The Impact of Sexual Abuse: Implications for Drug Treatment

Impact of Sexual Abuse: Implications for Drug Treatment The DENISE PAONE, Ed.D., WENDY CHAVKIN, M.D., M.P.H., ILENE WILLETS, Ph.D., PATRICIA FRIEDMANN, M.S., and DON DES JARLAIS, Ph.D. ABSTRACT Previous research has shown a high incidence of sexual abuse histories among chemically dependent women. This paper reports on the associations among sexual abuse, past traumatic experiences, and current drug-associated behaviors in a study of chemically dependent pregnant and parenting women in New York City in order to examine the implications for drug treatment. Interviews were conducted with 146 indigent New York City women. Subjects were eligible for the study if they met the following criteria: were current users of crack/cocaine or had used crack/cocaine within the past 3 years, were currently pregnant, and/or were the mother of a preschool-age child. Subjects were recruited and interviewed from drug treatment programs (n 72) and nontreatment sites (n 74). One hundred thirty-three (91%) of the 146 women interviewed were African American or Latina. Study participants had a mean age of 29.4 years, with an average of 11.5 years of education. Seventy-four (51%) of the women interviewed reported having been victims of at least one forced sexual encounter. Sexual abuse was associated with both past experiences and current drug-associated behaviors. The age of abuse had a significant impact on outcome. Given the frequency with which sexual abuse has been found in the histories of chemically dependent women, and the linkages of sexual abuse to indicators of drug problem severity, it appears important to integrate therapy for sexual abuse into treatment for chemically = = dependent women. INTRODUCTION Research has shown a high incidence of previous sexual abuse histories among chemically dependent women1,2 (S.D. Peters, unpublished report). Studies estimate higher rates of rape (46%) and incest (28-40%) within the chemically dependent population than among the general population (2025% of all women report a history of sexual abuse both during childhood and as adults.)3-7 Some investigators estimate that as many as three-quarters of women in treatment for substance abuse have been victims of sexual violence. Researchers now recognize that sexual abuse victims may experience both immediate or short-term effects as well as long-term symptoms.910 Findings of long-term impact are especially persuasive. Eight nonclinical studies of adults"-13 (C. Bagley & R. Ramsey; M.E. Fromuth; S.D. Peters; A. Seidner & K. S. Calhoun, unpublished reports) and three random sample community surveys found that child sexual abuse vie- tims had higher degrees of emotional impairment when compared with nonvictims (S.D. Peters, unpublished report). This paper reports on the associations among sexual abuse, past traumatic (negative) experiences, and current drug-associated behaviors in a study of chemically dependent pregnant and parenting women in New York City in order to examine the implications for drug treatment. METHODS Study population conducted with 146 indigent New York City for the study if they met the users of crack/cocaine or had used crack/cocaine within the past 3 years, were currently pregnant, and/or were the mother of a preschool-age child. Because this was an exploratory study, and because of the Interviews were Subjects were eligible following criteria: were current women. Chemical Dependency Institute, Beth Israel Medical Center, New York, New York. anticipated difficulty in soliciting participation among the popa nonprobability, purposive sample was used. These data have generated hypotheses with respect to therapeutic approaches for this population.14 The sample (N 146) was recruited from a variety of ulation, = treatment and nontreatment sites. Data were obtained from women in all treatment modalities available in New York City: methadone maintenance treatment programs (n 17) (Division = of Substance Abuse Services [DSAS] reports that 35-55% of methadone clients are using crack/cocaine), therapeutic communities (n 15), drug-free outpatient programs (n = 14), acutreatment (n 15), as well as graduates of treatment puncture 11). Nontreatment sites included outreach proprograms (n 14), homeless shelters (n 15), post-partum units grams (n (n 15), prenatal clinics (n 17), and jails (n 13). = = = = = = = = Instrument Women participants were surveyed through use of a semistructured interview schedule. This instrument was administered in a 1 hour, face-to-face interview to elicit information regarding demographic characteristics, and reproductive, druguse, and drug-treatment histories. Study participants were guaranteed anonymity. All participants received a watch valued at $20 in appreciation for their participation. Respondents were asked if anyone had ever forced them to have any unwanted sexual encounter/activity, the nature of the abuse, their relationship to the perpetrator, and their age at the time of the episode(s) of abuse. Statistical analysis To determine differences between groups, chi-square and Fisher exact two-tailed probability test were used for categorical variables. Nonpaired two-tailed t test were used for the continuous variables. Table 1. Selected Demographic Characteristics Participants in Study of Sexual Abuse and Drug Treatment Characteristic N Ethnicity (%) (58) (32) (9) 2(1) Black 84 Hispanic 47 13 White Other Homeless last 2 years Yes No Currently on welfare Yes No Average age Average number of years of education of * 84 (58) 62 (42) 104(71) 42 (29) 29.4 [SD 6.2] 11.5 [SD 2.0] = = having had parents who were chemically dependent (p < .05). Sexual abuse was also associated with high-risk behaviors, including initiation of drug use by age 15, pressure by a male partner to use drugs during the index pregnancy, and engaging in sex for drug transactions. An odds ratio indicated that women who had a history of sexual abuse were 2.9 times more likely to engage in sex for drug transactions than women who were not sexually abused. The sexual abuse group was subdivided into two subgroups: those abused for the first time at 16 years of age or younger (the childhood abuse group) and those abused for the first time at 17 years of age or older (adult abuse group). Table 4 presents data stratified by age of abuse and indicates an age-related gradient: and Childhood abuse showed the strongest association with the variables of early drug use, male pressure to use drugs during pregnancy, and psychiatric history; no abuse showed the weakest association; and abuse in adulthood was in between. RESULTS DISCUSSION One hundred thirty-three (91%) of the 146 women interviewed were African American or Latina and the majority (137, or 95%) were from the United States and Puerto Rico. Study participants had a mean age of 29.4 years (SD 6.2), with an average of 11.5 years of education (SD 2.0), as shown in Table 1. Seventy-four (51%) of the women interviewed reported having been victims of at least one forced sexual encounter. Fifteen of these women were victims of multiple or repeated unwanted sexual encounters and 11 were victims of gang rape. Thirty-four (46% of this subsample) had been 16 years old or younger at the time of the assault. Fourteen of these women who were victimized in childhood had also been victims of incest. Fifty-one percent of the women who reported sexual abuse histories indicated that the abuse took place prior to the initiation of substance use, as shown in Table 2. Data comparing women who had been sexually abused with the women who had no history of sexual abuse are presented in Table 3. Sexual abuse was associated with certain past experiences: psychiatric treatment (p < .01), incarceration (p < .01), = = In this sample of 146 female crack/cocaine users from New York City, more than half reported at least one instance of sexual abuse. Fifty-seven (59%) of the 97 subjects who were in drug abuse treatment at the time of the interview reported histories of sexual abuse. These findings are consistent with other research showing high rates of sexual abuse among women in treatment for chemical dependency problems.115 Because studies are often conducted on women in treatment, we lack comparative data on drug-using women not in treatment. This study extends previous research by showing that even within a sample of drug-using women sexual abuse was significantly associated with several indicators of severity of drug abuse and other important social problems. Furthermore, the data indicate that abuse at an early age is more likely to be associated both with other past negative experiences and with current drug-associated behaviors. Discerning causation is not possible with cross-sectiona! data. The fact that sexual abuse was related to a variety of indicators of drug abuse and other psychological and social problems in this Table 2. Sexual Abuse History of Participants Having Had Forced Sexual Encounters N(%) Age at first forced sexual encounter 19(26) 15(20) 40(54) 1-10 11-16 17+ Perpetrator of first encounter Stranger Nonstranger Nonstranger perpetrator (n 58) 16 (22) 58 (78) = 14 (24) 13 (23) Friend Acquaintance Relative (excluding father) Father/Father Figure Boyfriend/Husband 11(19) 8 (14) 4 (7) 3 (5) 3 (5) 2 (3) Date Drug Related Babysitter Perpetrators of gang rapes (n 11) Strangers Nonstrangers Multiple/continuous unwanted sexual = 6 5 encounters Number of Encounters with a stranger Number of Encounters with a Nonstranger Gang rape Age when incest occurred (n 14) Ages 1-10 Ages 11-16 Perpetrator of incest Relative (excluding father) Father (n = 15) 16 12 4 = Note: n encounter. = 74 8 6 10 4 (51% of sample) participants in study reporting sample suggests that there may be multiple causal linkages rather than a single causal pathway. The strength of the association between sexual abuse and drug-associated behaviors may indicate an underlying causal relationship. At this point we can only offer hypotheses about the possibility of causal linkages between sexual abuse, drug abuse, and other psychological and social problems, which can then be tested in further research. The first hypothesis is that drug use served as a means of "self-medication" for many of these women. Root and others suggest that the psychological sequelae of sexual assault can best be understood in terms of post-traumatic stress response (PTSD),1617 which is considered to follow a stressful event that exceeds the person's resources for coping. According to this paradigm, the negative symptoms and results of substance abuse may be perceived as more tolerable than the anxiety, depression, and relationship difficulties that ensued from the assault. Unless resolution of this trauma transpires, according to this model, abstinence from drugs will predictably be followed by symptom substitution and/or relapse. Although previous research has demonstrated a high incidence of sexual abuse among this population of women, therapy for sexual abuse is not prevalent within drug treatment programs. The implication from our research is that therapy for recovery from this trauma should be included under the rubric of at least one forced sexual drug treatment. Although literature now reports that self-medication with illicit drugs may be a response to PTSD, it is important to point out that PTSD need not be the only mechanism through which this response could develop. The second hypothesis, more complex and more specific to crack/cocaine use, involves "vicious cycle causation." According to this model, early negative experiences, including sexual abuse, are likely to severely impair self-esteem. Crack use has been frequently reported to substantially (if temporarily) increase feelings of self-esteem. Crack use, however, may also increase the likelihood of experiencing negative events, including further sexual abuse, exchanging sex for drugs, and incarceration, that would further damage self-esteem and create a greater need for the self-esteem enhancement offered by using crack. Given the frequency with which sexual abuse has been found in the histories of chemically dependent women, and the linkages of sexual abuse to indicators of drug problem severity, it appears important to integrate therapy for sexual abuse into chemical dependency treatment for women. Further research will be needed to address the possible multiple causal linkages between sexual abuse and chemical dependency among women. Such research requires carefully collected longitudinal data to establish the temporal order of events needed to test causal Table 3. Sexual Abuse History and Associated Characteristics Sexual abuse No sexual abuse history history p value 28 (38%) 46 (62%) 13 (18%) 59 (82%) <.01 30 27 (53%) (47%) 17 (29%) 42(71%) <.01 38 35 (52%) (48%) 19 51 (27%) (73%) <.01 35 39 (47%) (53%) 17 (24%) 55 (76%) <.01 57 17 (77%) (23%) 42 (58%) 30 (42%) <.05 Characteristic Psychiatric history Yes No Male pressure to Yes No use drugs Early drug use Yes No Sex for drugs Yes No Family history of drug use Yes No Have been in jail Yes No Average age at first alcohol use Average age at first drug use 42 (57%) 32 (43%) 14.9 [SD 3.8] 16.6 [SD 5.0] 25 = = = = Table 4. Sexual Abuse and Associated Characteristics Abuse Characteristic (n Early experiences Psychiatric history Prison Family history Drug-associated behavior Early use Male pressure Sex for drugs = ^ 16 (35%) 46 (65%) 16.3 [SD 3.8] 18.8 [SD 5.4] Abuse > 17 35) (n = 38) by <.01 <.05 <.05 Age Gradient No abuse (n = 72) p value 17/35 20/35 27/35 11/38 21/38 30/38 13/72 25/71 42/72 <.005 <.05 <.05 20/34 14/22 11/35 17/38 15/34 24/38 19/70 17/59 17/72 <.01 <.02 <.001 The integration of treatment for recovery from sexual abuse into drug treatment programs will warrant rigorous evaluation on the efficacy of this approach. hypotheses. ACKNOWLEDGMENTS Supported by the Greater New York March of Dimes, the United Hospital Fund, and the JM Foundation. The opinions are those of the authors, who accept sole responsibility. The authors gratefully acknowledge Deborah Fish Ragin, Ph.D., and Maureen Miller for their work on the manuscript. REFERENCES 1. Browne A, Finkelhor D. 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