Neisseria gonorrhoeae in urine specimens, female endocervical swabs, and male urethral swabs. J Clin Microbiol. 2001;39(3):1008–1016. doi: 10.1128/JCM.39.3.1008-1016.2001. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 32.Caliendo AM, Jordan JA, Green AM, Ingersoll J, Diclemente RJ, Wingood GM. Real-time PCR improves detection of Trichomonas vaginalis infection compared with culture using selfcollected vaginal swabs. Infect Dis Obstet Gynecol. 2005;13(3):145–150. doi: 10.1080/10647440500068248. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 33.Wingood GM, DiClemente RJ. Partner influences and gender-related factors associated with noncondom use among young adult African American women. Am J Community Psychol. 1998;26(1):29–51. doi: 10.1023/a:1021830023545. [DOI] [PubMed] [Google Scholar]
- 34.Zimmerman RS, Sprecher S, Langer LM, Holloway CD. Adolescents' perceived ability to say "no" to unwanted sex. J Adolesc Res. 1995;10(3):383–399. doi: 10.1177/0743554895103005. [DOI] [PubMed] [Google Scholar]
- 35.DiClemente RJ, Lodico M, Grinstead OA, et al. African-American adolescents residing in high-risk urban environments do use condoms: Correlates and predictors of condom use among adolescents in public housing developments. Pediatrics. 1996;98(2 Pt 1):269–278. [PubMed] [Google Scholar]
- 36.Niveau G. Prevention of infectious disease transmission in correctional settings: A review. Public Health. 2006;120(1):33–41. doi: 10.1016/j.puhe.2005.03.017. [DOI] [PubMed] [Google Scholar]
- 37.Spaulding AC, Seals RM, Page MJ, Brzozowski AK, Rhodes W, Hammett TM. HIV/AIDS among inmates of and releasees from US correctional facilities 2006: Declining share of epidemic but persistent public health opportunity. PLoS One. 2009;4(11):e7558. doi: 10.1371/journal.pone.0007558. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 38.Campbell DW, Sharps PW, Gary FA, Campbell JC, Lopez LM. Intimate partner violence in African American women. Online J Issues Nurs. 2002;7(1):5. [PubMed] [Google Scholar]
- 39.Sharps PW, Campbell JC. The contribution of intimate partner violence to health disparities for women of color. Family Violence Prevention and Health Practice. 2006 [Google Scholar]
- 40.Thomas JC, Sampson LA. High rates of incarceration as a social force associated with community rates of sexually transmitted infection. J Infect Dis. 2005;191(Suppl 1):S55–S60. doi: 10.1086/425278. [DOI] [PubMed] [Google Scholar]