Celia M. Lescano

Psychiatric Disorders and Sexual Risk among Adolescents in Mental Health Treatment.

OBJECTIVE To examine the relationship between psychiatric disorders and sexual behaviors among adolescents receiving mental health treatment. Adolescents in mental health treatment have been found to have higher rates of HIV risk behavior than their peers, but data concerning the relationship between psychopathology and risk are inconsistent and limited. METHOD Eight hundred and forty adolescents (56% female, 58% African American, mean age = 14.9 years) and their parents completed computerized assessments of psychiatric symptoms via the Computerized Diagnostic Interview Schedule for Children (Shaffer, 2000a, 2000b). Adolescents also reported on sexual risk behaviors (vaginal/anal sex, condom use at last sex) and completed urine screens for a sexually transmitted infection (STI). RESULTS Adolescents meeting criteria for mania, externalizing disorders (oppositional defiant, conduct, and attention-deficit/hyperactivity disorders), or comorbid for externalizing and internalizing disorders (major depressive, generalized anxiety, and posttraumatic stress disorders) were significantly more likely to report a lifetime history of vaginal or anal sex than those who did not meet criteria for any psychiatric disorder (odds ratio [OR] = 2.0, 2.3, and 1.9, respectively). Adolescents meeting criteria for mania were significantly more likely to have 2 or more partners in the past 90 days (OR = 3.2) and to test positive for a STI (OR = 4.3) relative to adolescents who did not meet criteria for a psychiatric disorder. CONCLUSIONS The presence of internalizing and externalizing disorders, especially mania, suggests the need for careful screening and targeting of adolescent sexual behavior during psychiatric treatment.

Self-Esteem and Theoretical Mediators of Safer Sex Among African American Female Adolescents: Implications for Sexual Risk Reduction Interventions:

Theories of health behavior posit that change is accomplished by modifying factors deemed as mediators. A set of mediators from several theoretical models used in sexual risk reduction programs was assessed among a sample of 522 African American female adolescents. The goal was to determine whether self-esteem was associated with sexually transmitted disease (STD), pregnancy, and the set of theoretical mediators controlling for covariates. Bivariate analyses showed no relationship between self-esteem and STD or pregnancy; multivariate regression analysis revealed a significant relation between self-esteem and the set of mediators. Girls higher in self-esteem were more likely to hold positive condom attitudes, felt more efficacious in negotiating condom use, had more frequent communication with sex partners and parents, perceived fewer barriers to using condoms, and were less fearful of negotiating condom use. Self-esteem should be considered when designing and evaluating sexual risk reduction programs for this population.

Parent–Adolescent Sexual Communication: Associations of Condom Use with Condom Discussions

This study investigated the relationship between parent–teen sexual communication, discussion of condoms, and condom use among adolescents in mental health treatment. Adolescents with a history of sexual intercourse and their parents completed questionnaires assessing adolescent sexual risk behavior, sexual communication, and discussion of sexual topics. Greater condom use by adolescents was associated with parent–adolescent condom discussion but was not associated with openness in sexual communication. Seventy-six percent of adolescents reported that parents had discussed condoms with them and these discussions were significantly associated with protected sexual acts. In a logistic regression, accounting for age, gender, race, and psychiatric diagnosis teens that discussed condoms with their parent were more likely to report condom use at last sex. Increasing direct communication about condoms may be an important step in increasing adolescent’s safer sex behavior. Mental health disorders and family distress may make such discussions challenging but are not an insurmountable barrier to direct discussions about condoms.

Sexual Abuse and Sexual Risk Behavior: Beyond the Impact of Psychiatric Problems

OBJECTIVE This study examined the association between sexual abuse (SA) and sex risk in girls and boys placed in alternative and therapeutic school settings while controlling for psychiatric problems. METHOD Adolescents were recruited from alternative and therapeutic schools. Youth completed audio computer-assisted self-interviews assessing childhood abuse, sexual behaviors, sexual attitudes, and psychiatric symptoms. RESULTS Of the 162 youth with available data, 23% reported a moderate or severe SA history. After controlling for gender and the presence of a psychiatric diagnosis, youth with a SA history were significantly more likely to have engaged in sex, had sex in the last 90 days, and engaged in unprotected sex. Adolescents with a history of SA also endorsed fewer advantages of using condoms. CONCLUSIONS SA is uniquely associated with sexual behavior and attitudes even when adjusting for the presence of a psychiatric diagnosis. These data have implications for interventions for those with SA histories.

Correlates of Heterosexual Anal Intercourse Among At-Risk Adolescents and Young Adults

OBJECTIVES We sought to learn what factors are associated with anal intercourse among adolescents and young adults. We examined demographic, behavioral, relationship context, attitudinal, substance use, and mental health correlates of recent heterosexual anal intercourse among adolescents and young adults who reported engaging in recent unprotected sex. METHODS Among 1348 at-risk adolescents and young adults aged 15 to 21 years in 3 US cities, we assessed sexual risk behavior with each sexual partner in the past 90 days. Data were collected from 2000 to 2001. RESULTS Recent heterosexual anal intercourse was reported by 16% of respondents. Females who engaged in anal intercourse were more likely to be living with a sexual partner, to have had 2 or more partners, and to have experienced coerced intercourse. For males, only a sexual orientation other than heterosexual was a significant predictor of engaging in heterosexual anal intercourse. CONCLUSIONS Our findings document the prevalence of heterosexual anal intercourse among adolescents and young adults who had recent unprotected sex. Among females, the variables associated with anal intercourse relate to the context and power balance of sexual relationships. Different influences for males and females suggest different foci for interventions.

Cultural Factors and Family-Based HIV Prevention Intervention for Latino Youth

Latino youth are the fastest growing ethnic group in the United States and are at considerable risk for HIV and other sexually transmitted infections (STIs), given that they have an earlier onset of sexual activity and use condoms less consistently than European American adolescents. Theorists and scholars have emphasized the importance of taking culture into account in sexuality interventions with Latino adolescents, yet few culturally tailored interventions have been developed for this population. Given the emphasis on familismo and collectivism among Latinos, family-based programs are likely to be well received and could contribute to long-term maintenance of adolescent safety. In this synthesis of the relevant literature, cultural factors that have been identified as relevant to Latino sexuality are reviewed and implications for family-based intervention with Latinos are addressed.

Associations between sexually transmitted disease diagnosis and subsequent sexual risk and sexually transmitted disease incidence among adolescents.

Background Empiric evidence is lacking in regard to the subsequent sexually transmitted disease (STD)-associated risk behaviors of adolescents diagnosed and treated for an STD. Goal The goal of this study was to prospectively identify associations between STD diagnosis and subsequent sexual risk and STD incidence among a sample of U.S. adolescents. Study Design A cohort of 455 adolescents (age 15–21 years) was followed for 3 months. Adolescents were recruited from primary care clinics and through outreach activities. Results A total of 10.8% were initially diagnosed with at least one STD. After adjusting for observed covariates, these adolescents (compared with those testing negative) were 2.8 times (P = 0.0001) more likely to be abstinent from sex and 2.2 times more likely to report always using condoms (P = 0.04). However, during the ensuing 3 months, they were approximately 2.4 times more likely to report having sex with multiple partners (P = 0.01), 8.9 times more likely to test positive for trichomonas (P = 0.009), and 3.0 times more likely to test positive for chlamydia (P = 0.04). Conclusions Compared with those testing negative, adolescents diagnosed with an STD may subsequently adopt safer sex behaviors, including abstinence. However, perhaps in part as a result of having sex with multiple partners, they might fail to practice safer sex behaviors stringently enough to avoid subsequent STD acquisition.

Suicide Attempt and Sexual Risk Behavior: Relationship among Adolescents

The objective of this study was to examine the relationship between a history of suicide attempt and a range of current sexual risk behaviors in a large sample of sexually high-risk adolescents. Baseline data from 1,245 sexually active 15 to 21 year olds were collected as part of a multi-site, randomized trial of a brief HIV prevention program. Measures were collected using audio computer assisted self-interviews. Accounting for demographic, contextual, and substance use variables, a lifetime history of suicide attempt significantly added to multivariate regression models predicting sexual risk. Inconsistent condom users were almost twice as likely to have attempted suicide, and adolescents with an STI diagnosis were approximately twice as likely to have a history of suicide attempt. A history of suicidal behavior can be identified by clinicians and appears to be an important marker for sexual risk, which may represent an expression of emotional distress or a passive form of self-injury for suicidal adolescents.

Project STYLE: A Multisite RCT for HIV Prevention Among Youths in Mental Health Treatment

OBJECTIVE The study examined the efficacy of family-based and adolescent-only HIV prevention programs in decreasing HIV risk and improving parental monitoring and sexual communication among youths in mental health treatment. METHODS A randomized controlled trial (RCT) with 721 adolescents (ages 13-18 years) and their caregivers from mental health settings in three U.S. cities were randomly assigned to one of three theory-based, structured group interventions: family-based HIV prevention, adolescent-only HIV prevention, and adolescent-only health promotion. Interventions were delivered during an all-day workshop. Assessments were completed at baseline and three months postintervention. RESULTS Compared with those in the health intervention, adolescents in the HIV prevention interventions reported fewer unsafe sex acts (adjusted rate ratio=.49, p=.01), greater condom use (adjusted relative change=59%, p=.01), and greater likelihood of avoiding sex (adjusted odds ratio=1.44, p=.05). They also showed improved HIV knowledge (p<.01) and self-efficacy (p<.05). The family-based intervention, compared with the other interventions, produced significant improvements in parent-teen sexual communication (p<.01), parental monitoring (p<.01), and parental permissiveness (p=.05). CONCLUSIONS This RCT found that the HIV prevention interventions reduced sexual risk behavior over three months in a large, diverse sample of youths in mental health treatment and that the family-based intervention improved parental monitoring and communication with teens about sex. These interventions show promise.

Frequency of adolescent self-cutting as a predictor of HIV risk.

Objective: A wide range exists in the frequency of adolescent self-cutting behavior; however, the implications of this variability are relatively unexplored. Although evidence suggesting a relationship between self-harm and sexual risk behaviors has been identified, little is known regarding the relationship between frequency of self-cutting and sexual risk. The present study aimed to test the hypothesis that adolescents who repeatedly self-cut would report more HIV risk behaviors and riskier attitudes than those who had engaged in infrequent self-injury. Method: Adolescents (11–18 years; mean age, 15 years) from intensive psychiatric treatment programs with a history of self-cutting (N = 105, 53% female) completed measures of self-cutting, sexual risk behaviors, and risk attitudes. Results: Frequent self-cutting (more than three times, lifetime) was associated with being sexually active, using condoms inconsistently, and sharing cutting instruments. Frequent self-cutters were significantly more likely to be female and nonwhite, and report low self-restraint. They also showed a trend toward being more likely to have a history of sexual abuse. Conclusions: This study found important differences in self-cutters based on frequency of cutting. Adolescent self-cutting may be a spectrum of behavior that ranges from habitual, repeated behavior contrasted with infrequent, experimental, socially motivated cutting. The associations between frequent cutting, sexual risk, and low self-restraint suggest that common underlying mechanisms may determine these patterns.