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
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Trauma and Risky Behavior 40
Appendix
A. 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?