The Interaction between Pubertal Timing and Childhood Maltreatment on the Risk of Human Papillomavirus Infection among Adolescent Girls and Young Women

Abstract

Purpose:

The goal of this study was to evaluate the effect of pubertal timing, and its interaction with prior childhood maltreatment, on the risk of cervical human papillomavirus (HPV) among sexually active adolescent minority female adolescents and young adults.

Methods:

This cross-sectional study includes 842 adolescent girls and young women (aged 12 to 20 years; predominately Black and Hispanic) enrolled in an HPV vaccine surveillance study at a large adolescent health clinic in New York City between 2007 and 2016. Pubertal timing was assessed by self-reported age at menarche at baseline, with “early” and “late” defined as one standard deviation below (<11 years) or above (>13 years) the mean. Childhood exposure to abuse (sexual, physical and emotional) and neglect (physical and emotional) was assessed using the Childhood Trauma Questionnaire. Over 40 types of HPV infection were detected using the polymerase chain reaction in cervical Pap specimens.

Results:

Results from multivariable logistic regression showed that early and late pubertal timing were marginally associated with a higher risk of HPV infection, adjusting for demographic and health covariates. Childhood maltreatment moderated the association between early pubertal timing and HPV infection: early pubertal timing was associated with a higher risk for HPV infection among maltreated girls (OR=3.32, 95%CI:1.61–6.85), but not among non-maltreated girls (OR=0.96, 95%CI:0.61–1.50; p-interaction<0.01).

Conclusions:

Variation in the timing of puberty and history of childhood maltreatment may have implications for adolescent sexual and reproductive health. Findings suggest that clinicians need to assess the biological and psychosocial risks in caring for youth.

Introduction

Cervical human papillomavirus (HPV) is the most common sexually transmitted infection (STI) in women and a key risk factor for cervical cancer.^2,3 As girls become sexually active during adolescence and young adulthood, they are at an increased risk for HPV infection and its long-term health consequences.³ Recent estimates indicate that youth aged 15 to 24 years account for nearly half of the 14 million new HPV cases reported in the United States (U.S.) each year.^2,4 These risks are disproportionately borne by Black and Hispanic female populations, who have the highest rates of cervical cancer in adulthood.⁵

Early pubertal timing is associated with increased sexual risk behaviors such as early sexual debut and multiple sexual partners.^6–8 According to the maturational disparity hypothesis, girls who mature at a younger age are more likely to engage in risky sexual behaviors due to the mismatch between their advanced physical appearance and reproductive capacity, and more slowly developing cognitive and psychosocial capacities.⁹ Early maturing girls not only develop sexual desires before same-aged girls, but also are perceived as sexually ready by male peers.^10–11 As a result, they are exposed to greater opportunities for sexual encounters and relationships, yet still lack knowledge and skills to successfully manage them. Another theory from the pubertal timing literature, the off-time hypothesis, suggests that girls who mature either early or late are at greater risk for adjustment difficulties due to deviance from the normative physical and social experiences.¹² Despite growing evidence that early pubertal timing increases risky sexual behaviors, very little is known about the direct association between early (or late) puberty and STIs,^13,14 and no studies have focused on urban minority girls who may have various life stressors that negatively impact their sexual and reproductive health.

Childhood maltreatment is another risk factor for sexual risk behaviors and STIs among urban minority girls.¹⁵ Childhood abuse and neglect may impair girls’ self-efficacy and decision-making capacity when managing intimate and sexual relationships, resulting in an increased risk of unwanted sexual advances, unsafe sex, and STIs.^16–18 Maltreated youth are also more likely to experience violence and crime, which regularizes and incites norm-breaking and problem behaviors.¹⁷ Childhood maltreatment also amplifies the consequences associated with early maturation.^19,20 For example, physical and emotional abuse and neglect may lead to more unsupervised time for early maturing girls to associate with deviant peers.^17,19 Further, childhood maltreatment may sensitize girls to their physical and social changes during a vital transition period to sexual maturity, potentially heightening the association between early puberty and poor sexual health outcomes.

Hispanic and Black girls begin puberty almost one year earlier than White and Asian girls in the U.S.²¹ and are much more likely to experience childhood maltreatment.²² However, few studies have investigated the effects of pubertal timing and childhood maltreatment together on sexual health outcomes among girls of color. The current study examines the effect of pubertal timing, and its interaction with prior childhood maltreatment, on the risk of HPV infection, in a sample of racial and ethnic minority girls. We hypothesized that early or late pubertal timing would be associated with higher risk of HPV infection than average pubertal timing, and that girls with prior childhood maltreatment would have higher risk of HPV infection than girls without. We also hypothesized that childhood maltreatment would exacerbate the risk of HPV infection in girls who mature early.

Methods

Data

Study participants included sexually active adolescent girls and young women enrolled in an HPV4 vaccine surveillance study in New York City. Female participants aged 12 to 20 who were sexually active and were planning to receive or had already received the HPV vaccine (Gardasil) vaccine were recruited between October 2007 and April 2016 and followed every six months until age 25. At each visit, participants completed a self-administered questionnaire on demographic characteristics, sexual behaviors, and psychosocial functioning, and received a comprehensive gynecological examination that included sexual, reproductive, and psychosocial history, immunization update, and blood and urine testing. To assess the burden of child abuse and neglect, the Childhood Trauma Questionnaire (CTQ) was introduced in 2013 and administered at enrollment for new participants and at first assessment for returning subjects.

Cross-sectional data of 882 participants at baseline were used in this study. We excluded participants with missing data on HPV infection (n = 20) and age at menarche (n = 4). We further excluded girls with signs of precocious puberty (menarche before 8 years old, n = 5) or delayed puberty (menarche on or after 16 years old, n = 11), due to potential medical conditions that affect their growth and health,²³ resulting in a final analytic sample of 842 participants. The study was approved by the Institutional Review Board at //REMOVED FOR PEER REVIEW//.

Measures

HPV infection.

Detection of over 40 HPV types was performed using the polymerase chain reaction (PCR) detection in cervical Pap specimens collected at baseline; positive test results were grouped as any type and high-risk types associated with cervical cancer (HPV16/18/31/33/35/39/45/51/52/56/58/59).²⁴ Details of specimen collection and HPV DNA extraction procedures in the larger study are described elsewhere.²⁵

Pubertal timing.

In the baseline questionnaire, participants reported in whole years how old they were when they had their first menstrual period. According to the relative distribution of age at menarche within the sample (mean = 11.7, standard deviation [SD] = 1.4 years), we defined “early” and “late” pubertal timing as one SD below (10.3 years, or <11 years) or above (13.1 years, or >13 years) the sample mean. The proportion of early, average, and late menarche was similar to that reported in previous research.^26,27

Child maltreatment.

Childhood maltreatment was assessed using the Childhood Trauma Questionnaire (CTQ), a 28-item retrospective inventory of childhood exposure to abuse (sexual, physical and emotional) and neglect (physical and emotional).^28,29 Studies in both clinical and community samples have supported the reliability and validity of maltreatment history obtained using the CTQ.^28,29 The scale includes five items for each type of abuse and neglect and a three-item minimization/denial scale to detect false-negative reports. Participants responded to all items using a 5-point scale; we summed responses to calculate subscale scores for each type of abuse or neglect. Using the CTQ clinical screening cut-off scores for moderate to extreme,²⁸ we created a dichotomized score to indicate if a participant had experienced any type of abuse or neglect.

Covariates.

We considered a range of covariates drawn from the baseline questionnaire in the analysis. Demographic covariates were age, race and ethnicity (grouped by mutually exclusive categories: non-Hispanic Black, Hispanic Black, and non-Hispanic Other, with non-Black Hispanic as the reference group), the highest education completed (10^th grade or lower, high school graduate, and some college, with 11–12^th grade as the reference group), whether parents were separated or deceased, whether parents received welfare checks, and household food insecurity (0 = enough to eat, 1 = sometimes or often not enough to eat). Correlates of HPV infection, such as HPV vaccine completion status (0 dose, 1–2 doses, with all 3 doses as the reference group), early sexual debut, and multiple sexual partners were also included. Early sexual debut was defined as age of sexual onset before 13 years, consistent with the Centers for Disease Control and Prevention’s Youth Risk Behavior Surveillance System (YRBSS)³⁰ as well as prior studies among adolescents and young adults.^31,32 Multiple sexual partners was assessed by the number of vaginal sex partners in the past 6 months (response options were 0, 1, 2, 3–4, 5–9, and 10 or more partners); response categories were recoded as 1 = having two or more sexual partners and 0 = not. We included the CTQ minimization/denial indicator to address underreporting of maltreatment. Finally, we controlled for body mass index (BMI) calculated from weight and height reported in a clinical interview because of its association with early puberty.³³

Statistical analysis

We fit two multivariable logistic regression models on HPV any type and high-risk types to test for the main effects of early and late menarche and childhood maltreatment on the odds of HPV infection (Model 1). We then included two 2-way interaction terms between early and late menarche and childhood maltreatment to test for effect modification (Model 2). We adjusted for covariates in all models.

We conducted all analyses in Stata (version 15.0). All continuous variables were standardized (mean = 0; SD = 1) before analysis to facilitate interpretation. To address missing data on covariates (ranging from 1% on race/ethnicity to 6% on BMI), we performed multiple imputation using chained equations.³⁴ Independent variables (age at menarche, childhood maltreatment, and their interaction terms) and outcome variables had complete cases, and were used as predictors in the imputation process. Ten complete datasets were imputed to help ensure stable parameters and standard error estimates. All analyses were conducted using the mi estimate command in Stata.

Results

The mean age of the study population was 18.1 years (±1.4 SD), and most girls were from racial and ethnic minority backgrounds (36.1% non-Hispanic Black, 13.8% Hispanic Black, and 44.9% non-Black Hispanic). The majority of the participants were enrolled in middle school (23.8%) or high school (42.2%). The age of sexual debut ranged from 10 to 19 years (mean = 15.0, SD = 1.5), with 15.9% of the girls reporting sexual onset before 13 years. About 40% of participants reported multiple sexual partners in the past 6 months (23.3% reported 2 partners, 13.3% reported 3 to 4 partners, and 3.4% reported 5–9 or 10 or more partners), while others either reported one partner (55.8%) or no partner (4.1%). The mean age at menarche was 11.7 years (±1.4 SD). A total of 176 girls (20.9%) had menarche before 11 years (i.e., early), and 88 (10.5%) had menarche after 13 years (i.e., late).

Of the participants, 32.5% reported moderate to extreme abuse or neglect; the rates were not different across participants with early, average, or late menarche (Table 1). One or more HPV types were detected in cervical specimens of 48.2% of participants (n = 406), with 35.3% (n = 257) testing positive for high-risk HPV types. The rates of one or more HPV types among adolescents with early, average, and late age at menarche were 53.4%, 45.7%, and 54.5%, respectively.

Table 1.

Descriptive Statistics of the Sample Stratified by Age at Menarche

Characteristics	Early menarche: <11 yrs	Average menarche: 11–13 yrs	Late menarche: >13 yrs	Total	p-value
	(n = 176)	(n = 578)	(n = 88)	(N = 842)
Childhood maltreatment	30.1%	33.2%	33.0%	32.5%	p = .741
Race and ethnicity					p = .693
NH Black	33.0%	36.9%	37.5%	36.1%
Hispanic Black	17.0%	13.1%	11.4%	13.8%
NB Hispanic	45.5%	44.5%	46.6%	44.9%
NH Other	3.4%	5.5%	4.5%	5.0%
Education					p = .652
<=10th grade	26.1%	23.9%	18.2%	23.8%
11–12th grade	39.2%	41.9%	50.0%	42.2%
High-school graduate/GED	17.0%	15.6%	15.9%	15.9%
Some college	17.0%	18.7%	14.8%	17.9%
Food insecurity	6.3%	6.8%	9.1%	6.9%	p = .678
Parent received welfare checks	8.6%	8.8%	14.0%	9.3%	p = .377
Parent living status
Separated	72.1%	74.4%	67.4%	73.2%	p = .796
Parent deceased	6.4%	5.4%	3.5%	5.4%
Age, mean (SD)	17.96 (1.52)	18.16 (1.34)	18.34 (1.30)	18.14 (1.38)	p = .084
Body mass index	27.61 (7.34)	25.44 (5.86)	24.92 (6.36)	25.85 (6.31)	p < .001
HPV vaccine completion status					p = .787
0 dose	10.2%	12.6%	12.5%	12.1%
1–2 doses	20.5%	23.0%	23.9%	22.6%
3 doses	69.3%	64.4%	63.6%	65.3%
Early sexual debut	27.6%	14.6%	1.1%	15.9%	p < .001
Multiple sexual partners	42.3%	40.0%	36.4%	40.1%	p = .650
HPV any type	53.4%	45.7%	54.5%	48.2%	p = .090
HPV high-risk types	35.8%	33.2%	47.7%	35.3%	p = .182

Note. Percentages within each group may not add to 100% due to missing data. BMI = body mass index, NH = non-Hispanic, NB = non-Black. Group differences were tested using chi-square test of independence for categorical variables or ANOVA for continuous variables. p-values were based on complete case analysis.

Results from multivariable logistic regression showed early menarche was marginally associated with a higher odds of detection for any HPV type (OR=1.41, 95%CI: 0.98–2.01) and high-risk types (OR=1.40, 95%CI: 0.95–2.05), compared to average menarche, independent of family demographics, age at first intercourse, and number of partners in the past 6 months. Childhood maltreatment was significantly associated with risks of HPV infection for high-risk types (OR=1.44, 95% CI: 1.03–2.01). Being Non-Hispanic Black vs. Non-Black Hispanic, having a parent who received welfare checks, and having multiple sexual partners were associated with higher risks for HPV infection for any type and high-risk types. Late (vs. average) menarche was marginally associated with a higher risk for any HPV type (OR=1.58, 95%CI: 0.98–2.54), but was not significantly associated with high-risk HPV types (OR=1.47, 95%CI: 0.88–2.41)(Table 2, Model 1).

Table 2.

Logistic Regression Analyses Predicting HPV Infection from Age at Menarche and Childhood Maltreatment (N = 842)

	HPV any type		HPV high-risk types
	Model 1	Model 2	Model 1	Model 2
	OR (95% CI)	OR (95% CI)	OR (95% CI)	OR (95% CI)
Main effects
Age at menarche (ref. = average)
Early	1.41 (0.98, 2.01)	1.04 (0.67, 1.58)	1.40 (0.95, 2.05)	1.01 (0.62, 1.62)
Late	1.58 (0.98, 2.54)	1.48 (0.83, 2.64)	1.47 (0.88, 2.41)	1.63 (0.89, 2.99)
Childhood maltreatment	1.18 (0.86, 1.61)	0.95 (0.65, 1.37)	1.44 (1.03, 2.01)	1.22 (0.81, 1.81)
Interaction effects
Early x childhood maltreatment		2.88 (1.29, 6.43)		2.74 (1.22, 6.12)
Late x childhood maltreatment		1.19 (0.43, 3.22)		0.69 (0.23, 2.00)
Covariates
Race/ethnicity (ref. = NB Hispanic)
NH Black	1.69 (1.22, 2.32)	1.67 (1.21, 2.30)	1.82 (1.29, 2.56)	1.82 (1.29, 2.56)
Hispanic Black	1.24 (0.80, 1.92)	1.25 (0.80, 1.94)	1.54 (0.96, 2.46)	1.54 (0.96, 2.47)
NH Other	0.66 (0.32, 1.33)	0.68 (0.33, 1.37)	0.65 (0.28, 1.51)	0.67 (0.29, 1.55)
Food insecurity	0.60 (0.33, 1.07)	0.61 (0.34, 1.09)	0.62 (0.32, 1.18)	0.63 (0.33, 1.21)
Parent received public assistance	1.75 (1.05, 2.90)	1.78 (1.06, 2.95)	2.29 (1.23, 4.27)	2.31 (1.23, 4.32)
Parent living status
Separated	1.15 (0.80, 1.64)	1.15 (0.79, 1.65)	1.15 (0.77, 1.71)	1.13 (0.75, 1.68)
Parent deceased	1.14 (0.57, 2.28)	1.15 (0.57, 2.31)	1.31 (0.63, 2.70)	1.33 (0.64, 2.75)
Age	1.04 (0.89, 1.20)	1.04 (0.89, 1.20)	1.01 (0.86, 1.18)	1.01 (0.85, 1.18)
Body mass index	0.99 (0.85, 1.15)	0.98 (0.84, 1.14)	0.86 (0.73, 1.01)	0.86 (0.72, 1.01)
HPV vaccine completion status (ref. = 3 doses)
0 dose	1.37 (0.87, 2.14)	1.35 (0.86, 2.12)	1.55 (0.97, 2.45)	1.55 (0.97, 2.46)
1–2 doses	1.18 (0.82, 1.66)	1.18 (0.83, 1.68)	0.94 (0.64, 1.38)	0.95 (0.64, 1.39)
Early sexual debut	1.00 (0.66, 1.50)	0.95 (0.63, 1.44)	1.08 (0.69, 1.66)	1.02 (0.65, 1.59)
Multiple sexual partners	2.25 (1.68, 3.01)	2.26 (1.68, 3.03)	1.80 (1.31, 2.45)	1.78 (1.29, 2.43)
Completed maltreatment at enrollment	0.88 (0.65, 1.18)	0.87 (0.64, 1.16)	0.93 (0.67, 1.28)	0.91 (0.66, 1.26)
CTQ minimization/denial	1.00 (0.73, 1.35)	1.02 (0.74, 1.37)	1.23 (0.88, 1.71)	1.25 (0.89, 1.73)

Note. OR = odds ratio; CI = confidence interval; NB = non-Black; NH = non-Hispanic; CTQ = Childhood Maltreatment Questionnaire

The effects of early menarche on HPV infection (any type and high-risk types) were significantly moderated by childhood maltreatment (p-interaction < .01 and <.05, respectively; Table 2, Model 2). Figure 1 shows the effects of early menarche on HPV any type and HPV high-risk types, conditional on childhood maltreatment. Specifically, early menarche, compared to average menarche, was significantly associated with higher risks of HPV infection for any type and high-risk types among girls who were exposed to childhood maltreatment (OR=3.28, 95%CI:1.60–6.75 and OR=2.89, 95%CI:1.43–5.85, respectively); however, for non-maltreated girls, early menarche was not associated with HPV infection (OR=1.03, 95%CI:0.66–1.59 and OR=0.97, 95%CI:0.60–1.58, respectively).

Figure 1.

Interaction between early menarche and childhood maltreatment predicts risk of HPV infection. Y-axis shows the predicted probability of HPV infection.

To test the robustness of our findings, we fit the same set of models including participants on the full spectrum of age at menarche (n = 858) to test whether including girls with precocious or delayed menarche may impact the association between pubertal timing and HPV outcomes. Results showed similar associations between early and late menarche and HPV infection, and the interaction effect between early menarche and childhood maltreatment on HPV infection remained significant. In addition, we tested a parallel set of regression models removing behavioral correlates of HPV infection (i.e., HPV vaccine completion status, multiple sexual partners, early sexual debut). Results showed similar effects of pubertal timing, and the interaction effect between early menarche and childhood maltreatment on HPV infection remained significant.

Discussion

This is the first known study to examine the effect of early puberty on an objectively measured STI, while examining childhood maltreatment as a moderator. Although Hispanic and Black girls typically begin puberty earlier than their White peers and they are at a higher risk for sexually transmitted infections, few studies have examined the sexual and reproductive health implications of pubertal timing among youth of color. We found that both early and late pubertal timing (compared to average timing) were marginally associated with cervical HPV infection in a sample of predominately Hispanic and Black girls. Importantly, childhood maltreatment moderated the association between early pubertal timing and HPV infection such that early pubertal timing was associated with a higher risk for HPV infection among maltreated girls, but not among non-maltreated girls. These effects were found even after controlling for a comprehensive set of familial and health covariates commonly associated with HPV infection.

Our finding that early maturing girls were at a higher risk for acquiring HPV than girls with average pubertal timing is consistent with past research linking early puberty to early dating, early onset of sexual intercourse, risky sexual behavior, multiple sexual partners, sexual harassment, dating abuse, and teen pregnancy among girls.^5–7,9–11 The higher risk in early maturing girls is hypothesized to stem from the rapid brain maturation in regions involved in reward-seeking, precipitated by pubertal hormones, while their self-control and emotional systems are developing more slowly.^35,36 Additionally, due to the dramatic overt physical changes of puberty, early maturing girls often elicit perceptions of maturity from older and opposite-sex peers and are treated differently based on their adult-like physical appearance.^{10, 11} This is particularly true for Hispanic and Black girls, who grow curvier body shapes during puberty than White and Asian girls.

One important finding from this study is that the negative effect of early pubertal timing on HPV infection was further amplified in girls who experienced childhood maltreatment. These results are consistent with the contextual amplification hypothesis, which posits that one’s social context can “either facilitate or impede early puberty effects through the opportunities, norms, expectations, and implicit reward and punishment structures that the contexts provide” (p. 329).³⁷ Past studies have found that early maturing girls who had parents characterized by harsh parenting and low nurturance experienced more conflict at home and had more unsupervised time to associate with deviant peers.^19,20 According to Briere’s self-trauma model, childhood maltreatment may lead to symptoms of posttraumatic stress disorder, maladaptive coping strategies, and negative appraisals of oneself and others, as well as a lower threshold for negative reactions to physical and social changes occurring during puberty and adolescence.¹⁵ This pattern of stress sensitization may be most salient for girls who make an earlier transition to puberty, and often navigate through romantic and sexual encounters and relationships at a younger age.^5,10 The interaction effect between early puberty and childhood maltreatment on HPV risk was found after accounting for key sexual risk behaviors (i.e., early sexual debut and multiple sexual partners), pointing to possibilities of more complex biological, psychosocial, contextual, and behavioral pathways (e.g., neuroendocrine systems, stress, social relationships, and negative coping strategies such as inconsistent condom use) that link early pubertal timing to HPV infection among youth with a history of maltreatment. It is also important to note that prior literature suggests that childhood abuse and neglect could trigger the increase of estrogen and precipitate earlier timing of puberty in girls.³⁸ However, in this study, we did not find a direct association between childhood maltreatment and age at menarche. Continued research is needed to clarify causal relationships and explore mediating mechanisms between childhood maltreatment, pubertal timing, and youth health outcomes.

Late maturing girls were also at a marginally higher risk for HPV infection than girls with average pubertal timing, supporting the off-time hypothesis that being out of sync in pubertal maturation, in either direction, places youth at greater risk for negative outcomes.¹² Late maturing girls tend to begin sexual intercourse at a later age,^7,8 which may protect them against STIs initially; however, they may also be more prone to emotional problems such as depressive symptoms, body dissatisfaction, and low self-esteem,^11,12 which affect their decision-making in the contexts of sexual encounters and relationships and increase their likelihood of engaging in unwanted and unsafe sexual behaviors.¹⁸ More research is needed to replicate findings from this study in samples of different age and racial/ethnic groups, and expand the sparse research of late pubertal timing effects to explore psychological, social, and physical experiences of late maturing youth.

The current study highlighted the importance of early pubertal timing and childhood maltreatment in HPV infection among a key understudied population: low-income, urban Black and Hispanic girls. Our findings highlighted the need for high-quality puberty education that reaches girls before their pubertal onset. Currently, most puberty education occurs in middle and high school. Only 21% of elementary schools teach puberty-related content, and they typically occur in 5^th grade, with sometimes inaccurate and negative contents.⁴ Considering that the age of breast development and menarche has declined steadily in the U.S. during the last 25 years, with the average age of experiencing signs of secondary sex characteristics being age 9 for White and Asian girls or 8 for Black and Hispanic girls, current levels of puberty instruction may leave many girls uninformed and ill-prepared for pubertal transition, especially for those who mature earlier than the average.³⁹ It also imperative that parents, including those with challenging life circumstances, are educated on how best to inform and support girls.

Clinicians and public health practitioners need to capitalize on pubertal onset as a window of opportunity to promote positive development, which has implications for adolescent sexual and reproductive health. Clinicians need to assess the biological and psychosocial risks in caring for youth. This also requires that primary care settings provide open, supportive relationships where youth feel comfortable talking about pubertal changes and life experiences. Girls who begin pubertal development at a young age and have high psychosocial risk (e.g., childhood maltreatment, stressful home environment) may benefit from health resources such as sexual and reproductive health education and HPV vaccination beginning earlier in adolescence.⁴⁰ Although HPV vaccination is currently recommended at 11 or 12 years of age in all girls, and at 9 years of age in youth with any history of sexual abuse, only 35% of girls aged 13 to 17 years have received three doses, with lower uptake in those who are Black and Hispanic, low-income, and received less HPV education.^41,42 Continued efforts are needed to improve HPV knowledge and HPV vaccination uptake, particularly among vulnerable populations.

Limitations

Although menarche is one of the most commonly used indicators of pubertal timing, it typically occurs at Tanner Stage 4 or 5 and therefore our single, self-reported measure does not capture the complexity of pubertal maturation.⁴³ By the time of enrollment, the vast majority of the participants were already in their late adolescence, so it was not possible to assess physical or hormonal processes that occur earlier in puberty among the participants. Second, the questionnaire on childhood maltreatment was added in the middle of the study, and as a result, 62.4% of the study participants completed the survey during a follow-up visit, and 37.6% completed the survey at enrollment. To account for the potential bias related to participants’ recall of maltreatment, we controlled for whether participants completed the maltreatment questionnaire at enrollment in all analysis. Additionally, we did not know when abuse and neglect occurred, the severity of the event(s), and in the case of sexual abuse, if it led directly to HPV infection. Future prospective studies with detailed maltreatment assessment may help to pinpoint the epidemiology of HPV infection and how childhood maltreatment affects the long-term sexual health sequelae in girls with different onset of pubertal timing. Finally, all participants were sexually active upon enrollment and thus more likely to have sexual risk behaviors than other adolescent girls and young women populations, which may limit the generalizability of our findings. Furthermore, participants were predominantly urban Hispanic and Black girls and young women in the U.S. (who typically begin puberty earlier than their peers); thus, results may not apply to adolescent girls and young women from White or Asian groups. However, given that racial/ethnic minority girls and young women are understudied in the puberty literature ⁴⁴ and are at significantly higher risks for sexual risk behavior and STIs, understanding risk factors of HPV infection within this particular group has substantial public health implications.

Conclusion

This study suggests that variation in the timing of puberty and history of childhood maltreatment may have implications for adolescent sexual and reproductive health. Findings suggest that clinicians need to assess the biological and psychosocial risks in caring for youth.

Abbreviations:

HPV

human papillomavirus

BMI

body mass index

CTQ

Childhood Trauma Questionnaire

STI

socioeconomic status, sexually transmitted infection

U.S.

United States