Substance Abuse, High-Risk Sex, and Sexual Violence: What's the Connection?
Article by Rowan Frost, Community Outreach Liaison, Southern Arizona Center Against Sexual Assault
When we care about someone who abuses
substances, or puts themselves at risk for HIV repeatedly, we may have a
difficult time understanding why they do things that are so obviously harmful.
We may get angry and blame them, or accuse them of a lack of willpower.
Unfortunately, they usually don't understand why they are hurting themselves
either, and our anger and judgment doesn't help. There are clues, though, that
may help professionals, family members, and the individuals we care about gain a
better understanding of these behaviors. Research demonstrates that for both men
and women, having experienced sexual violence is strongly associated with later
substance abuse, high-risk sex, and other harmful behaviors. This article
summarizes some of that research.
The term "sexual violence"
includes a wide range of events that cause trauma to an individual, including:
sexual abuse, child molestation, rape, hate crimes based on gender identity or
perceived sexual orientation, and sexual harassment. Because sexual violence is
so often unreported (the National Crime Victimization Survey found only 1 in 3
rapes, and 1 in 4 sexual assaults were reported to police), and because most
victims do not seek support services, it often becomes an invisible precursor to
further physical and emotional injury. (Rennison, 2002)
It is always appropriate to screen
for sexual abuse/assault and mental health issues in any intake for behavioral
health or medical services. The deep connections between body-mind-spirit mean
that sexual trauma must be considered in all treatment planning with survivors,
since it may be an underlying or predicating factor in the disease processes of
addiction, depression, anti-social behavior, or a variety of physical problems.
The physical and mental health
effects of sexual abuse and assault on a child or adolescent often extend well
into adulthood. Forty-eight percent of child survivors meet the DSM-IV criteria
for a diagnosis of Post-Traumatic Stress Disorder (PTSD), and their symptoms are
often more intense and severe than those of non-sexual abuse victims with PTSD.
(Briere & Elliott, 1994; Corbin, et al., 2001). Adult and child survivors
are 4 times more likely to be diagnosed with major depression, and 5 times more
likely to be diagnosed with an anxiety disorder. One out of six survivors of
sexual violence reports at least one suicide attempt. (Briere & Elliott) It
is essential that mental health professionals working with survivors have
specialized training in sexual trauma in order to ensure that the issues are
adequately addressed in treatment.
The relationship between sexual
violence and substance abuse is commonly misunderstood. Popular perception is
that being drunk or high makes one more susceptible to sexual abuse or assault;
in fact, the first incidence of sexual abuse or assault usually precedes first
alcohol or drug use. In other words, people don't get raped because they are
drunk; they may get drunk because they have been raped. Female college students
who had been abused as children were more likely to drink heavily than those who
had not. (Corbin, et al., 2001) Perpetrators may get drunk in order to justify
their actions, or may try to get their victims drunk or high to facilitate
sexual assault. Again, the long-term consequences of sexual violence can be
devastating: studies have found that survivors of sexual violence are more
likely to develop drug addiction and alcoholism, and are less successful in
completing substance abuse treatment. (Briere & Elliott, 1994; Corbin, et
al.) This may be due in part to the structure of some substance abuse programs.
Women, in particular, may feel unsafe in coed residential treatment programs,
and there is some evidence that women do better in female-only treatment
programs. (Gray & Nye, 2001; Kang, et al., 1999) Clients with symptoms of
PTSD may need a longer period of time to establish trust with therapists; this
should be taken into account in treatment planning. Confrontational styles of
treatment are counterproductive in clients with trauma histories, increasing
anxiety and decreasing engagement. When clients are encouraged to take
responsibility for their own behavior it should also be reinforced that they are
not responsible for the harm others have done to them in order to avoid blaming
or shaming victims for any abuse they experienced. Whenever possible, client
preferences for a therapist of a specific gender or cultural background should
be respected. (Gray & Nye) Mental health professionals must consider the
functions that alcohol and drug use provide. It is usually necessary to begin
therapy to replace substance use with healthier coping strategies before clients
can be expected to maintain sobriety for any length of time. (Glover, et al.,
1995)
Both adolescent and adult
survivors may "act out" sexually, engaging in high risk sexual
activities with multiple partners.(Diaz, et al., 1999; Greenberg, 2001; Kang, et
al., 1999) Studies consistently demonstrate strong links between adolescent and
adult HIV risk behaviors, unintended pregnancy and partner pregnancy, and a
history of sexual trauma (Greenberg). These findings are constant across gender,
race, and region, although individuals from lower socio-economic levels tend to
experience greater long-term impacts. (Crowell & Burgess, 1996; Neville
& Heppner, 1999) Among women living with HIV in New York City, 38% had
experienced childhood sexual abuse; 46% had experienced sexual abuse in
adulthood. The mean age at first incident for both groups was 15; the mean
number of perpetrators was 3. (Simoni & Ng, 2000) One study of Hispanic men
in San Francisco found that 50% had been sexually abused before the age of 16 by
someone at least five years older. Among men in the study who had unprotected
anal sex in the previous month, 73% had a history of sexual abuse. (Diaz, et
al.,1999)
Knowledge of the consequences of
high-risk sex (unintended pregnancy, transmission of HIV and other STDs) is not
enough to change behavior. Counselors and medical professionals need to bring up
the issue of sexual violence when discussing safer sex. Sexual abuse and assault
may affect a person's ability to negotiate safer sex in several ways. Does the
person have enough power within a sexual relationship to require, or to discuss,
safer sex? Even to have consensual sex with a beloved and non-abusive partner, a
survivor may have to dissociate (mentally remove themselves from a situation) or
use substances in order to create distance between themselves and the memories
of the violence. A person with a history of sexual trauma may not be able to
think and have sex at the same time: intrusive memories may interfere.
Non-cognitive sex is high risk sex. Interventions which stress risk-reduction
and planning sexual activity are of limited use to someone who must take their
mental processes out of gear in order to have sex. Again, addressing the
underlying issue of sexual trauma is essential to providing appropriate services
for survivors.
Other coping mechanisms for
survivors of sexual trauma include self-mutilation, avoidance of relationships,
and eating disorders (especially bulimia). (Briere & Elliott, 1994) After
rape, 59% of female survivors experienced at least one form of sexual
dysfunction, usually fear of sex or lack of interest and arousal. (Neville &
Heppner, 1999) Behavioral health and medical professionals should be aware of
the possibility of co-morbidity, and screen all clients.
Some service providers may hesitate
to ask questions about sexual trauma when taking client histories for fear of
invading privacy or retraumatizing victims, or perhaps out of discomfort with
the subject. When asked whether or not they would like to be asked about sexual
trauma, women responded that they felt it was both appropriate and relevant for
medical personnel to include the topic in routine medical care. (Felitti, et.
al., 1998) Providers who are uncomfortable bringing up the subject can receive
continuing education to increase their ability to work with survivors.
This is only a brief summary of some
of the research into the profound impact of sexual trauma on an individual's
life. Sexual violence is fundamentally about power: the power someone else has
to hurt the victim, and the loss of power (over body, identity, and environment)
experienced by the victim. What we see as "high-risk behaviors" can be
viewed as coping mechanisms, used by the individual in an attempt to get their
power back. Survivors of sexual violence engaged in high-risk behaviors may be
trying to empower themselves, to take back some control over how they feel and
experience the world; the irony, of course, is that substance abuse and
high-risk sexuality provide only temporary feelings of control, and ultimately
put the individual at risk for revictimization. As empathic helping
professionals and concerned family members and friends, we can support survivors
by understanding how sexual trauma may be affecting their lives, and by helping
them begin to replace dysfunctional coping mechanisms with skills that will
truly serve them.
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