SPECIAL SECTION SEXUAL HEALTH IN GAY AND BISEXUAL MENComp.docx

SPECIAL SECTION: SEXUAL HEALTH IN GAY AND
BISEXUAL MEN
Complexity of Childhood Sexual Abuse: Predictors of Current
Post-
TraumaticStressDisorder,MoodDisorders,SubstanceUse,andSexu
al
Risk Behavior Among Adult Men Who Have Sex with Men
Michael S. Boroughs1,2 • Sarah E. Valentine1,2 • Gail H.
Ironson3 • Jillian C. Shipherd4,5 •
Steven A. Safren1,2,6 • S. Wade Taylor6,7 • Sannisha K.
Dale1,2, • Joshua S. Baker6 •
Julianne G. Wilner1 • Conall O’Cleirigh1,2,6
Received: 11 August 2014/Revised: 7 April 2015/Accepted: 10
April 2015/Published online: 10 July 2015
� Springer Science+Business Media New York 2015
Abstract Men who have sex with men (MSM) are the group
mostatriskforHIVandrepresentthemajorityofnewinfections
intheUnitedStates.Ratesofchildhoodsexualabuse(CSA)among
MSM have been estimated as high as 46%. CSA is associated
with increased risk of HIV and greater likelihood of HIV sexual

risk behavior. The purpose of this study was to identify the
relationships between CSA complexity indicators and mental
health, substance use, sexually transmitted infections, and HIV
sexual risk among MSM. MSM with CSA histories (n=162)
whowerescreenedforanHIVpreventionefficacytrialcompleted
comprehensive psychosocial assessments. Five indicators
ofcomplexCSAexperienceswerecreated:CSAbyfamilymember,
CSA withpenetration,CSA withphysicalinjury,CSA withintense
fear,andfirstCSAinadolescence.Adjustedregressionmodelswere
used to identify relationships between CSA complexity and
outcomes.ParticipantsreportingCSAbyfamilymemberwere
at 2.6 odds of current alcohol use disorder (OR 2.64: CI
1.24–5.63), two times higher odds of substance use disorder
(OR 2.1: CI 1.02–2.36), and 2.7 times higher odds of reporting
anSTIinthepastyear(OR2.7:CI1.04–7.1).CSAwithpenetration
wasassociatedwithincreasedlikelihoodofcurrentPTSD(OR
3.17: CI 1.56–6.43), recent HIV sexual risk behavior (OR 2.7:
CI 1.16–6.36), and a greater number of casual sexual partners

(p= 0.02). Both CSA with Physical Injury (OR 4.05: CI 1.9–
8.7) and CSA with Intense Fear (OR 5.16: CI 2.5–10.7) were
related to increased odds for current PTSD. First CSA in ado-
lescencewasrelatedtoincreasedoddsofmajordepressivedis-
order.Thesefindings suggest thatCSA,with one ormorecom-
plexities,createspatternsofvulnerabilitiesforMSM,includingpost-
traumaticstressdisorder,substanceuse,andsexualrisktaking,
and suggests the need for detailed assessment of CSA and the
development of integrated HIV prevention programs that
address
mental health and substance use comorbidities.
Keywords Men who have sex with men (MSM) �
Childhoodsexualabuse(CSA)�PTSD�HIV�Sexualorientation
Introduction
Childhood Sexual Abuse: Mental Health and Sexual
Health Consequences
Intheextantliterature,childhoodsexualabuse(CSA)hasemerged
asanon-specificriskfactorforarangeofnegativehealthandmen-
talhealthsequelaeinadults.Forinstance,CSAhasbeenassociated

withmentalhealthproblemssuchasdepressionandpost-traumatic
stress disorder (PTSD), as well as substance use disorders
(e.g., Browne & Finkelhor, 1986; Maniglio, 2010; Neu-
mann, Houskamp, Pollock, & Briere, 1996; Suvak, Brogan,
& Shipherd, 2012). In addition to mental health and substance
abuseproblems,CSAhasbeenassociatedwithsexualriskbehav-
ior,sexualdysfunction,andinterpersonaldifficulties(i.e.,impaired
& Conall O’Cleirigh
[email protected]
1
Department of Psychiatry, Massachusetts General Hospital, One
Bowdoin Square, 7th Floor, Boston, MA 02114, USA
2
Department of Psychiatry, Harvard Medical School, Boston,
MA,
USA
3
Department of Psychology, University of Miami, Coral Gables,
FL, USA
4
National Center for PTSD –Women’s Health Sciences, Division,
VA Boston Healthcare System, Boston, MA, USA

5
Department of Psychiatry, Boston University School of
Medicine,
Boston, MA, USA
6
The Fenway Institute, Fenway Health, Boston, MA, USA
7
DepartmentofSocialWork,WheelockCollege,Boston,MA,USA
123
Arch Sex Behav (2015) 44:1891–1902
DOI 10.1007/s10508-015-0546-9
http://crossmark.crossref.org/dialog/?doi=10.1007/s10508-015-
0546-9&domain=pdf
http://crossmark.crossref.org/dialog/?doi=10.1007/s10508-015-
0546-9&domain=pdf
social cognitions, emotional lability, and poor interpersonal
relatedness) amongadults (e.g.,Neumann et al., 1996; Van
Bruggen,Runtz,&Kadlec,2006).Severalstudieshaverevealed
anassociationbetweenCSAandsexualriskvariablesincluding
unprotectedsex,sexwithmultiplepartners,andengaginginsex
trading among women (Arriola, Louden, Doldren, & Forten-

berry, 2005; Fargo, 2009; Gidycz, Coble, Latham, & Layman,
1993; Kaltman, Krupnick, Stockton, Hooper, & Green, 2005;
Suvak et al., 2012).
Childhood Sexual Abuse Among Gay, Bisexual,
and Other Sexual Minority Men
Although much of the extant literature has focused on the vic-
timizationofwomen,estimatesofCSAamonggayandbisexual
men reach as high as 47% (Arreola, Neilands, Pollack, Paul, &
Catania, 2008; Lenderking et al., 1997; Mimiaga et al., 2009;
O’Cleirigh, Safren, & Mayer, 2012). As a group, gay and
bisexual adults report more childhood psychological and phy-
sicalabusebyparentsandcaretakers(i.e.,familymembers)than
theirheterosexualsiblingsofthesamesex,andmoreCSA(Balsam,
Rothblum, & Beauchaine, 2005). In a study of young gay and
bisexual men (ages 15–22), 68% of the sample reported expe-
riencing verbal and physical violence victimization from family
members(Koblinetal.,2006).Agrowingbodyofresearchongay
and bisexual men’s health has revealed correlates of CSA that

parallel those first established among women. Specifically, gay
and bisexual men with CSA histories are more likely to expe-
riencenegativeemotional,cognitive,andinterpersonaloutcomes
as adults, including depression, suicidal ideation, substance
abuse,
andsexualrisk-takingbehaviorcomparedtogayand bisexual men
withoutCSAhistories(Bartholowetal.,1994;Brennan,Heller-
stedt, Ross,& Welles,2007; Kalichman,Gore-Felton, Benotsch,
Cage, & Rompa, 2004; Lloyd & Operario, 2012; Relf, 2001b;
Stalletal.,2003).Further,theseearlyexperiencesofvictimization
appear to put gay and bisexual men at increased risk for subse-
quent experiences of violence and abuse in adulthood, including
increasedriskofvictimizationintheiradultromanticrelationships
(Balsam, Lehavot, & Beadnell, 2011; Balsam et al., 2005;
Koblin
et al., 2006; Lalor & McElvaney, 2010).
Childhood Sexual Abuse in the Context of HIV Risk
and Prevention
Among gay, bisexual, and other men who have sex with men

(herein MSM for each of these groups), CSA history has been
consistently associated with increased risk for HIV acquisition
(Limetal.,2010;Lloyd&Operario,2012;Mimiagaetal.,2009;
O’Cleirigh et al., 2011; Stall et al., 2003). In addition, CSA has
been linked to a variety of sexual risk behaviors among MSM
including unprotected anal sex with a non-primary partner,
serodiscordant unprotected anal sex, sex with multiple partners,
and sex in exchange for money or drugs (Bartholow et al., 1994;
Brennan et al., 2007; Carballo-Diéguez & Dolezal, 1995;
Kalichman et al., 2004; Lenderking et al., 1997; O’Leary,
Purcell, Remien, & Gomez, 2003; Paul, Catania, Pollack, &
Stall,
2001;Relf,2001a;Stalletal.,2003).Theexperienceofviolencein
MSM’sadultromanticrelationshipshasalsobeenassociatedwith
unprotected sex and HIV acquisition (Merrill & Wolfe,
2000; Nieves-Rosa, Carballo-Dieguez, & Dolezal, 2000; Relf,
Huang,Campbell,&Catania,2004).Thus,MSMareatincreased
risk of HIV acquisition both in primary and non-primary sexual

relationships.Inprimaryrelationships,MSMwithCSAhistories
are morelikelytoreport feelingunsaferequestingthattheir abu-
sive partners use barrier protection (Heintz & Melendez, 2006).
Preliminary evidence from HIV prevention trials suggests that
sexual risk reduction interventions may be less effective for
MSMwhohaveCSAhistories(Crepazetal.,2006;Mimiaga
et al., 2009; Safren, Reisner, Herrick, Mimiaga, & Stall, 2010).
Thesefindingssuggesttheneedforbetterunderstandingofthose
constructs linking CSA to sexual risk that may be achieved by
more nuanced assessment of CSA.
Assessment of Childhood Sexual Abuse
The correlation between CSA and HIV risk is well established
among MSM, although exact mechanisms remain unclear. One
of the main limitations of the current literature is that the way
in
which CSA is operationalized (often as a binary indicator) dis-
counts the within-group heterogeneity of experiences. Defining
CSAinthiswaydilutesthelivedexperiencesofvictimsforwhom
CSAcanrepresentasingle-eventthatisincongruentwithinasur-

vivor’s context (‘‘an anomaly’’); or, CSA may represent just
one
event in the context of pervasive interpersonal abuse and
neglect
(‘‘the norm’’). In support of a more nuanced conceptualization
of
CSA, previous researchers have highlighted the importance of
abusecharacteristicssuchasduration,ageoffirstexperience,use
ofthreatorharm,andabuseinvolvingpenetration,inunderstand-
ingpost-traumaticadjustment,includingcopingstyleandriskfor
mental health and substance abuse problems (Cloitre & Rosen-
berg, 2006; Merrill, Guimond, Thomsen, & Milner, 2003).
Inaddition, recent researchon the nuance of definingand char-
acterizing CSA experiences among MSM suggests that there
may
be additional considerations when defining CSA for this popula-
tion. For instance, some researchers have taken a closer
examina-
tionoftheconsequencesofchildhoodsexualexperiencewitholder
partners (i.e., partners prior to the age of 13 who are at least
four

years older) among MSM (e.g., Arreola et al., 2008; Carballo-
Dieguez, Balan, Dolezal, & Mello, 2012). Carballo-Dieguez et
al.
only define the subset of these experiences, namely, experiences
where the child felt emotionally or physically hurt as a result of
CSA.Carballo-Dieguezetal.suggestthatnotenoughattentionhas
been paid to the perceptions of survivors of the events, such as
whether or not men choose to label these childhood sexual expe-
riencesasabuse(Carballo-Dieguez&Dolezal,1995;seealsoRind,
Tromovitch, & Bauserman, 1998).
1892 Arch Sex Behav (2015) 44:1891–1902
123
AfewstudieshavefoundthatonlyMSMwhoperceivedforce
orcoercionaspartoftheirchildhoodsexualexperiencesreported
poor adjustment, including depression and suicidal ideation
(Arreola et al., 2008; Stanley, Bartholomew, & Oram, 2004).
Importantlythough,MSMwhoreportedchildhoodsexualexpe-

rienceswitholderpartners(withandwithoutforce/coercion) were
more likely to engage in HIV sexual risk behaviors compared to
MSM without these experiences (Arreola et al., 2008). It is also
importanttonoteherethattheseauthorsrelyonadultretrospective
perceptions experiences from childhood, and do not adequately
acknowledgehoweasilytheseperceptionscanbedistortedbypost-
traumatic sequelae, such as guilt or denial (for detailed
summary
of this argument, see Dallam et al., 2001; Ondersma, Chaffin,
Berliners, Cordon, & Goodman, 1998). Althoughmostadults
who experienced CSA do not go on to have negative sequelae,
thisdoesnotmeanthatadult–childsexisnotharmfultochildren
(Dallam et al., 2001; Ondersma et al., 1998). Further, a recent
study on the labeling of CSA experiences, among HIV-positive
MSM, suggests that negative mental health sequelae are present
regardless of how the survivor labels the experience (Valentine
&Pantalone,2013).Despitewidedisagreementinthefield,these
findings highlight that it is important to distinguish between
forced/coercive sex and consensual sex when reporting findings

regarding childhood sexual experiences, and this is particularly
truewhendiscussingthechildhoodsexualexperiencesofMSM.
These nuances and characteristics are thought to represent
CSA complexities that warrant further study. Five dimensions,
orcomplexityindicators,wereinvestigatedinthisstudybecause
they may contribute to making the traumatic experience more
difficult given their association with greater disturbance and
impact upon functioning, and because they may predict distress
ordisturbanceintoadulthoodcomplicatingassessmentandtreat-
ment. Thus, we define complexity indicators as those character-
istics, supported by previous work, that influence negative
health
outcomes and complicate assessment and treatment of sexual
trauma for MSM.
Thereiscurrentlynogoldstandardforthemeasurementof
CSAcomplexity,although researchersagreethatfrequencyand
intensity of abuse, current functioning, and context of CSA
matters when attempting to characterize post-abuse adjustment

(Casey & Nurius, 2005; Kaysen, Rosen, Bowman, & Resick,
2010; Loeb, Gaines, Wyatt, Zhang, & Liu, 2011; Zink, Klesges,
Stevens, & Decker, 2009). Given the evidence demonstrated in
theliterature,webelievethattheCSAcomplexityissignificantly
influential in risk for impaired mental health, substance use,
and
sexualrisktaking.Theseoutcomesareofparticularinterestbecause
of their influence in the adult mental health and adult
adjustment
particularly among MSM with CSA histories. However, depres-
sion (Koblin et al., 2006; Mustanski, Newcomb, Du Bois,
Garcia,
& Grov, 2011; O’Cleirigh et al., 2013), PTSD (El-Bassel,
Gilbert,
Vinocur, Chang, & Wu, 2011; Ibañez, Purcell, Stall, Parsons, &
Gómez, 2005; Reisner, Mimiaga, Safren, & Mayer, 2009), and
substance use (e.g., Skeer et al., 2012) have each independently
been identified as predictors of sexual risk for HIV among MSM
regardless of CSA history.
The relationship between CSA complexity indicators, sexu-

allytransmittedinfections,andHIVsexualriskbehaviormayalso
helptospecifyaspectsoftheCSAexperiencethatserveaspoten-
tiatorsoftheproximalrisksforHIVinfectionamongMSM.Thus,
thecurrentstudyexaminedtherelationshipsbetweenempirically
derivedindicatorsofCSAcomplexity(i.e.,CSAbyafamily
member, CSA with penetration, CSA with physical injury, CSA
withintensefear,orfirstCSAinadolescence)andadultfunction-
ing,includingmentalhealth,substanceuse,andsexualrisktaking
withanexpectationthatthecomplexityofCSAwillimpactthese
outcomes among MSM.
Method
Participants
Datawerecollectedasapartofacomprehensiveassessmentfrom
amulti-siterandomizedclinicaltrialfromHIV-uninfectedMSM
(n = 162) that reported sexual risk and had a history of CSA
beforeage17.ThestudysiteswerelocatedinBoston,MA,and
Miami, FL. The average age was M = 39.4, SD= 11.8 (range
19–67).Thesamplewas66.1%EuroAmerican,22.6%African

American,3.6%Asian/PacificIslander,3.6%NativeAmerican,
with 27.8% identifying as Latino distributed across racial cate-
gories. Sexual orientation was assessed resulting in a sample
that
identified as 61 % gay, 27 % bisexual, 9 % unsure, and 3 %
heterosexual. The majority of the sample (81 %) experienced
multiple episodes of CSA before age 13, while 51% reported
experiencingsexualabusebetweenages13and17.Asignificant
minority (43%) of participants reported CSA across both age
ranges (see Table1).
Procedure
Recruitment
Recruitment was accomplished via outreach including at bars,
clubs, and cruising areas, community outreach, and advertising.
Recruitment for the study was done in conjunction with recruit-
ment for other, ongoing studies, and health promotion activities
todecreasestigmaandprotectindividualswhospokewithstudy
stafffrombeingidentifiedbyothersinthevenueassomeonewho
experienced sexual abuse in childhood.

Study Procedure
Following recruiting procedures, prospective participants were
screened by trained clinical staff via a structured questionnaire.
Arch Sex Behav (2015) 44:1891–1902 1893
123
Those who self-identified as HIV-negative were considered for
participation in the study, confirmed via rapid testing. All study
participantscompletedacomprehensivebaselineassessment
that included a thorough psychiatric evaluation, HIV and other
STItesting,andcomputer-basedpsychosocialassessments.Par-
ticipants responded to survey questions directly into a computer
because of the preponderance of studies that reveal that partici-
pants are more likely to disclosure sensitive information in this
manner (Des Jarlais et al., 1999; Metzger et al., 2000; Millstein,
1987;Navalineetal.,1994;O’Reilly,Hubbard,Lessler,Biemer,
& Turner, 1994; Turner et al., 1998; Wilson, Genco, & Yager,
1985).Inordertobeincludedinthestudy,participantshadto(1)

identify as a biological man who has sex with men age 18 or
older,(2)reportsexualcontactbeforetheageof13withanadult
oraperson5yearsolder,orsexualcontactbetweentheagesof13
and16inclusivewithaperson10yearsolder(oranyagewiththe
threatofforceorharm),(3)reportmorethanoneepisodeofunpro-
tected anal or vaginal intercourse within the past three months,
and (4) be HIV uninfected. Participants were excluded if all
episodesofunprotectedanalorvaginalintercourseoccurred
withonlyasingle,primary,HIV-negativepartner.Allprocedures
were IRB-approved.
Measures
Demographics
Theseincludedself-reportedage,race,ethnicity(independentof
racialcategory),income,relationship/maritalstatus,andedu-
cational attainment.
Assessment of Childhood Sexual Abuse
The parameters of CSA were assessed through a clinician-ad-
ministered interview adapted from previous work in HIV treat-

ment and prevention and used previously to assess sexual abuse
in a variety of medical populations (Leserman et al., 1997; Le-
serman, Li, Drossman, & Hu, 1998) including those HIV in-
fected(Lesserman,Ironson,&O’Cleirigh,2006).Theinterview
provided standardized questions that assessed sexual abuse
history comprised of 20 closed-ended questions predominantly
requiringyes/noanswers.CSAwasassessedacrosstwoageranges
0–12 years old and 13–16 years old. CSA is indicated in the
younger age range with any unwanted sexual contact report-
ed with someone 5 or more years older. In the older age range,
CSAwasindicatedifwithanysexualcontactreportedwithsome-
one 10years older or with some one of any age if there was the
threatofforceorharm.CSAwasindicatedifanyofthefollowing
occurred: genital touching, being touched, or penetrative inter-
course(i.e.,vaginaloranalpenetration).Thismeasureofunwanted
sexual contact was adapted from earlier research (Kilpatrick,
1992). All items on the measure asked about unwanted sexual
contact.Tomeetcriteriaforsexualabuse,theremustbeclearforce

or threat of harm for adolescents with a perpetrator less than 10
yearsolder;however,inchildren(13years),thethreatofforceor
harmisimpliedbya5-yearagedifferentialbetweenthevictimand
perpetrator.
CSA Complexity Indicators
Each of these CSA characteristics was coded dichotomously
indicating the presence or absence of the indicator.
Table1 Participant characteristics
Participant sample (N=162)
n %
Race Euro American 111 66.1
African American 38 22.6
Asian/Pacific Islander 6 3.6
Native American 6 3.6
Ethnicity Latino 45 27.8
Income $10,000 per year 50 30.2
[$60,000 per year 30 18.6
Educational attainment Some High School 10 6.2
High School Diploma 40 24.7

Some College 58 35.8
College Graduate 27 16.7
Some Graduate or above 27 16.7
Relational status Partnered 50 30.4
Single 112 69.6
Age M (SD) 39.4 (11.8)
1894 Arch Sex Behav (2015) 44:1891–1902
123
CSA by Family Member Participants were asked to identify
theirrelationshiptotheperpetrator(s),withapositivecodeinthis
category if the participant reported any CSA perpetrated by a
parent, stepparent, guardian, brother, other family member, or
other adult living in the family home.
CSA with Penetration was indicated if the participant repor-
tedthatpenetrativesexoccurredasdescribedaboveduringeither
age range.
CSA with Physical Injury was assessed via one question that

asked‘‘during any of the abuse experiences did you suffer ‘no
physicalinjuries,’‘minorphysicalinjuries’(scrapesandbruises),
or‘majorphysicalinjuries’(injuriesrequiringmedicalatten-
tion).’’CSAwithphysicalinjurywasindicatedifminorormajor
physical injury was reported.
CSA with Intense Fear was assessed through the question
‘‘Duringthe worst episode were youafraidthatyoumightbe
killed or seriously injured.’’
First CSA in Adolescence Participants’ CSA experiences
were assessed within two age ranges, one prior to their 13th
birthday and the other from age 13 through age 16. Partici-
pants who reported their first CSA experience during the
older age range were coded in this category.
Post-Traumatic Stress Symptom Assessment
Structured Clinical Interview for DSM-IV Axis I Disorders
(SCID-IV; Spitzer, Gibbon, & Williams, 1997)
Only the section on PTSD was used to provide an independent
assessment of current PTSD diagnosis and symptoms.

Sexual Risk Assessment
HIV sexual risk behavior was defined as insertive or receptive
anal or vaginal intercourse without a condom with any casual
partner or with any primary partner who had not specifically
disclosed that he/she was HIV uninfected and reported a recent
(past 3months) negative HIV test result. The number of HIV
sexual risk acts in the previous 3months as defined above was
summeddichotomizedatthemeantoreflecthighandlowsexual
risk. As recent sexual risk was one of the inclusion criteria in
order to enroll inthe study, thisconstruct lacksvariabilityinthat
no one reported zero risk episodes. The data were also heavily
skewed at the upper end of the range. To account for these
characteristics in the distribution, the distribution of sexual risk
behaviorwasdichotomizedatthemeantodistinguishthosewith
higher levels of recent sexual risk behaviors.
Sexually Transmitted Infections
As part of the self-report assessment, participants were asked if
theyhadbeendiagnosedwithanSTI inthe past 12months.This

generated a dichotomous variable.
Distress Assessment
The Mini-International Neuropsychiatric Interview (M.I.N.I.;
Sheehan et al., 1998)
TheMINIisashortstructureddiagnosticinterviewthathasgood
reliabilityandvaliditythatiscomparabletotheStructuredClinical
InterviewforDSM-IV(SCID-IV)(Sheehanetal.,1998).This
assessmentwascompletedwitheachparticipantbyatrainedInde-
pendentAssessoratthebaselineevaluationtoprovideinformation
on the presence of major mental illness (e.g., untreated severe
mood disorders, psychotic disorders), which is one of the exclu-
sioncriteria,andassistwithprovidingdiagnosisofothermoodor
substanceusedisorders.MajorDepressiveDisorderwasscoredas
present for anyone meeting diagnostic criteria for major depres-
siveepisodeatanytimeupto2weekspriortothebaselineassess-
ment.AnySubstanceUseDisorderwasscoredaspresentforthose
meeting diagnostic criteria for either substance abuse or depen-
denceacrossanyofthesubstancecategoriesinthepast12months.

Similarly,anyAlcoholUseDisorderwasscoredaspresentforeach
participant who met diagnostic criteria for either alcohol abuse
or
dependence in the past 12months.
Data Analysis
The demographics and background information provided in
Table 1 were generated through frequency counts, percent-
ages, and the calculation of means and standard deviations. The
interrelationships between the CSA complexity indicators were
examinedusingunadjustedlogisticregressions.Therelationships
between the CSA complexity indicators and the adult mental
health,substanceuse,andsexualhealthoutcomeswereestimated
using logistic regressions adjusted for age, race, education
level,
andtheabsenceorpresenceofadiagnosisofcurrentPTSD.Cur-
rent PTSD was included as a covariate to identify the magnitude
and significance of these relationships over and above what is
contributed by PTSD. The magnitude and significance of these
relationships are provided by the odds ratios and the associated

95% confidence interval. In one instance, the outcome variable
wascontinuous,i.e.,numberofcasualsexualpartners,andlinear
regressionsmodelswereusedwiththeidenticalcovariatesusedin
the logistic regression models. For the continuous outcome, the
tstatistic,degreesoffreedom,andthepvalueassociatedwiththe
CSA complexity predictor are reported. For the models predict-
ing current PTSD, PTSD was omitted from the list of covariates.
Results
Background Characteristics
Thetotalnumberofsexualpartnersintheprevious3-monthperiod
wasM=7.9,Median=5(range1–50),andtheHIVstatusofmale
Arch Sex Behav (2015) 44:1891–1902 1895
123
andfemalesexualpartnerswasoftenunknown.Themajorityofthe
sample reported male sexual partners exclusively (68.7%), fol-
lowed by both male and female partners (29.5%), and just 1.8%
reported female sexual partners exclusively over the previous

3-month period.
Examination of Outcome Data
Each of the outcomes of interest was descriptively examined.
Given the full sample, sexual risk behavior was M=7.52, SD=
12.43 suggesting an average of 7–8 partners in the past 3month
period. For the other outcomes interest, a sizable number of par-
ticipantshadcurrentPTSD(46%),anymooddisorder(40%),or
any alcohol use disorder (36 %). A smaller number of par-
ticipants reported an STI (17 %).
Interrelationships Between CSA Complexity Indicators
The strongest relationships were observed between CSA with
physical injury and CSA with penetration (OR 11.8: CI 4.4–
31.8) and between CSA with physical injury and CSA with
intensefear(OR9.4:CI4.3–20.5).FirstCSAinadolescencewas
significantly associated with increased odds of CSA with pen-
etration(OR4.1:CI2.1–8.3),CSAwithphysicalinjury(OR3.0:
CI 1.4–6.6), and CSA with intense fear (OR 2.3: CI 1.2–4.7).
Allbuttwooftheindicatorsweresignificantlyrelatedtoeach

other.CSAwithpenetrationwasnotsignificantlyrelatedtoCSA
by family member and neither was first CSA in adolescence
significantly related to CSA by family member. The complete
matrix of these interrelationships is presented in Table2.
Relationships between CSA Complexity Indicators
and Psychological and Health/Risk in Adulthood
Those reporting CSA with physical injury had more than four
times higher odds (OR 4.05: CI 1.90–8.70) tobe diagnosedwith
current PTSD than those who reported no physical injury. CSA
withinjurywasnotsignificantlyassociatedwithanyoftheother
outcomes under investigation (See Table3a, b for full results).
Similarly, CSA with penetration was significantly associated
with more than three times higher odds of being diagnosed with
current PTSD (OR 3.17: CI 1.56–6.43). CSA with penetration
wasalsoassociatedwithnearlythreetimeshigheroddsofreport-
ing very high levels unprotected anal intercourse in the past 3
months (OR 2.72: CI. 1.16–6.36) and with a higher number of
casual sexual partners in the past 3months.

ThosereportingCSAbyfamilymemberhad2.6timeshigher
odds(OR2.64:CI1.24–5.63)ofbeingdiagnosedwithanalcohol
usedisorderandmorethantwicetheodds(OR2.1:CI1.02–4.36)
of being diagnosed with a current substance use disorder. CSA
byfamilymemberwasnotsignificantlyassociatedwithincreased
risk of current mood disorder, current PTSD, or increased
sexual
riskforHIV.ThosereportingCSAwithphysicalinjuryhadnearly
threetimeshigheroddsinreportingasexuallytransmitteddisease
inthepastyear(OR2.7:CI1.04–7.10).ThosewhoreportedCSA
withintensefear(i.e.,fearofbeingkilledorseriouslyinjured)had
morethanfivetimeshigheroddsinmeetingdiagnosticcriteriafor
current PTSD than those who did not (OR 5.15: CI 2.5–10.7).
CSAwithintensefearwasnotsignificantlyassociatedwithanyof
the other adult outcomes. See Table3a, b for full results.
ThosewhoreportedfirstCSAinadolescencewerelesslikely
to meet criteria for major depressive disorder compared to those
who had first been abused during childhood. Despite its strong

relationshiptoallbutoneoftheotherCSAcomplexityindicators
first CSA in adolescence was not significantly related to any of
the other adult outcomes.
The reference group for each of these analyses is gay, bisex-
ual, other MSM with CSA histories, but who did not experience
each of the complexity indicators.
Discussion
This is the first study, of which we are aware, to link indices of
CSAcomplexitytoincreasedrisk for mental health,alcoholand
substance use disorders, and to increased risk for sexually trans-
mitted infections, and sexual risk for HIV, among adult MSM
overandabovewhatcanbeascribedtodiagnosticlevelsofPTSD.
Bothalcoholandothersubstanceusedisorderswerepredictedby
a history of CSA by family member. This category was also sig-
nificantly associated with a participant self-report of at least
one
sexuallytransmittedinfectioninthepastyear.Thus,therelational
Table2 Interrelationships between CSA complexity indicators
CSA complexity

indicators
% (n) CSA with injury CSA with
penetration
CSA by family
member
CSA with intense
fear
First CSA
in adolescence
CSA with physical injury 31.1 (52) – 11.8 (4.4–31.8) 2.0 (1.01–
3.9) 9.4 (4.3–20.5) 3.0 (1.4–6.6)
CSA with penetration 58.3 (98) – 1.4 (0.97–2.0) 6.1 (3.0–12.6)
4.1 (2.1–8.3)
CSA by family member 31.5 (53) – 1.95 (1.01–3.8) 0.6 (.30–
1.2)
CSA with intense fear 41.7 (70) – 2.3 (1.2–4.7)
First CSA in adolescence 61.3 (103) –
Expressed as unadjusted Odds Ratio (95% Confidence Interval)
Odds ratios that are significant at p.05 or less are indicated in
bold

1896 Arch Sex Behav (2015) 44:1891–1902
123
complexity of CSA is linked with sexual risk taking resulting in
STIs. Because risk for the acquisition of HIV is increased while
infected with another STI, assessment and intervention address-
ingthiscomplexitywouldbebeneficialtoMSMwiththishistory.
Thus,evaluationoftheseCSAcomplexityindicatorscouldserve
twoimportantfunctions.First,assessmentoftheseindicatorsmay
prove to be key in adapting the most effective intervention, at
the
individual level, to bring about positive behavioral change asso-
ciated with sexual risk reduction, moderation of substance use,
andimprovedmentalhealth.Second,atthepopulationlevel,there
is an impetus to address the public health crisis of HIV
infection
rateswhichmaybereducedthroughtheindirecttreatmentofpast
trauma given its role in current adult risk behaviors. Therefore,
thesefindingssupportthenotionthatgayandbisexualmen’smen-

tal health should be addressed with empirically supported
assess-
ment and interventions that need to be developed and tested to
support MSM’s sexual health with integrated programs that
include elements of sexual risk reduction and trauma treatment.
Current PTSD was predicted by three CSA complexity indi-
cators: CSA with penetration, CSA with physical injury, and
CSA with intense fear. These findings are consistent with other
studiesthatexaminedPTSDcomplexities(Gold,Feinstein,Skid-
more, & Marx, 2011; Johnson, Pike, & Chard, 2001; Kendall-
Tackett, Williams, & Finkelhor, 1993; McKibben, Bresnick,
Wiechman-Askay,&Fauerbach,2008).Together,currentPTSD
was predicted by CSA that included the complexities of pene-
tration, injury, or intense fear. Only CSA by family member was
not associated with current PTSD. The latter finding is unclear,
but perhaps repeated exposure to a family member that per-
petrated CSA reduces a variety of symptoms across the mul-
tipleclustersrequiredforadiagnosisofPTSD.Inaddition,itis

possiblethatthosewithfamilyperpetrationhadlifetimePTSD
but did not meet diagnostic criteria for current PTSD. Finally,
the only complexity of the five to predict current alcohol or
other substance use disorders was CSA by family member.
This may be a marker for‘‘self-medicating’’and influential in
explainingwhythosewiththiscomplexitydidnothavecurrent
PTSD.
OnlyfirstCSAinadolescencewasrelatedtolessthanhalfthe
likelihood of meeting diagnostic criteria for a major depressive
disorder. It is plausible that men who are sexually abused at an
older age are more resilient to the impact of the abuse on their
mood over time compared to those who are first abuse during
childhood.Thelackofsignificantrelationshipsbetweenageof
firstabuseandthestudyoutcomesissurprisinggivenitsstrong
relationship to the other complexity indicators. It is plausible
Table3 The relationship between (a) indices of CSA and
psychological diagnoses and (b) indices of CSA and health/risk
behaviors
(a) Indices of CSA and psychological diagnoses

CSA complexity measure Mental health/substance use diagnoses
Lifetime MDD Current PTSD
a
Alcohol disorder Substance use disorder
OR 95% CI OR 95% CI OR 95% CI OR 95% CI
CSA with physical injury 1.42 0.39-1.93 4.05 1.90–8.70 1.55
0.70–3.44 0.84 0.38–1.87
CSA with penetration 0.87 0.41–1.84 3.17 1.56–6.43 0.91 0.43–
1.95 0.79 0.37–1.65
CSA by family member 1.43 0.71–2.88 1.55 0.76–3.12 2.64
1.24–5.63 2.10 1.02–4.36
CSA with intense fear 1.83 0.83–4.07 5.16 2.5–10.70 1.06 0.48–
2.29 0.52 0.24–1.15
First CSA in adolescence 0.41 0.18–0.93 1.38 0.70–2.85 0.94
0.43–2.04 0.86 0.40–1.85
(b) Indices of CSA and health/risk behaviors
CSA complexity measure Sexual health/risk
Any STI past year High sexual risk for HIV # of casual sex
partners
b
OR 95% CI OR 95% CI t (df) p
CSA with physical injury 1.50 0.51–4.42 1.02 0.45–2.30 1.18
(154) 0.24

CSA with penetration 1.49 0.53–4.11 2.72 1.16–6.36 2.39 (155)
0.02
CSA by family member 2.7 1.04–7.10 0.78 0.36–1.72 -0.39
(155) 0.70
CSA with intense fear 1.94 0.70–5.39 1.38 0.61–3.13 0.57 (155)
0.57
First CSA in adolescence 1.39 0.50–3.91 0.87 0.39–1.95 0.77
(155) 0.44
Oddsratiosand95%confidenceintervalarereportedforlogisticregre
ssionmodelsadjustedforcovariatesage,race,education,andthepres
enceorabsenceof
current PTSD
Odds ratios or t values that are significant at p.05 or less are
indicated in bold
a
In the models predicting current post-traumatic stress disorder,
PTSD was omitted from the list of covariates
b
The relationship with number of sexual partners was examined
using linear regression models with the same covariates as the
logistic regression models
Arch Sex Behav (2015) 44:1891–1902 1897
123

that the relationship between age of first CSA and impairment
and dysfunction in adulthood is complex with suggestions
from the broader literature that the proximity of CSA to pub-
erty may be particularly relevant (Bifulco, Brown, & Adler,
1991;Briere&Runtz,1990).Posthocanalysesexaminingage
of first abuse as a continuous variable, or estimated time from
puberty of first abuse did not generate additional significant
relationships.
No other CSA complexity indicators were related to major
depressive disorder. Although current PTSD was covaried in
these models (PTSDwas significantly related tomajordepres-
sive disorder in every model), the relationship between these
aspectsoftheCSA(withtheexceptionoffirstCSAinadoles-
cence) and major depressive disorder was not significant even
when PTSD was omitted from the regression models. This sug-
geststhatamongCSAvictimswhoareMSM,theothercomplexi-
ties assessed here (CSA by a family member, CSA with penetra-
tion,CSAwithphysicalinjury,andCSAwithintensefear)donot

contribute to increased risk for a current mood disorder.
Alterna-
tively,theoverlappingsymptomsofMDDandPTSDmayaccount
forthisfindingparticularlyamongthoseMSMwithcurrentPTSD
whereasimilarsymptompresentationisbetteraccountedforby
post-traumatic stress.Thus,one opportunityforimprovedpsycho-
logical assessment among MSM would include improved differ-
ential diagnosis whenan individual presents with mood
problems,
particularlywhentheseareatypicalandseeminglyunrelatedsymp-
tomsare present,e.g., those that are inthe hypervigilanceclus-
ter of PTSD.
Given the overrepresentation of MSM among those with
CSA histories, behavioral health care would improve if health-
careproviderschosetoconducttraumascreeningsforMSMthat
presentwithmoodproblems,orprovideappropriatereferralsfor
a comprehensive mental health evaluation. It is also plausible
that the adult mental health vulnerability realized because of a
history of CSA may be more apparent among the anxiety dis-

orders than mood disorders. Mood Disorders tend to be inter-
mittentandareoften,formany,aself-limitingillnessthatimproves
withorwithouttreatment.Therefore,futureinvestigationsmay
endeavortoexaminetheroleoflifetimemooddisturbancesrather
than a current mood problem. Additional hypotheses to explain
this finding should be a focus in future investigations. For
exam-
ple,perhapsamooddisorder,asakeyoutcomeofinterest,wasnot
influenced by any of the included complexities because boys
and
mentendtowardexternalizingratherthaninternalizingdiagnoses
(Ackerman, Newton, McPherson, Jones, & Dykman, 1998).
Inaddition tobeingassociatedwithcurrent PTSD,CSAwith
penetrationwasalsosignificantlyassociatedwithaproximalrisk
for HIV through its relationship with higher numbers of casual
sexual partners and greater risk of unprotected anal intercourse,
the latter of which is one of the most risky behaviors associated
with seroconversion. This finding suggests that a detailed
assessment of CSA history among MSM may identify proximal

conduits to sexual risk for HIV than can be addressed through
tailored HIV prevention interventions. Thus, simply identifying
those MSM with a past CSA history may prove to be an insuffi-
cient level of data with which to conduct the most effective
treat-
mentofmultiplepsychiatriccomorbiditiesaswellasinterveneat
the level of behavioral health interventions to reduce sexual and
substancerisktaking.Instead,healthcareprovidersmightusestan-
dardizedstructuredassessments,suchasthoseusedinthisstudy,in
ordertoevaluatethenatureofCSAexperienceandthepotential
impact these variables have on risk behaviors and treatment
options.
RegardlessofwhetheracurrentPTSDdiagnosiswaspresent,
CSA complexity indicators improved the prediction of health
risk behaviors including an STI over the past year, HIV sexual
risk behavior, and the number of sexual partners. This finding
providesfurthersupportforathoroughevaluationofCSAamong
MSM to include assessment of these, and perhaps other, CSA
complexities.ThisinformationwouldpossiblycontributetoHIV

preventioninthecontextofinteractionsbetweenMSMandtheir
health providers.
A history of CSA appears to create a broad base of vul-
nerabilitiesforMSMthatarenotaccountedforbytheclinicalcon-
ceptualizationofPTSD,andthusmaybemissedbytraditionaltrau-
ma-focused assessment. These problems endure into adulthood.
This study examined mental health, substance use, and sexual
health across five complexity indicators from a childhood trau-
matic event. Each of these was associated with at least one di-
agnosedimpairment inadulthoodandthree proximal healthrisk
behaviors in adulthood. These findings begin to provide a foun-
dationforbothpublichealthinitiatives,andpsychosocialassess-
ment and intervention, to address a cascade of negative physical
and mental health problems in adulthood that stem from a child-
hood event. It is notable that across a variety of disorders, (e.g.,
substance use, alcohol, trauma history, or PTSD), each was in-
dependentlyrelatedtosexualriskbehaviorand/orincreasedrisk
for seroconversion (Bedoya et al., 2012; Chesney et al., 2003;

Mimiaga et al., 2009; Stall et al., 2003). With these additional
burdens,MSMmustalsonavigateadifficultcoursetodealwitha
history of CSA.
The consequent adult vulnerabilities that appear to be related
to the contextual aspects of CSA reported here are perhaps most
appropriately examined within the context of the theory of syn-
demic production (Stall et al., 2003) and the more recent exami-
nationsof these relationships(Dyer et al., 2012; Kurtz, Buttram,
Surratt, & Stall, 2012; Mimiaga et al., 2015; Mustanski, Garo-
falo,Herrick,&Donenberg,2007;Parsons,Grov,&Golub,2012).
This growing body of work suggests that developmental chal-
lenges associated with sexual minority status (including dispro-
portionate rates of CSA) contribute to multiple psychosocial
vul-
nerabilitiesinadulthood(depression,substanceuse,intimatepart-
ner violence, sexual compulsivity, and others) and combine and
interact to generate health challenges for gay, bisexual, and
other
menwhohavesexwithmen.Traditionally,CSAhasbeenincluded

asoneofthedriversofsyndemicproduction(e.g.,Stalletal.,2003).
1898 Arch Sex Behav (2015) 44:1891–1902
123
Ourfindings,thatcharacteristics(i.e.,complexities)ofCSAare
stronglyrelatedtoincreasedoddsofmeetingdiagnosticcriteriafor
current PTSD in adulthood and relationships between these
char-
acteristicsandimpairment,independentofPTSD,allowustosug-
gestthatCSA-relatedPTSDisoneofthemechanismsofsyndemic
productionratherthanCSAitself.Moreaccurately,CSArepresents
adevelopmentalvulnerabilityforgay,bisexual,andothermenwho
have sex with men, which contributes to the mechanisms of syn-
demicproductionthatmayormaynotincludeadultpost-traumatic
stress responses.
It is interesting within this syndemic framework to note that
from a consideration of CSA alone, relationships to major psy-
chological,substanceuse,andsexualhealthimpairmentsemerge,

without reference to other developmental challenges and inde-
pendent of adult PTSD (which was covaried in these analyses).
These findings underscore the enduring, damaging, and often
devastating effects, across multiple areas of adult functioning,
of
sexual trauma perpetrated on gay and bisexual young boys and
emerging adolescents.
Thehealthofgay,bisexual,andotherMSMisapublichealth
crisis(InstituteofMedicine,2011).ThisisregardlessoftheHIV
prevention efforts currently underway. Traditional HIV pre-
vention interventions are have been shown ineffective with
MSM
with CSA histories (Mimiaga et al., 2009) and thus improving
accesstohealthcare,referralformentalhealthcare,andappropriate
and evidence-based assessment and diagnosis resulting in inte-
gratedinterventionsarecentralgoalsformultiplehealthdisciplines,
the NIH, and the community being served.
Some of the limitations of this study include the use of self-
report measures which have a variety of challenges. In order to

mitigatethislimitation,standardizedcliniciandiagnosticassess-
ments were used in addition to paper-and-pencil and computer-
based assessments. Although we were looking to address lon-
gitudinal relationships, including predicting factors associated
with childhood trauma and its impact on adult health and func-
tion, this was cross-section research. Our STI results were based
on self-report at study entry and therefore are subject to recall
bias. And finally, the data represent a restricted rage given that
only men with CSA together with recent sexual risk-taking be-
haviors were included in the study. This may limit generaliz-
ability, and also may leave some relationships undetected.
These findings, however, provide additional support for and
underscore the need for integrated behavioral health interven-
tionstoaddressHIVpreventionforMSMinthecontextofCSA,
andpossiblyother,trauma-relatedvulnerabilities.Thisincludes,
but is not limited to, current PTSD and substance use in the
con-
textofsexualrisktaking.Fromaclinicalpracticepointofview,a
moredetailedassessmentofCSAisneededbeyondthepresence

orabsenceofthediagnosisofPTSD.Thisisespeciallyimportant
amongMSM.Thebenefitsofamoredetailedassessmentinclude
the identification of complexities that negatively influence both
physical and mental health outcomes.
Futuredirectionsinthisareaofresearchincludeadditional
work in adaptive psychosocial and integrated prevention inter-
ventions to protect the physical and mental health of the MSM
population. These interventions require studies using RCTs in
order to demonstrate efficacy, acceptability, sustainability, and
empirical support.
Acknowledgments Thisstudywas
supportedbyaGrantfromtheNIMH
(R01 MH095624) PI: O’Cleirigh; Author time (Safren) was
supported, in
part, by Grant 5K24MH094214.
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1902 Arch Sex Behav (2015) 44:1891–1902
123

http://dx.doi.org/10.1177/1077559505285780
http://dx.doi.org/10.1177/1077559505285780
http://dx.doi.org/10.1016/0747-5632(85)90017-2
http://dx.doi.org/10.1177/0886260508317198
http://dx.doi.org/10.1177/0886260508317198
Copyright of Archives of Sexual Behavior is the property of
Springer Science & Business
Media B.V. and its content may not be copied or emailed to
multiple sites or posted to a
listserv without the copyright holder's express written
permission. However, users may print,
download, or email articles for individual use.
Complexity of Childhood Sexual Abuse: Predictors of Current
Post-Traumatic Stress Disorder, Mood Disorders, Substance
Use, and Sexual Risk Behavior Among Adult Men Who Have
Sex with MenAbstractIntroductionChildhood Sexual Abuse:
Mental Health and Sexual Health ConsequencesChildhood
Sexual Abuse Among Gay, Bisexual, and Other Sexual Minority
MenChildhood Sexual Abuse in the Context of HIV Risk and
PreventionAssessment of Childhood Sexual
AbuseMethodParticipantsProcedureRecruitmentStudy
ProcedureMeasuresDemographicsAssessment of Childhood
Sexual AbuseCSA Complexity IndicatorsPost-Traumatic Stress
Symptom AssessmentStructured Clinical Interview for DSM-IV
Axis I Disorders (SCID-IV; Spitzer, Gibbon, & Williams,
1997)Sexual Risk AssessmentSexually Transmitted
InfectionsDistress AssessmentThe Mini-International
Neuropsychiatric Interview (M.I.N.I.; Sheehan et al., 1998)Data
AnalysisResultsBackground CharacteristicsExamination of
Outcome DataInterrelationships Between CSA Complexity
IndicatorsRelationships between CSA Complexity Indicators
and Psychological and Health/Risk in
AdulthoodDiscussionAcknowledgmentsReferences

Module 9 Paper 2 Assignment | Race and Family
Representations in the Media
Electronic Version | File Attached:
Preparation for Writing Paper 2:
1. Review course materials on race and the American family
2. Find 4 (four) outside sources on race and the American
family/and or media representations.
3. Choose 3 (three) television shows you believe are good
examples of how the US media represents race and family on
television (stereotypes, traditional racial stereotypes, etc.).
4. Once you have chosen your television shows, watch an
episode or two, and take notes. Your notes will help provide
more detail for your examples on this assignment.
Your paper should include the following:
Appendix of your three TV shows episodes
The appendix (in your own words) needs to provide general
information on each of the programs included in your analysis.
This should include an overview of the setting, relevant
characters, and the target audience. Again, you do not need to
summarize the episodes that you watched. Just give me a quick
background of the show Make sure to tell me the TV show
name, the season of the episode you are using for your paper,
and the episode number and title that you are using. You can
use more than one episode, but it tends to be easiest to select
one episode per TV show.
Introduction
Explain what your paper is about.
1. What about race and family are you covering?
In order to guide your writing, you should have a couple of
questions that you are attempting to answer.
· Example: What are the differences across the programs in
terms of portraying race within the family and work, gender,
romantic relationships, children/parent dynamics, family
dynamics, class status, reproduction of children (adoption, IVF,
biological children, blended families, etc.)?

Include those in your introduction, and name the shows you
have watched. In this paper, you would obviously focus on
gender.
Literature Review and Overall Body of Paper
This is where you bring in course materials and outside sources.
Use them to support your statements about media representation
of race and family. This is where you also include your
television shows as examples.
Conclusion
Why does this paper matter? Tell us about the importance of
accurate representations of race in American Television. Give
us a summary of what you observed.
Reference List of Your Four Outside Scholarly Resources
Note: Do not use blogs, Wikipedia or other online encyclopedia
sources such as answer.com in this assignment. These are not
reputable, peer-reviewed scholarly sources.
An excellent place to start is the “Web of Science Database
Links to an external site.
", which you can access via the library website (you do not have
to be on campus to access the database – you will just have to
log in via off-campus access).
If you are a fan of Google, be sure to check out the library’s
tailored google scholar search. It allows you to access the
content available through FAU directly and request it via
interlibrary loan (again a login is required to do this off
campus).
List your four resources in reference formatting (APA or ASA)
Don’t forget that the librarians are available to help you with
your searches!
Following Directions
· Paper 1 should be 2-3 pages in length.
· Make sure that all of the required information is clearly
detailed.
· Your assignment must be typed and uploaded to turnitin.com.
If you are not sure how to do this, see the instructions provided
on the syllabus.

Here is what I will use to score your paper: (Rubric attached)
You will earn an A if you turn in a detailed appendix that meets
all the required parts; four scholarly references in APA or ASA
formatting; and have a strong intro that includes guiding
questions, a compelling literature review and examples,
followed by a strong conclusion.
You will earn a B if you turn in a good paper 2, but are missing
minor parts and/or formatting is off.
You will earn a C if you are missing details (or parts) in one of
the sections of paper 2. Your work is difficult to follow or
sloppy, your intro/conclusion is weak.
If you earn a D or F, this means you are missing significant
details or sections from Paper 2.
--//--
Don't hesitate to contact me via email if you need assistance in
completing this assignment successfully.
*This assignment links to module objective 1-2.Rubric
Assignment Paper Rubric
Criteria
Ratings
Pts
This criterion is linked to a Learning Outcome
Description of Criterion
Overall Content & Requirements
35.0 to >25.0 pts
EXCEEDS EXPECTATIONS
Excels in content. Follows directions exactly as they are given.
Meets all the required scholarly references. Provides a strong
intro that includes a clear description of the shows chosen, and
an explanation of media representations. Should be in APA or
ASA formatting. All of the requirements of the assignment
completed.
25.0 to >15.0 pts
MEETS EXPECTATIONS

The paper presents the content well. Missing part of all the
required scholarly references: a strong intro that includes a
description of the shows chosen, a compelling argument and
examples. Should be in APA or ASA formatting. Most of all the
requirements of the assignment completed.
15.0 to >0 pts
DOES NOT MEET EXPECTATIONS
The paper lacks meaningful content. Missing details in one of
the required scholarly references: a weak intro and generally
disorganized. No conclusion. Paper is difficult to follow or
sloppy. The intro/ conclusion is weak. Significant details or
sections from papers are missing.
35.0 pts
Critical Thinking & Integration of Theory
30.0 to >20.0 pts
Present original ideas and critical thinking skills. Integrates
course material well in analysis of media.
20.0 to >15.0 pts
MEETS EXPECTATIONS
Present few original ideas and critical thinking skills. Somewhat
integrates course material in analysis.
15.0 to >0 pts
Present only the ideas of others and lacks critical thinking
skills. Does not integrate course material in analysis.
30.0 pts

Overall Writing, English Usage & Sentence Construction
35.0 to >25.0 pts
Extremely well written. The spelling, grammar, punctuation,
and language skills are correctly presented. Sentences and
paragraphs are effectively constructed. The writing is concise
and focused. The assignment conforms to guidelines.
25.0 to >15.0 pts
MEETS EXPECTATIONS
Well written. The spelling, grammar, punctuation, and language
skills are mostly correct (some errors). Sentences and
paragraphs are constructed well but with some errors. The
writing is mostly concise and focused. The assignment
somewhat conforms to length guidelines.
15.0 to >0 pts
It is not well written. The spelling, grammar, punctuation, and
language skills are not correct (many errors). Sentences and
paragraphs are poorly constructed. The writing is not concise
and focused. The assignment does not conform to length
guidelines.
35.0 pts
Total Points: 100.0
PreviousNext
Article
Sex Offender Recidivism Revisited: Review of
Recent Meta-analyses on the Effects of Sex
Offender Treatment

Bitna Kim
1
, Peter J. Benekos
2
, and Alida V. Merlo
1
Abstract
The effectiveness of sex offender treatment programs continues
to generate misinformation and disagreement. Some literature
reviews conclude that treatment does not reduce recidivism
while others suggest that specific types of treatment may
warrant
optimism. The principal purpose of this study is to update the
most recent meta-analyses of sex offender treatments and to
com-
pare the findings with an earlier study that reviewed the meta-
analytic studies published from 1995 to 2002. More importantly,
this study examines effect sizes across different age populations
and effect sizes across various sex offender treatments. Results
of
this review of meta-analyses suggest that sex offender
treatments can be considered as ‘‘proven’’ or at least
‘‘promising,’’ while age
of participants and intervention type may influence the success
of treatment for sex offenders. The implications of these
findings
include achieving a broader understanding of intervention
moderators, applying such interventions to juvenile and adult
offenders,
and outlining future areas of research.
Keywords

offenders, sexual assault, recidivism, intervention
Introduction
The topic of sex offenders generally elicits fear and anxiety
from the public and contributes to punitive policies aimed at
harsh, exclusionary punishments. The perspective that commu-
nities need to be protected from sex offenders through incar-
ceration and surveillance often overshadows the prospects
that treatment can also provide public safety. In their study,
Kernsmith, Craun, and Foster (2009) found that citizen respon-
dents who reported higher levels of fear of sex offenders were
more supportive of registration requirements for sex offenders.
Levenson, Brannon, Fortney, and Baker (2007) also reported
that public perceptions of sex offenders reflect public anxiety
and support for community protection.
Although negative attitudes toward sex offenders are not
reflective of all countries, cultural differences and historical
context can account for less punitive public responses. For
example, McAlinden (2012) found that therapeutic interven-

tions for sex offenders were more prevalent in European coun-
tries than in England and Wales. She attributes this to a more
scientific and medical approach to sex offending across Europe
and less emphasis on ‘‘sexual abuse as a moral, legal, and social
problem’’ (p. 170). Nevertheless, the sex offender problem has
become more serious across Europe and policies reflect a shift
toward more punitive attitudes and sanctions (McAlinden,
2012). Not only in European countries but also in the United
States, one of the misgivings about how to respond to sex
offenders concerns the effectiveness of treatment.
In this article, the authors address the treatment issue by
updating the meta-meta-analytic study of Craig et al. (2003)
on sexual offender treatment. This study augments the original
work of Craig et al. by incorporating more recent meta-analytic
studies in the analysis. In this research, all salient meta-analytic
sex offender treatment studies from 1995 to 2010 were
included. The purpose of this study is to systematically review
what is known about the effectiveness of sex offender treat-

ments based on results of extant meta-analyses of different
types of treatment for sex offenders.
Furthermore, the study examines the issue of treatment spe-
cificity and which treatment strategies are effective for adult
versus juvenile offenders. Juvenile offenders who commit sex
offenses can evoke more alarm and fear among the public and
prosecutors because age is viewed as an aggravating character-
istic that can contribute to reoffending. When the prosecutors
emphasize public safety, this not only reinforces fears, but also
justifies more punitive rather than therapeutic responses.
Michels reports that prosecutors can take the position that
1
Department of Criminology, Indiana University of
Pennsylvania, Indiana, PA,
USA
2 Criminal Justice Department, Mercyhurst University, Erie,
PA, USA
Corresponding Author:
Bitna Kim, Department of Criminology, Indiana University of
Pennsylvania,
Indiana, PA 15705, USA.

Email: [email protected]
TRAUMA, VIOLENCE, & ABUSE
2016, Vol. 17(1) 105-117
ª The Author(s) 2015
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DOI: 10.1177/1524838014566719
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juvenile sex offenders are the ‘‘worst of the worst’’ because
they
are more prone to reoffending and ‘‘therefore too dangerous to
release’’ (2012, { 9). This demonizing of juvenile sex offenders
reflects a concern that this population cannot be effectively
treated, that they are at greater risk of recidivism, and that they
present a threat to public safety. Although these views are gen-
erally inaccurate, they do impact public reaction and
prosecutor-
ial responses (Chaffin, 2008; Letourneau & Miner, 2005).
This study assesses the effectiveness of sex offender treat-
ment programs and includes 11 meta-analytic studies, 6 of

which were included in the Craig et al. (2003) study and 5 of
which are more recent. Cohen’s d was reported to aid in the
interpretation of effect sizes. Definitions of small (d ¼ .20),
medium (d ¼ .50), and large (d ¼ .80) effects were based on
Cohen’s (1988) guide and based on effect sizes encountered
in the behavioral sciences (Cooper, 2010). These guides are
most appropriately employed ‘‘when no better basis for esti-
mating the effect size is available’’ (Cohen, 1988, p. 25).
Two other descriptors of research results related to program
evaluations that have recently received attention among some
social scientists are ‘‘proven’’ and ‘‘promising’’ (Cooper,
2010). Among different guides for magnitude labels of proven
and promising, the Promising Practices Network (PPN) is con-
sidered as credible by associating the terms such as proven and
promising with the solid evidence criteria (e.g., type of out-
comes affected, substantial effect size, statistical significance,
comparison groups, sample size, and availability of program
evaluation documentation (Cooper, 2010; PPN, 2007).
According to the PPN (2007), in order for a program to be

labeled proven, the associated evidence must meet the follow-
ing criteria: ‘‘(1) the program must directly affect one of the
indicators of interest; (2) at least one outcome is changed by
20%, d ¼ .25, or more; (3) at least one outcome with a substan-
tial effect size is statistically significant at the 5% level; (4) the
study design used a convincing comparison group to identify
program impacts, including studies that used random assign-
ment or some quasi-experimental designs; (5) the sample size
of the evaluation exceeds 30 in both the treatment and compar-
ison groups; and (6) the report is publicly available’’ (Cooper,
2010, p. 209). An intervention would be labeled promising if it
measured the outcomes of most interest and used rigorous
designs and revealed a smaller effect size (e.g., an associated
change in outcome of more than 1%) that PPN requires for a
program to be considered proven (Cooper, 2010, p. 209). One
purpose of this study is to determine whether the current evi-
dence supports a conclusion that sex offender treatment is pro-
ven or promising. This study utilizes both Cohen’s (1988)
guide and the PPN (2007) guide to convey proven and promis-

ing findings of sex offender treatments.
Sex Offender Treatments
Cognitive Behavioral Therapy
The treatment foundation that is used in many sex offender pro-
grams is cognitive behavioral therapy (CBT) and relapse
prevention (Baker, 2012; Brandes & Cheung, 2009; Center
for Sex Offender Management, 2006; McGrath, Cumming,
Burchard, Zeoli, & Ellerby, 2009; Worling & Langton, 2012).
Based on their survey of 1,379 programs in the United States
and Canada, McGrath et al. (2009) reported that the cognitive
behavioral model was in the top three choices for most adult
and adolescent programs (86%) and relapse prevention was
in the top two choices for 50% of the programs.
CBT combines two psychotherapies to address thoughts and
beliefs as well as behaviors and actions (Development Services
Group, Inc., 2009). The cognitive focus is on assumptions and
attitudes that contribute to dysfunctional thinking that rein-
forces patterns of unacceptable or inappropriate behaviors. The
behavioral component emphasizes actions and settings that

contribute to patterns of behavior. This problem-focused
approach helps sex offenders learn new skills and develop com-
petencies in maintaining appropriate behaviors. CBT confronts
rationalizations about behavior and provides skills to control
sexual impulses. Similarly, relapse prevention is also a cogni-
tive approach that helps sex offenders regulate their own beha-
viors by recognizing internal and external risks and learning to
manage their behaviors.
In his review of CBT, Greenwald (2009) described struc-
tured intervention strategies that improve interpersonal
problem-solving skills and facilitate more effective communi-
cation skills. By developing self-management skills that recog-
nize social cues and maladaptive behaviors, treatment provides
more constructive ways of thinking and understanding the con-
sequences of behavior. Corson (2010) also noted that social and
life skills training and cognitive restructuring are characteris-
tics of CBT. Essentially, treatment programs include various
strategies that focus on correcting thoughts, feelings, and beha-

viors that promote inappropriate behaviors and replacing them
with self-directed behavioral skills that maintain prosocial
beliefs and behaviors.
As previously noted, CBT presents strategies that are effec-
tive in cognitive restructuring that improve victim empathy and
complement relapse prevention (Craig, Browne, & Stringer,
2003; Hanson, Bourgon, Helmus, & Hodgson, 2009). Galla-
gher, Wilson, Hirschfield, Coggeshall, and MacKenzie
(1999) noted that cognitive behavioral treatment is not only
broadly supported in the literature, but also in their meta-
analytic study of 25 studies, in which they found that ‘‘ . . .
cognitive behavioral programs are effective in reducing the
recidivism of treated offenders’’ (p. 27). In addition, Marshall
and McGuire (2003) found supporting evidence that treatment
of sex offenders is effective. In reporting that recidivism among
sexual offenders is lower than among other offenders, Mann,
Hanson, and Thornton (2010) observe that this contradicts
common beliefs.

CBT is also the most prevalent treatment approach for ado-
lescent sex offenders and has wide support. For example, in
their
meta-analytic study, Reitzel and Carbonell (2006) found that
cognitive behavioral approaches were the most effective for
juvenile offenders. The cognitive behavioral treatment–relapse
prevention (CBT-RP) approach to treatment underscores
106 TRAUMA, VIOLENCE, & ABUSE 17(1)
changing ‘‘thoughts, behaviors, and arousal patterns of juvenile
sex offenders’’ (Fanniff & Becker, 2006, p. 273).
Generally, programs that use CBT-RP to work with adoles-
cent sex offenders motivate them to reject their thinking errors
and to identify situations and ideations that precipitate inap-
propriate behaviors. In addition, adolescents learn to recognize
the connection between their emotions and behaviors. (Bourke
& Donohue, 1996; Hall, 1995; Hunter & Santos, 1990; Lipsey,
2009; Marques, Wiederanders, Day, Nelson, & van Ommeren,
2005). Since juveniles are still maturing, developing, and

experimenting, there is an expectation that they are more
responsive to cognitive restructuring and skills development.
This is consistent with findings that juvenile sex offenders who
receive treatment have low rates of reoffending (Baker, 2012;
Center for Sex Offender Management, n.d.; Reitzel & Carbo-
nell, 2006).
Multisystemic Therapy
Another promising approach for treating sex offenders is multi-
systemic therapy (MST) (Borduin, Schaeffer, & Heiblum,
2009; Fanniff & Becker, 2006; Henggeler, 2012; Huey, Heng-
geler, Brondino, & Pickrel, 2000; MST Associates, n.d.). MST
was originally developed by Scott Henggeler as a family-based
treatment program for antisocial children and serious delin-
quent offenders. The emphasis of MST was on working with
families to improve monitoring, supervising, and disciplining
youth, and on reducing deviant peer affiliations (MST Services,
n.d.). MST has been adapted and has demonstrated effective-
ness in treating adolescent socialization issues and interperso-

nal relations (Crime
Solution
s, n.d.; Henggeler, 2012). The
intervention is provided at home or in the community and
focuses on interrupting the sexual assault cycle by working
with the offender and his family to develop a safety plan, by
empowering the family with skills and resources to more effec-
tively parent, and by targeting treatment toward individual
and family risk factors for sexual and nonsexual delinquency
(Fanniff & Becker, 2006; Henggeler, 2012).
Borduin et al. (2009) reported that juvenile sexual offenders
treated with MST had lower recidivism rates than offenders

receiving ‘‘usual’’ community services. Multiple randomized
controlled trials of MST provided to juvenile sex offenders
have found reductions in recidivism, problematic sexual beha-
vior, and out-of-home placements (Letourneau et al., 2009). In
their meta-analytic study, Walker, McGovern, Poey, and Otis
(2004, p. 289) found that MST appeared promising and they
recommended that future research on adolescent sexual offen-
der treatment ‘‘test the effectiveness of CBT against that of
multisystemic therapy.’’
Using their findings from a meta-analysis and distinguishing
between specialist and generalist sex offenders, Pullman and
Seto (2012) recommended both MST and CBT in order to
achieve more effective treatment outcomes. They concluded

that using MST and CBT to focus on sexual self-regulation
results in lower recidivism for specialist adolescent sex offen-
ders than using MST alone.
Additional Sex Offender Treatments
Sex offender therapy can also include medical interventions
that are either physical or chemical. Surgical procedures denote
mechanical castration, and chemical castration refers to hormo-
nal drugs such as antiandrogen, which are used to reduce sexual
arousal (Pray, 2002, p. 99). Gallagher et al. (1999) reported that
cognitive behavioral treatment (or other psychological treat-
ment) is sometimes used in conjunction with hormonal treat-
ment such as Depo-Provera, which reduces physiological

drive to engage in deviant behavior (Gallagher, Wilson,
Hirschfield, Coggeshall, & MacKenzie, 1999, p. 25).
In his study of hormonal treatments, Hall (1995) found that
effect sizes in studies that used a cognitive behavioral approach
were not significantly different from those that employed hor-
monal treatments. Hall performed a meta-analysis of 12 pri-
mary studies and found that both cognitive behavioral and
hormonal treatments were effective. However, the refusal and
discontinuation rates of hormonal treatment participants is con-
siderably higher compared to cognitive behavioral treatment
participants, and Hall suggests that this may indicate that cog-
nitive behavioral treatment is more advantageous (p. 807).
More recently, Rice and Harris (2011) also considered the

effectiveness of androgen deprivation therapy (ADT) to reduce
sexual recidivism. In describing the outcomes of surgical and
chemical treatment, the authors acknowledge that voluntary
subjects and weak methodology limit confidence in the out-
comes. Although some studies comparing volunteers with refu-
sers report favorable outcomes using pharmacological ADT,
the authors identify sufficient concerns to conclude that ‘‘ADT
cannot serve as a guarantee against sexually violent recidi-
vism’’ (p. 325). In the cases of men who volunteer and request
ADT, sexual recidivism may be reduced but this may be more
indicative of the characteristics of volunteers rather than the
effects of ADT (p. 328).

In addition to qualified conclusions about the effectiveness
of ADT, the authors recognize legal and ethical issues that sur-
round the use of castration. For example, long-term effects of
ADT on health, sexual behavior, and sexual recidivism remain
a concern among researchers and therapists. In spite of the sup-
port that androgen reduction therapy receives from some thera-
pists, the differential effects experienced by sex offenders and
the methodological limitations of many studies lead Rice and
Harris to conclude that ‘‘Clearly, much more research is needed
before ADT has a sufficient scientific basis to be relied upon as
a principal component of sex offender treatment’’ (p. 328).
Although it is more controversial, surgical castration can be
used in concert with other types of treatment, including psycho-

logical approaches. Although the operation is performed infre-
quently, it has been utilized in Western Europe and in the
United States. In one study of German offenders, Wille and
Beier (1989) found that the surgically castrated offenders
(volunteers) were more likely to refrain from further sexual
offending than offenders who had applied for the surgery but
were denied approval or withdrew their request (Gallagher
et al., 1999, p. 25). Due, in part, to the dearth of studies on this
Kim et al. 107
treatment approach and the lack of a similar control group in
the Wille and Beier study, researchers are reluctant to embrace

its effectiveness (Eher & Pfäfflin, 2011).
Current Study
Although several narrative reviews of sex offender interventions
exist, the most useful are meta-analyses that quantitatively
synthesize the literature. Meta-analyses are characterized by a
number of strengths, including (1) exhaustive literature
searches, (2) an ability to synthesize large literature, (3) a focus
on precise effect sizes rather than solely on statistical signifi-
cance, and (4) an ability to empirically test moderators of study
outcomes and help understand why certain studies had stronger
effects than others (Noar, 2008). Given that the literature of sex
offender treatment has continued to grow at a rapid pace, these
more recent meta-analyses have taken advantage of more

sophisticated analyses that larger literature permit (Noar, 2008).
Craig et al. (2003) previously reviewed six meta-analytic
studies that were published from 1995 to 2002 (Alexander,
1999; Aos, Phipps, Barnoski, & Lieb, 2001; Gallagher et al.,
1999; Hall, 1995; Hanson et al., 2002; Polizzi, MacKenzie,
& Hickman, 1999) and concluded that there were positive
treatment effects in reducing sexual offense recidivism. The
principal purpose of this study is to update the most recent
meta-analyses of sex offender treatments and compare the
findings with those of Craig et al. (2003). This is a replication
of the earlier Craig et al. (2003) study with an expanded sample
of meta-analyses. In addition, this study extends the earlier

review by examining and comparing: (1) effect sizes across the
meta-analytic literature, (2) effect sizes across different target
populations (adolescents vs. adults) in order to examine how
sex offender treatments have performed across populations, and
(3) effect sizes across different types of sex offender
treatments.
Method
Search Strategy and Inclusion Criteria
To comprehensively identify meta-analysis studies on sex
offender treatment, the authors conducted a search of a number
of online databases in which criminal justice-related meta-
analyses might plausibly be reported. The intent was to locate
all meta-analyses of sex offender treatments published in peer-

reviewed journals that were available (in print or electronic
form) or in dissertation databases and met criteria for this
review (Noar, 2008).
The search looked for any mention in the title, the abstract,
or the keyword list of the words ‘‘meta-analysis,’’
‘‘quantitative
review,’’ and ‘‘systematic review,’’ paired with any of the fol-
lowing terms: sex offender treatment or sex offender interven-
tion. The specific databases used were: Criminal Justice
Abstracts, Sociological Abstracts, PsychINFO, MEDLINE,
Social Science Abstracts, Psychology and Behavioral Science
Collections, and Current Contents. In addition, computer and
manual searches identified listings of unpublished materials

(Dissertation Abstracts International, ERIC). The reference
lists of those articles retrieved from each of the databases were
scanned to identify additional studies that may have used
meta-analytic procedures (Lundahl, Taylor, Stevenson, &
Roberts, 2008). The abstracts of likely references were
reviewed to confirm that they used meta-analysis, and an
attempt was made to obtain copies of each of the likely candi-
dates (Wells, 2009).
Meta-analyses were included in the review if they: (1) con-
ducted a meta-analysis (quantitative research synthesis) of
formally developed and evaluated sex offender treatments tar-
geting recidivism; (2) were focused on a defined target popu-
lation of adolescent and adult sex offenders; and (3) examined

outcome variables of sexual recidivism, violent recidivism, or
any recidivism. As a result of these search strategies and
inclusion criteria, a final set of 11 meta-analyses were
included in the current review. Of the 11 meta-analyses, 5
studies were published since 2002 and not included in Craig
et al. (2003).
Effect Size Conversion
Effect size essentially refers to the magnitude of the ‘‘effect’’
of
the program on recidivism (Cohen, 1988). Bigger program
effects (impacts) imply that the program had a greater effect
than smaller effect sizes. The meta-analyses included in this
review used differing effect size indicators. In order to provide

a common metric for interpretation and comparison across all
meta-analyses, effect sizes and confidence intervals in the odds
ratios and r meta-analyses were converted to d using the fol-
lowing equations (Ellis, 2010):
d ¼
2r
ffiffiffi
1
p
�r2
and d ¼ log odds ratio�
ffiffiffi
3
p
p

Negative effect size indicates recidivism reduction among
intervention participants. One arbitrary criterion used to
determine what constitutes a big effect size as opposed to a
smaller one is that effect sizes of .20 are small, .50 are
medium, and .80 or higher are large (Polizzi et al., 1999).
Cohen (1988) suggests that a small effect of d ¼ .20 is typical
of those found in personality, social, and clinical psychology,
while a large effect as d ¼ .80 is more likely to be found in
sociology, economics, and experimental or physiological psy-
chology (Cooper, 2010).
Although d is probably one of the best known effect size
indexes, a more compelling way to provide a translation of the
effects of discrete interventions on dichotomous outcomes
(e.g., success or recidivism) is to present the results in a bino-

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