Running Head: Trauma and Risky Behavior Examining the Relationship between Trauma and Risky Sexual Behavior in a Substanceinvolved sample Tegan M. Lesperance Honors Thesis, University of South Florida Thesis Director: Kathleen Moore, PhD Thesis Committee: Colleen Clark, PhD, Scott Young, PhD Trauma and Risky Behavior 1 Acknowledgements Special thanks are due to the author’s mentors, Dr. Kathleen Moore, Dr. Colleen Clark, and Dr. Scott Young for lending their support and expertise. Special thanks are also due to Blake Barrett and Amy Godin. The author would like to acknowledge the team at Goodwill-Suncoast Industries Inc. for their willingness to collaborate and their continued support and enthusiasm for the project. Finally, the author would like to thank the participants for their willingness to share their personal stories and time and for making this research rich and exciting. This research was funded in part by the Office of Undergraduate Research at the University of South Florida Trauma and Risky Behavior 2 Table of Contents List of Tables and Figures Page 3 Abstract Page 4 Introduction Page 5 Current Study Page 12 Method Page 13 Results Page 18 Discussion Page 27 References Page 34 Appendix Page 40 Trauma and Risky Behavior 3 List of Tables and Figures Table 1. Page 7 Studies assessing the effect of substance abuse on risky sexual behaviors Table 2. Participant Demographic Information Page 19 Figure 1. Exposure to Trauma Page 20 Figure 2. Sexual Activity Page 21 Figure 3. Self-reported Risky Sexual Behavior Page 22 Table 3. Page 23 Significant Correlations of LSC-r Subscales and Self-reported Behaviors Table 4. Use and Non-use of Contraceptives other than Condoms Page 25 Trauma and Risky Behavior 4 Abstract Trauma has been linked to an increased risk of substance abuse and risky sexual behavior in both women and men. Strong evidence exists linking high drug use with low condom use and some research suggests a relationship between substance use and risky sexual behavior. This study interviewed 25 substance-involved parents involved in the child welfare system 12-months after beginning treatment as part of a Family Dependency Treatment Court (FDTC). A Risky Behavior Questionnaire (including both quantitative and qualitative questions) was administered to participants and analyzed along with other data collected as part of this evaluation of a Substance Abuse and Mental Health Services Adminstration treatment initiative, including demographic information and Lifetime Trauma. There were two hypotheses: (1) participants with a higher prevalence of trauma will have more experience with risky sexual behaviors, and (2) participants will reveal many risky sexual activities. Results demonstrated a strong correlation between lifetime trauma and binge drinking, gambling, being arrested, and having sex with an intoxicated person. Significant decreases in unprotected and intoxicated sex were found from baseline to 12month follow-up. Qualitative analyses revealed a tendency to associate condom use with infidelity within monogamous relationships. Participants prefer risky sex despite being able to identify the potential dangers associated with the behaviors. Further analysis of locus of control may reveal a tendency to attribute positive change to personal characteristics despite enrollment in FDTC. The FDTC program appears to be effective in decreasing risky behaviors, even among individuals with a high prevalence of trauma. Keywords: Trauma, Substance Abuse, Risky Sexual Behavior Trauma and Risky Behavior 5 Introduction Trauma and Substance Abuse The link between trauma and substance abuse are well documented with prevalence rates of Post Traumatic Stress Disorder (PTSD) in populations seeking treatment for substance abuse estimated between 30 and 50% (Ouimette et al., 2005). Traumatic events, during childhood and adulthood, have been linked to increased risk of substance abuse in both women and men (Bensley, Van Eenwyk, & Simmons, 2000; Gidycz, Orchowski, King, & Rich, 2008). Furthermore, trauma has been identified as an independent risk factor for relapse in substance abusing populations (Driessen et al., 2008). Trauma, particularly during childhood or adolescence, has been linked to increased risk of substance abuse. Using self-reported information on childhood trauma, Bensley and colleagues found that women with childhood experiences of both physical and sexual abuse were five times more likely to drink heavily when compared to women with no abuse history (Bensley, VanEenwyk, & Simmons, 2000). Men who experienced physical abuse were three times more likely to drink heavily when compared to nonabused men. Similarly, a study of college women found that participants with a history of adolescent sexual victimization were more likely to smoke cigarettes and marijuana (Gidycz, Orchowski, King & Rich, 2008). Additionally, in a multi-site study across Germany, Driessen et al. (2008) found that 25.3% of substance-involved participants had PTSD and many more had experienced traumatic events but did not meet the criteria for a PTSD diagnosis. The study also reported a higher prevalence of PTSD among those using Trauma and Risky Behavior 6 drugs or a combination of drugs and alcohol than among participants who used only alcohol. Substance Abuse and Risky Sexual Behavior For those working with substance-involved populations it is important to recognize the impact of trauma. Similarly, it is important to understand behaviors commonly linked to both trauma and substance abuse such as risky sexual behavior. Popular opinion suggests that substance use and risky sexual behavior are positively correlated. However, the evidence for a relationship between drug use and condom use is mixed (see Table 1) (Clutterbuck, Gorman, McMillan, Lewis & Macintyre, 2001; Ku, Sonenstein, & Pleck, 1993; Weinstock, Lindan, Bolan, Kegeles, & Hearts, 1993). Trauma and Risky Behavior 7 Table 1. Studies assessing the effect of substance abuse on risky sexual behaviors Study Leigh, Ames, and Stacy, 2008 Clutterbuck, Gorman, McMillan, Lewis & Macintyre, 2001 Zule, Costenbader, Meyer, & Wechsberg, 2007 Ku, Sonenstein, & Pleck, 1993 Schafer, Blanchard, Fals-Stewart, 1994 Weinstock, Lindan, Bolan, Kegeles, & Hearts, 1993 Leonard & Ross, 1997 Rosengard, Anderson, & Stein, 2006 Santelli et al., 1997 Kapadia et al., 2007 Leigh et al., 2008 Definition of Risky Sexual Behavior Failure to use condoms Defined Substances Risky Sex related to Substance Use? Limitations Alcohol and illegal drugs Mostly male sample Retrospective selfreport data Failure to use condoms during anal intercourse Alcohol and illegal drugs Failure to use condoms, anal intercourse, intercourse with a new partner Failure to use condoms Methamphetamine Yes- Amphetamines (smoked or injected) related to decreased condom use. No- Other drugs and alcohol unrelated to condom use. Yes- Marijuana and inhaled nitrates related to risky sex. No- Alcohol and other drugs unrelated to risky sex. Yes Alcohol and illegal drugs Yes All-male sample Failure to use condoms Alcohol and illegal drugs Yes (with the exception of alcohol) Small sample Cross-sectional data Failure to use condoms Alcohol and illegal drugs Sample not representative Failure to use condoms Failure to use condoms Alcohol and illegal drugs Alcohol and illegal drugs Yes- Men and some women (Black and Hispanic) who had difficulty convincing partners to use condoms No No Convenience sample Failure to use condoms Failure to use condoms Failure to use condoms Alcohol and illegal drugs Injection drugs No Self-report data No All-male sample Alcohol No Focus on single drug Self-report data Self-report data All-male sample Focus on single drug No random assignment Sample not representative Self-report data Trauma and Risky Behavior 8 There is a lack of conclusive evidence for or against the idea that substance and risky sexual behaviors are highly correlated. However, there were limitations with the majority of studies. For example, several did not utilize representative samples and two focused on the interaction of a single drug, making it difficult to generalize results to the general substance-involved population. Overwhelmingly, studies defined risky sexual behavior as failure to use a condom. Although failing to use a condom is certainly a risky sexual behavior, many other behaviors are not addressed including sex while intoxicated or with someone who is intoxicated, sex with a stranger, prostitution, and sex with a prostitute. Several studies also relied exclusively on self-report data. While self-report data is often the easiest way to assess substance involvement, it is also susceptible to deception and forgetting. One way to address the possibility of forgetting is to focus questions to a specific event. In an event-based study of methamphetamine users during heterosexual sex, results found that methamphetamine users were more likely to be involved in risky sexual behaviors such as unprotected sex (Zule, Costenbader, Meyer, & Wechsberg, 2007). Risky sexual behaviors dramatically increased when both partners were using methamphetamine. Similarly, Schafer, Blanchard, Fals-Stewart, (1994) found that people were less likely to use condoms if they were intoxicated using any drug, not including alcohol. By contrast, many studies have shown no significant relationship between substance use and risky sexual behavior (often measured by condom use) (Leonard & Ross, 1997; Rosengard, Anderson, & Stein, 2006; Santelli et al., 1997, Weinstock, Lindan, Bolan, Kegeles, & Hearts, 1993). Leigh et al. (2008), found that people tend to Trauma and Risky Behavior 9 follow their usual pattern of condom use whether or not they are intoxicated, in this case drunk. Those participants who imbibed alcohol before engaging in sexual activity were no less likely to use a condom than those who were not intoxicated. Similarly, Kapadia et al. (2007) found that male injection drug users were not less likely to use condoms while intoxicated but their condom use increased when their partner was supportive of using condoms and when the man anticipated positive results to a request for condom use. It has also been suggested that different drugs have different effects on risky sexual behavior. Leigh, Ames, and Stacy (2008) conducted a study in a court-ordered drug diversion program to assess the effect of different substances on risky sexual behavior. Participants were asked to complete a questionnaire by reporting on their most recent casual sexual encounter (those who reported on long-term relationships were excluded). Results showed no significant relationship between alcohol use and condom use in either men or women. Among men, 52% who used alcohol used condoms and 56% who did not drink alcohol used condoms. Among women, 47% of both drinkers and nondrinkers used condoms. The use of amphetamines (smoked or injected) was associated with decreased condom use. Using cocaine, marijuana, and orally-administered amphetamines were not significantly associated with condom use in either men or women. (Leigh, Ames, & Stacy, 2008). Trauma and Risky Sexual Behavior The literature is less conflicted when discussing the correlation between trauma and risky sexual behavior. Many studies have found that participants who experience trauma are more likely to engage in risky sexual behavior (Bensley, Van Eenwyk, & Simmons, 2000; Cohen et al., 2000; Hamburger et al., 2004; Steel & Herlitz, 2005; Testa, Trauma and Risky Behavior 10 VanZile-Tamsen, & Livingston, 2005; Thompson, Potter, Sanderson, & Maibach, 1997). In addition to finding an association between adolescent sexual victimization and cigarette and marijuana use in college women, Gidycz, Orchowski, King & Rich (2008) found that traumatized women began having sexual intercourse at an earlier age and had more sexual partners. In a study of 1645 women, those who had experienced forced sexual contact before the age of 18 were more likely to have a partner who was at risk for HIV infection, engage in sex for money, drugs or shelter, and have more than ten sexual partners during a lifetime (Cohen et al., 2000). Although research has found connections between trauma, substance abuse and risky sexual behavior in men, the vast majority of the literature focuses on this relationship in women (Coker, 2007). Research suggests that trauma affects more women with more severity and as a result, female trauma survivors have an increased risk of becoming substance involved (Felitti, 1991; Johnson & Harlow, 1996; Miller, Downs, & Testa, 1993; Wilsnack, Vogelantz, Klassen, & Harris, 1997; Zierler, Feingold, & Laufer, 1991). In a study of 221 women, Lang et al. (2003) found that women with histories of sexual assault demonstrated increased substance abuse and risky sexual behavior including earlier initiation of sexual activity and more total partners. Abused women were also more likely to have sex with someone without knowing their sexual history and to smoke or drink heavily (Lang et al., 2003). The link between interpersonal abuse and risky sexual behavior in women is well documented. While some contend that the positive relationship between abuse and risky behavior in women may be less than the literature suggests (Arriola, Louden, Doldren, & Fortenberry, 2004), studies have shown that women with histories of sexual abuse often Trauma and Risky Behavior 11 report experiencing consensual sexual intercourse at an earlier age, more teenage pregnancy, more sexual partners, more substance-involved sexual intercourse, and more HIV-risk behaviors including unprotected sex, prostitution, and sex with partners who are at risk for sexually transmitted infections (Brenner, McMahon, Warren, & Douglas, 1999; Cunningham, Stillman, Dore, & Earls, 1994; Springs & Friedrich, 1992; Wingood & DiClemente, 1998). Physical abuse of women has been linked to inconsistent condom use in numerous studies (Bogart et al., 2005; Hamburger et al., 2004; Wu, El-Bassel, Witte, Gilbert, & Chang, 2003). Non-monogamy has also been linked to physical abuse. Parish, Wang, Laumann, Pan, and Luo (2004) found that women who reported being hit hard by an intimate partner were more likely to be non-monogamous than their non-abused counterparts. One study (Littleton, Radecki Breitkopf, & Barenson, 2007) reported a significant difference in the effect of trauma on risky behavior in women based on what type of trauma was experienced. The study found that women who were physically abused by a romantic partner were more likely to have had multiple sexual partners and sex while intoxicated. Women who had experienced physical abuse by a romantic partner were also more likely to exhibit risky sexual behaviors. By contrast, women who experienced physical or sexual abuse within the family were not found to have increased sexual risk (Littleton, Radecki Breitkopf, & Barenson, 2007). Substance abuse, risky sexual behavior and trauma interact in myriad ways but little research has assessed the simultaneous interaction of all three variables. Furthermore, research addressing these variables in a male population is scarce despite strong evidence for the co-occurring presence of trauma, substance abuse and risky sex Trauma and Risky Behavior 12 among men and women alike. In a previous pilot study, we examined the effects of trauma and found that women experienced, on average, thirteen potentially traumatizing events (Moore, Lesperance, Clark, & Barrett, 2008). Given the potentially harmful interactions between trauma, substance abuse and risky sexual behavior, it is prudent to investigate these relationships further, particularly with men and women who are substance-involved. It is also important to address the narrow definition of risky sexual behavior presented in the majority of the literature. Although a lack of condom use should be treated as risky, the definition must be expanded to include intoxicated sex, sex for money and sex with strangers. These behaviors are considerably risky and the literature has done little to address their significance. Current Study The current study examines men and women involved in a Family Dependency Treatment Court program (FDTC) and received treatment at a local substance abuse treatment facility. FDTC was designed to provide treatment services to parents who were substance involved and had their children removed from the home. Participants in the FDTC program participated in a 9-12 month treatment process. This study interviewed participants 12-months after enrolling in FDTC. There were two hypotheses: (1) participants who experienced higher numbers of potentially traumatic events will exhibit greater tendency to engage in unprotected sexual intercourse and other risky sexual behaviors, and (2) participants will reveal through qualitative data that they engage(d) in many different risky sexual activities including unprotected sex and sex while intoxicated. Trauma and Risky Behavior 13 Method Participants The 25 participants for this study were recruited from a group of men and women enrolled in a Family Dependency Treatment Court (FDTC) program in Hillsborough County, Florida. The treatment was an intensive outpatient program that took place at Goodwill-Suncoast Industries Inc. The majority of participants had been court-mandated to receive treatment because of neglect primarily due to substance abuse issues. All participants had their children removed from the home and placed with either relatives or in a foster home. Participants were asked to participate in this study twelve months after initial enrollment in FDTC, regardless of the status of their care or parental rights. To be eligible for FDTC, the individuals in this study were required to meet three criteria: (1) history of substance abuse, (2) had their child(ren) removed from the home, and (3) identified reunification with their children as a goal. Individuals were excluded from treatment if they had a previous termination of parental rights, past history of violent criminal offenses, a diagnosed serious mental illness, were on methadone maintenance, or if they were an alleged sexual perpetrator. Measures CSAT GPRA Client Outcome Measures for Discretionary Programs. The CSAT GPRA Client Outcome Measures for Discretionary Programs (GPRA) contains questions about past 30-day drug use, family and living conditions, education, employment, income, crime and criminal justice status, mental and physical health problems and treatment, children, and abuse as well as demographic information including gender, ethnicity, race and age. The information from the GPRA was necessary to answer basic Trauma and Risky Behavior 14 questions using demographic information and information about drug use that is pertinent to the study. GPRA data was collected on each participant at baseline and 12-months. Treatment and Administrative Data. Information on required drug and alcohol screenings included positive and negative screens as well as information about no-shows. Treatment information included the number of group sessions participants were scheduled to attend and the number they actually attended and the length of stay in the program. Life Stressors Checklist-revised. The LSC-r is a 31-item scale specifically designed for use with populations of women who have experiences that may not meet the criteria of traumatic events in the DSM. The LSC-r gives insight into a participant’s exposure to trauma through behaviorally specific language (McHugo et al., 2005). The LSC-r has demonstrated excellent test-retest reliability and has been shown to be well tolerated by participants (McHugo et al., 2005). In addition, the measure has demonstrated good content validity (Wolfe & Kimerling, 1997). The LSC-r was administered at baseline upon enrollment in the FDTC. The measure was included in this study to allow analysis of the prevalence of trauma in the population, and the correlation between trauma and risky sexual behavior. LSC-r data are not available on all participants because the scale was added to baseline measures after the start of the program. LSC-r data are available for 18 of the 25 participants. Risky Behavior Questionnaire. (Appendix A) Fifteen questions were devised by the research team and administered in a face-to-face interview. The interviews lasted approximately 15 minutes and ranged from 7 minutes to 25 minutes. The interviews took place at a place of the participants’ choosing (typically their home, a public place, Trauma and Risky Behavior 15 Goodwill-Suncoast Industries Inc) or at the court where the participant was scheduled to appear. The researcher manually recorded the responses verbatim using a pen and paper. The questions asked were designed to assess the participants’ involvement in risky behaviors. Participants were asked to estimate the number of incidences in which they were involved in activities such as unprotected sex, sex while intoxicated, sex with multiple partners at the same time as well as non-sexual activities such as drugs, binge drinking, and crime. Participants were first asked to estimate the number of times they had engaged in each behavior in the year prior to enrollment in FDTC. Next, they were asked to answer the same questions about the year in which they were enrolled in FDTC. In addition, qualitative questions were asked to assess attitudes about sexuality, risky behaviors, condoms, birth control and changes due to participation in FDTC. Participants were also asked to identify their sexual orientation, number of sexual partners over the lifetime, and their relationship to the majority of their sexual partners (friends, partners, spouses, strangers, etc.). Procedure This study was approved by the Institutional Review Board at the University of South Florida. The participants were taking part in a larger study funded by the Substance Abuse and Mental Health Services Administration (SAMHSA) Center for Substance Abuse Treatment (CSAT). A convenience sample of twenty-five participants was recruited and everyone who was recruited for this additional interview agreed to participate. Meetings with each participant took place either at the court or the meeting was set up via telephone, and was conducted at a location and time of the participants’ Trauma and Risky Behavior 16 choosing. At this meeting, informed consent was obtained and care was taken to explain the nature of the questionnaire and the rights of the participant to refuse to answer or discontinue the interview. Participants were also reminded of their rights if they became visibly uncomfortable during the interview. In this study no participants refused to answer questions or chose to stop the interview prematurely. Next, the researcher administered the Risky Behavior Questionnaire verbally. The participant was allowed to look at the questions on the page if it helped them to comprehend the question more thoroughly. Participants were also permitted to record their own answers rather than answer aloud when there were others present, particularly children, who might overhear sensitive information. In these cases, the researcher was careful to explain the question and oversee the answer before moving on to ensure the proper follow-up questions were asked. The participant was compensated with $10 in cash whether or not they completed the Risky Behavior Questionnaire. Analysis First, descriptive analyses were conducted with the baseline GPRA and treatment and administrative data to describe participant demographics, including age, income, numbers of children, housing situation, race, ethnicity, education, and employment status. Next, subscales were computed and analyzed for the Life Stressors Checklist-Revised (LSC-r) data. Frequencies were calculated to describe participants’ histories of traumatic events such as child sexual abuse, adult sexual abuse, physical abuse, emotional abuse, and other instances of interpersonal abuse. Analyses were next performed to ensure the generalizability of the participants’ demographics by comparing the participants to nonparticipants using chi squared tests for categorical variables and t-tests for continuous Trauma and Risky Behavior 17 measures. Similar analyses were conducted to compare the 18 participants with available LSC-r data with the remaining 7 participants without LSC-r data. A series of dependent sample t-tests using each individual item from the RBQ were run to determine if significant changes were reported over the first 12 months of participation in FDTC. A correlation matrix was then computed to examine the relationship between the LSC-r subscales and the risky behaviors reported in the 12months before treatment. This allowed for further assessment of participant characteristics prior to treatment and relative to the amount and types of trauma experienced. Qualitative data were entered into a spreadsheet and individual responses to each question were analyzed and placed into categories based on common themes. This procedure was repeated multiple times until the data were placed into inclusive categories. This provided information regarding attitudes toward risk and contraceptives as well as perceived changes in risky behavior in relation to FDTC. Trauma and Risky Behavior 18 Results Demographic Information The GPRA scale contains in-depth demographic information about the participants (see Table 2). There were 46 participants who were eligible to participate (i.e., they had completed 12 months of treatment). No significant differences were found between the 25 participants and the 21 people who did not participate. Participants ranged in age from 19 to 50 with the average age being 29 with 72% female. The sample was 52% Caucasian, 36% African American and 12% American Indian. Ethnically the sample was 16% Hispanic/Latino. The majority of participants had four or more children (40%) while 16% had three children, 20% have two and 24% have one child. One participant reported being pregnant at the time of her interview. The participants reported completing an average of 11th grade education with 40% graduating high school and only 8% having some college education. The average income at baseline was $701/month. Treatment and Administrative Information Treatment and administrative data revealed that 48% of participants had graduated from treatment at 12 months. Of the remaining 52%, some were still in treatment, others had been transferred to another treatment facility, dropped out of the program, or were incarcerated. Participants attended 87% of their group meetings and 94% of their mandatory drug screens. On average, each participant completed 81 drug screens and screened positive for a substance 15% of the time, maintain a drug-free lifestyle 85% during their time in treatment. Trauma and Risky Behavior 19 Table 2. Participant Demographic and Treatment Information Average Age 29 (range 19-50) Gender Male Female 28% 72% Race/Ethnicity Caucasian African-American American Indian Hispanic/Latino 52% 36% 12% 16% Number of Children One Two Three Four+ 24% 20% 16% 40% Educational Level Average 11th grade No High School Diploma 52% High School Diploma or GED 40% Some College 8% Average Monthly Income $701 Graduated from Treatment Program Yes No 48% 52% Group Meetings Attended 87% Drug Screens Average # of screens No-shows Positive screens 81 6% 15% Trauma and Risky Behavior 20 Trauma As can be seen by Figure 1, male and female participants reported having experienced an average of 12 types of traumatic events with a range from 6 to 21. While the average lifetime frequency of abuse was 11.6, women reported an average frequency of abuse of 13 while men reported an average of 6. The average frequency of childhood abuse was 2 (women =3.5 and men=0.5). On average, participants reported 2.8 types of current abuse (women=3.4, men=1.8) and current exposure to non-abusive trauma was 9 (women=8.7, men=10.5). Figure 1. Exposure to Trauma Risky Behavior Questionnaire (see Figure 2) Trauma and Risky Behavior 21 Participants reported an average of 17.2 sexual partners over the lifetime (women=16, men=20). In the 12-months prior to enrollment in FDTC, participants averaged 2 sexual partners (women=3, men=1). Similarly, in the 12-months during FDTC enrollment, participants averaged 2 sexual partners (women=2, men=4). The majority of participants (64%) reported not using condoms and 60% reported not using other contraception options. A majority of participants (68%) also reported that risk makes sex better. Figure 2. Sexual Activity As can be seen in Figure 3, all risky sexual behaviors decreased over the past 12 months, with significant decreases for unprotected sex, sex with an intoxicated person, and sex while intoxicated. Oral sex, while not considered risky, also significantly decreased. Trauma and Risky Behavior 22 Figure 3. Self-reported Risky Sexual Behavior There were several significant correlations (see Table 3). Binge drinking in the 12 months prior to FDTC was significantly correlated with four of the five LSC-r subscales (Lifetime Exposure, Lifetime Frequency of Abuse, Current Abuse, and Current Nonabusive Trauma). Binge drinking in the 12 months during FDTC, gambling in the 12months during FDTC, being arrested in the 12 months during FDTC, and having sex with an intoxicated person in the 12 months during FDTC were all significantly correlated with lifetime exposure to trauma, frequency of childhood abuse, and frequency of current non-abusive trauma. Trauma and Risky Behavior 23 Table 3. Significant Correlations of LSC-r Subscales and Self-reported Behaviors LSC-r Subscale Self-reported Behaviors Lifetime Frequency of Trauma Lifetime Frequency of Abuse Childhood Abuse Current Abuse Current Nonabusive Trauma Binge drinking year prior to FDTC Binge drinking year during FDTC Gambling year during FDTC Arrested year during FDTC Sex with intoxicated person year during FDTC r = .633 r = .532 r = .519 r = .584 r = .504 r = .534 r = .495 r = .489 r = .488 Arrested year prior to FDTC # of sexual partners year prior to FDTC Being sexually active at baseline r = .491 r = .471 r = .617 r = .507 r = .522 r = .515 r = .522 r = .607 r = .500 r = .546 Qualitative Findings The qualitative questions yielded many noteworthy results. First, 52% of participants felt that condoms are unnecessary in monogamous relationships. Common responses included the following: “If it is just you and your partner then condoms aren’t needed,” “We’ve been together for a long time so we don’t use condoms,” “We used to use them before we both knew we were clean.” When asked to state pros and cons of condom use, 19 responses were pros and only 10 were cons or neutral responses. The identified pros of using condoms were disease prevention (n=10), pregnancy prevention (n=6), general feelings of safety (n=4), and condoms are inexpensive (n=1). Identified cons of condoms were offensive smell Trauma and Risky Behavior 24 (n=1), lack of feeling or discomfort (n=2) and lack of 100% protection from pregnancy and disease (n=1). Several barriers to condom use were identified including cost, lack of feeling, lack of spontaneity, superfluity within relationships, lack of support for condom use from a partner, and the belief that not using condoms is a sign of trust for ones partner. Some responses included the following: “We’ve been together for six years. We have a lot of trust in each others’ faithfulness,” “We don’t use them because we have enough trust.” In all, 13 participants said they did not use condoms because they are in a monogamous relationship and of those 13, 2 listed trust outright as a reason they did not use condoms and the remaining 11 implied trust was a factor either by listing the number of years they have been with their partner or by stressing the seriousness of the relationship. Partner attitudes toward condom use were reported by 12 participants. Of those 12 respondents, 2 said their partners were in favor of using condoms, 3 said their condoms did not have strong feelings for or against condom use, and the remaining 7 said their partners were not in favor of using condoms. Contraceptive (other than condoms) use among participants was 40% (see Table 4). The most common form of contraception was the birth control pill (n=6) followed by surgical sterilization (n=3) and Depo-Provera shots (n=1). Many reasons for not using contraceptives emerged including being in a situation where contraception is unnecessary such as being in a same-sex relationship (n=1), currently abstaining from sex (n=1), Trauma and Risky Behavior 25 infertility (n=1) and current pregnancy (n=1). Other reasons included being in a monogamous relationship (n=2) and being ‘careful’ (either by pulling out before ejaculation or using the rhythm method to predict fertility (n=2). Some participants who were not using contraception did not provide a reason (n=4). Table 4. Use and Non-use of Contraceptives other than Condoms Use contraceptives other than condoms No Yes 60% 40% Other contraceptives used (order by % - highest to lowest) Birth control pills 24% Surgical procedure 12% Depo-Provera shots 4% Reasons for not using contraceptives other than condoms Monogamous relationship 8% Being careful (pulling out or rhythm method) 8% Infertility 4% Currently pregnant 4% Same-sex relationship 4% Not having sex 4% No reason given 16% The role of the FDTC program in changing sexual behavior was assessed using three questions (1) While enrolled in FDTC did treatment affect your sexual behavior? (2) While enrolled in FDTC did treatment affect your risky sexual behavior? (3) While enrolled in FDTC did treatment affect your risky non-sexual behavior? Overall, there was a mixed response to these questions. Responses to question 1 varied the most with 15 Trauma and Risky Behavior 26 participants answering “no” and 10 answering “yes”. When asked about risky sexual behavior (question 2) 12 reported the FDTC did not have an effect while 13 reported the FDTC did have an effect. Similarly, 13 participants reported the FDTC had no effect on their risky non-sexual behavior while12 said FDTC did have an effect. Trauma and Risky Behavior 27 Discussion Given the potential for risky behaviors among populations who are either substance-involved or exposed to trauma, it makes sense to look at the ways these factors interact. This study aimed to assess these interactions and their implications using a mixed methods approach, and it has yielded many interesting and important findings. As predicted, a higher prevalence of trauma was significantly correlated to a high prevalence of risky behavior, including both sexual and non-sexual behaviors. The FDTC program proved to be effective in reducing risky behaviors, even among those exposed to many forms of trauma. Qualitative data revealed attitudes and beliefs about sexual risk that offer insight into the FDTC population that will aid in the improvement of the program. Trauma and Substance Use The one substance use variable that was correlated with trauma was binge drinking 12-months prior to treatment, including lifetime exposure to trauma and abuse, current interpersonal abuse, and current non-abusive trauma. This suggests that those with exposure to more trauma are more likely to binge drink before beginning the program. This finding is consistent with the literature that suggests individuals who have been traumatized are more likely to drink heavily (Bensley, VanEenwyk, & Simmons, 2000). Binge drinking in the 12 months during FDTC was also significantly correlated with lifetime exposure to trauma and abuse, and current non-abusive trauma. This suggests those participants with high levels of trauma were more likely to continue to binge drink while in treatment, though their drinking decreased significantly. The legality of alcohol separates it from other substances participants may abuse and makes it easier Trauma and Risky Behavior 28 for drinkers to continue while in treatment. Alcohol may also be a secondary substance used by participants because alcohol can only be detected in the first 24 hours, as it passes quickly through the body. Trauma and Sexual Behavior Having sex with someone who was high during FDTC was significantly correlated with lifetime exposure to trauma and abuse, and current non-abusive trauma. Individuals with high levels of trauma may be personally abstaining from substances but they are still having sex with users. This may mean they are more likely to remain close with sexual partners who use substances as well as less likely to successfully remove themselves from their substance-abusing culture. Perhaps individuals with high trauma seek the thrill of risky sex or substance users more often than those with lower trauma scores. It is also possible that those who are high trauma are less able to cut ties to communities of support even when they are destructive to their overall goals. Evidence for this may be found in the strong correlation between trauma and other risky behaviors such as gambling and arrests during FDTC. It is clear that participants with more traumas were more likely to be involved in risky behaviors during FDTC. Risky Behavior Outcomes There were significant decreases in unprotected sex, sex with an intoxicated person, and sex while intoxicated from the year before they entered treatment till current. It is impossible to know how much of this can be attributed to individual and group treatment counseling and how much is due to simply abstaining from drugs, but this significant decrease points to the effectiveness of the overall holistic approach taken by Trauma and Risky Behavior 29 the FDTC. It would be beneficial to compare FDTC participants with participants of other dependency court programs to assess the relative effectiveness of FDTC. Condom use was the interview topic yielding the richest data. Condoms were familiar to all of the participants and they were seen as a primary method of pregnancy and disease prevention. Many studies of risky sexual behavior focus on condom use and perhaps one reason is the salience of condoms and the variety of beliefs circulating in the culture about condoms. The majority of participants were able to identify benefits of condoms but only 36% chose to use them. This suggests the participants understand sexual risk, and the steps necessary to prevent disease and pregnancy, but they may not see themselves as at risk, or the perceived risk may not be enough to motivate them to action. The majority of participants felt risk makes sex better, and perhaps some of that risk is forgoing condoms. Many participants believed monogamous relationships do not require condoms and the majority of participants were in monogamous relationships, as evidenced in their responses to qualitative questions on condom use and also the lack of change in the number of sexual partners 12 months before and 12 months during FDTC. Often condoms were associated with mistrust and infidelity and these associations themselves create a barrier to condom use. Consistent with the literature, participants with higher lifetime exposure to trauma were significantly more likely to be engaging in sexual activity at baseline (Gidycz, Orchowski, King & Rich, 2008). There is a need to address sexuality in trauma-exposed populations because they are likely engaging in sex, and often risky sex. Evidence suggests the need to reframe condom use in more positive ways and address the identified Trauma and Risky Behavior 30 barriers in order to encourage their use, even within monogamous relationships. Debunking myths and opening dialogue about sex may be one way to lessen the likelihood that this population will engage in risky sexual behavior. Specifically, condom use may increase if the FDTC treatment program emphasizes the concrete ways condoms can benefit participants and their partners. Some participants reported their partners were not supportive of condom use. These individuals need to be given concrete information that they can bring to their partners about condoms. The disconnect between knowledge about condoms and the applicability to the participants’ lives needs to be addressed with specific information and examples that portray condoms as relevant even in monogamous relationships when the couple does not desire more children. Contraceptive (other than condoms) use among participants was 40%. If participants are choosing to engage in sexual activity without the use of contraception or condoms they are putting themselves at risk for unplanned pregnancy. As they recover, an unplanned pregnancy can derail their efforts and financially strain them. It is therefore important to offer clients information about contraceptives and family planning. Putting the power of controlling fertility in their hands will enable them to make decisions about if and when their families will grow. Despite significant self-reported decreases in risky behaviors, such as drug use and sex while intoxicated, after 12 months in FDTC, only half of the participants attribute this change to FDTC. Furthermore, many participants reported change when asked specifically about behaviors but claimed to see no change in their behaviors when asked about the effect of treatment. Popular responses included “My risky behaviors didn’t Trauma and Risky Behavior 31 change” and “I changed myself by getting clean.” This suggests the participants either attribute the changes in their behavior to a source other than FDTC (perhaps their own strength) or they misinterpreted the meaning of the word “affect” to mean negatively affect. It may be worthwhile to analyze locus of control and self-efficacy in this sample to determine whether these results are due to a misunderstanding or feelings of empowerment. Limitations There are some limitations to this study that warrant mention. First, the sample size was small due to the complexities of locating participants after their discharge from treatment or the court system. The small sample size makes it more difficult to find statistically significant results. Many potential participants were missing at the time of this study and others could not be contacted because information was scarce or unavailable. The remaining sample, while not statistically different in demographics, may differ from the group of clients who could not be located. Most of the participants had telephone access, left contact information with the treatment agency or the court, and remained in the area where they could be located. It is possible that these participants are more stable and financially better equipped than those who could not be located. It is also possible that they differ in their connection to the FDTC program because they willingly left contact information upon discharge. Their willingness to be contacted may also be evidence of their stronger commitment to recovery or confidence in their success at the conclusion of the program. Trauma and Risky Behavior 32 Another limitation to this study is the use of self-report measures of risky behavior. The study relies on the candor of the participants and their willingness to share personal information. It also relies on retrospective data, requiring the participants to list the number of times they had engaged in certain behaviors over the last two years. This type of question almost always led the participant to estimate or guess the prevalence of a behavior because they could not remember, did not keep track, or they were impaired when the behavior took place. Perhaps focusing on event-specific data could have reduced the effect of retroactive estimation. Conclusions and Treatment Implications Overall, the treatment is effective in decreasing risky sexual behaviors, but the amount of trauma experienced has an effect on the recovery process. While it is effective, there are some small curriculum changes that may further improve the program’s ability to change behaviors, rather than just attitudes toward risky sex. Debunk myths about condoms- Opening dialogue about condom use, particularly with clients who are in monogamous relationships, will encourage honest communication about contraception. The curriculum should include information about effectiveness and also the steps proper condom use. Give concrete examples- Providing information about sex is not enough because the clients often do not apply the knowledge to their own lives. It is important to give concrete examples, perhaps in the form of an exercise that will connect the material to their lives. The change could be as simple as asking the clients to list the reasons why they might want to use condoms in their own lives. A similar connection should be drawn when talking about other forms of contraception. In Trauma and Risky Behavior 33 particular, it is important to give female clients examples of things that can be said to partners who are unwilling to use condoms. Teaching assertive communication about condoms and sex will give these women a better chance of convincing their partners to use condoms. One-on-one family planning - Controlling fertility is important for this group as they regain control of their lives and families. Having the opportunity to map out plans for future pregnancies and birth control options will help the clients personally connect to the importance of contraception and planned pregnancy. Having a plan of action and someone with whom to talk about delicate family planning issues may decrease the likelihood of unplanned pregnancy. While the FDTC was found to be effective in reducing risky behaviors, these small changes to the program may benefit their clients even more and have a lasting impact on the choices they make. This study is an important step in understanding the effects of substance use and trauma on risky behaviors. Trauma was found to be significantly correlated to several sexual and non-sexual risky behaviors. Decreases in risky behaviors suggest the overall effectiveness of the FDTC program in addressing these behaviors, while qualitative results indicate a need for more individualized education regarding sexual risk. These important insights will enable the FDTC to improve services for those in treatment. Trauma and Risky Behavior 34 References American Psychiatric Association. (2000). Diagnostic and Statistical Manual of Mental Disorders Fourth Edition (Text Revision). American Psychiatric Publishing, Inc. Washington DC: American Psychiatric Publishing, Inc. 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Risky Behavior Questionnaire Family Dependency Treatment Court (FDTC) Evaluation: 12Month Follow-up Substudy of Risky Behavior Introduction The Louis de la Parte Florida Mental Health Institute (FMHI) at the University of South Florida is conducting an evaluation of the Family Dependency treatment Court (FDTC). As part of the evaluation, we are conducting a substudy at 12-month follow-up to examine risky behavior. Past research has shown that risky behavior is associated with substance abuse and trauma-related symptomatology. The purpose of this study is to collect information from approximately 30 clients who have been through the FDTC process for at least a year regarding past and current sexual behavior as well as other types of risky behavior. Trauma and Risky Behavior 41 Interview Questions 1. What is your sexual orientation: ____________________________ 2. Before being enrolled in FDTC, where did you receive information about sex? a. School b. Family c. Friends d. Other: __________________ e. None 3. If you did receive sex education, how would you classify the information? a. Abstinence-only b. Faith-based c. Biology-based d. Comprehensive (i.e., includes birth control, condom use, abstinence, etc.) e. Other: __________________ f. None 4. In the twelve months prior to being enrolled in FDTC, what type(s) of risky sexual behavior(s) did you engage in and how often (indicate “0” if never engaged in behavior)? a. Sex while intoxicated (drugs and/or alcohol) _____ # of times b. Sex with someone who is high _____ # of times c. Unprotected sex _____ # of times d. Sex with a stranger _____ # of times e. Prostitution _____ # of times f. Sex with a prostitute _____ # of times g. Sex with more than 1 partner at a time _____ # of times h. Oral sex _____ # of times i. Sex for 60 minutes or longer _____ # of times j. Other: _____________________ _____ # of times 5. While enrolled in FDTC, what type(s) of risky sexual behavior(s) have you engaged in and how often (indicate “0” if never engaged in behavior)? a. Sex while intoxicated (drugs and/or alcohol) _____ # of times b. Sex with someone who is high _____ # of times c. Unprotected sex _____ # of times d. Sex with a stranger _____ # of times e. Prostitution _____ # of times Trauma and Risky Behavior 42 f. g. h. i. j. Sex with a prostitute Sex with more than 1 partner at a time Oral sex Sex for 60 minutes or longer Other: _____________________ _____ # of times _____ # of times _____ # of times _____ # of times _____ # of times 6. In the twelve months prior to being enrolled in FDTC, what type(s) of risky nonsexual behavior(s) did you engage in and how often (indicate “0” if never engaged in behavior)? a. Using drugs _____ # of times b. Binge drinking _____ # of times c. Gambling _____ # of times d. Dropping out of school _____ # of times e. Getting arrested _____ # of times f. Non-drug related crime (e.g., vandalism, theft) _____ # of times g. Other: ____________________ _____ # of times 7. While enrolled in FDTC, what type(s) of risky non-sexual behavior(s) have you engaged in and how often (indicate “0” if never engaged in behavior)? a. Using drugs _____ # of times b. Binge drinking _____ # of times c. Gambling _____ # of times d. Dropping out of school _____ # of times e. Getting arrested _____ # of times f. Non-drug related crime (e.g., vandalism, theft) _____ # of times g. Other: ____________________ _____ # of times 8. In the twelve months prior to being enrolled in FDTC, how many sexual partners did you have? a. # of partners _____ Relationship(s) _________________________ 9. While enrolled in FDTC, how many sexual partners have you had? a. # of partners _____ Relationship(s) _________________________ 10. During your lifetime, how many sexual partners have you had? a. # of partners _____ Relationship(s) _________________________ Trauma and Risky Behavior 43 11. While enrolled in FDTC, do you think your participation in treatment has had an effect on your: a. Sexual behavior? Why or why not? b. Risky sexual behavior? Why or why not? c. Risky non-sexual behavior? Why or why not? 12. Do you think risk makes sex more enjoyable? Why or why not? 13. Do you or your partner use condoms? Why or why not? How does/do your partner(s) feel about condoms? What do you see as the pros and/or cons of using condoms? 14. Do you or your partner use any other type of contraception (e.g., birth control pill, diaphragm, spermicide, etc.)? Why do you/don’t you use them? 15. Other comments related to sexuality or sexual behavior?