Relation of Childhood Sexual Abuse,Intimate Partner Violence,and Depression to Risk Factors for HIV Among Black Men Who Have Sex With Men in 6 US Cities

Objectives. We assessed the relation of childhood sexual abuse (CSA), intimate partner violence (IPV), and depression to HIV sexual risk behaviors among Black men who have sex with men (MSM).Methods. Participants were 1522 Black MSM recruited from 6 US cities between July 2009 and December 2011. Univariate and multivariable logistic regression models were used.Results. Participants reported sex before age 12 years with someone at least 5 years older (31.1%), unwanted sex when aged 12 to 16 years (30%), IPV (51.8%), and depression (43.8%). Experiencing CSA when aged 12 to 16 years was inversely associated with any receptive condomless anal sex with a male partner (adjusted odds ratio [AOR] = 0.50; 95% confidence interval [CI] = 0.29, 0.86). Pressured or forced sex was positively associated with any receptive anal sex (AOR = 2.24; 95% CI = 1.57, 3.20). Experiencing CSA when younger than 12 years, physical abuse, emotional abuse, having been stalked, and pressured or forced sex were positively associated with having more than 3 male partners in the past 6 months. Among HIV-positive MSM (n = 337), CSA between ages 12 and 16 years was positively associated with having more than 3 male partners in the past 6 months.Conclusions. Rates of CSA, IPV, and depression were high, but associations with HIV sexual risk outcomes were modest.Despite significant medical advances, the HIV epidemic remains a health crisis in Black communities. The Black population represents only 14% of the total US population but accounted for 44% of all new HIV infection (68.9 of 100 000) in 2010.1 Black men who have sex with men (MSM) are disproportionately impacted by HIV compared with other racial/ethnic groups of MSM.1,2 Male-to-male sexual contact accounted for 72% of new infections among all Black men.1 Young Black MSM (aged 13–24 years) have a greater number of new infections than any other age or racial group among MSM.1 Researchers have been challenged with developing HIV prevention strategies for Black MSM.3–7 Higher frequencies of sexual risk behaviors, substance use, and nondisclosure of sexual identities do not adequately explain this disparity.8,9 High rates of sexually transmitted infections (STIs), which facilitate HIV transmission, and undetected or late diagnosis of HIV infection only partially explain disproportionate HIV rates.8Researchers have begun to examine a constellation of health factors that may contribute to HIV among MSM. For example, syndemic theory or the interaction of epidemics synergistically, such as intimate partner violence (IPV) and depression, may help explain HIV-related sexual risk behaviors among Black MSM.9 Childhood sexual abuse (CSA), IPV, and mental health disorders including depression may comprise such a constellation and warrant further exploration.Experiences of CSA have been identified as being associated with negative sexual health outcomes, with MSM reporting higher CSA rates than the general male population.10–12 Men with CSA experiences are more likely than men without CSA experiences to engage in high-risk sexual behaviors,13–21 have more lifetime sexual partners,13–16 use condoms less frequently,13,14,16 and have higher rates of STIs,13,14,17 exchanging sex for drugs or money,13,14,17 HIV,13,14 alcohol and substance use,13–21 and depression.13–15,18,21 Such findings suggest that sexual risk reduction counseling may need to be tailored for MSM with CSA experiences.15Childhood sexual abuse histories have also been correlated with sexual revictimization, including IPV.22–24 One study with population-based estimates of CSA found that gay and bisexually identified men had higher odds of reporting CSA (9.5 and 12.8, respectively) compared with heterosexual men.25 For sexual minority men, CSA histories were associated with higher HIV and STI incidence.25 However, research examining CSA, revictimization, and sexual risk behaviors is lacking among Black MSM.In one existing study, Black and Latino MSM with CSA histories identified their trauma experiences as influencing their adult sexual decision-making.26 Among Black MSM in 2 additional studies, emotional distress and substance use were attributed to having CSA experiences (Leo Wilton, PhD, written communication, October 2, 2013).27 In an ethnically diverse sample of 456 HIV-positive MSM, CSA was associated with insertive and receptive condomless anal sex.19Similar to CSA, IPV has not been extensively examined among MSM or Black MSM,28 but may be associated with sexual risk behaviors. Intimate partner violence is defined as a pattern of controlling, abusive behavior within an intimate relationship that may include physical, psychological or emotional, verbal, or sexual abuse.29 Little research exists on IPV among same-sex couples despite incidence rates being comparable to or greater than that of heterosexual women.28,30–34 Important IPV information comes from the National Intimate Partner and Sexual Violence Survey, a nationally representative survey for experiences of sexual violence, stalking, and IPV among men and women in the United States.28 Among men who experienced rape, physical violence, or stalking by an intimate partner, perpetrator differences by gender were found among gay, bisexual, and heterosexual men; 78% of bisexual and 99.5% of heterosexual men reported having only female perpetrators, and 90.7% of gay men reported having only male perpetrators.28 Being slapped, pushed, or shoved by an intimate partner during their lifetime was reported by gay (24%), bisexual (27%), and heterosexual (26.3%) men.28Intimate partner violence has been linked to condomless anal sex, HIV infection, substance use, CSA, and depression.35–37 Being an HIV-positive MSM has been linked with becoming a victim of IPV.38,39 Welles et al. found that being an African American MSM who initially disclosed having male partners and early life sexual abuse experiences was associated with IPV victimization.39 Wilton found that a high percentage of Black MSM reported IPV histories: emotional abuse (48.3%), physical abuse (28.3%), sexual abuse (21.7%), and stalking abuse (29.2%; Leo Wilton, PhD, written communication, October 2, 2013). Such findings lend to the importance of exploring, both independently and together, the association of CSA and IPV with sexual risk behaviors.Some studies have reported the influence of mental health (e.g., depression) on sexual risk behaviors among MSM,9,40,41 whereas others have not corroborated such findings.42 Greater rates of depression among MSM than among non-MSM samples43–45 and elevated rates of depression and anxiety among Black MSM have been reported.46 The Urban Men’s Health Study, a cross-sectional sample of MSM in 4 US cities, did not find a significant relationship between high depressive symptoms and condomless anal sex.42 However, the EXPLORE study, a randomized behavioral intervention for MSM in 6 US cities, supported the association between moderate depressive symptoms and an increased risk for HIV infection.47 Moderate levels of depression and higher rates of sexual risk were also reported for HIV-infected MSM over time.48 Another study conducted with 197 Black MSM found that moderate depressive symptoms were associated with having condomless anal sex with a serodiscordant casual partner.49 These mixed findings support the need to better understand the relationship between the severity of depression (i.e., moderate vs severe) and HIV risk behaviors.The HIV Prevention Trials Network 061 study, also known as the BROTHERS (Broadening the Reach of Testing, Health Education, Resources, and Services) Project, was a multisite study to determine the feasibility and acceptability of a multicomponent intervention for Black MSM. The current analysis aims to assess the prevalence of CSA, IPV, and depressive symptomology, and examine the relationships between these factors and insertive and receptive condomless anal sex and number of sexual partners in a large cohort of Black MSM.     

Effects of the It’s Your Game . . . Keep It Real Program on Dating Violence in Ethnic-Minority Middle School Youths: A Group Randomized Trial

Objectives. We examined whether It’s Your Game . . . Keep It Real (IYG) reduced dating violence among ethnic-minority middle school youths, a population at high risk for dating violence.Methods. We analyzed data from 766 predominantly ethnic-minority students from 10 middle schools in southeast Texas in 2004 for a group randomized trial of IYG. We estimated logistic regression models, and the primary outcome was emotional and physical dating violence perpetration and victimization by ninth grade.Results. Control students had significantly higher odds of physical dating violence victimization (adjusted odds ratio [AOR] = 1.52; 95% confidence interval [CI] = 1.20, 1.92), emotional dating violence victimization (AOR = 1.74; 95% CI = 1.36, 2.24), and emotional dating violence perpetration (AOR = 1.58; 95% CI = 1.11, 2.26) than did intervention students. The odds of physical dating violence perpetration were not significantly different between the 2 groups. Program effects varied by gender and race/ethnicity.Conclusions. IYG significantly reduced 3 of 4 dating violence outcomes among ethnic-minority middle school youths. Although further study is warranted to determine if IYG should be widely disseminated to prevent dating violence, it is one of only a handful of school-based programs that are effective in reducing adolescent dating violence behavior.Adolescent dating violence is a serious public health concern in the United States. National estimates indicate that almost 10% of high school youths (9th–12th graders) are victims of physical dating violence,1 and more than 20% are victims of emotional dating violence.2 In addition to being associated with many negative health outcomes (i.e., substance abuse, suicide, depression, and sexual activity),3–8 adolescent dating violence may be predictive of intimate partner violence in adulthood,8–10 which has exceedingly high economic costs (particularly those related to health care).11 Thus, preventing adolescent dating violence may not only protect youths from severe health consequences, but also reduce the short- and long-term health costs associated with this type of violence.Although most research on adolescent dating violence focuses on high school youths, recent studies indicate that adolescent dating violence begins in middle school.12–14 For example, in a survey of seventh graders from diverse geographic locations, 37% reported being victims of psychological dating violence, and 15% reported being victims of physical dating violence in the last 6 months.14 Furthermore, there is mounting evidence that dating violence disproportionately affects ethnic-minority middle school youths. For instance, in a sample of multiethnic sixth graders from 4 US states, approximately one third of Hispanics and African Americans with a history of dating each reported physical dating violence perpetration, compared with only 14% of Whites.15 A similar racial/ethnic pattern emerged for physical dating violence victimization. Thus, it is becoming increasingly evident that dating violence is prevalent among middle school youths, especially among those who belong to ethnic-minority groups.Adolescent dating violence prevention programs are available, but only a few have been rigorously evaluated. Of these, only 2 school-based programs—Safe Dates and Fourth R: Skills for Youth Relationships (Fourth R)—have been shown to produce significant behavioral effects: both reduced dating violence perpetration or victimization.16–18 However, these programs may not be as effective in ethnic-minority middle school youths because they were developed for and evaluated in older, predominantly White youths. Of the relatively fewer dating violence programs developed for and evaluated in ethnic-minority youths, most have been shown to produce either no19 or inconsistent20 behavioral effects, or have been limited by a weak study design (i.e., lack of control group).21,22 Thus, there is a need for rigorously evaluated, effective dating violence prevention programs16 that specifically target younger, ethnic-minority youths.It’s Your Game…Keep It Real (IYG) is a health education program designed to delay sexual behavior and promote healthy dating relationships in ethnic-minority middle school youths. It is based on the premise that healthy relationships are foundational to healthy adolescent sexual health. In 2 previous randomized controlled trials, IYG was shown to be effective in delaying sexual initiation and reducing other sexual risk behaviors.23,24 An additional research question was whether IYG had an impact on emotional and physical dating violence perpetration and victimization. Thus, our goal was to determine if IYG reduces dating violence behavior among ethnic-minority middle school youths. We hypothesized that, by ninth grade, students who did not receive IYG would report more physical and emotional dating violence perpetration and victimization than students who did receive IYG.     

Prevalence of Abuse and Violence Before,During, and After Pregnancy in a National Sample of Canadian Women

Objectives. We describe the prevalence of abuse before, during, and after pregnancy among a national population-based sample of Canadian new mothers.Methods. We estimated prevalence, frequency, and timing of physical and sexual abuse, identified category of perpetrator, and examined the distribution of abuse by social and demographic characteristics in a weighted sample of 76 500 (unweighted sample = 6421) Canadian mothers interviewed postpartum for the Maternity Experiences Survey (2006–2007).Results. Prevalence of any abuse in the 2 years before the interviews was 10.9% (6% before pregnancy only, 1.4% during pregnancy only, 1% postpartum only, and 2.5% in any combination of these times). The prevalence of any abuse was higher among low-income mothers (21.2%), lone mothers (35.3%), and Aboriginal mothers (30.6%). In 52% of the cases, abuse was perpetrated by an intimate partner. Receiving information on what to do was reported by 61% of the abused mothers.Conclusions. Large population-based studies on abuse around pregnancy can facilitate the identification of patterns of abuse and women at high risk for abuse. Before and after pregnancy may be particularly important times to monitor risk of abuse.The World Health Organization (WHO) defines violence against women as

any act of gender-based violence that results in, or is likely to result in physical, sexual or mental harm or suffering to women, including threats of such acts, coercion or arbitrary deprivation of liberty, whether occurring in public or in private life.1

This definition is based on the United Nations Declaration on the Elimination of Violence Against Women,2 which affirms that “violence against women constitutes a violation of the rights and fundamental freedoms of women and impairs or nullifies their enjoyment of those rights and freedoms.”2^(p1)Despite the fact that many countries signed this declaration, violence against women still persists in many developed and developing nations.1 It is a global public health concern as it puts many women at severe risk for their health and lives.3,4 Among women of reproductive age, violence has been associated with a range of adverse health and pregnancy problems and outcomes such as unwanted pregnancy,5,6 maternal pregnancy complications,7,8 lower birth weight and preterm birth,9–11 perinatal morbidity,12 maternal physical health problems,13 abortions,14 higher utilization of health care services,15 postpartum depression,16 substance abuse,17 and suicide.18 Socially vulnerable women with low income and low education, unmarried or not cohabitating,19 and at younger age,20 are at higher risk for abuse.Despite 4 decades of research, however, including hundreds of studies on violence against women in North America, sound estimates of the prevalence of abuse and violence toward women during the childbearing period are difficult to obtain. A recent systematic review of research on violence against pregnant women reported that prevalence varied widely across studies, from a low of 0.9% to a high of 21%.21 In Canada, population-based studies showed that physical violence during pregnancy was 6.6% in Ontario,22 5.7% in Saskatoon,23 and 1.2% in Vancouver.24 Such wide-ranging estimates are not useful to policymakers and program planners designing services to address this critical public health problem.Prevalence variability across studies is due in part to a variety of factors related to study design. Antenatal clinic-based samples, which are the norm for this type of research,17,25–31 may not be representative of the general population, leading to variations in estimates if, for example, women are predominantly from urban clinic samples or low-income patient populations.19,24,32,33 Response rates vary widely across studies, from a low of 17%27 to a high of 97%30; samples with lower response rates may overrepresent low-risk women.Modes of inquiry used to assess abuse also vary widely, making comparison across studies a challenge. Although use of face-to-face interviews is common in studies from developing countries, and phone interviews and mailed surveys are often used in developed counties,34 community-based surveys33 and self-administered assessments have also been employed.30 Studies have shown that women have different levels of comfort in disclosing abuse depending on the mode of inquiry, with phone and self-administered methods facilitating disclosure.35–37 Assessment tools also vary in their coverage of behaviors that constitute partner violence.37–40 Thus, myriad study design features have influenced the population prevalence rates reported in studies and their generalizability.In summary, few studies on abuse during pregnancy employ large population-based samples of women that enable a presentation of prevalence by subgroups and include rich information about the type, timing, frequency, and severity of abuse and the perpetrators involved. We build on the existing literature on abuse and perpetration patterns using a Canadian national sample of new mothers who were asked about abuse prior to and during pregnancy, as well as in the first several months postpartum.Our objectives were to estimate the prevalence, frequency, timing, and types of physical abuse before, during, and after pregnancy; to identify the category of perpetrator; and to examine the onset and cessation of abuse around pregnancy among a national representative sample of mothers who participated in the Maternity Experiences Survey (MES).     

The Long-Term Health Consequences of Relationship Violence in Adulthood: An Examination of Low-Income Women From Boston, Chicago, and San Antonio

Objectives. We examined the long-term health consequences of relationship violence in adulthood.Methods. Using data from the Welfare, Children, and Families project (1999 and 2001), a probability sample of 2402 low-income women with children living in disadvantaged neighborhoods in Boston, Massachusetts; Chicago, Illinois; and San Antonio, Texas, we predicted changes in the frequency of intoxication, psychological distress, and self-rated health over 2 years with baseline measures of relationship violence and a host of relevant background variables.Results. Our analyses showed that psychological aggression predicted increases in psychological distress, whereas minor physical assault and sexual coercion predicted increases in the frequency of intoxication. There was no evidence to suggest that relationship violence in adulthood predicted changes in self-rated health.Conclusions. Experiences with relationship violence beyond the formative and developmental years of childhood and adolescence can have far-reaching effects on the health status of disadvantaged urban women.Over the past 2 decades, numerous studies have examined the long-term health consequences of relationship violence during childhood. This body of research suggests that physical and sexual abuse in early life can be devastating to health in adulthood, contributing to poor mental^1–6 and physical health^3–5,7 and to higher rates of substance abuse.^5,6,8,9 These patterns are remarkably consistent across studies and notably persistent through the life course. In a recent study of more than 21 000 older adults, Draper et al.³ reported that physical and sexual abuse before 15 years of age is associated with poor mental and physical health well into late life.Although previous research has made significant contributions to our understanding of the lasting effects of abuse in early life, few studies have considered the long-term health consequences of relationship violence in adulthood. Our review of the literature revealed 5 longitudinal studies of relationship violence and health in adulthood. Not surprisingly, research suggests that women who experience relationship violence in adulthood are vulnerable to poor health trajectories, including increases in depressive symptoms,^10–12 functional impairment,^10,12 and alcohol consumption.^13,14Relationship violence is an important issue in all segments of society; however, studies consistently show that women of low socioeconomic status exhibit higher rates of intimate partner victimization than do their more affluent counterparts.^15–17 For example, Tolman and Raphael¹⁷ reported that between 34% and 65% of women receiving welfare report having experienced some form of relationship violence in their lifetime, and between 8% and 33% experience some form of relationship violence each year, levels that surpass those for women overall.¹⁸ Research also shows that residence in disadvantaged neighborhoods^19,20 and the presence of children in the household^21,22 may elevate the odds of relationship violence. Given their high violence-risk profile, attention must be directed to the patterns and health consequences of intimate partner victimization in the lives of disadvantaged urban women with children.^23–25Building on previous research, we used data collected from a large probability sample of low-income women with children living in low-income neighborhoods in Boston, Massachusetts, Chicago, Illinois, and San Antonio, Texas, to predict changes in the frequency of intoxication, psychological distress, and self-rated health over 2 years with measures of relationship violence in early life and adulthood and a host of relevant background variables. In accordance with previous research, we expected that intimate partner victimization in adulthood would predict increases in psychological distress and the frequency of intoxication and decreases in self-rated health over the study period.     

Health status, neighborhood socioeconomic context, and premature mortality in the United States: The National Institutes of Health-AARP Diet and Health Study

Objectives. We examined whether the risk of premature mortality associated with living in socioeconomically deprived neighborhoods varies according to the health status of individuals.Methods. Community-dwelling adults (n = 566 402; age = 50–71 years) in 6 US states and 2 metropolitan areas participated in the ongoing prospective National Institutes of Health–AARP Diet and Health Study, which began in 1995. We used baseline data for 565 679 participants on health behaviors, self-rated health status, and medical history, collected by mailed questionnaires. Participants were linked to 2000 census data for an index of census tract socioeconomic deprivation. The main outcome was all-cause mortality ascertained through 2006.Results. In adjusted survival analyses of persons in good-to-excellent health at baseline, risk of mortality increased with increasing levels of census tract socioeconomic deprivation. Neighborhood socioeconomic mortality disparities among persons in fair-to-poor health were not statistically significant after adjustment for demographic characteristics, educational achievement, lifestyle, and medical conditions.Conclusions. Neighborhood socioeconomic inequalities lead to large disparities in risk of premature mortality among healthy US adults but not among those in poor health.Research dating back to at least the 1920s has shown that the United States has experienced persistent and widening socioeconomic disparities in premature mortality over time.^1–5 However, it has been unclear whether socioeconomic inequalities affect the longevity of persons in good and poor health equally. Socioeconomic status (SES) and health status are interrelated,^6–8 and both are strong independent predictors of mortality.⁹ Low SES is associated with greater risk of ill health and premature death,^{1–5,8,10–13} partly attributable to disproportionately high prevalence of unhealthful lifestyle practices^10,14,15 and physical and mental health conditions.^13,16 Correspondingly, risk of premature mortality is higher in poor than in more affluent areas.^16,17 Although the association between neighborhood poverty and mortality is independent of individual-level SES,^17,18 aggregation of low-SES populations in poor areas may contribute to variations in health outcomes across neighborhoods. Conversely, economic hardships resulting from ill health may lead persons in poor physical or mental health to move to poor neighborhoods.¹⁹ This interrelatedness may create spurious associations between neighborhood poverty and mortality.Although previous studies have found that the risk of premature death associated with poor health status varies according to individuals'' SES,^20,21 no published studies have examined whether the relative risks for premature mortality associated with living in neighborhoods with higher levels of socioeconomic deprivation vary by health status of individuals. Clarifying these relationships will inform social and public health policies and programs that aim to mitigate the health consequences of neighborhood poverty.^22,23We used data from a large prospective study to examine whether the risk of premature mortality associated with neighborhood socioeconomic context differs according to health status at baseline and remains after adjustment for person-level risk factors for mortality, such as SES, lifestyle practices, and chronic medical illnesses.     

The Impact of Emotional,Physical, and Sexual Abuse on Contraceptive Method Selection and Discontinuation

Objectives. We evaluated the impact of exposure to emotional, physical, or sexual abuse on contraceptive method selection and discontinuation.Methods. We performed a secondary analysis of 7170 women enrolled in the Contraceptive CHOICE Project in St. Louis, Missouri, a prospective cohort study in which 9256 women were provided their preferred method of contraception at no cost from 2007 to 2011. We defined contraceptive discontinuation as device removal or nonuse for at least 4 weeks within the first 12 months after initiation.Results. One third of women experienced some abuse in their lifetimes. Women with an abuse history were as likely as those without to select a long-acting reversible contraceptive method and more likely to choose a contraceptive injection, the patch, or the ring. When we compared women who were abused to those who were not, rates of discontinuation at 12 months were higher among women who selected long-acting reversible contraception (17% vs 14%; P = .04) and significantly higher among women who selected non–long-acting methods (56% vs 47%; P < .001). Type of abuse did not alter the association between abuse and contraceptive continuation.Conclusions. Previous experiences of abuse are associated with both contraceptive method selection and continuation.Research has shown that violence against women is disturbingly common.1,2 A 2000 Centers for Disease Control and Prevention nationally representative survey of 8000 women aged 18 years and older found that the lifetime prevalence of physical intimate partner violence was 25%, and 56% of women reported at least 1 incident of physical or sexual assault.1 A 2010 survey conducted by the National Center for Injury Prevention and Control found that 36% of women reported intimate partner violence during their lifetime, 18% of women had been raped, and 45% of women reported some other form of sexual violence.2A developing body of evidence suggests that childhood and adulthood violence has far-reaching effects on women’s lives.1,3,4 Women with a history of violence report more high-risk health behaviors, such as early age at first intercourse or more lifetime sexual partners,5,6 more psychological effects including posttraumatic stress disorder and depression, higher rates of physical injury, and decreased access to social networks than women with no history of violence.1,7 In addition, women with current or past histories of violence may face unwanted or mistimed pregnancies, are at an increased risk of acquiring sexually transmitted infections (STIs), and are more likely to undergo repeat abortions.1,8–14Exposure to all forms of violence may influence the choices that women make regarding contraceptive use.10,12,15,16 Women’s perceptions and experience of loss of reproductive control may affect their decisions to use contraception, lead to decreased conviction to use condoms, or result in partner control over administration and type of contraception used.11,16 Gee et al. demonstrated that, because of difficulties imposed by their partners, women with exposure to intimate partner violence were less likely than nonexposed women to use birth control.9 Compared with women without violence exposure, women with a history of intimate partner violence reported that their male partners were more likely to refuse to use condoms (21% vs 7%; P < .001) and to refuse to allow contraception (5% vs 1%; P < .001).15 Women exposed to violence were also less likely than their nonexposed peers to ask their partners to wear condoms (35% vs 56%; P < .001).15 Finally, previous experiences of abuse, particularly those occurring in childhood, might have an impact on contraceptive choices via alternate pathways including depression, substance abuse, and alcohol use.17–19In light of these findings, women who experience histories of abuse may benefit from contraceptive methods that are independent of their partners. In this analysis, we sought to estimate the association of childhood, adult, and lifetime exposure to physical, emotional, or sexual abuse with contraceptive method selection and duration of use for both long-acting reversible contraception (LARC; intrauterine devices and hormonal implant) and non–long-acting methods of contraception (non-LARC; birth-control pill, injection, ring, or patch) in the Contraceptive CHOICE Project (CHOICE).     

A Systematic Review of the Correlates of Violence Against Sex Workers

We conducted a systematic review in June 2012 (updated September 2013) to examine the prevalence and factors shaping sexual or physical violence against sex workers globally.We identified 1536 (update = 340) unique articles. We included 28 studies, with 14 more contributing to violence prevalence estimates. Lifetime prevalence of any or combined workplace violence ranged from 45% to 75% and over the past year, 32% to 55%. Growing research links contextual factors with violence against sex workers, alongside known interpersonal and individual risks.This high burden of violence against sex workers globally and large gaps in epidemiological data support the need for research and structural interventions to better document and respond to the contextual factors shaping this violence. Measurement and methodological innovation, in partnership with sex work communities, are critical.Frequent reports of incidents of widespread violence against sex workers continue to emerge globally,1–3 including media reports of abuse, human rights violations, and murder.4–7 Despite increasing recognition of violence in the general population as a public health and human rights priority by policymakers, researchers, and international bodies,8–10 violence against sex workers that occurs within and outside the context of sex work is frequently overlooked in international agendas to prevent violence. Although increasing research has explored the prevalence, determinants, and correlates of violence against women,8,11–14 comparable research specifically among sex workers is lacking. There remains limited review of the magnitude, severity, or type of violence experienced by sex workers globally. This paucity of data on prevalence and incidence of violence against sex workers has been highlighted in a review on the magnitude and scope of violence globally.15Negative health effects of intimate partner violence in the general population include poor health overall, physical and sexual injury, and mental health problems including depression, anxiety, and posttraumatic stress disorder.16–21 Intimate partner violence faced by women in the general population has also been linked to unwanted pregnancy, abortion, and increased risk for HIV and other sexually transmitted infections (STIs), through different direct and indirect mechanisms.22–26 Victims of violence in early childhood are also more likely to have increased risk for HIV and other STIs.27 However, the role of violence, both workplace violence and violence by intimate or other nonpaying partners, in influencing negative health outcomes among sex workers, who are highly stigmatized and often criminalized, has received comparably less attention.The legal status of sex work can be a critical factor in shaping patterns of violence against sex workers.1,28 In many settings, the criminalized or quasicriminalized nature of sex work means that violence that occurs in the context of sex work (i.e., as a workplace harm and abuse) is not monitored by any formal bodies, with few to no legal protections afforded to sex workers by police and judicial systems.1,28 Violence against sex workers is often not registered as an offense by the police and in some cases is perpetrated by police.29,30 Physical and sexual violence, and verbal abuse or threats of abuse from police, can prevent sex workers from reporting violence to the police or accessing other public agencies (e.g., health or social services), exacerbating their trauma and health risks.1,29,30 These risks include the risk for HIV and other STIs, and in some settings, threats of arrest for possession of condoms as evidence of engaging in sex work can deter sex workers from carrying condoms.30–32 This can create a climate of tolerance of violence and thereby perpetuate violence against sex workers.We conducted a systematic review to examine the documented magnitude of violence against sex workers and to review the factors that shape risk for violence against sex workers. In our review we were guided by theoretical frameworks that implicate structural factors in shaping vulnerabilities experienced by vulnerable populations.33–35 Within the interrelated physical, social, economic, and policy environments, factors operate to create different levels of susceptibility and risk.33–35 The current review provides an evidence base pertaining to violence against sex workers from which to better inform the development of public health and social interventions to reduce violence and ameliorate its impacts on sex workers.     

Posttraumatic Stress Disorder and Incident Heart Failure Among a Community-Based Sample of US Veterans

Objectives. We investigated the association between posttraumatic stress disorder (PTSD) and incident heart failure in a community-based sample of veterans.Methods. We examined Veterans Affairs Pacific Islands Health Care System outpatient medical records for 8248 veterans between 2005 and 2012. We used multivariable Cox regression to estimate hazard ratios and 95% confidence intervals for the development of heart failure by PTSD status.Results. Over a mean follow-up of 7.2 years, veterans with PTSD were at increased risk for developing heart failure (hazard ratio [HR] = 1.47; 95% confidence interval [CI] = 1.13, 1.92) compared with veterans without PTSD after adjustment for age, gender, diabetes, hyperlipidemia, hypertension, body mass index, combat service, and military service period. Additional predictors for heart failure included age (HR = 1.05; 95% CI = 1.03, 1.07), diabetes (HR = 2.54; 95% CI = 2.02, 3.20), hypertension (HR = 1.87; 95% CI = 1.42, 2.46), overweight (HR = 1.72; 95% CI = 1.25, 2.36), obesity (HR = 3.43; 95% CI = 2.50, 4.70), and combat service (HR = 4.99; 95% CI = 1.29, 19.38).Conclusions. Ours is the first large-scale longitudinal study to report an association between PTSD and incident heart failure in an outpatient sample of US veterans. Prevention and treatment efforts for heart failure and its associated risk factors should be expanded among US veterans with PTSD.Posttraumatic stress disorder (PTSD) is a psychiatric illness that affects approximately 7.7 million Americans aged older than 18 years.1 PTSD typically results after the experience of severe trauma, and veterans are at elevated risk for the disorder. The National Vietnam Veterans Readjustment Study reported the prevalence of PTSD among veterans who served in Vietnam as 15.2% among men and 8.1% among women.2 In fiscal year 2009, nearly 446 045 Veterans Administration (VA) patients had a primary diagnosis of PTSD, a threefold increase since 1999.3 PTSD is of growing clinical concern as evidence continues to link psychiatric illnesses to conditions such as arthritis,4 liver disease,5 digestive disease,6 and cancer.6 When the postwar health status of Vietnam veterans was examined, those with PTSD had higher rates of diseases of the circulatory, nervous, digestive, musculoskeletal, and respiratory systems.7The evidence linking PTSD to coronary heart disease (CHD) is substantial.8–10 Veterans with PTSD are significantly more likely to have abnormal electrocardiograph results, myocardial infarctions, and atrioventricular conduction deficits than are veterans without PTSD.11 In a study of 605 male veterans of World War II and the Korean War, CHD was more common among veterans with PTSD than among those without PTSD.12 Worldwide, adults exposed to the disaster at Chernobyl experienced increased rates of CHD up to 10 years after the event,13 and studies of stressors resulting from the civil war in Lebanon found elevated CHD mortality.14,15Although the exact biological mechanism by which PTSD contributes to CHD remains unclear, several hypotheses have been suggested, including autonomic nervous system dysfunction,16 inflammation,17 hypercoagulability,18 cardiac hyperreactivity,19 altered neurochemistry,20 and co-occurring metabolic syndrome.16 One of the hallmark symptoms of PTSD is hyperarousal,21 and the neurobiological changes brought on from sustained sympathetic nervous system activation affect the release of neurotransmitters and endocrine function.22 These changes have negative effects on the cardiovascular system, including increased blood pressure, heart rate, and cardiac output.22,23Most extant literature to date examining cardiovascular sequelae has shown a positive association between PTSD and coronary artery disease.8–10 Coronary artery disease is well documented as one of the most significant risk factors for future development of heart failure.24 Despite burgeoning evidence for the role of PTSD in the development of coronary artery disease, there are few studies specifically exploring the relationship between PTSD and heart failure. Limited data suggest that PTSD imparts roughly a threefold increase in the odds of developing heart failure in both the general population5 and in a sample of the elderly.25 These investigations, however, have been limited by cross-sectional study design, a small proportion of participants with PTSD, and reliance on self-reported measures for both PTSD and heart failure.5,25 Heart failure is a uniquely large public health issue, as nearly 5 million patients in the United States are affected and there are approximately 500 000 new cases each year.26 Identifying predictors of heart failure can aid in early detection efforts while simultaneously increasing understanding of the mechanism behind development of heart failure.To mitigate the limitations of previous investigations, we undertook a large-scale prospective study to further elucidate the role of prevalent PTSD and development of incident heart failure among veterans, while controlling for service-related and clinical covariates. Many studies investigating heart failure have relied on inpatient records; we leveraged outpatient records to more accurately reflect the community burden of disease.     

Clustering of Midlife Lifestyle Behaviors and Subsequent Cognitive Function: A Longitudinal Study

Objectives. We examined the association between individual and clustered lifestyle behaviors in middle age and later in cognitive functioning.Methods. Middle-aged participants (n = 2430) in the Supplémentation en Vitamines et Minéraux Antioxydant study self-reported their low physical activity, sedentary behavior, alcohol use, smoking, low fruit and vegetable consumption, and low fish consumption. We assessed cognition 13 years later via 6 neuropsychological tests. After standardization, we summed the scores for a composite cognitive measure. We estimated executive functioning and verbal memory scores using principal component analysis. We estimated the mean differences (95% confidence intervals [CIs]) in cognitive performance by the number of unhealthy behaviors using analysis of covariance. We identified latent unhealthy behavior factor via structural equation modeling.Results. Global cognitive function and verbal memory were linearly, negatively associated with the number of unhealthy behaviors: adjusted mean differences = −0.36 (95% CI = −0.69, −0.03) and −0.46 (95% CI = −0.80, −0.11), respectively, per unit increase in the number of unhealthy behaviors. The latent unhealthy behavior factor with low fruit and vegetable consumption and low physical activity as main contributors was associated with reduced verbal memory (RMSEA = 0.02; CFI = 0.96; P = .004). No association was found with executive functioning.Conclusions. Comprehensive public health strategies promoting healthy lifestyles might help deter cognitive aging.Noncommunicable diseases with notable lifestyle components are the leading causes of death worldwide.1,2 There is also growing evidence of the critical role of different midlife health and risk behaviors in cognitive aging.3–7 Because lifestyles are inherently modifiable and no treatment of cognitive decline is available, such findings argue for the paramount importance of prevention.8,9Current data support a deleterious effect of alcohol abstinence or abuse (compared with moderate alcohol consumption),10 smoking,7 low fruit and vegetable intake,11 low fish intake,12 and low physical activity (PA) levels13 on cognitive aging. However, it has been widely documented that lifestyle factors are strongly correlated with each other, forming a cluster of healthy or unhealthy behaviors.14 Traditionally, such interrelations have been accounted for by statistical adjustment; however, it is of major public health interest to consider the cumulative and combined effect of the various lifestyle behaviors on health by using multidimensional strategies.14Research that examines the combined effect of lifestyle factors on mortality is plentiful, and data have been colligated in a recent meta-analysis.15 These authors reported a 66% reduction in mortality risk by comparing adherence to 4 or more healthy lifestyle behaviors versus engagement in any number of unhealthy behaviors.The combined effect of lifestyle factors has also been explored in relation to cardiovascular diseases,16–18 cancer,18–22 diabetes,18,23 memory complaints,24 and dementia25–27; however, very few studies have reported findings regarding cognition.28,29 Despite heterogeneity in the definition of a healthy lifestyle, study design, and residual confounding, available, but scarce, data support a critical, protective role of healthy lifestyles in cognitive health through their beneficial properties via oxidative, inflammatory, vascular, and other neuroprotective pathways.30–33Our objectives in this study were to examine the association between individual and clustered lifestyle behaviors and later cognitive functioning. We employed traditional and innovative techniques (structural equation modeling) in our epidemiological pursuit.     

Correlates of Sexual Risk Among Sexual Minority and Heterosexual South African Youths

We explored psychosocial correlates of sexual risk among heterosexual and sexual minority youths (SMYs) in Johannesburg, South Africa. Young people 16 to 18 years old (n = 822) were administered surveys assessing demographic characteristics, sexual behaviors, mental health, and parent–child communication. Adjusted multivariate regressions examining correlates of sexual risk revealed that SMYs had more sexual partners than heterosexual youths (B = 3.90; SE = 0.95; P < .001) and were more likely to engage in sex trading (OR = 3.11; CI = 1.12-8.62; P < .05). South African SMYs are at increased risk relative to their heterosexual peers.South Africa has the highest burden of HIV in the world; 9.2% of young persons aged 15 to 19 years living in the country are infected with HIV.1,2 Few studies have examined multilevel sexual risk factors (e.g., individual, partner, family) among sexual minority youths (SMYs)3 in South Africa, despite their increased vulnerability.4–8 Research has shown that rates of sexual risk behavior are high among adult men who have sex with men (MSM) in sub-Saharan Africa,5,9 and South African SMYs may be especially vulnerable given the transitional nature of adolescence, fear of discrimination, and lack of cultural acceptance of homosexuality.4,7,10Our analyses were guided by theories of syndemics (i.e., collective risk or co-occurring epidemics)11–13 and minority group stress.14 These theories posit that young MSM experience psychosocial disparities in numerous areas (substance use, abuse and victimization, mental health problems, risk taking)15–18 and that SMYs are at increased risk for poor mental health, sexual vulnerability, substance use, and violence.19,20 Moreover, stigma creates stressful environments, another cause of mental health problems among SMYs.14 This situation is especially salient in South Africa, where same-sex behavior is so highly stigmatized that even normative adolescent sexual exploration would likely be denounced.7We hypothesized that South African SMYs would be at increased sexual risk relative to heterosexual youths. To our knowledge, this is one of the first investigations to examine risk and protective factors associated with sexual risk in this population.     

Utilizing Screening,Brief Intervention,and Referral to Treatment: Teaching Assessment of Substance Abuse

Although social workers regularly encounter clients with substance use problems, social work education rarely addresses addictions with any depth. This pilot study explored the use of screening, brief intervention, and referral to treatment (SBIRT) with 74 social work students. Students completed SBIRT training with pre- and post-questionnaires that assessed attitudes, knowledge, and skills concerning substance misuse. Statistically significant differences were demonstrated with students reporting more confidence in their ability to successfully assess for alcohol misuse and subsequently intervene.Substance misuse in the United States is high; 30% of adults engage in at-risk drinking.1 At-risk drinking (typically categorized as “misuse”) does not meet diagnostic criteria for abuse or dependence and is inconsistently identified. Because approximately 70% of the US adult population sees a primary care physician at least once every 2 years,2 a screening and brief intervention model for substance misuse was developed for primary care settings.Screening, brief intervention, and referral to treatment (SBIRT)3 is based on the transtheoretical model of change,4 incorporating motivational interviewing to “briefly intervene” with patients who are at-risk drinkers. The transtheoretical model presents 5 stages of client readiness to change: precontemplation (change is not considered); contemplation (some awareness of consequences but ambivalence to change); preparation (change is planned); action (change begins); and maintenance (change is managed).4 The idea is to “meet the patient where they are.” SBIRT is efficacious with assessing and intervening with at-risk drinkers in primary care settings5–7 and emergency departments8,9; however, SBIRT has not been integrated into social work education or practice.Social workers are employed in a variety of venues. Like other health care professionals, they are not necessarily trained to identify or treat misuse. Less than 10% of accredited social work programs offer a graduate certificate specific to substance abuse.10 Research shows similar barriers to screening among health care providers: lack of training to assess alcohol misuse, how to or when to screen for it, and what to do if the client indicates a need for treatment.11 Training practitioners can be effective in increasing confidence in screening and intervention as well as improving attitudes toward people with alcohol problems.12–15This pilot study assessed social work students’ attitudes, perceived skills, and knowledge of alcohol misuse before and after receiving training on SBIRT. We hypothesized that students would improve skills and knowledge of substance misuse as well as improve attitudes toward people who misuse alcohol.     

Social Branding to Decrease Smoking Among Young Adults in Bars

Objectives. We evaluated a Social Branding antitobacco intervention for “hipster” young adults that was implemented between 2008 and 2011 in San Diego, California.Methods. We conducted repeated cross-sectional surveys of random samples of young adults going to bars at baseline and over a 3-year follow-up. We used multinomial logistic regression to evaluate changes in daily smoking, nondaily smoking, and binge drinking, controlling for demographic characteristics, alcohol use, advertising receptivity, trend sensitivity, and tobacco-related attitudes.Results. During the intervention, current (past 30 day) smoking decreased from 57% (baseline) to 48% (at follow-up 3; P = .002), and daily smoking decreased from 22% to 15% (P < .001). There were significant interactions between hipster affiliation and alcohol use on smoking. Among hipster binge drinkers, the odds of daily smoking (odds ratio [OR] = 0.44; 95% confidence interval [CI] = 0.30, 0.63) and nondaily smoking (OR = 0.57; 95% CI = 0.42, 0.77) decreased significantly at follow-up 3. Binge drinking also decreased significantly at follow-up 3 (OR = 0.64; 95% CI = 0.53, 0.78).Conclusions. Social Branding campaigns are a promising strategy to decrease smoking in young adult bar patrons.Tobacco companies1 and public health authorities2–5 recognize young adulthood as a critical time when experimenters either quit or transition to regular tobacco use. Young adults are also aspirational role models for youths.1,6,7 Tobacco companies devote considerable resources to reaching young adults to encourage tobacco use,1,8–11 and young adults have a high prevalence of smoking.12 In California in 2011, young adults had the highest smoking prevalence of any age group, and the Department of Health estimated that 32% of California smokers started smoking between the ages of 18 and 26 years.13 Although they are more likely to intend to quit and successfully quit than older adults,14–17 young adults are less likely to receive assistance with smoking cessation.18,19 Although there are few proven interventions to discourage young adult smoking,20 cessation before age 30 years avoids virtually all of the long-term adverse health effects of smoking.21Tobacco companies have a long history of using bars and nightclubs to reach young adults and to encourage smoking.1,6,9–11,22–24 Bar attendance and exposure to tobacco bar marketing is strongly associated with smoking.25 The 1998 Master Settlement Agreement and Food and Drug Administration regulations that limit tobacco advertising to youths, explicitly permit tobacco marketing in “adult only” venues, including bars and nightclubs.26,27Aggressive tobacco marketing may actually be more intensive in smoke-free bars: a 2010 study of college students attending bars found that students in the community with a smoke-free bar law were more likely to be approached by tobacco marketers, offered free gifts, and to take free gifts for themselves than in communities without a smoke-free bar law.28 Bars and nightclubs also attract young adults who are more likely to exhibit personality traits such as sensation seeking,29 increasing their risk30 independently of receptivity to tobacco advertising; tobacco promotional messages resonate with these personality traits.8,31 Tobacco marketing campaigns are tailored to specific segments of the population defined by psychographics (e.g., values, attitudes, shared interests, such as tastes in music and fashion, and friend groups) and demographic criteria, and they aim to create positive smoker images, identities, and social norms for smoking.1,8 Tobacco marketing campaigns also focus on young adult trendsetters to leverage peer influence to promote smoking.6,10In contrast to the tobacco companies’ efforts, most young adult health interventions take place in colleges or health centers rather than social environments.32–39 Bars and nightclub venues represent an opportunity to reach those at highest risk for long-term smoking morbidity and mortality.40 We evaluated the effectiveness of an intervention to decrease cigarette smoking by countering tobacco industry marketing strategies targeting young adults attending bars and nightclubs in the San Diego, California, “hipster” scene. Because tobacco and alcohol use are strongly linked,41,42 we also examined the effects of the intervention on alcohol use and among binge drinkers. We found a significant decrease in smoking in the community where the intervention took place, including significant decreases among nondaily smokers and binge drinkers, as well as a significant decrease in binge drinking.     

Community Violence Perpetration and Victimization Among Adults With Mental Illnesses

Objectives. In a large heterogeneous sample of adults with mental illnesses, we examined the 6-month prevalence and nature of community violence perpetration and victimization, as well as associations between these outcomes.Methods. Baseline data were pooled from 5 studies of adults with mental illnesses from across the United States (n = 4480); the studies took place from 1992 to 2007. The MacArthur Community Violence Screening Instrument was administered to all participants.Results. Prevalence of perpetration ranged from 11.0% to 43.4% across studies, with approximately one quarter (23.9%) of participants reporting violence. Prevalence of victimization was higher overall (30.9%), ranging from 17.0% to 56.6% across studies. Most violence (63.5%) was perpetrated in residential settings. The prevalence of violence-related physical injury was approximately 1 in 10 overall and 1 in 3 for those involved in violent incidents. There were strong associations between perpetration and victimization.Conclusions. Results provided further evidence that adults with mental illnesses experienced violent outcomes at high rates, and that they were more likely to be victims than perpetrators of community violence. There is a critical need for public health interventions designed to reduce violence in this vulnerable population.The risk of violence associated with mental illnesses is a topic of research, media coverage, and debate. Research indicates that between 11% and 52% of adults with mental illnesses have been violent within a 12-month period,1–7 and data from the National Comorbidity Survey show that rates of violence for adults with mental illnesses are 2 to 8 times greater than in the general population.8 Other studies show modest but significant relationships between mental illness and violence,3,9,10 even after controlling for substance abuse.11 Although highly publicized cases of violence perpetrated by adults with mental illnesses have highlighted their “dangerousness,” data suggest they experience victimization at rates comparable to or higher than their rates of perpetration.12 Studies show 12-month prevalence rates between 20% and 44%,7,12–15 and indicate the likelihood of experiencing violent victimization is 23 times higher in adults with mental illnesses compared with the general population.12 Despite these findings, there remains a focus on violence perpetration to the neglect of victimization in this vulnerable population.The increased risk of violent outcomes that is associated with mental illnesses represents a substantial public health burden. Violence can be devastating to victims and perpetrators alike, as well as being costly to the public.16,17 In addition to physical injury, violence may precipitate the loss of personal liberty because of incarceration18 or civil commitment,19 require implementation of expensive clinical and risk assessment and management strategies,20 perpetuate the stigma associated with mental illness,21 and disrupt continuity of care.22 Consequently, an understanding of the prevalence and nature of community violence—both perpetration and victimization—among adults with mental illnesses is critical to public health research and practice.Unfortunately, the empirical literature is limited. First, there are many more studies of perpetration than victimization; a review of the literature found 3 times as many publications about the link between mental illness and violence compared with the link between mental illness and victimization.23 Second, although they are risk factors for each other,24–26 there have been few studies of community violence perpetration and victimization. Only a handful of peer-reviewed publications report on both outcomes in the same sample of adults with mental illnesses during the same reference period.27–30 Third, studies that have examined both outcomes have restricted power and generalizability because of the relatively small, nonrepresentative samples. Fourth, there is heterogeneity in the operational definitions of violence, preventing meaningful comparisons or aggregation of findings. Fifth, violent outcomes are frequently measured with a single yes or no question (e.g., “Have you been victimized in the past 12 months?”), a measurement approach with limited sensitivity.31     

Posttraumatic stress disorder and HIV risk among poor, inner-city women receiving care in an emergency department

Objectives. We examined the associations between posttraumatic stress disorder (PTSD) and HIV risk behaviors among a random sample of 241 low-income women receiving care in an urban emergency department.Methods. We recruited participants from the emergency department waiting room during randomly selected 6-hour blocks of time. Multivariate analyses and propensity score weighting were used to examine the associations between PTSD and HIV risk after adjustment for potentially confounding sociodemographic variables, substance use, childhood sexual abuse, and intimate partner violence.Results. A large majority of the sample self-identified as Latina (49%) or African American (44%). Almost one third (29%) of the participants met PTSD criteria. Women who exhibited symptoms in 1 or more PTSD symptom clusters were more likely than women who did not to report having had sex with multiple sexual partners, having had sex with a risky partner, and having experienced partner violence related to condom use in the preceding 6 months.Conclusions. The high rate of PTSD found in this sample and the significant associations between PTSD symptom clusters and partner-related risk behaviors highlight the need to take PTSD into account when designing HIV prevention interventions for low-income, urban women.The relationship between posttraumatic stress disorder (PTSD) and HIV risk behaviors remains relatively underresearched. However, several studies have shown that PTSD is associated with sexual HIV risk behaviors and HIV seropositive status.^1–3 Emergency departments have been identified as the first and primary source of medical treatment of many women infected with or at high risk for HIV^4–6 and for those with high rates of interpersonal violence and trauma, including those suffering from PSTD.^7–11Hutton et al. found that, after adjustment for potentially confounding factors, a PTSD diagnosis was associated with engaging in anal intercourse and exchanging sex for money or drugs in a sample of 177 female inmates.¹² High rates of PTSD have also been found among HIV-positive women,^3,13,14 many of whom have experienced repeated traumas associated with PTSD, such as childhood sexual abuse and intimate partner violence (IPV).^3,13,14 In a study of HIV-positive women, 35% of those with a trauma history met the criteria for PTSD,¹⁵ a rate far exceeding both the lifetime PTSD rate (10.4%) among women in the general population¹⁶ and the PTSD rate (4.6%) in a nationally representative sample of female crime victims.¹⁷The relationship between PTSD and HIV risk behaviors has been found to vary according to the presence of different PTSD symptoms (avoidance, hyperarousal, and reexperiencing trauma). In their study of 64 HIV-positive women and men, Gore-Felton and Koopman found that moderate to severe reexperiencing symptoms were associated with multiple sexual partners and unprotected sex during the preceding 3 months.¹⁸ Individuals with avoidant symptoms were less likely to have engaged in unprotected sex, possibly as a result of deficits in establishing and maintaining intimate partnerships.¹⁸ The presence of hyperarousal symptoms may trigger individuals to seek sexual stimulation and engage in riskier sex, and they may experience difficulty in problem solving and negotiating safe sex.¹⁹The research just described highlights mechanisms of how different PTSD symptom clusters may increase the likelihood of engaging in HIV risks. However, it should also be acknowledged that the relationship may be bidirectional: a traumatic experience (e.g., forced unprotected sex) associated with a risk of HIV may lead to PTSD.Furthermore, research suggests that the relationship between PTSD and HIV risk may be mediated by several factors, including childhood sexual abuse, IPV, and substance abuse. Those who have experienced childhood sexual abuse are at increased risk of developing PTSD,^20–22 engaging in subsequent sexual HIV risk behaviors, and HIV transmission.^3,23 Similarly, IPV has been found to increase the risk of both developing PTSD and engaging in a range of HIV risk behaviors, including unprotected sex,^24–38 sexual practices leading to a high risk of sexually transmitted infections,^6,32,39–42 sex with multiple partners,^31,32,43 trading of sex for money or drugs,^40,44 sex with risky partners,^38,45 and sex with HIV-positive partners.³⁸ Finally, substantial research indicates that drug and alcohol dependencies are associated with both PTSD^46,47 and engaging in a range of HIV risk behaviors.^48–51We examined the relationship between PTSD (and the symptom clusters of avoidance, reexperiencing trauma, and hyperarousal) and sexual HIV risk behaviors in a random sample of 241 women attending an emergency department in a low-income neighborhood of the Bronx, New York. We hypothesized that women who met the criteria for PTSD and the symptom clusters of hyperarousal, reexperiencing trauma, or avoidance would be more likely than women who did not meet these criteria to engage in sexual HIV risk behaviors after adjustment and matching for potentially confounding factors such as sociodemographic characteristics, childhood sexual abuse, substance abuse, and IPV.     

Violence Against Women in Selected Areas of the United States

Objectives. We determined the prevalence of recent emotional, physical, and sexual violence against women and their associations with HIV-related risk factors in women living in the United States.Methods. We performed an assessment of women ages 18 to 44 years with a history of unprotected sex and 1 or more personal or partner HIV risk factors in the past 6 months from 2009 to 2010. We used multivariable logistic regression to examine the association of experiencing violence.Results. Among 2099 women, the prevalence of emotional abuse, physical violence, and sexual violence in the previous 6 months was 31%, 19%, and 7%, respectively. Nonmarried status, food insecurity, childhood abuse, depression symptomology, and posttraumatic stress disorder were significantly associated with multiple types of violence. All types of violence were associated with at least 3 different partner or personal HIV risk behaviors, including unprotected anal sex, previous sexually transmitted infection diagnosis, sex work, or partner substance abuse.Conclusions. Our data suggested that personal and partner HIV risk behaviors, mental illness, and specific forms of violence frequently co-occurred in the lives of impoverished women. We shed light on factors purported to contribute to a syndemic in this population. HIV prevention programs in similar populations should address these co-occurring issues in a comprehensive manner.Violence against women is increasingly recognized as a critical national public health concern in the United States, as evidenced by the recent signing of the Violence Against Women Act by President Obama.1 Based on nationally representative samples, it is estimated that in their lifetime, nearly 1 in 3 US women has survived physical violence, and 1 in 10 has survived rape.2 Women who experience emotional, physical, and sexual violence not only experience the injury of the initial trauma, but also have higher rates of depression, posttraumatic stress disorder (PTSD), substance abuse, re-victimization, and high-risk sexual behaviors.3–7There is strong evidence that supports the relationship between experiencing intimate partner violence (IPV) and HIV risk, as well as acquiring HIV.8–20 In the United States, the relationship between IPV, especially sexual violence, and HIV came to light almost 20 years ago.5 Several studies6,10,17,18,20,21 during the past decade reported high co-occurring rates of violence, HIV risk, mental illness, and substance use in the United States among incarcerated women,22 female substance users,19 women in shelters,23,24 women living in impoverished areas,25–28 and women engaging in prostitution.29 Not only do these conditions frequently co-occur, but the presence of one may magnify the effects of the others, thus demonstrating the notion of a “syndemic,” which is a term used to refer to a set of synergistic or intertwined and mutually enhancing health and social problems facing vulnerable populations such as women living in poverty.30 However, interpretation and generalizability across studies has been difficult because of small sample sizes, convenience samples (e.g., women in methadone treatment, shelters, or clinics), narrowly defined study populations, the inclusion of both women living with HIV and women living without HIV, and poorly standardized study variables that typically did not include emotional abuse (e.g., combining different types of violence or combining childhood and adult violent experiences).5,6,10,31Overall, most published US data have suggested that women living with HIV experience IPV at the same rate as women not living with HIV from the same population, but that women living with HIV experience such violence more frequently and with increased severity.9,31 In addition, substance abuse, poverty, and other HIV risk factors were associated with experiencing violence and therefore, also contribute to the HIV and IPV relationship.9,32 However, many of these studies focused on “intimate” partner violence specifically and not on violence overall. For example, using a large representative sample of US women (n = 13 928), Sareen et al.8 found that women who experienced any IPV in the past year were more than 3 times as likely to report an HIV/AIDS diagnosis by a health professional as women who had not experienced IPV. They postulated that nearly 12% of HIV/AIDS infections among US women in intimate relationships was caused by IPV. Despite its novel contribution to the examination of the relationship between HIV infection and IPV among US women, this study was limited because it only examined physical and sexual IPV in the past 12 months. Another large-scale domestic study by Stockman et al. assessed specific types of sexual coercion in a nationally representative sample of 5857 US women and found positive associations among coerced sex, using drugs and alcohol, and having multiple sexual partners.20 However, this study was limited in the way it assessed HIV risk by not examining perceived partner risk factors. Other recent studies have further elucidated this complex clustering of risk factors, but sample sizes have remained small, and measures of sexual HIV risk behaviors have varied widely.9,33,34Because of the concentration of HIV/AIDS in key areas of the United States, the HIV Prevention Trials Network (HPTN) study 064 was uniquely designed to recruit a representative sample of women living in US areas with high poverty and a high prevalence of HIV.26,27 Unlike the more diffuse HIV epidemics seen in other countries, HIV in the United States has striking socioeconomic and racial disparities that are concentrated in key “hot spots” of the Northeast, South, and West. However, HIV among women in the United States is still not fully appreciated in the current HIV prevention research.26,27 HPTN 064 made a significant public health contribution by assessing key social and behavioral factors that contribute to HIV acquisition among women in the United States by exploring the risk of HIV infection among certain populations of US women and providing information about their risk behaviors.35 We used this large data set to assess the following: (1) the prevalence of emotional abuse, physical violence, forced sex, and experiencing 2 or more types of violence; and (2) sociodemographic characteristics, personal HIV-risk behaviors, and perceived sex partner behaviors associated with each type of violence.     

Social support, exposure to violence and transphobia, and correlates of depression among male-to-female transgender women with a history of sex work

Objectives. We determined racial/ethnic differences in social support and exposure to violence and transphobia, and explored correlates of depression among male-to-female transgender women with a history of sex work (THSW).Methods. A total of 573 THSW who worked or resided in San Francisco or Oakland, California, were recruited through street outreach and referrals and completed individual interviews using a structured questionnaire.Results. More than half of Latina and White participants were depressed on the basis of Center For Epidemiologic Studies Depression Scale scores. About three quarters of White participants reported ever having suicidal ideation, of whom 64% reported suicide attempts. Half of the participants reported being physically assaulted, and 38% reported being raped or sexually assaulted before age 18 years. White and African American participants reported transphobia experiences more frequently than did others. Social support, transphobia, suicidal ideation, and levels of income and education were significantly and independently correlated with depression.Conclusions. For THSW, psychological vulnerability must be addressed in counseling, support groups, and health promotion programs specifically tailored to race/ethnicity.The term “transgender” has been used as an umbrella term, capturing people who do not conform with a binary male–female gender category.¹ In this study, we use the term “transgender women” or “male-to-female transgender women” to describe individuals who were born biologically male but self-identify as women and desire to live as women.² Although transgender persons or those who identify their gender other than male or female have been historically reported in many cultures around the world, their social roles, status, and acceptance have varied across time and place.³ In the United States, as part of the gay rights movement in the 1970s, a transgender civil rights movement emerged to advocate for transgender people''s equal rights and to eradicate discrimination and harassment in their daily lives.⁴ However, transphobia—institutional, societal, and individual-level discrimination against transgender persons—is still pervasive in the United States and elsewhere. It often takes the form of laws, regulations, violence (physical, sexual, and verbal), harassment, prejudices, and negative attitudes directed against transgender persons.^5–7Studies have reported that transgender persons lack access to gender-sensitive health care^6,8,9 and often experience transphobia in health care and treatment.^5,9 Transgender persons are frequently exposed to violence, sexual assault, and harassment in everyday life, mainly because of transphobia.^5–7,9–11 Physical and sexual assaults and violence, and verbal and nonphysical harassment, derive from various perpetrators (e.g., strangers, acquaintances, partners, family members, and police officers). Transgender persons suffer from assaults, rape, and harassment at an early age, and these experiences persist throughout life.¹ A number of studies have examined violence and harassment against sexual minorities, although these have mainly focused on gay men.^12–15 A limited literature has described the prevalence of violence, transphobia, and health disparities among transgender persons.^7–9Psychological indicators such as depression and suicidal ideation and attempts have been reported among transgender persons.^{5,6,10,16–18} Transgender women of color, such as African Americans, Latinas, and Asians/Pacific Islanders (APIs), are at high risk for adverse health outcomes because of racial/ethnic minority status and gender identity,⁶ as well as for depression through exposure to transphobia.¹⁹ Although transgender persons have reported relatively high rates of using basic health care services,²⁰gender-appropriate mental health services are needed,⁵ particularly among African Americans.²¹ A lack of social support, specifically from the biological family, is commonly reported among transgender persons and is associated with discomfort and lack of security and safety in public settings.²² Sparse research exists on social support among transgender persons, although such support could ameliorate adverse psychological consequences associated with transphobia and also mitigate racial discrimination for transgender persons of color.Because of relatively high rates of unemployment, lack of career training and education, and discrimination in employment, many transgender women engage in sex work for survival.^23,24 Sex work is linked to high-risk situations, including substance abuse, unsafe sex, and sexual and physical abuse.²⁵ Physical abuse, social isolation, and the social stigma associated with sex work exacerbate transgender women''s vulnerability to mental illness and HIV risk.^5,17 High HIV seroprevalence rates among transgender women have been reported,^5,20,26–28 particularly among racial/ethnic minorities,⁵ substance users,²⁷ and sex workers.^{20,24,25,29–31} Transgender women of color face multiple adversities, such as racial and gender discrimination; transphobia; economic challenges including unemployment, substance abuse, HIV and other sexually transmitted infections; and mental illness. However, few studies have investigated racial/ethnic differences in psychological status among transgender women of color in relation to social support and exposure to transphobia.To develop culturally appropriate and transgender specific mental health promotion programs, we describe the prevalence of violence, transphobia, and social support in relation to racial/ethnic background among transgender women with a history of sex work (THSW). We also investigated the role of social support and exposure to transphobia on participants’ levels of depression.     

Sexual Minority Women and Depressive Symptoms Throughout Adulthood

Objectives. We examined the associations between depressive symptoms and sexual identity and behavior among women with or at risk for HIV.Methods. We analyzed longitudinal data from 1811 participants in the Women’s Interagency HIV Study (WIHS) from 1994 to 2013 in Brooklyn and the Bronx, New York; Chicago, Illinois; Washington, DC; and Los Angeles and San Francisco, California, by comparing depressive symptoms by baseline sexual identity and ongoing sexual behavior. We controlled for age, socioeconomic status, violence history, and substance use.Results. In separate analyses, bisexual women and women who reported having sex with both men and women during follow-up had higher unadjusted odds of depressive symptoms compared with heterosexuals and women who reported only having male sexual partners (adjusted odd ratio [AOR] = 1.36; 95% confidence interval [CI]  = 1.10, 1.69 and AOR = 1.21; 95% CI = 1.06, 1.37, respectively). Age was a significant effect modifier in multivariable analysis; sexual minority women had increased odds of depressive symptoms in early adulthood, but they did not have these odds at midlife. Odds of depressive symptoms were lower among some sexual minority women at older ages.Conclusions. Patterns of depressive symptoms over the life course of sexual minority women with or at risk for HIV might differ from heterosexual women and from patterns observed in the general aging population.Depression is a major health concern for women. According to the Centers for Disease Control and Prevention (CDC), 10% of US women reported any depression and 5% reported major depression in the previous 2 weeks.1 Depression has been reported in 19% to 62%2–4 of HIV-infected women and is associated with reduced cognitive function,5 decreased adherence to highly active antiretroviral therapy (HAART),6 higher rates of unprotected sex among substance users,7 and increased mortality.2,6Women with or at risk for HIV are often exposed to factors such as poverty,8 substance use, and violence,9–11 which can independently and jointly contribute to depression. A recent study found that any combination of intimate partner violence (IPV), substance use, and HIV infection increased the odds of depression.12 Lower socioeconomic status (SES) in women12 and HIV infection4,5 were also independently associated with depression. However, studies showed no association among HIV stage, HAART use,4,8 CD4 count,8,13 or viral load and depression.4,8,13There is a strong association between sexual minority status (i.e., women who identify as lesbian or bisexual or have female sex partners) and poor mental health. In a US survey, lifetime major depression was reported by 42% of lesbians, 52% of bisexuals, and 27% of heterosexual women (P < .01); in the same study, major depression was reported by 15% of women who have sex with women (WSW), 51% of women who have sex with men and women (WSMW), and 27% of women who have sex with men (WSM; P < .01).14 In this study, we examined 2 aspects of sexual orientation15–17: sexual identity and sexual behavior. Although sexual attraction is also considered part of an individual’s sexual orientation, data on attraction was not collected in the original study.Despite the strong association between sexual minority status and depression, it is unknown whether sexual minority status acts as an independent predictor or effect modifier of depressive symptoms among women affected by HIV, substance use, and violence. Our original hypothesis was that lesbian, bisexual, and WSMW (but not WSW) would have higher odds of depression, with race/ethnicity acting as a potential effect modifier.     

Impact of Rurality,Broiler Operations,and Community Socioeconomic Factors on the Risk of Campylobacteriosis in Maryland

Objectives. We evaluated the combined impact of community-level environmental and socioeconomic factors on the risk of campylobacteriosis.Methods. We obtained Campylobacter case data (2002–2010; n = 3694) from the Maryland Foodborne Diseases Active Surveillance Network. We obtained community-level socioeconomic and environmental data from the 2000 US Census and the 2007 US Census of Agriculture. We linked data by zip code. We derived incidence rate ratios by Poisson regressions. We mapped a subset of zip code–level characteristics.Results. In zip codes that were 100% rural, incidence rate ratios (IRRs) of campylobacteriosis were 6 times (IRR = 6.18; 95% confidence interval [CI] = 3.19, 11.97) greater than those in urban zip codes. In zip codes with broiler chicken operations, incidence rates were 1.45 times greater than those in zip codes without broilers (IRR = 1.45; 95% CI = 1.34, 1.58). We also observed higher rates in zip codes whose populations were predominantly White and had high median incomes.Conclusions. The community and environment in which one lives may significantly influence the risk of campylobacteriosis.Campylobacter is a leading cause of bacterial gastroenteritis in much of the developed and developing world.1,2 In addition to the diarrhea and vomiting associated with gastroenteritis, infection with Campylobacter can lead to more serious sequelae, such as Guillain-Barré syndrome, a demyelinating autoimmune disorder that can sometimes lead to death.3 Scallan et al.4 estimated that Campylobacter causes approximately 845 000 domestically acquired illnesses in the United States each year, along with 8463 hospitalizations and 76 deaths. Although the majority of these illnesses are estimated to be foodborne,4 attributing specific infections to specific sources has been challenging.Commonly reported risk factors for Campylobacter outbreaks include exposure to undercooked poultry,5 unpasteurized milk,6,7 and contaminated water.8 Eating in restaurants,9 not observing proper food preparation practices,10 and traveling abroad9,11 have also been associated with both outbreaks and sporadic (nonoutbreak) cases of campylobacteriosis. Additional risk factors for sporadic infections include contact with pets,5,12 contact with farm animals and livestock,13,14 and contact with animal feces.15 Significant associations of living in rural areas with risk of campylobacteriosis also have been identified in Europe and Canada.16–18 Moreover, a specific feature of rural environments—animal density—has been identified as a significant predictor of Campylobacter incidence in Canada and New Zealand.16,17Several sociodemographic risk factors for campylobacteriosis have also been identified, the 2 most consistent being gender (males) and age (< 5 years).8,16–19 Previous studies have also evaluated socioeconomic factors associated with the incidence of Campylobacter infection, and the findings suggest that these infections may occur more frequently among individuals characterized by higher socioeconomic status.16,20 Moreover, Samuel et al.21 reported that the incidence of campylobacteriosis among African Americans was lower than that among other ethnic groups across multiple sites in the United States, although hospitalization rates for this group were higher. These findings, however, may be influenced by differentials in illness reporting among varying races and ethnic groups.Nonetheless, these previous reports have largely resulted from population-based case–control studies focused on individual-level data. To our knowledge, no US study has examined the combined effect of community-level environmental and socioeconomic risk factors on the risk of campylobacteriosis. Such an analysis can be useful in (1) identifying (and possibly predicting) “hot spot” communities that bear high burdens of this illness, and (2) addressing significant research gaps concerning potential health disparities in the risk of infectious diseases.22 We linked Maryland Foodborne Diseases Active Surveillance (FoodNet) data to US Census data and US Department of Agriculture Census of Agriculture data at the zip code level to evaluate associations between community-level environmental and socioeconomic risk factors and the incidence of Campylobacter infections in Maryland.     

Elevated Risk of Posttraumatic Stress in Sexual Minority Youths: Mediation by Childhood Abuse and Gender Nonconformity

Objectives. We examined whether lifetime risk of posttraumatic stress disorder (PTSD) was elevated in sexual minority versus heterosexual youths, whether childhood abuse accounted for disparities in PTSD, and whether childhood gender nonconformity explained sexual-orientation disparities in abuse and subsequent PTSD.Methods. We used data from a population-based study (n = 9369, mean age = 22.7 years) to estimate risk ratios for PTSD. We calculated the percentage of PTSD disparities by sexual orientation accounted for by childhood abuse and gender nonconformity, and the percentage of abuse disparities by sexual orientation accounted for by gender nonconformity.Results. Sexual minorities had between 1.6 and 3.9 times greater risk of probable PTSD than heterosexuals. Child abuse victimization disparities accounted for one third to one half of PTSD disparities by sexual orientation. Higher prevalence of gender nonconformity before age 11 years partly accounted for higher prevalence of abuse exposure before age 11 years and PTSD by early adulthood in sexual minorities (range = 5.2%–33.2%).Conclusions. Clinicians, teachers, and others who work with youths should consider abuse prevention and treatment measures for gender-nonconforming children and sexual minority youths.Posttraumatic stress disorder (PTSD) has severe sequelae that can particularly affect youths by disrupting the achievement of adulthood milestones. PTSD negatively affects career prospects through elevated risk of substance abuse1 and unemployment,2 reduces educational attainment by increasing the risk of school dropout,2 and affects family formation by increasing the risk of relationship instability and adolescent pregnancy.2 Studies have also indicated that the course of PTSD is chronic in one third of cases2; identifying risk factors in children and early adulthood is therefore particularly important for public health because PTSD in adolescence or early adulthood may affect health and well-being throughout adulthood. Research indicates that lesbian, gay, and bisexual youths have higher prevalence of mental health problems than heterosexuals, including anxiety, depression, and suicidality3–6; to our knowledge, however, no studies of youths have examined the association between sexual orientation and probable PTSD in samples including both sexual minorities and heterosexuals.Childhood abuse greatly increases risk of developing PTSD.7–9 Child abuse can directly trigger PTSD,10 increase the risk of exposure to subsequent stressful events,8 and increase the conditional risk of developing PTSD following exposure to subsequent stressful events.11,12 Sexual minorities—lesbians, gay men, bisexuals, and “mostly heterosexuals”—experience higher rates of childhood abuse than do heterosexuals.13–18 Thus, disparities in childhood abuse may be a cause of higher prevalence of PTSD among sexual minority youths compared with heterosexuals.Additionally, gender-nonconforming appearance and behavior in childhood is more common among persons who will later have a minority sexual orientation.19–21 Differences in gender nonconformity may contribute to sexual-orientation disparities in maltreatment in early and middle childhood, before sexual identity has developed, as childhood gender nonconformity has been associated with parental rejection, harassment, and physical and verbal victimization related to sexual orientation.22–26We examine whether there are disparities in lifetime probable PTSD in youths by sexual orientation and whether greater exposure to child abuse may account for differences in PTSD. Additionally, we examine whether gender nonconformity accounts for higher prevalence of abuse before age 11 years and possible increased risk of PTSD among sexual minorities compared with heterosexuals. Because gender nonconformity has been associated with psychosocial stressors other than childhood abuse—namely, harassment and bullying—nonconformity may increase the risk of PTSD above and beyond its possible effects on childhood abuse. Given the high population prevalence of PTSD, its chronicity, and its associated impairment,2 identifying factors that put children and youths at risk for PTSD is vital.Although several studies have separately noted elevated prevalence of both child maltreatment and adulthood PTSD in sexual minorities,17,22 to date, only 1 study in adults has shown that higher rates of childhood abuse may partially account for higher prevalence of PTSD in sexual minorities.15 Very few studies have examined whether childhood gender nonconformity might explain elevated exposure to child abuse before adolescence24,27 or probable PTSD among sexual minorities. We examine possible sexual-orientation disparities in childhood abuse and PTSD separately by gender because studies have found gender differences in PTSD and childhood abuse.28,29 We further examine possible gender-by-sexual-orientation interactions in risk of PTSD and abuse.     

Mediation by Peer Violence Victimization of Sexual Orientation Disparities in Cancer-Related Tobacco,Alcohol, and Sexual Risk Behaviors: Pooled Youth Risk Behavior Surveys

Objectives. We examined the role of adolescent peer violence victimization (PVV) in sexual orientation disparities in cancer-related tobacco, alcohol, and sexual risk behaviors.Methods. We pooled data from the 2005 and 2007 Youth Risk Behavior Surveys. We classified youths with any same-sex sexual attraction, partners, or identity as sexual minority and the remainder as heterosexual. We had 4 indicators of tobacco and alcohol use and 4 of sexual risk and 2 PVV factors: victimization at school and carrying weapons. We stratified associations by gender and race/ethnicity.Results. PVV was related to disparities in cancer-related risk behaviors of substance use and sexual risk, with odds ratios (ORs) of 1.3 (95% confidence interval [CI] = 1.03, 1.6) to 11.3 (95% CI = 6.2, 20.8), and to being a sexual minority, with ORs of 1.4 (95% CI = 1.1, 1.9) to 5.6 (95% CI = 3.5, 8.9). PVV mediated sexual orientation disparities in substance use and sexual risk behaviors. Findings were pronounced for adolescent girls and Asian/Pacific Islanders.Conclusions. Interventions are needed to reduce PVV in schools as a way to reduce sexual orientation disparities in cancer risk across the life span.The Institute of Medicine recently reviewed the research literature on health disparities between lesbian, gay, bisexual, and transgender individuals and heterosexuals across the life span.1 It identified the significant role of stigma in the health of lesbian, gay, bisexual, and transgender individuals and areas in need of research, including disparities in cancer between sexual minorities (lesbian, gay, and bisexual persons) and heterosexuals. Behaviors that increase cancer risk (e.g., tobacco and alcohol use, unprotected sexual intercourse) may be initiated during adolescence. For sexual minorities, peer violence victimization (PVV) may partly explain disparities in cancer-related risk behaviors because such disparities between sexual minorities and heterosexuals have been attributed to the differential burden of stigma experienced by sexual minorities.1Certain behaviors place one at risk for cancer, and sexual orientation disparities exist in those cancer-related risk behaviors. Tobacco and alcohol use are risk factors for various types of cancers, such as lung, esophageal, oropharyngeal, and colon.2–8 More sexual minority adults and youths than their heterosexual peers report tobacco and alcohol use.9–18Several sexual risk behaviors (number of partners, early age of first intercourse, concurrent sexual partners, lack of condom use, and substance use during intercourse) are known to increase vulnerability to infection with, for example, human papillomavirus (HPV)19–29 and hepatitis B.30,31 Women who have sex with women have elevated rates of such sexual risk behaviors relative to women who only have sex with men.32–34 Women who only have sex with women are less likely to be screened for sexually transmitted infections,33,35,36 despite the risk of HPV transmission during female-to-female sexual intercourse.37 HPV in men is important because it is linked to anal, oral, and penile cancers.24,38 The risk of cancer-related sexual behaviors may be elevated among sexual minority men, because of the links between anal intercourse, HPV, and anal cancer,39 especially among men who are HIV positive.40 Hepatitis B has been linked to liver cancer41 and increased risk of anal HPV among men.31