HIV and intimate partner violence among methadone-maintained women in New York City
Introduction
Over the past decade, HIV/STIs and intimate partner violence (IPV) have emerged as significant co-occurring public health problems affecting a large number of women in drug treatment programs (Amaro, 1995; Amaro, Fried, Cabral, & Zuckerman, 1990; Cunningham, Stiffman, Dore, & Earls, 1994; El-Bassel, Gilbert, & Rajah, 2003; El-Bassel, Gilbert, Rajah, Foleno, & Frye, 2000a; Fernandez, 1995; Gilbert, El-Bassel, Schilling, Wada, & Bennet, 2000b; Worth, 1989; Wyatt, 1991). Studies have shown that past year prevalence rates of physical and sexual IPV among women in drug treatment have ranged between 25% and 57% (Brewer, Fleming, Haggerty, & Catalano, 1998; Chermack, Fuller, & Blow, 2000; El-Bassel, Gilbert, Schilling, & Wada, 2000b). These past year prevalence rates for IPV are 3–5 times higher than those found in epidemiological surveys of community-based samples of women, which range between 8% and 16% (Caetano, Nelson, & Cunradi, 2001; Straus & Gelles, 1990; Tjaden & Thoennes, 1998). Cross-sectional research suggests that IPV is associated with a number of sexual HIV/STI transmission risk related factors, including (1) engaging in unprotected sex (Amaro, 1995; Amaro et al., 1990; Cunningham et al., 1994; Fernandez, 1995; Gilbert et al., 2000a; Wingood & DiClemente, 1997; Worth, 1989), (2) higher rates of STIs (El-Bassel et al., 2000b; Gilbert, El-Bassel, Schilling, Catan, & Wada, 1998; Wu, El-Bassel, Witte, Gilbert, & Chang, 2003), (3) sex with multiple partners (Gilbert et al., 2000a), (4) engaging in unprotected anal sex (El-Bassel et al., 2000a), (5) positive HIV status (North & Rothenberg, 1993; Rothenberg & Paskey, 1995), (6) trading sex for drugs or money (El-Bassel et al., 2000b), and (7) having a risky sexual partner (e.g., one who injects drugs, is HIV positive and/or has had sex with multiple partners) (Gilbert et al., 2000a; Wu et al., 2003). Sexual risk reduction behaviors such as requesting or insisting that a partner use condoms have also been found to be associated with IPV (Gilbert et al., 2000a; Wu et al., 2003).
To date, however, research has yet to elucidate the possible temporal relationships between sexual HIV/STI transmission risk related factors and experiencing IPV among drug-involved women: Do such sexual HIV/STI transmission risk-related factors and/or sexual risk reduction behaviors, such as requesting that a partner use condoms, lead to IPV? Does experiencing IPV lead to an increase in a woman's risk of sexual HIV/STI transmission or to a decrease in sexual risk reduction behaviors?
The first temporal direction considered—that sexual HIV/STI risk-related factors or sexual risk reduction behavior leads to IPV—can be explained through the context of gender roles and power imbalances in relationships. The balance of power in intimate heterosexual relationships is influenced by the gender role norms and beliefs of both partners (Marin, Gomez, Tschann, & Gregorich, 1997). Men who subscribe to traditional gender roles are likely to exert control over the sexual relationship and to decide when, where and how sex occurs. Within this context, a woman's request to use condoms represents a challenge to prevailing traditional beliefs about gender roles, raising questions regarding the male's level of control over the sexual relationship as well as regarding the level of intimacy, trust, and commitment in the relationship (Amaro, 1995; El-Bassel et al., 1998). If a woman suspects infidelity, injection drug use, or other risky behaviors, requesting that her partner use condoms or get tested for HIV may be interpreted by him as a lack of trust or care (El-Bassel et al., 2000a; Gilbert et al., 2000b; Kelly & Kalichman, 1995; Kelly et al., 1993). It may imply to some men that she has engaged in risky behaviors and be perceived as a sign of infidelity and a breach of gender role expectations on her part (El-Bassel et al., 2000a). Such perceptions threaten the stability of the couple, increasing the likelihood of abuse (O’Leary & Wingood, 2000), as some men resort to using physical and/or sexual IPV as a mechanism to repair their masculine self-esteem and maintain power. Some women may try to safeguard themselves from HIV/STI transmission by refusing sex or, at least, refusing unprotected sex or asking their partners to use condoms. In retaliation to the refusal, the partner may react violently towards the woman (El-Bassel et al. (1998), El-Bassel, Gilbert, Rajah, Foleno, & Frye (2000a); Gilbert et al., 2000b).
Similarly, a woman's disclosure of an STI or positive HIV status may raise questions of infidelity and trigger episodes of IPV (Gielen, O’Campo, Anderson, Keller, & Faden, 2000). Existing research has found positive STI or HIV status to be associated with IPV (Gielen et al., 2000; Gielen, O’Campo, Faden, & Eke, 1997; North & Rothenberg, 1993; Rothenberg & Paskey, 1995). It is not clear whether this association is related to disclosure of positive STI or HIV status or a result of other mediators factors, such as relationship power dynamics, that make condom use more unlikely, and consequently, HIV/STIs more likely.
Furthermore, because drug-dependent women are often considered “sexually promiscuous” or “damaged goods,” they are perceived as violating traditional gender role norms, and thus, viewed as more deserving of abuse (Miller, 1990). Several studies have documented the perilous and degrading circumstances under which women who exchange sex for money or drugs operate, where coercive sex is common and condom use infrequent (Edlin et al., 1994; El-Bassel et al., 1996; Fullilove, Lown, & Fullilove, 1992; Irwin et al., 1995; Lown, Winkler, Fullilove, & Fullilove, 1993).
The second direction posits that the experience of IPV leads to unprotected sex and a greater likelihood of HIV and other STIs as abused women are less likely to request or insist that their partners use condoms to avoid risking future IPV. Experiencing IPV and engaging in unsafe sex occurs as an extension of the unequal distribution of sexual, social and economic power between men and women and the low social status of drug-involved women. Gender theory provides a useful conceptual framework for understanding how gender roles reinforce differentials in sexual relationship power that create a pretext for IPV and leave women vulnerable to HIV/STIs (Amaro, 1995; Zierler & Krieger, 1997). After experiencing IPV, some women may be hesitant to attempt to negotiate condom use as well as be afraid to refuse unprotected sex (El-Bassel et al., 1998; Gilbert et al., 2000b). This context of fear of violence renders women unable to shield themselves from HIV/STI transmission. Fear of IPV has been implicated as a risk factor for having unprotected sex in several qualitative and quantitative studies (El-Bassel et al., 1998; Gilbert et al., 2000b; Morrill & Ickovics, 1996; Wingood & DiClemente, 1997).
Alternatively, the bi-directional relationships between IPV and HIV/STI transmission risk may be mediated by several psychosocial factors that have been found to be independently associated with both IPV and HIV/STI risk. Childhood sexual abuse has been independently associated with both IPV (Boyd, 1993; Downs, Miller, Testa, & Panek, 1992; Gilbert, El-Bassel, Schilling, & Friedman, 1997; Marshall & Rose, 1990) and with sexual HIV risk behaviors (Wingood & DiClemente, 1997; Wyatt et al., 2002; Zierler et al., 1991). Post-traumatic Stress Disorder (PTSD) has also been found to be independently associated with experiencing IPV (Dansky, Byrne, & Brady, 1999; Schiff, El-Bassel, Engstrom, & Gilbert, 2002) and engaging in HIV risk behaviors (Wyatt et al., 2002). Similarly, research has demonstrated that psychological distress is associated with experiencing IPV (Gilbert et al., 1997; Schiff et al., 2002) and HIV risk behavior (Camacho, Brown, & Simpson, 1996; El-Bassel, Ivanoff, Schilling, Borne, & Gilbert, 1997a).
Drug and/or alcohol use by women and/or their partners may also influence the relationship between IPV and sexual HIV risk behaviors. A growing body of research has documented associations between drug and alcohol use and IPV (Berenson, Stiglich, Wilkinson, & Anderson, 1991; El-Bassel et al., 1997a; El-Bassel & Witte, 2001; El-Bassel, Witte, Wada, Gilbert, & Wallace, 2001; Miller, 1990; Miller et al., 1990). Numerous studies have linked drug and alcohol use with having unprotected sex, sex with a risky partner, sex with multiple partners, exchanging sex for money or drugs as well as with HIV and other STIs (Chiasson et al., 1990; Edlin et al. (1992), Edlin et al. (1994); El-Bassel et al., 1997b). Studies have also linked having a low income, financial dependency and unemployment to both IPV (Mason & Blankenship, 1987; Straus, 1984) and HIV-risk behaviors (Monti-Catania, 1997; Zierler, 1997).
Most studies examining the relationship between IPV and sexual HIV/STI risk-related factors have used non-random samples of women and cross-sectional designs. Neither the study designs nor the methodologies used in these past studies are conducive to estimating causal effects. Cross-sectional designs generally do not allow for a time lapse between when a potential causing agent is measured and outcomes are observed. Moreover, causal estimation in any kind of observational study must rigorously address potential bias that may arise due to lack of randomization to treatment and control groups; rigorous approaches must account for shortcomings noted in the theoretical and empirical statistical literature regarding traditional or common approaches such as covariance adjustment which may be insufficient to remove bias due to potentially strong assumptions regarding model specification (Allison, 2002; Dehejia & Wahba, 2000; Rosenbaum, 1984; Rubin (1973), Rubin (1979); Rubin & Thomas, 2000).
To address these gaps, we conducted a longitudinal, panel study with a random sample of 416 women in MMTPs to examine the temporal relationship between sexual HIV/STI transmission risk-related factors and IPV. Using propensity score matching to minimize bias arising from the non-experimental design, we tested the following two hypotheses:
Hypothesis 1 (H1): Sexual HIV/STI transmission risk factors and/or risk reduction behavior increase the likelihood of subsequent IPV—We tested whether women who reported sexual HIV/STI transmission risk factors (i.e., being HIV positive, having an STI, inconsistent condom use, engaging in unprotected anal sex, or having more than one concurrent partner) or sexual risk reduction behaviors (i.e., requested or insisted that partner use condoms) were more likely to report experiencing physical or sexual IPV at a subsequent time point compared to women who did not report one of these risk factors or risk reduction behaviors. In this hypothesis the HIV/STI risk indicators are our predictor variables of interest and the IPV variables are our outcomes.
Hypothesis 2 (H2): IPV decreases the likelihood of sexual risk reduction behavior and increases the likelihood of subsequent risk of HIV/STI transmission—We tested whether women who reported IPV were at greater odds than women who did not report IPV to report elevated risk for HIV/STI transmission at the subsequent assessment time point. In this hypothesis, the IPV variables are our predictor variables of interest and the HIV/STI-risk indicators are our outcomes.
Section snippets
Recruitment and eligibility
We randomly selected 753 women from the total population of women who were enrolled in 14 MMTPs in New York City. Eligibility criteria were: (1) being female between the ages of 18–55 years; and (2) during the past year, having had a sexual or dating relationship with someone whom she described as her boyfriend, girlfriend, spouse, regular sexual partner, or the father of her children. A total of 559 women agreed to participate in a 15-min screening interview and 427 met eligibility criteria. Of
Findings
Socio-demographic characteristics of the sample that were collected at baseline are presented in Table 1. The average length of intimate relationships was 8.8 years (SD=7.8). In about two-thirds (68%) of the relationships, the women did not hold the housing lease. Half of the women reported that they contributed more than their partners to the household expenses. About one-quarter (26%) said that they relied on their partners to pay for or supply drugs. Almost half (45%) of the participants
Conclusion
To our knowledge, this is the first longitudinal investigation of the temporal relationships between an array of sexual HIV/STI transmission risk factors and IPV among a random sample of women in drug treatment. The study examined the temporal relationships between sexual HIV/STI transmission risks and IPV at two points in time over a 1-year period (waves 2 and 3), controlling for potentially confounding variables collected at baseline (wave 1). The methodology of this study significantly
Acknowledgements
This study was supported by NIDA Grant ♯ R01DA11027 awarded to Dr. El-Bassel.
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2019, Social Science and MedicineCitation Excerpt :Among women using drugs, sexual risk behaviours often result from a hightened vulnerability to violence and associated sexual health risks out of women's control (e.g., condoms are commonly not used in non-consensual sex) (Booth et al., 2000; Tyndall et al., 2002; Strathdee, 2003; Strathdee and Sherman, 2003; Strathdee and Stockman, 2010; El-Bassel et al., 2005, 2011; Des Jarlais et al., 2011; Edelman et al., 2014; Kulesza et al., 2016). Women are particularly at risk of violence mostly because of gender inequities that stem from socially constructed gender roles based on unequal socioeconomic and political power (Moss, 2002; Palència et al., 2014; Dunkle et al., 2004; El-Bassel et al., 2005, 2011). There is, nonetheless, a lack of research on gender-related stigma among drug-using populations.