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Associations between forced sex, sexual and protective practices, and sexually transmitted diseases among a national sample of adolescent girls

      Abstract

      Objective

      The main objective of this study is to better understand the associations between forced sex history and history of sexually transmitted disease (STD) infection. Three research questions are investigated. Is history of forced sex associated with risk-taking behaviors? Are these risk-taking behaviors associated with history of STD? Is history of forced sex independently associated with history of STD?

      Methods

      Information on the sexual and STD histories is obtained from 3,579 sexually active adolescent girls using data from the National Longitudinal Study of Adolescent Health. Weighted logistic and OLS regressions are employed, using techniques that account for the complex sampling design.

      Results

      Girls with a history of forced sex are significantly more likely to have a greater number of sexual partners, be younger at first sex, and be more likely to use alcohol or drugs at last sex; there is no difference in condom use at last sex. These factors, in turn, are significantly associated with a positive STD history. Condom use at last sex is negatively associated with ever having had an STD. When all five sexual and protective practices are investigated simultaneously, history of forced sex remains significantly associated with STD history (odds ratio [OR] = 1.39, p = .014); number of sexual partners and early onset of sex remain significant. Condom use and substance use at last sex reduce to marginal significance.

      Conclusions

      These results suggest that a history of forced sex is independently associated with a history of STD among sexually active adolescent girls. Programmatic strategies aimed at reducing STDs through encouraging responsible sexual behavior would potentially benefit from also including a component that addresses sexual victimization.

      Keywords

      Introduction

      Compared to adults, adolescents are at higher risk for acquiring sexually transmitted diseases (STD), and adolescent girls in particular are disproportionately affected (
      Centers for Disease Control and Prevention (CDC)Centers for Disease Control and Prevention (CDC)
      Sexually Transmitted Disease Surveillance, 2001.
      ). In 2001, adolescent girls had the highest rates of chlamydia and gonorrhea compared to all other gender and age categories (
      Centers for Disease Control and Prevention (CDC)Centers for Disease Control and Prevention (CDC)
      Sexually Transmitted Disease Surveillance, 2001.
      ). Moreover, adolescent girls have high rates of other sexually transmitted infections such as genital herpes, trichomonas, and bacterial vaginosis that are not reported as part of the CDC surveillance system (
      • Berman S
      • Hein K
      Adolescents and STDs.
      ). These statistics, along with the evidence that many cases of STDs are asymptomatic in women (
      • Biro F.M
      • Rosenthal S.L
      • Kiniyalocts M
      Gonoccocal and chlamydial genitourinary infections in symptomatic and asymptomatic adolescent women.
      ,
      • Farley T.A
      • Cohen D.A
      • Elkins W
      Asymptomatic sexually transmitted diseases The case for screening.
      ) and that untreated STDs contribute to long-term reproductive health sequelae (
      ), suggest a substantial burden of disease among adolescent girls. STDs, including human immunodeficiency virus (HIV) infections and acquired immunodeficiency syndrome (AIDS), continue to be a prominent public health priority, and Healthy People 2010 objectives highlight responsible sexual behavior as a key health indicator and target adolescents as an epidemiologically significant group (
      U.S. Department of Health and Human Services (USDHHS)U.S. Department of Health and Human Services (USDHHS)
      Healthy People 2010 Understanding and Improving Health.
      ).
      A complex matrix of behavioral, biological, and social factors contributes to the likelihood of contracting a STD. During adolescence, girls are more likely to engage in riskier sexual and contraceptive practices, are part of sexual networks that increase their risk, and have increased physiologic susceptibility of infection
      Although not the focus of this research, the heightened physiologic risk is because of increased cervical ectopy present in adolescent girls (
      ).
      than older women (
      • Berman S
      • Hein K
      Adolescents and STDs.
      ). Sexual and protective practices that have been consistently shown to affect the acquisition of STDs include the number of sexual partners (
      ,
      • Miller H.G
      • Cain V.S
      • Rogers S.M
      • Gribble J.N
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      • Coker A.L
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      ,
      • Miller H.G
      • Cain V.S
      • Rogers S.M
      • Gribble J.N
      • Turner C.F
      Correlates of sexually transmitted bacterial infections among U.S. women in 1995.
      ), substance use and substance use during sex (
      • Anderson J.E
      • Dahlberg L.L
      High-risk sexual behavior in the general population. Results from a national survey, 1988–1990.
      ,
      • Fergusson D.M
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      ), and condom use (
      • Cates W
      • Stone K.M
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      ,
      Centers for Disease Control and Prevention (CDC)Centers for Disease Control and Prevention (CDC)
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      ,
      • Upchurch D.M
      • Ray P
      • Reichart C
      • Celentano D.D
      • Quinn T
      • Hook III, E.W
      Prevalence and patterns of condom use among patients attending a sexually transmitted disease clinic.
      ,
      • Weller S.C
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      ). Number of sexual partners serves as both a direct measure of exposure as well as a proxy for other related risk-taking behaviors and beliefs (
      • Aral S.O
      Sexual behavior in sexually transmitted disease research. An overview.
      ,
      ). Similarly, early age at sexual initiation may place girls at greater risk for STDs because they are sexually active for a longer period (a duration effect) and because it may be correlated with other risk-taking behaviors (
      • Aral S.O
      Sexual behavior in sexually transmitted disease research. An overview.
      ,
      • Greenberg J
      • Magder L
      • Aral S
      Age at first coitus A marker for risky sexual behavior.
      ). Alcohol and/or drug use during sexual activity reduces sexual inhibitions, impairs judgment, and reduces the likelihood of engaging in protective behaviors (
      • Caetano R
      • Hines A.M
      Alcohol, sexual practices, and risk of AIDS among blacks, Hispanics, and whites.
      ,
      • Ericksen K.P
      • Trocki K.F
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      ). Last, condom use is a key protective behavior to reduce risk of STD transmission and acquisition (
      Centers for Disease Control and Prevention (CDC)Centers for Disease Control and Prevention (CDC)
      Update Barrier protection against HIV infection and other sexually transmitted diseases.
      ,

      National Institute of Allergy and Infectious Diseases (NIAID). (2001). Workshop summary: Scientific evidence on condom effectiveness for sexually transmitted disease (STD) prevention, July 12–13, 2000. Herndon, VA

      ) and increasing condom use is a priority identified in Healthy People 2010 (
      U.S. Department of Health and Human Services (USDHHS)U.S. Department of Health and Human Services (USDHHS)
      Healthy People 2010 Understanding and Improving Health.
      ). Although measurement of condom behavior is complex, there is growing agreement among researchers that condom use at last sex serves as a reasonable proxy for ongoing behavior and has been shown to give similar results to frequency of use measures (

      Anderson, J. E., Rietmeijer, C., Wilson, R., & Barker, P. (1998). Asking about condom use: Is there a standard approach that should be adopted across surveys? In 1998 Proceedings, American Statistical Association, Section on Survey Research Methods (pp. 873–877). Alexandria, VA: American Statistical Association

      ). Moreover, respondents are able to report last-time measures more accurately than reconstructing detailed histories (
      • Sudman S
      • Bradburn N
      • Schwarz N
      Thinking about answers.
      ). In the current work, we propose that all of these behaviors influence the likelihood that adolescent girls have ever had an STD.
      In addition, a history of forced sex victimization
      Throughout the remainder of the paper, forced sex victimization is defined as ever being physically forced to have sexual intercourse against ones' will. We acknowledge that this definition captures only a portion of all sexual victimization.
      is associated with an increased risk of having had a STD, including HIV/AIDS (
      • Hogben M
      • Gange S.J
      • Watts D.H
      • Robison E
      • Young M
      • Richardson J
      • et al.
      The effect of sexual and physical violence on risky sexual behavior and STDs among a cohort of HIV seropositive women.
      ,
      ,
      • Lechner M.E
      • Vogel M.E
      • Garcia-Shelton L.M
      • Leichter J.L
      • Steibel K.R
      Self-reported medical problems of adult female survivors of childhood sexual abuse.
      ,
      • Molitor F
      • Ruiz J.D
      • Klausner J.D
      • McFarland W
      History of forced sex in association with drug use and sexual HIV risk behaviors, infection with STDs, and diagnostic medical care. Results from the Young Women Survey.
      ,
      • Wingood G.M
      • DiClemente R.J
      Child sexual abuse, HIV sexual risk, and gender relations of African-American women.
      ,
      • Wyatt G.E
      • Myers H.F
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      • Kitchen C.R
      • Loeb T
      • Carmona J.V
      • et al.
      Does a history of trauma contribute to HIV risk for women of color? Implications for prevention and policy.
      ). This is, in part, because women with a history of forced sex are also more likely to engage in risk-taking behaviors such as those described. Women with a history of forced sex are more likely to have a greater number of sexual partners (
      • Fergusson D.M
      • Horwood L.J
      • Lynskey M.T
      Childhood sexual abuse, adolescent sexual behaviors and sexual revictimization.
      ,
      • Hillis S.D
      • Anda R.F
      • Felitti V.J
      • Marchbanks P.A
      Adverse childhood experiences and sexual risk behaviors A retrospective cohort study.
      ,
      • Lechner M.E
      • Vogel M.E
      • Garcia-Shelton L.M
      • Leichter J.L
      • Steibel K.R
      Self-reported medical problems of adult female survivors of childhood sexual abuse.
      ,
      • Raj A
      • Silverman J.G
      • Amaro H
      The relationship between sexual abuse and sexual risk among high school students Findings from the 1997 Massachusetts Youth Risk Behavior Survey.
      ,
      • Stock J.L
      • Bell M.A
      • Boyer D.K
      • Connell F.A
      Adolescent pregnancy and sexual risk-taking among sexually abused girls.
      ), have younger ages at first sex (
      • Fergusson D.M
      • Horwood L.J
      • Lynskey M.T
      Childhood sexual abuse, adolescent sexual behaviors and sexual revictimization.
      ,
      • Miller B.C
      • Monson B.H
      • Norton M.C
      The effects of forced sexual intercourse on white female adolescents.
      ,
      • Nagy S
      • DiClemente R
      • Adcock A.G
      Adverse factors associated with forced sex among southern adolescent girls.
      ), are more likely to have substance use problems or to use alcohol and/or drugs during sex (
      • Hernandez J.T
      Substance abuse among sexually abused adolescents and their families.
      ,
      • Shrier L.A
      • Pierce J.D
      • Emans S.J
      • DuRant R.H
      Gender differences in risk behaviors associated with forced or pressured sex.
      ,
      • Wilsnack S.C
      • Vogeltanz N.D
      • Klassen A.D
      • Harris T.R
      Childhood sexual abuse and women's substance abuse National survey findings.
      ), and are less likely to use condoms (
      • Fergusson D.M
      • Horwood L.J
      • Lynskey M.T
      Childhood sexual abuse, adolescent sexual behaviors and sexual revictimization.
      ,
      • Shrier L.A
      • Pierce J.D
      • Emans S.J
      • DuRant R.H
      Gender differences in risk behaviors associated with forced or pressured sex.
      ,
      • Molitor F
      • Ruiz J.D
      • Klausner J.D
      • McFarland W
      History of forced sex in association with drug use and sexual HIV risk behaviors, infection with STDs, and diagnostic medical care. Results from the Young Women Survey.
      ) than women with no history of forced sex. Thus, we hypothesize that a history of forced sex is associated with these risk-related behaviors. Moreover, we hypothesize that these risk-related behaviors are associated with a positive STD history.
      The main objective of this study is to better understand the association between a history of forced sex and ever having had an STD in a national sample of sexually active adolescent girls. Our conceptual framework regards a history of forced sexual intercourse as the focal variable and posits links between forced sex, sexual and protective practices, and STDs. That is, we propose that forced sex is antecedent to having had an STD and that the effects of forced sex can be explained, in part, by a set of variables that characterize sexual and protective practices, which in turn, are associated with STDs. Three related research questions are investigated. First, are girls with a history of forced sex more likely to engage in risky sexual behaviors and less likely to engage in protective ones? Second, to what extent are these sexual and protective practices associated with the likelihood of ever having had an STD? Finally, are girls with a history of forced sex more likely to have had an STD, and does this effect remain after controlling for the set of variables that characterize sexual and protective practices? Because STD risk varies by race and ethnicity as well as other sociodemographic factors (
      Centers for Disease Control and Prevention (CDC)Centers for Disease Control and Prevention (CDC)
      Sexually Transmitted Disease Surveillance, 2001.
      ), we include a comprehensive set of these variables in all of our multivariate models.

      Data and methods

      The data used for this analysis are from the first wave (Wave I) of the National Longitudinal Study of Adolescent Health (Add Health), a survey designed to assess the health status of adolescents in the United States (

      Bearman, P. S., Jones, J., Udry, J. R. (1997). The National Longitudinal Study of Adolescent Health: Research Design. Available: http://www.cpc.unc.edu/projects/addhealth/design. Accessed May 1, 2004

      ). The sampling frame consists of all U.S. high schools; younger students were sampled from one “feeder” school that included a 7th grade and sent graduates to one of the sampled high schools. Each participating school provided a student roster, which constitutes the student-level sampling frame. From that listing, a baseline sample was drawn consisting of a core sample and several special oversamples. The core sample is a probability sample of 12,105 and is nationally representative of adolescents enrolled in grades 7 through 12 during the 1994–1995 academic year. The oversamples include specific ethnic groups, disabled adolescents, and biologically related adolescents. The combined Wave I sample is 20,745; approximately half of the sample is female (10,480). The data used for this analysis are drawn from this base sample of girls and include sexually active girls only (defined below). Because we are interested in population-based estimates, observations that do not have Wave I sample weights are dropped from our analytic sample. Further drops for consistently poor data quality, missing data on sexual, STD, or forced sex history, or being American Indian or Other races,
      Adolescents who identified as American Indian or Other races are excluded from this analysis because of the limited number of cases and the heterogeneity of the Other race category.
      resulted in a final analytic sample of 3,579. (The vast majority of dropped observations were because they were male, not sexually active girls, or did not have a sample weight. Only a small number of observations were dropped because of incomplete or missing data on the variables of interest.)

      Variable description and measurement

      Respondents were asked by audio-CASI (computer-assisted self-interview) about their sexual, STD, and forced sex histories. Information on STD history, history of forced sex, and other sex-related behaviors is asked only for those who responded affirmatively to ever having had sexual intercourse. Specifically, all respondents were asked, “Have you ever had sexual intercourse? When we say intercourse, we mean when a male inserts his penis into a female's vagina.” Responses to this item were used to determine the sexually active subsample of adolescent girls.

      Std outcome

      The dependent variable of interest is lifetime history of any STD. For our purposes, history of STD is operationalized based on the following questions. Respondents were asked, “Have you ever been told by a doctor or nurse that you had…” for each of the following STDs: 1) chlamydia, 2) syphilis, 3) gonorrhea, 4) HIV or AIDS, 5) genital herpes, 6) genital warts, 7) trichomoniasis, 8) hepatitis B, and for females, 9) bacterial vaginosis, and 10) nongonoccocal vaginitis. The outcome is a binary response and is coded Y = 1 if the respondent reported yes to any of these STDs, Y = 0 otherwise.

      Sexual and protective practices

      Five behaviors are considered. Lifetime number of sexual partners is based on information from several questions on romantic relationships and the occurrence of sexual activity outside the context of romantic relationships. From these questions, we were able to create the total number of sexual partners that the respondent had ever had.
      Respondents who were sexually active but were missing data on this variable were assigned the race/ethnic and gender-specific mean number of sexual partners.
      Because the distribution of this variable is highly skewed toward 1, the final variable is the natural log of the lifetime number of sexual partners. Early onset of sexual activity is based on the question about sexual intercourse (see above) and an additional question on the date of first sex. The final variable is a dichotomy and is operationalized as less than age 14.
      Because we were concerned about losing cases in which there was missing information on date of first intercourse, for all analyses, we include a flag for cases with incomplete or missing date information, thus keeping all observations in the analysis. The flag was never significant in any of the analyses.
      Alcohol and/or drug use during the last sexual encounter is also measured as a dichotomy. Similarly, condom use at last sex is measured as a dichotomy. Last, the measure of history of forced sex is based on responses to the following question, “Were you ever physically forced to have sexual intercourse against your will?” It is also coded as a dichotomy.

      Control variables

      Age is measured in years and is a continuous variable. We created a race/ethnicity composite measure that gives priority to any mention of being Hispanic, with the following categories: 1) non-Hispanic white; 2) non-Hispanic African American; 3) Hispanic; and 4) non-Hispanic Asian American. This polytomy enters into the regressions as a set of dummy variables with non-Hispanic whites as the reference category. Family structure is coded into eight categories: 1) two biological parents, 2) biological mother and stepfather, 3) biological father and stepmother, 4) biological mother and cohabiting partner, 5) biological father and cohabiting partner, 6) biological mother only, 7) biological father only, and 8) other situations. Again, this polytomous variable enters into the regressions as a set of dummy variables, with two biological parents as the reference category. Mothers' and fathers' education are coded as years of school completed.
      For a resident parent whose education was not reported, the missing value was imputed using weighted mean education, stratified by the gender of the parent and the race/ethnicity of the adolescent (parental race/ethnicity was not available).
      The logarithm of the 1994 household income is also included.
      Where missing, values were imputed using OLS regression that included mother's and father's education, family structure, the number of hours worked by the father and/or mother, and whether or not the mother and/or father received public assistance.

      Analytic strategy

      To address our three research questions, we employ three related analyses using the sexually active sample of girls. First, we investigate the effects of forced sex history on each of the sexual and protective practices of interest. Four separate regression models are estimated. OLS regression is used to estimate the effects of forced sex on the (logged) lifetime number of sexual partners. For early onset of sex, substance use at last sex, and condom use at last sex, each outcome is a binary response and is coded Y = 1 if yes and Y = 0 if no; logistic regression is used for these outcomes. For the second analysis, we examine the effects of each of the sexual and protective practices, including forced sex, on the odds of ever having had a STD; again, logistic regression is employed. Five separate models are estimated with each behavior of interest analyzed separately. For the third analysis, we include all five behaviors of interest simultaneously to examine whether the effects of history of forced sex on STD history are diminished after controlling for number of sexual partners, early onset of sexual intercourse, substance use at last sex, and condom use at last sex, using logistic regression. For all three analyses, we control for age, race and ethnicity, family structure, parents' education, and household income. Also, all analyses are weighted and the standard errors of the coefficients are adjusted for the complex sample design (
      • Chantala K
      • Tabor J
      Strategies to Perform a Design-Based Analysis Using the Add Health Data.
      ) using Stata 8 (
      StataCorp.StataCorp.
      Stata Statistical Software: Release 8.0.
      ). For ease of presentation and interpretation, we present the adjusted odds ratios (OR) and 95% confidence intervals (CI) for the key variables of interest.

      Results

      Table 1 shows the sociodemographic characteristics and sexual and protective behaviors for the sexually active sample of adolescent girls in the Add Health survey. The average age of girls in the sample is 16.4 years (range 12 to 21). Two-thirds of the sample is white, 22.5% is African American, 10.2% is Hispanic, and only 1.9% is Asian American. Slightly over 40% of girls live with both biological parents, another 24.5% live with their biological mother only, 11.7% live in stepfamilies, and the remaining live with a biological parent and parent's cohabiting partner (7.8%), with biological father only (3.0%), or in other situations (12.1%). Among girls with a resident mother and/or father, the mean number of years of schooling for each parent corresponds to slightly more than high school completion. The average household income for 1994 is $37,936.
      Because the sample includes only those girls who were sexually active by the Wave I interview, we investigated how these girls differ from the full sample of girls. Sexually active girls were significantly more likely to be older, African American (compared to white), live in stepfamilies (compared to living with two biological parents), and have parents with less education. Compared to white girls, sexually active girls were significantly less likely to be Hispanic or Asian American. (Results are available from the authors.)
      Table 1Descriptive statistics of sexually active adolescent girls, Add Health
      VariablePercentage or mean
      Age at Wave I (mean)16.4
      Race and ethnicity
      White65.4
      African American22.5
      Hispanic10.2
      Asian American1.9
      Family structure
      Two biological parents40.9
      Biological mother/stepfather10.1
      Biological father/stepmother1.6
      Biological mother/cohabiting partner6.9
      Biological father/cohabiting partner.9
      Biological mother only24.5
      Biological father only3.0
      Other situations12.1
      Parents' education
      Mother's education (mean years)12.8
      Father's education (mean years)12.9
      1994 household income$37,936
      Lifetime number of sexual partners (mean)3.4
      Age at first sex younger than 1421.3
      Used alcohol or drugs at last sex8.0
      Used a condom at last sex49.7
      Ever forced to have sex20.3
      Ever had a STD11.2
      N3,579
      Note: N is unweighted; percentages and means are weighted. N = 3,579, except for maternal and paternal education, for which Ns are appropriately reduced for girls living in families lacking a mother or father.
      On average, girls report 3.4 sexual partners in their lifetime. Over one in five girls (21.3%) reported an age at first sexual intercourse younger than age 14. Eight percent report using alcohol and/or drugs at last intercourse and almost half (49.7%) of them report using a condom at last intercourse. Last, 20.3% of sexually active girls report that they had ever been forced to have sexual intercourse and 11.2% report they have ever had an STD.
      Table 2 presents the adjusted ORs and 95% CI for the effects of forced sex on each of the four variables that characterize the sexual and protective practices of interest. All four models control for age, race and ethnicity, family structure, parents' education, and household income.
      The full set of estimates for all tables is available from the authors.
      Girls with a history of forced sex have significantly higher odds of having a greater number of lifetime partners than those with no history. Moreover, girls with a history of forced sex are significantly more likely to report an age at first sex that is younger than age 14 and are significantly more likely to have used alcohol and/or drugs during their last sexual encounter. Although not significant, girls with a history of forced sex are less likely to have used a condom at last sex. Overall, this set of results generally supports our hypothesis that a history of forced sex is associated with increased odds of engaging in higher risk sexual behaviors and lower odds of engaging in the protective behavior we examined (i.e., condom use), although not significant.
      Table 2Adjusted OR and 95% CI for effects of forced sex on each sexual and protective practice among sexually active adolescent girls, Add Health (N = 3,579)
      Sexual and protective practices (outcome)Odds ratio forforced sex95% CIp-value
      Lifetime number of sexual partners (ln)1.56(1.43, 1.70).000
      Age at first sex younger than 142.11(1.58, 2.83).000
      Used alcohol or drugs at last sex1.72(1.17, 2.51).006
      Used a condom at last sex0.84(0.68, 1.04).110
      Note: Results represent four separate regressions for each of the four risk behaviors. All models control for age, race/ethnicity, family structure, parents' education, and household income.
      Abbreviations: CI, confidence interval; OR, odds ratio.
      In Table 3, we present the adjusted ORs for each of the sexual and protective practices that we hypothesize are associated with ever having had an STD. All five models control for age, race and ethnicity, family structure, parents' education, and household income. As expected, as the number of lifetime partners increases, the odds of a positive history of STD significantly increase. Similarly, girls with younger ages at first sex have significantly higher odds of positive STD history than those with older ages. Girls who used alcohol and/or drugs at last sex have significantly higher odds of positive STD history than those who did not. In contrast, girls who used a condom at last sex have significantly lower odds of positive STD history. Last, girls with a history of forced sex have significantly higher odds of ever having had an STD than those with no history (OR = 1.99). These results support our hypothesis that each of these sexual and protective practices is associated with ever having had an STD.
      Table 3Adjusted OR and 95% CI for each sexual and protective practice associated with history of STD among sexually active girls, Add Health (N = 3,579)
      Sexual and protective practicesOR95% CIp-value
      Lifetime number of sexual partners (ln)2.18(1.89, 2.53).000
      Age at first sex younger than 142.30(1.59, 3.34).000
      Used alcohol or drugs at last sex2.33(1.49, 3.63).000
      Used a condom at last sex0.67(0.49, 0.91).011
      Forced sex1.99(1.57, 2.52).000
      Note: Results represent five separate logistic regressions for each of the five risk behaviors. All models control for age, race/ethnicity, family structure, parents' education, and household income.
      Abbreviations: CI, confidence interval; OR, odds ratio; STD, sexually transmitted disease.
      Table 4 presents the results from the full model that includes forced sex and all sexual and protective practices simultaneously as well as the sociodemographic control variables. Here, we also present the findings for age and race and ethnicity.
      Although we also control for family structure, parents' education, and household income, none of these variables were significantly associated with ever having had a STD.
      When all five behaviors are included in the model, the effects are reduced for each behavior and reduced to only marginal significance for two of the behaviors (alcohol and/or drug use at last sex and condom use at last sex). Number of lifetime sexual partners is significantly associated with history of STD; as the number of partners increases, so does the odds of ever having an STD. Also, girls with a young age of onset of sexual intercourse have significantly higher odds of ever having had an STD than those who delay. Similarly, history of forced sex remains significantly associated with history of STD after controlling for all other sexual and protective practices: girls with a history of forced sex are more likely to ever have a STD (OR = 1.39) than those who do not. (To better highlight the temporal sequencing of the report of forced sex and STD acquisition, we performed an additional analysis, constrained in the following manner. We examined whether a history of forced sex reported at the Wave I interview was predictive of incident STD reported at Wave II. We found that girls with a history of forced sex reported at Wave I were significantly more likely to report incident STD at Wave II [OR = 1.52, p = .04] compared to girls with no history of forced sex [results not shown].) As expected, the odds of having a positive STD history significantly increase with age. Compared to whites, African American girls have significantly higher odds of ever having had an STD, as do Asian American girls.
      Table 4Adjusted OR and 95% CI for sexual and protective practices and sociodemographic characteristics associated with history of STD among sexually active girls, Add Health (N = 3,579)
      CovariatesOR95% CIp-value
      Lifetime number of sexual partners (ln)1.94(1.65, 2.28).000
      Age at first sex younger than 141.44(1.01, 2.05).045
      Used alcohol or drugs at last sex1.49(0.94, 2.35).086
      Used a condom at last sex0.76(0.56, 1.03).072
      Forced sex1.39(1.07, 1.81).014
      Age1.41(1.26, 1.59).000
      Race/ethnicity (white)
      African American3.45(2.50, 4.77).000
      Hispanic1.16(0.63, 2.15).635
      Asian American2.67(1.16, 6.17).022
      Note: Results based on final full model that includes all risk factors simultaneously and controls for family structure, parents' education, and household income.
      Abbreviations: CI, confidence interval; OR, odds ratio; STD, sexually transmitted disease.

      Discussion

      Overall, our key hypotheses are confirmed by the findings from this study. Girls with a history of forced sex are more likely to engage in riskier sexual practices and marginally less likely to use condoms than girls who do not have a history of forced sex. In turn, these riskier practices increase the likelihood of ever having had an STD and condom use marginally decreases the likelihood of ever having a STD. Moreover, the associations between forced sex history and ever having had an STD persist after controlling for the other sexual and protective practices. Thus, the association between history of forced sex and history of STD are only partially explained by differences in numbers of sexual partners, early onset of sex, substance use during sex, and condom use.
      Our findings confirm that multiple sexual and protective practices are associated with STDs, in the expected directions. Girls with greater numbers of sexual partners or who began sexual activity at younger ages are more likely to have a positive STD history when compared to girls with fewer partners or who delayed onset. Although we did not attempt to disentangle the extent to which these variables are measuring “exposure” or “selection” effects, we suspect that they are capturing both. Girls with multiple partners are more likely to be part of sexual networks with multiple concurrent partnerships linking them to chains of infection that increase their risk of acquiring an STD (
      ,
      • Morris M
      Sexual networks and HIV.
      ).
      Although we believe that concurrency is an important risk behavior and is associated with increased risk of STDs, we were unable to obtain a comprehensive measure of concurrency using the Add Health data because respondents were only asked about dates of sexual relationships for some of their relationships.
      Girls with multiple partners may also exhibit psychosocial traits that characterize them as greater risk takers than girls with fewer partners (
      • Basen-Engquist K
      • Parcel G.S
      Attitudes, norms, and self-efficacy A model of adolescents' HIV-related sexual risk behavior.
      ,
      • Boyer C.B
      • Shafer M
      • Wibbelsman C.J
      • Seeberg D
      • Teitle E
      • Lovell N
      Associations of sociodemographic, psychosocial, and behavioral factors with sexual risk and sexually transmitted diseases in teen clinic patients.
      ,
      • Millstein S.G
      • Moscicki A
      Sexually transmitted disease in female adolescents Effects of psychosocial factors and high risk behaviors.
      ). (We also examined the effects of number of recent [past 18 months] sexual partners on STD history; the results were similar.) Similarly, early onset of sexual activity may reflect both a duration effect as well as other underlying risk-taking propensities (
      • Aral S.O
      Sexual behavior in sexually transmitted disease research. An overview.
      ,
      • Greenberg J
      • Magder L
      • Aral S
      Age at first coitus A marker for risky sexual behavior.
      ). We note, however, that we control for current age in all models, suggesting that the effects of early onset on sexual activity may be tapping into a portion of this risk-taking dimension.
      Girls who used alcohol or drugs during their most recent sexual experience are also more likely to have had an STD, although this effect reduces to marginal significance when all sexual and protective behaviors are simultaneously included in the model. Several possible explanations have been proposed, although there is no clear consensus on a definitive causal mechanism linking substance use, risky sexual behavior, and STDs (for a review see
      • Leigh B.C
      • Stall R
      Substance use and risky sexual behavior for exposure to HIV. Issues in methodology, interpretation, and prevention.
      ). Some argue that the relationship can be explained as a result of the disinhibiting effects of alcohol and drugs, which may encourage sexual experimentation (e.g.,
      • Ericksen K.P
      • Trocki K.F
      Behavioral risk factors for sexually transmitted diseases in American households.
      ,
      • Strunin L
      • Hingson R
      Alcohol, drugs, and adolescent sexual behavior.
      ), whereas others argue that individuals who believe that alcohol and drugs promote risky sexual behaviors are more likely to engage in these behaviors when intoxicated (
      • Dermen K.H
      • Cooper M.L
      • Agocha V.B
      Sex-related alcohol expectancies as moderators of the relationship between alcohol use and risky sex in adolescents.
      ). Still others find no relationship between substance use (in this case alcohol) and engaging in risky sexual behaviors (
      • Morrison D.M
      • Gillmore M.R
      • Hoppe M.J
      • Gaylord J
      • Leigh B.C
      • Rainey D
      Adolescent drinking and sex Findings from a daily diary study.
      ). Because this was not the focus of our analysis, we choose to remain somewhat agnostic on the issues of causality; additional analysis is necessary to more fully elaborate the relationship between substance use during sex and risk of STDs. With respect to condom use at last sex, we find that girls who used condoms are less likely to have had an STD, but this effect also reduces to marginal significance in the full model. Issues of measurement are a continuing concern among researchers attempting to assess condom effectiveness and STD risk (

      National Institute of Allergy and Infectious Diseases (NIAID). (2001). Workshop summary: Scientific evidence on condom effectiveness for sexually transmitted disease (STD) prevention, July 12–13, 2000. Herndon, VA

      ,
      • Weller S.C
      A meta-analysis of condom effectiveness in reducing sexually transmitted HIV.
      ). In fact, our measure of condom use (last sex) is probably consequent to the majority of reported STD infections. We chose to use this particular measure because it references a specific sex act, has been shown to correlate well with ongoing behavior, and yields results that are similar to frequency of use measures (e.g.,

      Anderson, J. E., Rietmeijer, C., Wilson, R., & Barker, P. (1998). Asking about condom use: Is there a standard approach that should be adopted across surveys? In 1998 Proceedings, American Statistical Association, Section on Survey Research Methods (pp. 873–877). Alexandria, VA: American Statistical Association

      ,
      • Anderson J.E
      • Wilson R
      • Doll L
      • Jones T.S
      • Barker P
      Condom use and HIV risk behaviors among U.S. adults Data from a national survey.
      ,
      • Santelli J.S
      • Warren C.W
      • Lowry R
      • Sogolow E
      • Collins J
      • Kann L
      • et al.
      The use of condoms with other contraceptive methods among young men and women.
      ). Also, we chose to measure condom use at last sex because of our interest in examining the relationship between forced sex and subsequent condom use. Thus, given the literature and the multiple research questions addressed in this work, we believe condom use at last sex is a reasonable measure. Nevertheless, we acknowledge the multidimensionality of condom use behavior and note that it is often relationship specific (
      • Katz B.P
      • Fortenberry J.D
      • Zimet G.D
      • Blythe M.J
      • Orr D.P
      Partner-specific relationship characteristics and condom use among young people with sexually transmitted diseases.
      ,
      • Upchurch D.M
      • Brady W.E
      • Reichart C.A
      • Hook III, E.W
      Behavioral contributions to acquisition of gonorrhea in patients attending an inner city sexually transmitted disease clinic.
      ). Further elaborating the patterns of condom use and the ways in which these patterns influence risk of STD is part of our ongoing research.
      Because one reviewer was concerned that our measures of substance and condom use at last sex were behaviors that occurred subsequent to STD infection, we conducted two additional analyses. We first omitted these two variables from our original specification; the results for number of sexual partners and early onset remained unchanged. In a third specification, we replaced these measures with substance and condom use at first sex; the results were essentially the same. (Results are available from the authors.)
      Sexually active African American girls are substantially more likely to have a positive history of STD than sexually active white girls after controlling for multiple sexual and protective behaviors; these results have been demonstrated by others (
      Centers for Disease Control and Prevention (CDC)Centers for Disease Control and Prevention (CDC)
      Sexually Transmitted Disease Surveillance, 2001.
      ,
      • Miller H.G
      • Cain V.S
      • Rogers S.M
      • Gribble J.N
      • Turner C.F
      Correlates of sexually transmitted bacterial infections among U.S. women in 1995.
      ,
      • Tanfer K
      • Cubbins L.A
      • Billy J.O.G
      Gender, race, class and self-reported sexually transmitted disease incidence.
      ). Other research suggests that African American girls do not necessarily engage in higher risk behaviors than white girls,
      We performed additional analyses that, overall, support this statement. African American girls were not significantly different than whites in their numbers of sexual partners, were significantly more likely to use condoms at last sex, and were significantly less likely to use alcohol and/or drugs at last sex. They were, however, significantly more likely than white girls to have begun sex at younger ages. (Results are available from the authors.)
      rather their increased risk is due to higher prevalence rates of STDs in their sexual networks because the networks are somewhat more “closed” than those of other race and ethnic groups (
      • Ellen J.M
      • Aral S.O
      • Madger L.S
      Do differences in sexual behaviors account for the racial/ethnic differences in adolescents' self-reported history of a sexually transmitted disease?.
      ,
      • Ford K
      • Norris A
      Sexual networks of African-American and Hispanic youth.
      ,
      ,
      • Laumann E.O
      • Youm Y
      Racial/ethnic group differences in the prevalence of sexually transmitted diseases in the United States A network explanation.
      ). We also find that sexually active Asian American girls are significantly more likely to have a positive history of STD than sexually active white girls, again after controlling for differences in sexual and protective practices. Although Asian American girls are less likely than white girls to be sexually active (
      • Hou S
      • Basen-Engquist K
      Human immunodeficiency virus risk behavior among white and Asian/Pacific Islander high school students in the United States Does culture make a difference?.
      ,
      • Schuster M.A
      • Bell R.M
      • Nakajima G.A
      • Kanouse D.E
      The sexual practices of Asian and Pacific Islander high school students.
      ,

      Upchurch, D. M., Mason, W. M., Kusunoki, Y. (2003, July). The influences of multiple social contexts on the time to first sex. Paper presented at the annual Add Health User's Workshop, Bethesda, MD

      ), once they are sexually active they are more likely to acquire an STD, in part, because they are somewhat more likely to engage in higher risk behaviors (
      Centers for Disease Control and Prevention (CDC)Centers for Disease Control and Prevention (CDC)
      Sexually Transmitted Disease Surveillance, 2001.
      ,
      • Hou S
      • Basen-Engquist K
      Human immunodeficiency virus risk behavior among white and Asian/Pacific Islander high school students in the United States Does culture make a difference?.
      ,
      • Schuster M.A
      • Bell R.M
      • Nakajima G.A
      • Kanouse D.E
      The sexual practices of Asian and Pacific Islander high school students.
      ). The persistent race and ethnic differences in risk for STDs suggest the importance of investigating the influences of factors beyond individual behaviors, including relationship characteristics, partner concurrency, sexual networks, and underlying disease prevalence (
      • Howard M.M
      • Fortenberry J.D
      • Blythe M.J
      • Zimet G.D
      • Orr D.P
      Patterns of sexual partnerships among adolescent females.
      ,
      • Katz B.P
      • Fortenberry J.D
      • Zimet G.D
      • Blythe M.J
      • Orr D.P
      Partner-specific relationship characteristics and condom use among young people with sexually transmitted diseases.
      ,
      • Laumann E.O
      • Youm Y
      Racial/ethnic group differences in the prevalence of sexually transmitted diseases in the United States A network explanation.
      ,
      • Morris M
      Sexual networks and HIV.
      ,
      • Zenilman J.M
      • Ellish N
      • Fresia A
      • Glass G
      The geography of sexual partnerships in Baltimore Applications of core theory dynamics using a geographic information system.
      ) on the risk of STDs.
      Last, we find that girls with a history of forced sexual activity are more likely to engage in riskier sexual behaviors that may place them at an increased risk of acquiring an STD and that the association between forced sex history and history of STD remains after controlling for a set of variables characterizing sexual and protective practices. Girls with a history of forced sex are more likely to have greater numbers of lifetime partners, earlier ages at first intercourse, and are more likely to have used alcohol or drugs at last sex. The effect of forced sex on condom use at last sex is not significant, but is in the expected direction. Other studies report similar findings (
      • Fergusson D.M
      • Horwood L.J
      • Lynskey M.T
      Childhood sexual abuse, adolescent sexual behaviors and sexual revictimization.
      ,
      • Miller B.C
      • Monson B.H
      • Norton M.C
      The effects of forced sexual intercourse on white female adolescents.
      ,
      • Nagy S
      • DiClemente R
      • Adcock A.G
      Adverse factors associated with forced sex among southern adolescent girls.
      ,
      • Shrier L.A
      • Pierce J.D
      • Emans S.J
      • DuRant R.H
      Gender differences in risk behaviors associated with forced or pressured sex.
      ,
      • Wilsnack S.C
      • Vogeltanz N.D
      • Klassen A.D
      • Harris T.R
      Childhood sexual abuse and women's substance abuse National survey findings.
      ), but most often used information obtained from convenience or regional samples or did not investigate the effects of forced sex history on numerous sexual risk-taking behaviors, as we have done here. Our results suggest that the effects of having been forced to have sex may operate through multiple pathways that can adversely affect the reproductive lives of adolescent girls. Victims of sexual violence appear to be at increased risk of engaging in numerous behaviors (above and beyond those considered here) that potentially increase their risk of acquiring an STD, including chronic destructiveness and deliberate self-harm (
      • Boudewyn A.C
      • Liem J.H
      Childhood sexual abuse as a precursor to depression and self-destructive behavior in adulthood.
      ). In addition, there are psychological consequences of forced sexual activity, including depression and low self-esteem (
      • Briere J
      • Runtz M
      Childhood sexual abuse Long-term sequelae and implications for psychological assessment.
      ,
      • Zweig J.M
      • Barber B.L
      • Eccles J.S
      Sexual coercion and well-being in young adulthood Comparisons by gender and college status.
      ), which may also contribute to increased sexual risk taking, resulting in increased risk of STDs. Our results, along with those of other studies, suggest that there may be multiple and often enduring consequences of sexual violence against women.
      Although our research provides new information regarding the relationship between forced sexual activity and history of STD in a nationally representative sample of sexually active adolescent girls, it is not without limitations. First, we must underscore that we examined sexually active girls only (defined as ever having had vaginal intercourse). As noted, additional analyses revealed systematic differences between sexually active girls and virgins (see footnote 8). We therefore cannot generalize to all girls—rather, only those who are sexually active as we have defined here. Second, the sample is nationally representative of students, not all adolescents. The extent to which high school drop out is correlated with STD risk will result in potential bias; thus our findings probably underestimate the prevalence of STD and the effects of risky behaviors. Even though this population may be characterized as low risk, we still find that over 1 in 10 sexually active girls have ever had a STD (as we have defined). In a national sample of young adults, using a similar measure of STD,
      • Tanfer K
      • Cubbins L.A
      • Billy J.O.G
      Gender, race, class and self-reported sexually transmitted disease incidence.
      ) found a lifetime prevalence of 15.8% among young women. In another national study of women, a lifetime prevalence of STD (defined as gonorrhea or chlamydia) of 6% was reported (
      • Miller H.G
      • Cain V.S
      • Rogers S.M
      • Gribble J.N
      • Turner C.F
      Correlates of sexually transmitted bacterial infections among U.S. women in 1995.
      ). Taken together, these results demonstrate that adolescent girls are disproportionately affected by STDs and underscore the importance of continuing public health efforts to reduce their burden of disease (
      U.S. Department of Health and Human Services (USDHHS)U.S. Department of Health and Human Services (USDHHS)
      Healthy People 2010 Understanding and Improving Health.
      ). Third, our measure of STD history is based on self-report, and although audio-CASI techniques were employed to collect this information, it is possible that girls underreported infection, misremembered or forgot, or were not aware that they had ever had a STD. In fact, studies using convenience and/or high-risk samples in which STD self-report and biomarker assessments are compared show mixed results with respect to the validity of self-report (
      • Clark L.R
      • Brasseux C
      • Richmond D
      • Getson P
      • D'Angelo L.J
      Are adolescents accurate in self-report of frequencies of sexually transmitted diseases and pregnancies?.
      ,
      • Harrington K.F
      • DiClemente R.J
      • Wingood G.M
      • Crosby R.A
      • Person S
      • Oh M.K
      • et al.
      Validity of self-reported sexually transmitted diseases among African American female adolescents participating in an HIV/STD prevention intervention trial.
      ,
      • Orr D.P
      • Fortenberry J.D
      • Blythe M.J
      Validity of self-reported sexual behaviors in adolescent women using biomarker outcomes.
      ). Findings from our related research suggest, however, that self-reports of STD have a high face validity and can be used as markers to assess relative differences in the likelihood of infection (

      Upchurch, D. M., Mason, W. M. (2002, May). Validity of self-reports of incidents of sexually transmitted diseases. Paper presented at the Annual Meeting of the Population Association of America, Atlanta, GA

      ). Fourth, the available measure of sexual victimization is problematic. Girls were asked (again, using audio-CASI) only about sexual victimization that involved physical force to engage in sexual intercourse. Clearly, there are other forms of sexual victimization, including psychological coercion, that can be highly traumatic (
      • Zweig J.M
      • Crockett L.J
      • Sayer A
      • Vicary J.R
      A longitudinal examination of the consequences of sexual victimization for rural young adult women.
      ). In addition, the data do not contain information on when the forced sex experience occurred, if it occurred multiple times, or any information about the context within which it occurred (including lack of information on the perpetrator). Furthermore, forced sex history was only asked of those who reported that they had ever had sex and therefore girls who had been forced to have sex who may not have considered themselves sexually active were not included in our analytic sample. Although undoubtedly an underestimate, our finding that one in five sexually active girls report they have ever been physically forced to have sex against their will demonstrates that sexual victimization is relatively common. These results have also been confirmed by others (
      • Raj A
      • Silverman J.G
      • Amaro H
      The relationship between sexual abuse and sexual risk among high school students Findings from the 1997 Massachusetts Youth Risk Behavior Survey.
      ) and highlight the need for continued programmatic efforts in this area. Last, although we attempted to elaborate a conceptual framework that articulated antecedent and intermediate variables that influence risk of STD, our model was a simplification of the complex interrelationships between the key variables of interest. For example, a greater number of sexual partners may also be a consequence of early onset of sexual activity (e.g.,
      • Santelli J.S
      • Brener N.D
      • Lowry R
      • Bhatt A
      • Zabin L.S
      Multiple sexual partners among U.S. adolescents and young adults.
      ). In addition, forced sex may be a consequence of early sexual activity and may have occurred at first intercourse (
      • Abma J
      • Driscoll A
      • Moore K
      Young women's degree of control over first intercourse An exploratory analysis.
      ). Elaboration of theoretical models that more comprehensively characterize these complex interrelationships is warranted.
      In sum, our findings suggest that programmatic strategies aimed at reducing STDs among adolescents through encouraging responsible sexual behaviors would potentially benefit from also including a component that addresses sexual victimization. For example, such programs could incorporate strategies that increase adolescents' ability to prevent and contend with sexual coercion and violence and to develop healthy dating relationships (see, for example,
      • Kalmuss D
      • Davidson A
      • Cohall A
      • Laraque D
      • Cassell C
      Preventing sexual risk behaviors and pregnancy among teenagers Linking research and programs.
      ). Given that adolescents who report a history of forced sexual intercourse also report other sexual risk behaviors, program planners must be aware of the associations between multiple risk factors and accordingly adopt a more comprehensive framework aimed at reducing both sexual victimization and risky sexual practices.

      Notes

      This research uses data from Add Health, a program project designed by J. Richard Udry, Peter S. Bearman, and Kathleen Mullan Harris, and funded by a grant P01-HD31921 from the National Institute of Child Health and Human Development, with cooperative funding from 17 other agencies. Special acknowledgment is due Ronald R. Rindfuss and Barbara Entwisle for assistance in the original design. Persons interested in obtaining data files from Add Health should contact Add Health, Carolina Population Center, 123 W. Franklin Street, Chapel Hill, NC 27516-2524 (www.cpc.unc.edu/addhealth/contract.html).

      Acknowledgements

      This research was funded by the Jacobs Institute—Ortho-McNeil Pharmaceutical Research Scholar in Women's Health Award and by grant R01 HD36993 from the National Institute of Child Health and Human Development. The authors acknowledge Rachel Oakes for contributions early in the evolution of this work and the reviewers for their thoughtful comments.

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      Biography

      Dawn Upchurch is a Professor of Public Health at UCLA. She has a long-standing interest in adolescent and young women's reproductive health. More recently, she is studying complementary and alternative medicine (CAM) and women's health, especially Traditional Chinese Medicine and women's reproductive health during midlife.
      Yasamin Kusunoki is a doctoral student at the UCLA School of Public Health. She is currently using the Add Health data to characterize adolescent sexual relationships and their effects on sexual risk taking behaviors.