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Among individuals with a history of adverse childhood experiences, risky sexual behavior may represent their attempts to achieve intimate interpersonal connections. Having grown up in families unable to provide needed protection, such individuals may be unprepared to protect themselves and may underestimate the risks they take in their attempts to achieve intimacy. If so, coping with such problems represents a serious public health challenge.
Family Planning Perspectives , 2001, 33(5):206-211.
The adverse consequences of participating in high-risk sexual behaviors are disproportionately higher in women than in men. This disparity is influenced by a number of factors. Biologically, women are more susceptible to sexually transmitted infections. Also, women are more likely than men to have infections that are asymptomatic, and that thus remain undetected. Finally, women are at higher risk of complications than men. 1.
Furthermore, women singularly bear the health risks associated with pregnancy, which may affect both the mother and the newborn. The litany of outcomes associated with sexual risk behaviors in women includes the sexual transmission of more than 25 infectious organisms, cervical cancer, vaginal cancer, infertility, abortion, ectopic pregnancy, chronic pelvic pain, stillbirth, spontaneous abortion, violence-related trauma and death. Adverse outcomes that may occur in infants born to women engaging in risky sexual behaviors include low birth weight, prematurity, pneumonia, ocular infections, neurological damage and death. 2.
This article addresses whether childhood adversity, including exposure to household dysfunction and varying forms of abuse and violence, has long-term consequences on sexual risk behaviors. While childhood sexual or physical abuse have been associated with subsequent increases in substance abuse, sexual risk behavior, psychological morbidity and violence, 3 other measures of household dysfunction have received less attention. It is becoming increasingly clear that sexual abuse rarely occurs in a vacuum. Rather, abuse typically takes place within a broader context of adversity, including familial dysfunction, deprivation and destructiveness. 4.
Our analysis uses data from the Adverse Childhood Experiences Study,* which assessed the relationship between adverse experiences during childhood and adult diseases and health behaviors associated with leading causes of death and disability in the United States. 5 The adverse childhood experiences examined in this study are physical abuse; verbal abuse; sexual abuse; witnessing of intimate partner violence; and living with adult family members who are substance abusers, who are mentally ill or suicidal, or who have been imprisoned.
Adverse childhood experiences were endemic in the study population: Half of the adult participants in the study reported having had such experiences during childhood. 6 Further, previous reports using these data showed that exposure to adverse childhood experiences was associated with significantly increased risks of major causes of death and disability in adults, including alcoholism, drug abuse, depression, suicide, smoking, poor self-rated health, physical inactivity, severe obesity, ischemic heart disease, cancer, chronic lung disease, skeletal fractures and liver disease. 7.
Earlier publications from the Adverse Childhood Experiences Study have also demonstrated a strong association between exposure to adverse childhood experiences and two reproductive health outcomes—unintended pregnancy and sexually transmitted disease (STD) infection. 8 For both men and women, increases in exposure to adverse childhood experiences were associated with increases in the risk of STDs. 9.
Similarly, women exposed to multiple types of adverse childhood experiences had a 50% increase in the likelihood of an unintended first pregnancy (i.e., one that was unwanted or occurred before the woman had intended to become pregnant). 10 Prevention of unintended pregnancy is critical, since half of such pregnancies end in abortion. Moreover, those who have a live birth are at a significantly increased risk of maternal and infant complications. 11.
We evaluate here the association between seven adverse childhood experiences and three sexual risk behaviors associated with STDs and unintended pregnancy—onset of sexual intercourse by age 15, multiple sexual partners and self-reported risk of HIV and AIDS. These behaviors may be the mechanism through which adverse childhood experiences increase STDs and unintended pregnancy.
The methods used in this retrospective cohort study have been described elsewhere. 12 Study participants were adults ages 25 and older who were members of Kaiser Permanente in San Diego, California. All had been continuously enrolled between 1992 and 1995. Each year, approximately 80% of members (nearly 50,000) who were continuously enrolled during this period received a standardized biopsychosocial and medical evaluation at the primary care clinic.
Kaiser health plan members were eligible to participate if they had completed standardized medical examinations at the primary care clinic from August to November 1995 or from January to March 1996. A total of 13,494 eligible members received a mailed questionnaire one week following their clinic visit. This questionnaire addressed health behaviors and adverse childhood experiences, was administered in English, included 60 questions and required 45 minutes to complete. The questionnaire, which was developed by a multidisciplinary team, adapted many questions from previously used survey instruments, including the Conflict Tactics Scale 13 and questions developed by Gail Wyatt, an expert in the field of defining childhood sexual abuse. 14.

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