K.A. Ringwood, K. K. Thomas, J.M. Marrazzo, University of Washington The Acquisition of Bacterial Vaginosis in Lesbians and Bisexual Women Lesbians and Sexual Abuse: Implications for STD Risk and Pregnancy Outcomes Why is logo in B and W? I’m pretty sure I have a color one from a poster-- K.A. Ringwood, K. K. Thomas, J.M. Marrazzo, University of Washington

Background: Sexual Abuse & Risk Behaviors Childhood sexual abuse not uncommon Rates in general U.S. population * 27% for women 16% for men Up to 33% in MSM** Lifelong problems with psycho-social functioning Associated with high risk behaviors Early age of sexual initiation Higher rates of drug and alcohol use Prostitution (trading sex for money) HIV/STD infections Unintended pregnancy Mental health concerns Ok but not clear how necessary--I think you need a background slide explaining why you decided to look at the relationship between abuse and risk behaviors. Would cite any data for teens, or for MSM and mental health outcomes etc. * Finkelhor et al, 1990 ** Bartholow et al, 1994

Background: Most lesbians have had sex with men. National Survey of Family Growth: A-CASI interview of national sample of 12,571 U.S. adults (2002) 11% of women 15 - 44 years old reported lifetime same-sex behavior 4.4% report female partner during the last year Translates to 2.29 million U.S. women 18 to 44 years of age who self-identify as either homosexual or bisexual Most self-identified lesbians have had sex with men (61% in our study); some continue to do so. Study focused on lesbian and bisexual women because this population has a higher incidence of BV than straight women (25-52% vs 8-23%) To provide some context, in 2002, National Survey of Family Growth conducted a national sample of 12,571 adults in the U.S. 11% of women age 15-44 years reported lifetime same sex behavior, and during the last year, 4.4% This translates to 2.29 million U.S. women 18 to 44 years of age who identify as either homosexual or bisexual Most self-identified lesbians have had sex with men (61% IN OUR STUDY); some continue to do so Nice, but need to correct and update references It was your slide from another presentation. Thanks for letting me”steal” it.--kar National Center for Health Statistics, NSFG, Cycle 6 Reports

Objective: Evaluate relationships between childhood sexual abuse history in lesbians and sexual risk behaviors that have implications for STD acquisition and unintended pregnancy.

Definition: Child Sex Abuse The engagement of a child in sexual activities for which the child is developmentally unprepared and cannot give informed consent.* Child sexual abuse is characterized by deception, force or coercion. Very good! Might want to have ready in case someone asks you a question how those general US estimates were derived * AMA, 1992 Conte, 1986

CASI Question: Child Sex Abuse When you were under the age of 16, did any of the following experiences happen to you when you did not want them to happen? An adult showed his or her sex organs to you. You showed your sex organs to an adult at his/ her request. An adult touched or fondled your sex organs. You touched or fondled an adult’s sex organs An adult performed oral sex on you. You performed oral sex on an adult. An adult man put his penis in your vagina. An adult man put his penis in your anus. Other None of these things happened to me. Very good! Might want to have ready in case someone asks you a question how those general US estimates were derived Adult=person 18 years or older.

Methods 5 year NIH funded study on vaginal flora in lesbian and bisexual women Subjects were recruited through ads, flyers, and word of mouth Eligiblity: 16-35 years old and sex with >1 woman in the past year All subjects completed a detailed questionnaire detailing medical and sexual history via computer assisted self-interview (CASI) at baseline Statistical analyses: Fisher’s exact or T-tests to provide p-values Logistic or Linear regressions to provide p-values adjusted for age 5 year NIH funded study examining the acquisition of Bacterial Vaginosis in lesbian and bisexual women Subjects were recruited through ads, flyers and word of mouth Women were eligible to enroll if they were between 16-35 years of age and had sex with another woman in the past year All subjects completed a detailed questionnaire detailing medical and sexual history via computer assisted self-interview (CASI) at baseline Subjects were followed quarterly for 1 year

Findings: Demographics 335 women enrolled, median age 25 years 31% (103) report history of childhood sexual abuse before age 16 Race CSA (n=103) No CSA (n=232) p-values Black 9 (9%) 7 (3%) .048 Non-white 29 (28%) 43 (19%) .044 I don’t like CSA (or use of any uncommon abbreviations--would either highlight its meaning in a text box or use the whole term CSA=Childhood Sexual Abuse

Findings: Sexual History with Men Characteristics CSA (n=103) No CSA (n=232) P-values Sex with man ever 90 (89%) 178 (77%) .010 Sex with male past yr 49 (49%) 86 (37%) .053 Ever traded sex for money 14 (14%) 14 (6%) .030 CSA=Childhood Sexual Abuse

Findings: Sexual Initiation and Lifetime Partners Characteristics CSA (n=103) No CSA (n=232) p-values Median age at sexual initiation 14 16 .001 Median lifetime female partners 10 7 .002 Median lifetime male partners 11 6 Key slide, good CSAs report lower rates of condom use during vaginal and anal intercourse with male partners CSA=Childhood Sexual Abuse

Findings: Recent Drug Use Characteristics CSA (n=103) No CSA (n=232) p-values Cocaine use past year 22 (24%) 26 (13%) .026 Methamphetamine use past year 9 (10%) 7 (3%) .048 Marijuana use past year 50 (55%) 121 (62%) .245 Current cigarette use 40 (44%) 59 (30%) .023 Similar associations seen for lifetime drug use CSA=Childhood Sexual Abuse

Findings: Self Reported STD History Characteristics CSA (n=103) No CSA (n=232) p-values* Genital Warts 14 (14%) 9 (4%) .002 Gonorrhea 2 (2%) 0 (0%)  Trich 4 (4%) 4 (2%) .260 Chlamydia 8 (8%) 14 (6%) .537 Bacterial Vaginosis 37 (36%) 64 (27%) .135 PID 2 (1%) .096 Could also omit this, summarize briefly Will probably omit, but will mention in talk. Maybe I should combine just the genital wart history and Pap last 3 years (since both are significant) and omit the rest? Adjusted for age  Unable to calculate age adjusted p-value No Pap in last 3 years-12% CSA vs 6% No CSA, p=.049 CSA=Childhood Sexual Abuse

Findings: Pregnancy Outcomes Characteristics CSA (n=103) No CSA (n=232) p-values Ever pregnant** 31 (34%) 22 (12%) <.001* Median age @ first pregnancy 17.7 years 20 years .025 First pregnancy result in abortion 20 (65%) 11 (48%) .198* Is age younger significant? Yes--added. * Adjusted for age ** of those reporting sex with men CSA=Childhood Sexual Abuse

Findings: Mental Health Treatment Characteristics CSA (n=103) No CSA (n=232) p-values* Ever sought psychotherapy 64 (63%) 126 (54%) .177 Tx for Depression 43 (42%) 94 (40%) .764 Tx for Anxiety 28 (28%) 55 (24%) .407 Tx for PTSD 19 (19%) 11 (5%) <.001 Tx Other mental health issues 17 (17%) 35 (15%) .788 Prescribed meds 40 (63%) 80 (63%) .866 Nice table but would capitalize consistently (I.e. Mental Health) Adjusted for age CSA=Childhood Sexual Abuse

Conclusions STD/Unintended pregnancy risk for lesbian and bisexual women in VHP similar to women in other studies Child Sex Abuse Increase risk for mental health problems Earlier sexual initiation Higher number lifetime sex partners Higher alcohol and drug use/abuse Higher incidence of trading sex for money Increase in risky behaviors that lead to STD and unintended pregnancy Not sure you should start with that first bullet--the talk wasn’t really about them having sex with men, as adults. Would start by commenting on notable proportion of our subjects who reported CSA and what this was associated with (need to use your own words) Still a draft--comments or ideas? I know it’s too long. Maybe just use the major categories?

Why is this important? Implications Link between CSA and HIV/STD infection Development of timely interventions aimed at reducing trauma-related symptoms and behavioral difficulties resulting from CSA Risk reduction for CSA survivors Risk reduction for general public

Limitations Subjects were self referred or referred by partners Limits on generalizability, reproducibility Most subjects caucasian People of color underrepresented

Acknowledgements VHP Subjects Emily Hancock Nancy Dorn Becca Hutcheson Lauren Asaba Judy Jacobsen Susan Heideke Connie Mao Dana Varon Laura Merrell HMC WRC Staff Kathy Agnew

Findings: Sexual History & Drug/Alcohol Use Risk Behaviors Characteristics CSA (n=103) NCSA (n=232) p-values Daily alcohol use past year 13 (14) 27 (14) 1.000 Drink 6+ drinks per day weekly or more often 8 (10) 12 (6) 0.323 Unable to stop drinking monthly or more frequently 7 (9) 11 (6) 0.428 Omit this--NS--could just state after last slide you saw no differences

Findings/Risks: Pap screening Characteristic CSA (n=103) No CSA (n=232) p-values* Pap smear in past 3 yrs 78 (88) 190 (94) 0.049 Not sure so relevant? Could omit Pap in past 3 years is significant. I can omit the part about the entire population. * Adjusted for age CSA=Childhood Sexual Abuse NCSA= No Childhood Abuse

Findings/Risks: Lifetime Drug Use Characteristics CSA (n=103) NCSA (n=232) p-values Ever used marijuana 78 (86) 170 (88) 0.681* Ever used cocaine 45 (49) 62 (31) 0.002* Ever used methamphetamine 31 (34) 36 (18) 0.003* Ever used heroin 11 (12) 0.067* First one is highlighted but isn’t significant right? Yes==saw that this was highlighted after I sent to you. * adjusted for age CSA=Childhood Sexual Abuse NCSA= No Childhood Abuse