HIV and intimate partner violence among methadone-maintained women in New York City

https://doi.org/10.1016/j.socscimed.2004.11.035Get rights and content

Abstract

Intimate partner violence (IPV) has been recognized as a risk factor for HIV and sexually transmitted infections (STIs) among women, particularly among those who are drug involved. This study examines the temporal relationships between sexual and/or physical partner violence (IPV) and sexual risk of HIV/STI transmission in a longitudinal study with a random sample of 416 women enrolled in methadone maintenance treatment programs in New York City. Two hypotheses are tested: whether sexual risk-related factors or risk reduction behavior leads to subsequent IPV (H1); and whether IPV decreases likelihood of subsequent risk reduction behavior (i.e., requesting to use condoms) or increases likelihood of certain sexual risk-related factors (i.e., inconsistent condom use, having unprotected anal sex, having more than one partner, exchanging sex for drugs or money, having had an STI, being HIV positive, having a partner who engaged in HIV risk) (H2). Participants were interviewed at three waves: baseline, six months and twelve months. Hypotheses were examined using propensity score matching and multiple logistic regression analyses. The prevalence rate of any physical or sexual IPV was 46% at baseline. Findings for H1 indicate that women who reported always using condoms at wave 2 were significantly less likely than women who reported inconsistent or no condom use to experience subsequent IPV at wave 3. Similarly, increased risk of IPV at wave 3 was associated with self-reported STIs (OR=2.0, p=.03), and unprotected anal sex (OR= 2.0, p<.01); always requesting that partners use condoms was associated with a significant decrease in subsequent IPV (OR=.18, p<.01). Findings for H2 suggest that IPV at wave 2 decreased the subsequent likelihood of always using condoms at wave 3 (OR=.41, p<.01) and always requesting that a partner use condoms (OR=.42, p=.02). The implications of the findings for HIV prevention interventions for women on methadone are discussed.

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.

References (83)

  • A.T. Beck et al.

    Cognitive therapy of substance abuse

    (1993)
  • D.D. Brewer et al.

    Drug use predictors of partner violence in opiate dependent women

    Violence and Victims

    (1998)
  • R. Caetano et al.

    Intimate partner violence, dependence symptoms and social consequences from drinking among white, black and Hispanic couples in the United States

    American Journal of Addiction

    (2001)
  • L.M. Camacho et al.

    Psychological dysfunction and HIV/AIDS risk behavior

    Journal of Acquired Immune Deficiency Syndromes and Human Retrovirology

    (1996)
  • M.A. Chiasson et al.

    Risk factors for human immunodeficiency virus type 1 (HIV-1) infection in patients at a sexually transmitted disease clinic in New York City

    American Journal of Epidemiology

    (1990)
  • J.A. Chu

    The repetition compulsion revisitedreliving dissociated trauma

    Psychotherapy

    (1991)
  • A. Connors et al.

    The effectiveness of right heart catheterization in the initial care of critically ill patients. Support investigators

    JAMA

    (1996)
  • B.S. Dansky et al.

    Intimate violence and post-traumatic stress disorder among individuals with cocaine dependence

    American Journal of Drug and Alcohol Abuse

    (1999)
  • R. Dehejia et al.

    Causal effects in non-experimental studiesre-evaluating the evaluation of training programs

    Journal of the American Statistical Association

    (1999)
  • Dehejia, R., Wahba, S. (2000). Propensity score matching methods for non-experimental causal studies, National Bureau...
  • L. Derogatis et al.

    The Brief Symptom Inventoryan introductory report

    Psychological Medicine

    (1983)
  • L. Derogatis

    Brief Symptom Inventoryadministration, scoring, and procedures manual

    (1993)
  • L. Derogatis et al.

    The SCL-90-R, Brief Symptom Inventory, and matching clinical rating scales

  • W.R. Downs et al.

    The long-term effects of parent-to-child violence for women

    Journal of Interpersonal Violence

    (1992)
  • B.R. Edlin et al.

    High-risk sex behavior among young street-recruited crack cocaine smokers in three American citiesan interim report

    Journal of Psychoactive Drugs

    (1992)
  • B.R. Edlin et al.

    Intersecting epidemicscrack cocaine use and HIV infection in inner-city young adults

    New England Journal of Medicine

    (1994)
  • N. El-Bassel et al.

    Correlates of crack abuse among incarcerated womenpsychological trauma, social support and coping behavior

    American Journal of Drug and Alcohol Abuse

    (1996)
  • N. El-Bassel et al.

    Skills-building and social support enhancement to reduce HIV risk among women in jail

    Criminal Justice and Behavior

    (1997)
  • N. El-Bassel et al.

    Sex trading and psychological distress among women recruited from the streets of Harlem

    American Journal of Public Health

    (1997)
  • N. El-Bassel et al.

    Partner violence and sexual HIV-risk behaviors among women in an inner-city emergency department

    Violence and Victims

    (1998)
  • N. El-Bassel et al.

    Fear and violenceraising the HIV stakes

    AIDS Education and Prevention

    (2000)
  • N. El-Bassel et al.

    Drug abuse and partner violence among women in methadone treatment

    Journal of Family Violence

    (2000)
  • N. El-Bassel et al.

    Sex trading and psychological distress among women on methadone

    Psychology of Addictive Behaviors

    (2001)
  • N. El-Bassel et al.

    Drug use and physical and sexual abuse of street sex workers in New York City

    Research for Sex Work

    (2001)
  • N. El-Bassel et al.

    Correlates of partner violence among female street-based sex workerssubstance abuse, history of child abuse and HIV risks

    AIDS Patient Care and STDs

    (2001)
  • M.I. Fernandez

    Latinas and AIDSchallenges to HIV prevention efforts

  • D. Finkelhor

    Sexually victimized children

    (1979)
  • E.B. Foa

    Posttraumatic Stress Diagnostic Scale manual

    (1995)
  • M.T. Fullilove et al.

    Crack “hos and skeezers”traumatic experiences of women crack users

    Journal of Sex Research

    (1992)
  • A.C. Gielen et al.

    Women's disclosure of HIV statusexperiences of mistreatment and violence in an urban setting

    Women and Health

    (1997)
  • A.C. Gielen et al.

    Women living with HIVdisclosure, violence, and social support

    Journal of Urban Health

    (2000)
  • Cited by (136)

    • Patterns and Trajectories of Anal Intercourse Practice Over the Life Course Among US Women at Risk of HIV

      2020, Journal of Sexual Medicine
      Citation Excerpt :

      Our multinominal regression analysis of baseline characteristics found that Hispanic women (vs black women), women who identify as bisexual or lesbian (vs heterosexuals), women who had ever experienced both sexual and physical violence(vs no violence), and women who reported above median number of male sex partners (vs median or below) were more likely to be in the AI and VI persistors group than in the VI persistors group. These associations with longitudinal AI practice are similar to associations identified in cross-sectional studies, where AI practice has been reported as more common among Hispanic than black women,23–28 among white compared to black women,3,29,30 among women who have sex with both men and women,3,25,31,32 among survivors of sexual23,33–38 and physical violence,33,39–41 and among women with multiple male sex partners.3,8,42,43 Overall, AI was reported at a tenth of visits at which a male sex partner was reported, and by 12% of women within the first year of follow-up.

    View all citing articles on Scopus
    View full text