Navigation

Drug Abuse Pictures

INTRODUCTION

A growing number of studies have noted an association between a history of sexual victimization in childhood and subsequent use of drugs in adolescence (1-5) and/or in adulthood (6-16). Indeed, the literature suggests that as many as 60-84% of adult women in drug treatment programs have been victimized by child sexual abuse (11,14,17,18). The use of drugs by child sexual abuse (CSA) victims may be related to a process of self-medication (4,19-21) in an attempt to cope with assault-related anxieties, depression, and relationship difficulties. Moreover, some studies suggest that post-traumatic stress disorder (PTSD) may be a sequelae to CSA (11,22-25), and substance use has been found to accompany PTSD diagnosis (24,26-31), possibly as a means of self-medication. Alternately, abuse in early life may be viewed as an extreme form of parental rejection that may result in the weakening of the child's attachments to the family and an increased association with drug-using peers. Some researchers (32) have suggested that the association between history of CSA and substance use/dependence may be traced to the young victim's felt need to enhance self-esteem or reduce social isolation by identifying with a peer group--such as one that is centered upon drug use--which also enables him or her to avoid interpersonal closeness.

Hence, the exact nature of the relationship between early life sexual abuse and subsequent illicit drug use remains unclear. This is likely to remain the case in the absence of appropriate adjustments for potential mediating variables such as disturbed family functioning, adulthood sexual abuse, and the extent and type of assistance received by the victim following the incident(s). Also unclear are the roles played by specific aspects of the abusive incident(s), such as the type or severity of the abuse and the relationship of the abuse perpetrator to the victim.

This paper uses a controlled, multivariate approach in examining the following questions: is there an association between sexual abuse in early life and subsequent use of illicit drugs (in this case, crack cocaine) among a population of women who are at high-risk for drug use involvement? Does this association differ depending on the nature of the sexually abusive act or on the relationship between the perpetrator and victim? The answers to such questions constitute important kernels of information that might be usefully integrated into approaches to treating drug treatment clients who present with comorbid substance use and sexual abuse-related distress.

METHODS

Subjects

Subjects for this study were participants in the National Institute on Drug Abuse (NIDA)-supported Women Helping to Empower and Enhance Lives (WHEEL) project, a three-year research and evaluation study of an HIV prevention model for noninjecting female sexual partners of male heterosexual injection drug users (IDUs). Although the WHEEL project was conducted in Boston, Los Angeles, San Diego, Juarez (Mexico), and San Juan (Puerto Rico), only participants from the U.S. sites were analyzed in this study. The WHEEL project participants must not have injected drugs in the year prior to the baseline interview and must have had sexual intercourse with a male IDU at least once in the previous five years. Indigenous outreach workers used targeted sampling techniques (33) to recruit subjects. Women at the Boston site were recruited from neighborhoods characterized by high HIV seroprevalence rates; Los Angeles women were recruited through outreach in laundromats, check-cashing stores, in the Department of Social Services' waiting room, and in neighborhoods where drug use was prevalent; and San Diego women were recruited through community networking and presentations as well as street outreach. All WHEEL participants were randomized into either a one-session individual AIDS education intervention or into one that consisted of an individual session plus three group AIDS education sessions. Data used in this study were collected at program entrance through baseline interviews.

Instruments

Two research instruments were administered at WHEEL program intake: the Risk Behavior Assessment (RBA), which gathered information on lifetime and current (last 30 days) drug use as well as lifetime and current HIV sexual risk behaviors, and the Women's Supplement (WS), which collected data on respondents' childhood home environment, childhood, and abolescent sexual abuse history, adulthood relationships, and sexual abuse history. The RBA respondents have been found to consistently self-report drug use, injection practices, and sexual behaviors (34,35). Moreover, when compared to urine analysis results, RBA respondents' self-reports of cocaine and opiate use have been found to be accurate (35,36). Acceptable test-retest reliability coefficients (from 0.72 to 0.97) have been reported for the WS (37).

Dependent Variable

The dependent variable in these analyses was self-report of having ever used crack, a smokable form of cocaine. Crack was selected as the drug of investigation due to its popularity among sample women and because WHEEL eligibility criteria made drug injectors ineligible for the study, effectively eliminating heroin users from the sample.

Early Life Sexual Abuse

The WS measured four types of childhood (ages<12) sexual abuse and four types of adolescent (ages 12-18) sexual abuse. Questions measuring childhood incidents were prefaced by the following instruction, which was read to each respondent by the interviewer: "Now I would like you to think back to childhood--that is, when you were 11 or younger--and remember if a relative, family friend, or stranger ever made you do something sexual or touched you in ways that made you feel uncomfortable." The four questions asked of respondents were: "During childhood, did anyone ever force you to see their sexual private parts or force you to show yours?; During childhood, did anyone ever talk dirty or show you dirty pictures, magazines, or videos?; During childhood, did anyone ever touch your body in a sexual way, including your breasts or private parts, or have you touch their body in a sexual way?" and "During childhood, did anyone put their penis or another object in your body, including your mouth, private parts, or butt?"

In measuring incidents of adolescent sexual abuse, respondents were asked to read the following instruction: "I would like you to think back to your adolescence--when you were 12-18--and remember if you had any sexual contact that made you very uncomfortable or where the person was much bigger, stronger, or older than you were." Following this, four questions were asked: "During adolescence, did anyone ever force you to see their sexual private parts or force you to show yours?; During adolescence, did anyone ever force you to let them touch your body in a sexual way, including your breasts or private parts, or force you to touch their body in a sexual way?; During adolescence, did anyone try to make you have sex?"; and "During adolescence, did anyone put their penis or another object in your body, including your mouth, private parts, or butt?"

Respondents indicating that they had been victimized by any of these abusive acts were asked a series of follow-up questions probing their age, the first and last time they were so victimized in that particular life stage (i.e., age < 12 years or ages 12-18 years); the identity of the perpetrator (i.e., relationship to victim) the first time the respondent was victimized by that particular act in that particular life stage; whether the victim (i.e., the respondent) told anyone about this incident; who (i.e., relationship to victim) the respondent told about this incident (up to three responses coded); whether any of the persons told had believed the victim's story, and whether any of these people had assisted the victim in any way. Abuse perpetrators and persons who were informed of the incidents were coded from the following list: father, mother, brother, sister, uncle, aunt, other relative (male), other relative (female), teacher, neighbor/ family friend, a family member's boyfriend, a family member's girlfriend, stranger, your boyfriend (romantic), your girlfriend (romantic), social worker/ other helping professional, member of the clergy, police, friend, other person you know, stepfather, grandfather, and stepbrother. These responses were reclassified into seven categories: (1) family member (father, mother, brother, sister, grandfather); (2) aunt/uncle/other relative; (3) stepfather/stepbrother; (4) neighbor/family friend (including family member's boyfriend/girlfriend); (5) teacher/social worker/other helping professional/clergy/police; (6) boyfriend/ girlfriend (including friend and other person you know); and (7) stranger. Although interviewers could code up to three responses to the items probing identity of the persons told of the incidents, persons believing the victim, and persons helping the victim, few respondents reported that they had disclosed abuse incidents to more than one person. Duration of abuse was calculated on the basis of victim's reported age when a particular form of abuse began and age when it had last occurred.

Childhood sexual abuse and adolescent sexual abuse were examined separately in all multivariate analyses. Respondents who answered yes to any of the sexual abuse questions for a particular life stage were considered to have been sexually abused in that life stage. A set of dummy variables was created for an analysis examining type of childhood sexual abuse. These variables measured: (a) women who had been forced to see or show sexual private parts, or who had been forced to listen to "dirty" talk or to view "dirty" media, (b) women who had been sexually touched or forced to sexually touch someone else, and (c) women who had been the victims of unwanted penetration. Women who did not report sexual abuse served as the reference group. The dummy variables for the analysis of type of adolescent sexual abuse measured: (a) women who had been forced to see or show sexual private parts, (b) women who had been sexually touched or forced to sexually touch someone else, (c) women who had been victimized by attempted forced penetration (attempted rape), and (d) women who had been victimized by forced penetration (rape). Again, women who had not been sexually abused constituted the reference group. In coding those cases in which the respondent had been victimized by multiple forms of abuse in a particular life stage, precedence was given to the act that involved greater physical contact (e.g., a woman reporting victimization in the form of forced sexual touching and forced penetration was coded as having been the victim of the latter act).

Dummy variables also were created, separately for childhood and for adolescence, for analysis of abuse perpetrators. These variables measured sexual abuse by family members (defined as parents, stepfathers, siblings, grandfathers, uncles and aunts, and any other blood relative) and by non-family members (i.e., neighbors; family friends; teachers; strangers; a family member's boyfriend; the participant's boyfriend, girlfriend or friend; the police, social workers or helpers; members of the clergy; or some other person). Women reporting no history of sexual abuse served as the reference group. Respondents who reported sexual victimization by both family and non-family members were coded as having been abused by a family member.

Control Variables

Study recruitment site (Boston vs. Los Angeles or San Diego), age, and race/ethnicity (White race as the reference group) were included in the analyses to control for possible confounding effects.

Mediating Variables

Mediating variables, selected for possible connection to subsequent use of crack or protection against such use, were: self-reported running away from home for at least two days during adolescence; frequency of family arguments (never/occasionally vs. often/daily) while growing up; history of family homelessness while growing up; history of treatment for mental/emotional problems; having children younger than 18 years of age; receiving assistance after the first incident of any type of early life sexual abuse; history of coercion into drug use by a sex partner (as measured by the question, "Have you ever used drugs with a sex partner because you were afraid he/she would hurt you or leave you if you did not?)"; and history of rape in adulthood (measured on the basis of an affirmative response to at least one of the following questions: "Since you became an adult, have you ever been raped or sexually assaulted by a stranger or someone you did not consider a sex partner?", and "Since you became an adult, has a sex partner (including johns) ever forced you to have sex with him/her?").

Data Analysis

Independent variable that were significantly associated with lifetime crack use in bivariate analyses were entered into a series of stepwise logistic regressions to answer the research questions. Each regression analysis was conducted in two steps: (1) controlling for confounding factors, the association between each sexual abuse measure and lifetime crack use was assessed; and (2) mediating variables were added to the equations to examine their effects on the association between each sexual abuse measure and lifetime crack use.

RESULTS

Sample

Data were gathered from WHEEL participants who resided in the three U.S. study sites, who responded to all questions regarding early life sexual abuse history and lifetime use of crack cocaine, and whose sexual victimization was reported to have taken place prior to any use of crack. To further simplify the analyses, respondents who identified themselves as racial "others" (i.e., did not self-identify as African-American, non-Hispanic White, or Hispanic/Latina) were excluded from the analytical sample, yielding a sample of 1,478 women. The characteristics of these women are described in Table 1.

Drug Use

The majority of sample women had used illicit drugs in their lifetime: nearly two-thirds (63.7%) had ever used crack cocaine, 88.4% had ever used marijuana, 63.6% had ever used cocaine, 33.9% had ever used heroin by itself, and 23.5% had used speedball (cocaine and heroin mix) (Table 1). In addition, over one-fifth (22.3%) of sample women had used crack in the 30 days prior to their interview, while nearly as many (21.6%) had used marijuana during this period (Table 1); about 7% of the sample reported that they had used crack on at least 20 of the previous 30 days (data not shown). The mean age at which sample women initiated crack use was 26 years (SD = 7 years). Over half of sample women (53.1%) reported a drug treatment history (Table 1).

Sexual Abuse

The data in Table 2 reveal that 39.5% of sample women had experienced some form of sexual abuse in childhood; nearly the same proportion (38.8%) had experienced some form of sexual abuse in adolescence.

Over one-quarter (27.4%) of sample women reported that they had been forced to observe someone's sexual private parts or to reveal their own in childhood; slightly fewer (20.7%) reported such victimization in adolescence (Table 2). Close to one-fifth (17.7%) of the sample reported that someone had talked "dirty" to them or shown them "dirty" pictures, magazines or videos in childhood (item not measured for adolescence). Forced sexual touching, reported by 33.2% of sample women as occurring in childhood and 26.8% in adolescence, was the most commonly reported early life abusive act in this sample. In addition, many of these women reported victimization by rape in childhood (16.8%) or in adolescence (23.8%), while nearly one-third (31.0%) were the victims of attempted rape in adolescence (item not measured for childhood). Sample women were more likely to have been sexually abused in both childhood and adolescence (21.7%) than to have been victimized in childhood-only (17.2%) or in adolescence-only (17.2%) (Table 3).

Sexual abuse in this sample of women began at a mean age of 10 years (SD = 4 years) and continued for a mean duration of 4 years (SD = 4 years), ranging from less than one year (including those reporting just one episode of abuse) to 14 years (data not shown). The mean number of years between the last reported instance of early life sexual abuse and first use of crack was 13 years (SD = 8 years). Over half (58.2%) of abused women reported that a family member was the first perpetrator of any type of sexual abuse. About one-third (34.9%) of abused women reported that they had received some type of help after the initial incident of abuse. In adulthood, about half (49.3%) of sample women reported that they had been raped by a stranger and/or someone they considered a sexual partner (data not shown). In addition, approximately one in seven (14.6%) women reported having ever been coerced into using drugs by a sex partner.

Early Life Sexual Abuse and Lifetime Crack Use

In bivariate analyses, lifetime crack use was significantly associated with all of the childhood sexual abuse measures (i.e., any sexual abuse, type of sexual abuse, and perpetrator of sexual abuse) and one measure for adolescence (any sexual abuse). Mediating variables significantly associated with lifetime crack use at the bivariate level were: having children under age 18; running away from home for at least two days in adolescence; history of drug coercion by a sex partner; and rape in adulthood.

After controls were added, the logistic regression analysis indicated an association between any childhood sexual abuse and lifetime crack use, as well as an association between any sexual abuse in adolescence and lifetime crack use (Table 4, model 1).

After mediating variables were added to the model, any sexual abuse in childhood remained significantly associated with crack use, but sexual abuse in adolescence fell short of statistical significance (model 2). African-American race (compared to White), having a child under 18 years of age, running away from home in adolescence, report of drug coercion by a sexual partner, and rape in adulthood remained significantly associated with lifetime crack use.

The fact that adolescent sexual abuse fell short of statistical significance when mediating variables were added to the model suggested that such victimization likely was indirectly related to crack use through some of these variables. To determine which were most important in mediating the relationship between adolescent sexual abuse and crack use, separate logistic regressions were performed for each mediator while keeping the control and sexual abuse variables constant in each equation. Mediating variables that had the effect of reducing the odds ratios of the dependent variable by at least 25% were judged to be the most significant. Such an effect was noted when the variables running away from home and rape in adulthood were included in the equations (data not shown), suggesting an indirect association between adolescent sexual abuse and lifetime crack use through each of these mediators. Similar analyses conducted with the childhood abuse measures and mediating variables uncovered no such indirect associations with lifetime crack use.

Another logistic regression analysis (Table 5) assessed the association between type of childhood sexual abuse and lifetime crack use.

After controlling for confounding variables, women who had experienced sexual touching or rape were found to be significantly more likely to have ever used crack than were women who had never been sexually abused (model 1). Sexual touching was no longer statistically significant after mediating variables were added (model 2), but the association between penetrative abuse and lifetime crack use remained significant. In addition, African-American race (compared to White), having a child under age 18 years, running away from home in adolescence, coercion into drug use by a sex partner, and rape in adulthood were significantly associated with crack use.

A final logistic regression analysis (Table 6) assessed the association between the identified perpetrator of the first incident of childhood sexual abuse and lifetime crack use.

After controlling for confounding variables, compared to women who were not sexually abused, abuse perpetrated by a family member was associated with victims' subsequent crack use (model 1); this association remained significant when mediating variables were added to the model (model 2). In addition, African-American race (compared to White), having a child under 18 years of age, running away from home in adolescence, being coerced into drug use by a sex partner, and rape in adulthood were associated with crack use.

DISCUSSION

This study found that high proportions of women sexual partners of injection drug-using men are victims of early life and/or adulthood sexual abuse. Almost 40% of the women in this sample had experienced some form of sexual abuse before age 12, and nearly the same proportion experienced some form of sexual abuse in adolescence, with almost 17% of the sample reporting victimization by rape in childhood and almost 24% reporting such victimization in adolescence. Moreover, about half of sample women had been raped by a stranger and/or someone they considered a sexual partner in adulthood. In addition, about 64% of the present sample had ever used crack cocaine, supporting the findings regarding elevated crack use levels among this population that have been reported in other large, multisite studies (38,39).

This investigation found that, after controls, any form of sexual victimization in childhood, rape in childhood, and childhood sexual victimization at the hands of a family member were associated with lifetime crack use. Such results may lend support to the observations of researchers such as Wasserman and colleagues (27), who have suggested that, "Cocaine may be self-administered as a means of preventing recollection of a past traumatic event or to reduce the psychological and physiological symptoms caused by the event" (p. 5), while also noting that the drug might be used preventively in anticipation of situations that might stimulate or heighten symptoms related to a past event. The strong possibility exists that many of the respondents in this study may have been suffering from posttraumatic stress disorder. Although the present study did not investigate respondents' past or current PTSD symptoms, it should be noted that some studies have found that in most subjects with PTSD who are also drug abusers or drug dependent, onset of PTSD preceded onset of drug abuse/dependence (27,40), and that the original trauma among such patients often is childhood abuse (25). From a developmental perspective, Mullen and colleagues (41) have suggested that abuse that is initiated during the several years before puberty may adversely affect a child's developing sexual identity, ability to trust others, sense of control, self-esteem, and sense that the world is a fair and safe place, thus setting the stage for a vulnerability to later life problems that might be palliated by substance use.

The results reported here also broadly support those investigations that have found that the impact of sexual abuse is particularly severe when more serious or invasive sexual acts (42) or when force or the threat of force are involved (42-44), while specifically confirming the association between penetrative abuse occurring in childhood and later life substance use.

Other investigations have reported that increasing closeness of the victim--perpetrator relationship is directly related to victims' poorer social adjustment and more depressive symptoms (43,45-47). The present study extends this understanding of the deleterious consequences of sexual abuse perpetrated by a family member--defined to also include stepfathers and uncles--to encompass lifetime crack use. It should be noted that although the frequency of abuse occurring in each life stage could not be measured here, some studies have found that sexual abuse perpetrated by a family member tends to involve more recurrent episodes than does abuse committed by a non-family member (48,49).

While this study found no direct association between sexual abuse occurring in adolescence and lifetime crack use, indirect pathways between the two were uncovered. In one, women who experienced sexual abuse in adolescence were found to be more likely to run away from home, and these women were more likely to use crack. Such a finding lends support to those studies (50,51) that have found that being the target of parental violence is a significant factor in an adolescent's decision to run. Female runaway adolescents may form deviant peer associations on the streets (52), which likely contribute to the substantially higher rates of alcohol and other illicit drug use found among runaway youth in comparison to nonrunaway youth (53).

It also was found here that women victimized by sexual abuse during adolescence were more likely to be raped in adulthood, and that such women were more likely to use crack. Other investigations (54,55) have reported a greater likelihood of adulthood sexual revictimization among women who were sexually abused in early life. Sexual abuse in adolescence may contribute to greater likelihood of adulthood rape because of enhanced vulnerability stemming from lowered self-esteem or greater sense of powerlessness. Moreover, some evidence suggests that having PTSD is a risk factor for revictimization (56).

Unfortunately, the temporal order of the crack use and adulthood rape reported in this study cannot be determined. To be sure, the two events have been often found to be related. For instance, in a multisite study of young women recruited in urban communities where drug use was common (57), a history of rape was reported to be common among crack smokers. It seems clear that crack-smoking women who support their drug habit through sex trading are at particularly elevated risk of assault and rape at the hands of clients (58-60). Brady et al. (25) found that among those adult patients with co morbid PTSD and cocaine dependence and for whom cocaine dependence was primary, procurement and use of the drug appeared to contribute to subsequent experience of trauma. Rape in adulthood might spur a renewed effort to procure a substance to relieve the effects of the new trauma. Indeed, Fullilove et al. (59) have suggested a pattern whereby some women may initiate crack use to relieve the symptoms of trauma, become traumatized by their efforts to secure the drug, and then attempt to relieve this new trauma by making further efforts to obtain the drug, which frequently provides additional opportunities for revictimization.

The data in this report fail to provide support for previous studies that have found that parental support following sexual abuse may buffer victims from the development of psychological distress related to self-blame and low self-esteem (61), and that family flexibility/cohesion and family organization are significantly related to subsequent adjustment (62). In the present study, being helped in some way after the first instance of sexual abuse was not found to be protective of subsequent crack use, although the measures of assistance used here are likely to have been too crude to detect any influence that assistance may have had on the relationship between early life sexual abuse and lifetime crack use.

The present analysis is limited in several ways. Reports of sexual victimization could not be corroborated. Retrospective data collection, as was used here, is known to be subject to error from memory fading and reconstruction (63). Moreover, as these data were gathered from a convenience sample that was a function of the particular outreach and recruitment strategies employed by the individual WHEEL project sites, these results cannot be generalized to other samples. The fact that the specific temporal order of the mediating variables is unknown means that causation cannot be determined. In addition, the WS did not measure how victims were helped following an abusive act, and only gathered data on assistance received by the victim after the first instance of each type of sexual abuse in childhood and in adolescence. Likewise, as the WS only collected data on the perpetrator of the first instance of each type of sexual abuse in childhood and in adolescence, the number of different types of individuals (in terms of their relationship to the victim) who may have been involved in abuse of the respondent during a particular life stage cannot be determined. Finally, PTSD was not assessed on the WS.

Notwithstanding these limitations, the data reported here indicate that high proportions of women sexual partners of injection drug-using men are likely to have been victims of child/adolescent sexual abuse, particularly forms of sexual abuse that involve bodily contact. As these women also report high prevalence of drug use, many are likely to be eventually present at drug treatment programs. It would appear that screening for sexual abuse history as well as evaluation of possible PTSD should be included as an important component of the intake process into such programs, possibly augmented by the hiring of staff members specifically trained in handling sexual abuse-related issues; the creation of on-site victims' support groups; and provision of referrals to specialized programs that offer treatment and/or shelter for abuse victims (64,65).

In addition, interventions specifically aimed at treating effects of the abuse should be considered. The optimal temporal order of treatment for comorbid substance use and sexual abuse-related distress remains in some dispute. Some clinicians have asserted that, as a general rule, patients' substance use must be arrested before other syndromes can be effectively treated (66). However, so far as the substance use may be functioning as a coping mechanism for dealing with abuse-related psychological distress, some patients may be unable to halt their drug intake until alternative skills for dealing with trauma-related memories and cognitions have been put into place (7,13). Indeed, some observers (13) have argued that the requirement of abstinence as a first step in the treatment process may be inappropriate for such patients, as abstinence may give rise to a temporary increase in arousal that eventually results in treatment avoidance (24). Hence, treatment models that integrate the two approaches have been advocated (67,68), with some evidence suggesting that patients who suffer from both a current substance use disorder as well as PTSD favor simultaneous treatment of their two disorders (69).

Table 1. Characteristics of Sample Women (N = 1,478)
(% Reporting Unless Otherwise Noted)

Sociodemographics
  Race/ethnicity
    African American                                69.4
    Non-Hispanic White                              20.6
    Hispanic/Latina                                 10.1
  Mean age (SD)                                    32 (8)
  Sexual orientation
    Heterosexual                                    89.1
    Bisexual                                         7.8
    Lesbian                                          3.0
  Marital status
    Never married                                   52.2
    Separated/divorced/widowed                      27.8
    Married/common law married                      12.1
    Living with sex partner                          7.8
  Has child under age 18 years                      70.9
    Mean number of children (SD)                  2.2 (1.5)
    Lives with children                             56.1
  Living arrangement
    In own or others' house/apartment               68.6
    In transitional housing or on streets (a)       31.4
  Highest grade of schooling
    Less than high school                           39.0
    High school/GED or higher                       61.0
  Current work situation
    Unemployed                                      55.3
    Disabled                                        14.3
    Employed full-or part-time                      11.0
    Homemaker                                        9.0
    Other                                           10.4

Drug Use History
  Alcohol
    Ever used                                       94.6
    Used last 30 days                               51.5
  Marijuana
    Ever used                                       88.4
    Used last 30 days                               21.6
  Crack
    Ever used                                       63.7
    Used last 30 days                               22.3
  Cocaine (not crack)
    Ever used                                       63.6
    Used last 30 days                                6.0
  Heroin
    Ever used                                       33.9
    Used last 30 days                                0.8
  Speedball (heroin/cocaine mix)
    Ever used                                       23.5
    Used last 30 days                                0.8

History of Family Problems
  "Often"-"daily" family arguments in youth         40.2
  Ran away from home in adolescence                 54.5
  Family ever homeless in youth                      6.0

Arrest History
  Ever arrested/booked with a crime                 60.2

Treatment History
  Ever treated for mental/emotional problems        30.9
  Ever in a drug treatment program                  53.1
    Ever in detoxification program                   7.8
    Ever in methadone maintenance program            6.5
    Ever in outpatient drug free program            24.2
    Ever in residential treatment                   39.6
    Ever in jail/prison drug treatment program       4.6

HIV/STD history
  HIV-seropositive                                   2.5
  Any STDs (not HIV) (b)                            61.1

Percentages and means based on cases with complete data.

(a) Lives in a hotel, boarding home, halfway house [transitional
housing,] a shelter or on the streets [homeless].

(b) STDs: Hepatitis B, gonorrhea, syphilis, genital warts,
chlamydia, genital herpes, and/or trichomonas.
Table 2. Childhood and Adolescent Sexual Abuse History Reported by
Sample Women (N = 1,478)

                                         Childhood    Adolescence
Type of Sexual Abuse                   (age < 12) %  (age 12-18) %

Forced to see or show sexual private
  parts                                    27.4            20.7
Talked "dirty" to or shown "dirty"         17.7             --
  pictures, magazines or videos
Was sexually touched or forced to          33.2            26.8
  sexually touch someone
Victim of attempted rape                    --             31.0
Victim of rape                             16.8            23.8
Victim of any sexual abuse                 39.5            38.8

Percentages based on cases with complete data.
Table 3. Percentage of Sample Reporting Any
Victimization by Sexual Abuse in Early Life, by
Developmental Stage

Stage                                       %

Not sexually abused                        44.0
Abused in childhood (age < 12) only        17.2
Abused in adolescence (ages 12-18) only    17.2
Abused in both childhood and adolescence   21.7
Table 4. Stepwise Multiple Logistic Regression Analysis of the
Association Between Sexual Abuse History and Lifetime Crack Use,
Separately for Abuse Occurring in Childhood and Adolescence

                                              Model 1

                                          B         Odds Ratio
A. Childhood (ages < 12)
Variables (a)
  Any sexual abuse in childhood       0.51 ***   1.67 (1.33-2.10)
Controls
  African American race               0.79 ***   2.19 (1.74-2.77)
Mediators
  Has a child under age 18
  Ran away from home in adolescence
  Drug coercion by sex partner
  Rape in adulthood
B. Adolescence (ages 12-18)
Variables (a)
  Any sexual abuse in adolescence     0.31 **    1.37 (1.09-1.71)
Controls
  African American race               0.76 ***   2.14 (1.70-2.69)
Mediators
  Has a child under age 18
  Ran away from home in adolescence
  Drug coercion by sex partner
  Rape in adulthood

                                               Model 2

                                          B         Odds Ratio
A. Childhood (ages < 12)
Variables (a)
  Any sexual abuse in childhood       0.32 **    1.38 (1.08-1.76)
Controls
  African American race               0.83 ***   2.30 (1.80-2.93)
Mediators
  Has a child under age 18            0.51 ***   1.67 (1.31-2.13)
  Ran away from home in adolescence   0.38 ***   1.46 (1.16-1.84)
  Drug coercion by sex partner        0.49 **    1.63 (1.13-2.34)
  Rape in adulthood                   0.51 ***   1.67 (1.32-2.11)
B. Adolescence (ages 12-18)
Variables (a)
  Any sexual abuse in adolescence     0.04       1.04 (0.81-1.33)
Controls
  African American race               0.81 ***   2.24 (1.76-2.85)
Mediators
  Has a child under age 18            0.49 ***   1.63 (1.28-2.08)
  Ran away from home in adolescence   0.41 ***   1.51 (1.20-1.90)
  Drug coercion by sex partner        0.54 **    1.71 (1.19-2.45)
  Rape in adulthood                   0.56 ***   1.76 (1.38-2.23)

(a) Only those variables retained in each regression model are
reported in this table. Nonsignificant variables were age,
recruitment site, frequency of family arguments, family
homelessness while growing up, history of treatment for
mental/emotional problems, and receiving help after first incident
of sexual abuse.

* p < 0.05, ** p < 0.01, *** p < 0.001.
Table 5. Stepwise Multiple Logistic Regression Analysis of the
Association Between Type of Childhood Sexual Abuse and Lifetime
Crack Use

                                           Model 1

                                     B          Odds Ratio
Variables (a)
  Forced sexual touching          0.46 ***   1.58 (1.17-2.14)
  Forced penetration              0.63 **    1.87 (1.36-2.58)
Controls
  African American race           0.77 ***   2.17 (1.72-2.74)
Mediators
  Has a child under age 18
  Ran away in adolescence
  Drug coercion by sex partner
  Rape in adulthood

                                          Model 2

                                     B          Odds Ratio
Variables (a)
  Forced sexual touching          0.28       1.32 (0.96-1.80)
  Forced penetration              0.44 **    1.56 (1.11-2.18)
Controls
  African American race           0.82 ***   2.28 (1.79-2.90)
Mediators
  Has a child under age 18        0.52 ***   1.68 (1.32-2.14)
  Ran away in adolescence         0.38 ***   1.46 (1.16-1.84)
  Drug coercion by sex partner    0.49 **    1.64 (1.14-2.35)
  Rape in adulthood               0.51 ***   1.66 (1.31-2.10)

(a) Only those variables retained in each regression model are
reported in this table. Nonsignificant variables were being forced
to see or show sexual private parts in childhood, age, recruitment
site, frequency of family arguments, family homelessness while
growing up, history of treatment for mental/emotional problems,
and receiving help after first incident of sexual abuse.

* p < 0.05, ** p < 0.01, *** p < 0.001.
Table 6. Stepwise Multiple Logistic Regression Analysis of the
Association Between Perpetrator of Childhood Sexual Abuse and
Lifetime Crack Use

                                            Model 1

                                       B          Odds Ratio
Variables (a)
  Family member                    0.64 ***    1.89 (1.42-2.51)
Controls
  African American race            0.72 ***    2.06 (1.63-2.60)
Mediators
  Has a child under age 18
  Ran away in adolescence
  Drug coercion by sex partner
  Rape in adulthood

                                           Model 2

                                      B          Odds Ratio
Variables (a)
  Family member                   0.47 **     1.61 (1.20-2.16)
Controls
  African American race           0.78 ***    2.18 (1.71-2.79)
Mediators
  Has a child under age 18        0.50 ***    1.65 (1.29-2.10)
  Ran away in adolescence         0.39 ***    1.50 (1.17-1.87)
  Drug coercion by sex partner    0.45 *      1.56 (1.09-2.25)
  Rape in adulthood               0.52 ***    1.68 (1.33-2.13)

(a) Only those variables retained in each regression model are
reported in this table. Nonsignificant variables were sexual abuse
perpetrated by a non-family member, age, recruitment site,
frequency of family arguments, family homelessness while growing
up, history of treatment for mental/emotional problems, and
receiving help after first incident of sexual abuse.

* p < 0.05, ** p < 0.01, *** p < 0.001.

ACKNOWLEDGMENTS

This project was supported by National Institute on Drug Abuse (NIDA) grant No. DA 10408-02. The authors would like to thank Mark Williams, PhD, Paul Young, MBA, and Peggy Young, MA--all of the NOVA Research Company--for their support in the preparation of this manuscript. The authors also wish to thank Jennifer Lauby, PhD, for reviewing an earlier draft of this manuscript. An earlier version of this paper was presented at the 1999 meeting of The College on Problems of Drug Dependence held in Acapulco, Mexico, June 12-19.

REFERENCES

(1.) Watts, W.D.; Ellis, A.M. Sexual Abuse and Drinking and Drug Use: Implications for Prevention. J. Drug Educ. 1993, 23, 183-200.

(2.) Dembo, R.; Williams, L.; Wish, E.D.; Berry, E.; Getreu, A.; Washburn, M.; Schmeidler, J. The Relationship Between Physical and Sexual Abuse and Illicit Drug Use: A Replication Among a New Sample of Youths Entering a Juvenile Detention Center. Int. J. Addict. 1988, 23, 1101-1123.

(3.) Holmes, W.C. Association Between A History of Childhood Sexual Abuse and Subsequent Adolescent Psychoactive Substance Use Disorder in a Sample of HIV Seropositive Men. J. Adolesc. Health 1997, 20, 414-419.

(4.) Harrison, P.A.; Hoffman, N.G.; Edwall, G.E. Differential Drug Use Patterns Among Sexually Abused Adolescent Girls in Treatment for Chemical Dependency. Int. J. Addict. 1989, 24, 499-514.

(5.) Paone, D.; Chavkin, W.; Willets, I.; Friedmann, P.; Des Jarlais, D. The Impact of Sexual Abuse: Implications for Drug Treatment. J. Women's Health 1992, 1, 149-153.

(6.) Briere, J.; Runtz, M. Post Sexual Abuse Trauma: Data and Implications for Clinical Practice. J. Interpersonal Violence 1987, 2, 367-379.

(7.) Roesler, T.A.; Dafler, C.E. Chemical Dissociation in Adults Sexually Victimized as Children: Alcohol and Drug Use in Adult Survivors. J. Subst. Abuse Treat. 1993, 10, 537-543.

(8.) Allers, C.T.; Benjack, K.J. Connections Between Childhood Abuse and HIV Infection. J. Counseling Development 1991, 70, 309-313.

(9.) Johnsen, L.W.; Harlow, L.L. Childhood Sexual Abuse Linked with Adult Substance Use, Victimization, and AIDS-Risk. AIDS Educ. Prey. 1996, 8, 44-57.

(10.) McCauley, J.; Kern, D.E.; Kolodner, K.; et al. Clinical Characteristics of Women with a History of Childhood Abuse: Unhealed Wounds. J. Am. Med. Assoc. 1997, 277, 1362-1368.

(11.) Gil-Rivas, V.; Fiorentine, R.; Anglin, M.D.; Taylor, E. Sexual and Physical Abuse: Do They Compromise Drug Treatment Outcomes? J. Subst. Abuse Treat. 1997, 14, 351-358.

(12.) Brown, G.R.; Anderson, B. Psychiatric Morbidity in Adult Inpatients with Childhood Histories of Sexual and Physical Abuse. Am. J. Psychiatry 1991, 148, 55-61.

(13.) Root, M.P.P. Treatment Failures: The Role of Sexual Victimization in Women's Addictive Behavior. Am. J. Orthopsychiatry 1989, 59, 542-549.

(14.) Teets, J.M. Childhood Sexual Trauma of Chemically Dependent Women. J. Psychoactive Drugs 1995, 27, 231-238.

(15.) Benward, J.; Densen-Gerber, J. Incest as a Causative Factor in Antisocial Behavior: an Exploratory Study. Contemp. Drug Prob. 1975, 4, 323-340.

(16.) Boyd, C.J. The Antecedents of Women's Crack Cocaine Abuse: Family Substance Abuse, Sexual Abuse, Depression and Illicit Drug Use. J. Subst. Abuse Treat. 1993, 10, 433-438.

(17.) Cohen, F.S.; Densen-Gerber, J. A Study of the Relationship Between Child Abuse and Drug Addiction in 178 Patients: Preliminary Results. Child Abuse Negl. 1982, 6, 383-387.

(18.) Rohsenow, D.J.; Corbett, R.; Devine, D. Molested as Children: a Hidden Contribution to Substance Abuse? J. Subst. Abuse Treat. 1988, 5, 13-18.

(19.) Khantzian, E.J. The Self-Medication Hypothesis of Addictive Disorders: Focus on Heroin and Cocaine Dependence. Am. J. Psychiatry 1985, 142, 1259-1264.

(20.) Castaneda, R.; Galanter, M.; Franco, H. Self-Medication Among Addicts with Primary Psychiatric Disorders. Compr. Psychiatry 1989, 30, 80-83.

(21.) Weiss, R.D.; Griffin, M.L.; Mirin, S.M. Drug Abuse as Self-Medication for Depression: an Empirical Study. Am. J. Drug Alcohol Abuse 1992, 18, 121-129.

(22.) Rowan, A.B.; Foy, D.W.; Rodriguez, N.; Ryan, S. Post-traumatic Stress Disorder in a Clinical Sample of Adults Sexually Abused as Children. Child Abuse Negl. 1994, 18, 51-61.

(23.) Astin, M.C.; Ogland-Hand, S.M.; Coleman, E.M.; Fay, D.S. Posttraumatic Stress Disorder and Childhood Abuse in Battered Women: Comparisons with Maritally Distressed Women. J. Consult. Clin. Psychol. 1995, 63, 308-312.

(24.) Brady, K.T.; Killeen, T.; Saladin, M.E.; Dansky, B.S.; Becker, S. Comorbid Substance Abuse and Post-traumatic Stress Disorder: Characteristics of Women in Treatment. Am. J. Addict. 1994, 3, 160-164.

(25.) Brady, K.T.; Dansky, B.S.; Sonne, S.C.; Saladin, M.E. Post-traumatic Stress Disorder and Cocaine Dependence: Order of Onset. Am. J. Addict. 1998, 7, 128-135.

(26.) Wilcox, J.A.; Briones, D.F.; Suess, L. Substance Abuse, Post-traumatic Stress, and Ethnicity. J. Psychoactive Drugs 1991, 23, 83-84.

(27.) Wasserman, D.A.; Havassy, B.E.; Boles, S.M. Traumatic Events and Posttraumatic Stress Disorder in Cocaine Users Entering Private Treatment. Drug Alcohol Depend. 1997, 46, 1-8.

(28.) Ross, C.A.; Kronson, J.; Koensgen, S.; Barkman, K.; Clark, P.; Rockman, G. Dissociative Comorbidity in 100 Chemically Dependent Patients. Hospital Community Psychiatry 1992, 43, 840-842.

(29.) Najavits, L.M.; Weiss, R.D.; Shaw, S.R. The Link Between Substance Abuse and Post-traumatic Stress Disorder in Women: a Research Review. Am. J. Addict. 1997, 6, 273-283.

(30.) Keane, T.M.; Gerardi, R.J.; Lyons, J.A.; et al. The Interrelationship of Substance Abuse and Post-traumatic Stress Disorder: Epidemiological and Clinical Considerations. In Recent Developments in Alcoholism; Galanter, M., Ed.; Plenum Press: New York, 1988; Vol. 6.

(31.) Grice, D.E.; Brady, K.T.; Dustan, L.R.; et al. Sexual and Physical Assault History and Post-traumatic Stress Disorder in Substance-Dependent Individuals. Am. J. Addict. 1995, 4, 297-305.

(32.) Singer, M.I.; Petchers, M.K.; Hussey, D. The Relationship Between Sexual Abuse and Substance Abuse Among Psychiatrically Hospitalized Adolescents. Child Abuse Negl. 1989, 13, 319-325.

(33.) Watters, J.K.; Biernacki, P. Targeted Sampling: Options for the Study of Hidden Populations. Social Problems 1989, 36, 416-430.

(34.) Needle, R.; Fisher, D.G.; Weatherby, N.L.; Chitwood, D.; Brown, B.; Cesari, H.; Booth, R.; Williams, M.L.; Watters, J.; Andersen, M.; Braunstein, M.; The Reliability of Self-Reported HIV Risk Behaviors of Drug Users. Psychol. Addict. Behav. 1995, 9, 242-250.

(35.) Dowling-Guyer, S.; Johnson, M.; Fischer, D.; Needle, R.; Watters, J.; Andersen, M.; Williams, M.L.; Kotranski, L.; Booth, R.; Rhodes, F.; Weatherby, N.; Estrada, A.; Fleming, D.; Deren, S.; Tortu, S. Reliability of Drug Users' Self-Reported HIV Risk Behaviors and Validity of Self-Reported Recent Drug Use. Psychol. Assess. 1994, 1, 383-392.

(36.) Weatherby, N.L.; Needle, R.; Cesari, H.; Booth, R.; McCoy, C.B.; Watters, J.K.; Williams, M.; Chitwood, D.D.; Tortu, S.; Deren, S.; Davis, W.R. Validity of Self-Reported Drug Use Among Injection Drug Users and Crack Cocaine Users Recruited Through Street Outreach. Evaluation and Program Planning 1994, 17, 347-355.

(37.) NOVA Research Company. WHEEL Project: Program Outcome Evaluation; Progress as of 6/3/93; Bethesda, Maryland, 1993.

(38.) Feucht, T.E.; Stephens, R.C.; Sullivan, T.S. Handbook on Risk of AIDS: Injection Drug Users and Sexual Partners; Brown, R.S., Beschner, G.M., Eds.; Greenwood Press: Westport, Connecticut, 1993.

(39.) Tortu, S.; Beardsley, M.; Deren, S.; Davis, W.R. The Risk of HIV Infection in a National Sample of Women with Injection Drug-Using Partners. Am. J. Public Health 1994, 84, 1243-1249.

(40.) Chilcoat, H.D.; Breslau, N. Investigations of Causal Pathways Between PTSD and Drug Use Disorders. Addict. Behav. 1998, 23, 827-840.

(41.) Mullen, P.E.; Martin, J.L.; Anderson, J.C.; Romans, S.E.; Herbison, G.P. The Effect of Child Sexual Abuse on Social, Interpersonal and Sexual Function in Adult Life. Br. J. Psychiatry 1994, 165, 35-47.

(42.) Russell, D.E.H. The Secret Trauma: Incest in the Lives of Girls and Women; Basic Books: New York, 1986.

(43.) Finkelhor, D. Sexually Victimized Children; The Free Press: New York, 1979.

(44.) Fromuth, M.E. The Relationship of Childhood Sexual Abuse with Later Psychological and Sexual Adjustment in a Sample of College Women. Child Abuse Negl. 1986, 10, 5-15.

(45.) Browne, A.; Finkelhor, D. Impact of Child Sexual Abuse: a Review of the Research. Psychol. Bull. 1986, 99, 66-77.

(46.) Sedney, M.A.; Brooks, B. Factors Associated with a History of Childhood Sexual Experience in a Nonclinical Female Population. J. Am. Acad. Child Psychiatry 1984, 23, 215-218.

(47.) Tsai, M.; Feldman-Summers, S.; Edgar, M. Childhood Molestation: Variables Related to Differential Impacts on Psychosexual Functioning in Adult Women. J. Abnorm. Psychol. 1979, 88, 407-417.

(48.) Anderson, J.C.; Martin, J.L.; Mullen, P.E.; Romans, S.E.; Herbison, G.P. The Prevalence of Childhood Sexual Abuse Experiences in a Community Sample of Women. J. Am. Acad. Child Adolesc. Psychiatry 1993, 32, 911-919.

(49.) Fergusson, D.M.; Lynskey, M.T.; Horwood, L.J. Childhood Sexual Abuse and Psychiatric Disorders in Young Adulthood. Part I: the Prevalence of Sexual Abuse and the Factors Associated with Sexual Abuse. J. Am. Acad. Child Adolesc. Psychiatry 1996, 35, 1355-1364.

(50.) Widom, C.S.; Ames, M.A. Criminal Consequences of Childhood Sexual Victimization. Child Abuse Negl. 1994, 18, 303-318.

(51.) Farber, E.D.; Kinast, C.; McCoard, W.D.; Falkner, D.; Violence in Families of Adolescent Runaways. Child Abuse Negl. 1984, 8, 295-299.

(52.) Tyler, K.A.; Hoyt, D.R.; Whitbeck, L.B. The Effects of Early Sexual Abuse on Later Sexual Victimization Among Female Homeless and Runaway Adolescents. J. Interpersonal Violence 2000, 15, 235-250.

(53.) Greene, J.M.; Ennett, S.T.; Ringwalt, C.L. Substance Use Among Runaway and Homeless Youth in Three National Samples. Am. J. Public Health 1997, 87, 229-235.

(54.) Gilbert, L.; EI-Bassel, N.; Schilling, R.F.; Friedman, E.; Childhood Abuse as a Risk for Partner Abuse Among Women in Methadone Maintenance. Am. J. Drug Alcohol Abuse 1997, 23, 581-595.

(55.) Alexander, P.C.; Lupfer, S.L. Family Characteristics and Long-Term Consequences Associated with Sexual Abuse. Arch. Sex Behav. 1987, 16, 235-245.

(56.) Dansky, B.S.; Brady, K.T.; Saladin, M.E. Untreated Symptoms of PTSD Among Cocaine-Dependent Individuals: Changes Over Time. J. Subst. Abuse Treat. 1998, 15, 499-504.

(57.) Irwin, K.L.; Edlin, B.R.; Wong, L.; Faruque, S.; McCoy, H.V.; Word, C.; Schilling, R.; McCoy, C.B.; Evans, P.E.; Holmberg, S.D. Urban Rape Survivors: Characteristics and Prevalence of Human Immunodeficiency Virus and Other Sexually Transmitted Infections. Obstet. Gynecol. 1995, 85, 330-336.

(58.) Zierler, S.; Witbeck, B.; Mayer, K. Sexual Violence Against Women Living With or at Risk for HIV Infection. Am. J. Prev. Med. 1996, 12, 304-310.

(59.) Fullilove, M.T.; Lown, E.A.; Fullilove, R.E. Crack 'hos and Skeezers: Traumatic Experiences of Women Crack Users. J. Sex Res. 1992, 29, 275-287.

(60.) Bourgois, P.; Dunlap, E. Exorcising Sex-For-Crack: and Ethnographic Perspective from Harlem. In Crack Pipe as Pimp: An Ethnographic Investigation of Sex-for Crack Exchanges; Ratner, M.S., Ed.; Lexington Books: New York, 1993; 67-132.

(61.) Feiring, C.; Taska, L.S.; Lewis, M. Social Support and Children's and Adolescents' Adaptation to Sexual Abuse. J. Interpersonal Violence 1998, 13, 240-260.

(62.) Ray, K.C.; Jackson, J.L. Family Environment and Childhood Sexual Victimization: a Test of the Buffering Hypothesis. J. Interpersonal Violence 1997, 12, 3-17.

(63.) Gidycz, C.A.; Koss, M.P. The Impact of Adolescent Sexual Victimization: Standardized Measures of Anxiety, Depression, and Behavioral Deviancy. Violence Vict. 1989, 4, 139-149.

(64.) Ouimette, P.C.; Brown, P.J.; Najavits, L.M. Course and Treatment of Patients With both Substance Use and Post-traumatic Stress Disorders. Addict. Behav. 1998, 23, 785-795.

(65.) Dansky, B.S.; Roitzsch, J.C.; Brady, K.T.; Saladin, M.E. Post-traumatic Stress Disorder and Substance Abuse: Use of Research in a Clinical Setting. J. Trauma Stress 1997, 10, 141-149.

(66.) Nace, E.P. Post-traumatic Stress Disorder and Substance Abuse: Clinical Issues. In Recent Developments in Alcoholism; Galanter, M., Ed.; Plenum Press: New York, 1988; 9-26.

(67.) Sullivan, J.M.; Evans, K. Integrated Treatment for the Survivor of Childhood Trauma who is Chemically Dependent. J. Psychoactive Drugs 1994, 26, 369-378.

(68.) Triffleman, E.; Carroll, K.; Kellogg, S. Substance Dependence Posttraumatic Stress Disorder Therapy: an Integrated Cognitive-Behavioral Approach. J. Subst. Abuse Treat. 1999, 17, 3-14.

(69.) Brown, P.J.; Stout, R.L.; Gannon-Rowley, J. Substance Use Disorder-PTSD Comorbidity: Patients' Perceptions of Symptom Interplay and Treatment Issues. J. Subst. Abuse Treat. 1998, 15, 445-448.

Robert C. Freeman, * Karyn Collier, and Kathleen M. Parillo

NOVA Research Company, 4600 East-West Highway, Suite 700, Bethesda, MD 20814

* Corresponding author. Fax (301) 986-4931; E-mail: bfreeman@novaresearch.com

COPYRIGHT 2002 Marcel Dekker, Inc.
COPYRIGHT 2002 Gale Group