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We considered limitations that may have influenced the validity of our findings. First, all information on exposure to familial dysfunction and household violence and on sexual risk behaviors was collected by self-report, and for the adverse childhood experiences involved a considerable period of recall. The challenges of measuring sexual abuse have been clearly described; we therefore used measures that had been used previously by experts in the field. 25 The social stigma that can be associated with these risk behaviors probably led to their being underreported. It is unclear whether those who had experienced childhood adversity would be more likely to underreport sexual risk behaviors than those who had not experienced such adversity. In addition, our analysis would have been strengthened if data on nonuse of condoms had been available.
Finally, we cannot be certain that sexual risk behaviors always followed, rather than preceded, exposure to adverse childhood experiences, since a number of participants may have both participated in sexual risk behaviors and experienced adverse childhood experiences during adolescence. However, the focus of most of the questions regarding adverse childhood experiences was on events occurring during childhood; therefore, it is highly likely that most sexual risk behaviors followed, rather than preceded, the onset of exposure to adverse childhood experiences. In fact, it is counterintuitive that for the majority of the study participants, they first developed sexual risk behaviors, which then caused their families to become adversity-ridden. Future investigations would be strengthened by measuring the age at which exposure to adverse childhood experiences began.
To date, common public health interventions that have focused on reducing sexual risk behaviors include delaying initiation of sexual intercourse and increasing use of condoms. 26 Interventions that have focused on changing these sexual risk behaviors have met with only modest success, 27 which suggests that programs attempting to alter sexual behaviors after their development may be insufficient to achieve the desired magnitude of change. Broader interventions that focus on reducing exposure to familial violence and household dysfunction, such as public health nurse home visitation during the early years of life, have been shown to achieve their desired goals. 28 Such interventions, though more challenging, may ultimately lead to greater reductions in sexual risk behaviors decades later.
We have shown that high-risk adolescent and adult sexual behaviors are highly correlated with adverse childhood experiences. The failure of current public health attempts to alter many of these behaviors may well be a result of not recognizing that, for the people involved, these behaviors may also be a desperate search for affection and intimacy brought on by lack of these factors during childhood. In that instance, the public health “problem” may also represent a personal quest for a solution to these basic human needs. Understanding this may offer us a new way to approach old problems.
*The Adverse Childhood Experiences Study was approved by Institutional Review Boards of the Southern California Permanente Medical Group, Emory University and the Office of Protection from Research Risks, National Institutes of Health.
†We chose 30 as the cut-off point for lifetime number of sexual partners because preliminary analyses showed adverse childhood experiences to be associated with this variable in a dose-response fashion.
1. Institute of Medicine, The neglected health and economic impact of STDs, in: Eng TR and Butler WT, eds., The Hidden Epidemic , Washington, DC: National Academy Press, 1997, pp. 28-68.
2. Ibid.; and Ebrahim SH et al., Mortality related to sexually transmitted diseases in women, U.S., 1973-1992, American Journal of Public Health, 1997, 87(6):938-944.
3. Herrenkohl EC et al., The relationship between early maltreatment and teenage parenthood, Journal of Adolescence, 1998, 21(3):219-303; Stock JL et al., Adolescent pregnancy and sexual risk-taking among sexually abused girls, Family Planning Perspectives, 1997, 29(5):200-203; Luster T and Small SA, Sexual abuse history and number of sex partners among female adolescents, Family Planning Perspectives, 1997, 29(5):204-211; Widom CS and Kuhns JB, Childhood victimization and subsequent risk for promiscuity, prostitution, and teenage pregnancy: a prospective study, American Journal of Public Health, 1996, 86(11):1607-1612; Maxfield MG and Widom CS, The cycle of violence, revisited 6 years later, Archives of Pediatric and Adolescent Medicine, 1996, 150(4):390-395; Felitti VJ et al., The relationship of adult health status to childhood abuse and household dysfunction, American Journal of Preventive Medicine, 1998, 14(21):245-258; Holmes WC and Slap GB, Sexual abuse of boys, Journal of the American Medical Association, 1998, 280(21):1855-1862; Finkelhor D et al., Sexual abuse in a national survey of adult men and women: prevalence, characteristics, and risk factors, Child Abuse and Neglect, 1990, 14(1):19-28; and Fergusson DM, Lynskey MT and Horwood LJ, Childhood sexual abuse and psychiatric disorders in young adulthood: I. prevalence of sexual abuse and factors associated with sexual abuse, Journal of the American Academy of Child and Adolescent Psychiatry, 1996, 35(10):1355-1364.

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