Every year, thousands of American women and children suffer various forms of physical and sexual abuse, often perpetrated by family members or intimate partners. While this much is news to no one, the study of how such abuse affects women's sexual and reproductive health and behavior is a fairly recent addition to the research agenda. Two articles in this issue of Perspectives on Sexual and Reproductive Health tackle some of the many questions that warrant attention.
In the lead article [see article], Pamela Jo Johnson and Wendy Hellerstedt examine the relationship between abuse and sexually transmitted diseases (STDs) among women. Previous studies have found a positive relationship between having a history of experiencing physical or sexual violence and having a self-reported STD history. Johnson and Hellerstedt, however, add two twists to this line of inquiry: Using data on a sample of prenatal clinic patients, they analyze how the odds not only of having a history of STD but also of having a current STD infection are affected by the experience of abuse. And they use medical documentation (a more reliable indicator than self-reports) to assess women's past and current STD status.
In this population of pregnant women of low socioeconomic status, those who had suffered any abuse had a significantly increased likelihood both of having a history of STD and of having a current infection. Their odds of either outcome were about twice those of nonabused women; the differential was even sharper--the odds were roughly tripled--for women who had suffered both physical and sexual abuse. Further research will be needed to determine the biological and behavioral risks that characterize the sexual environments of women who experience abuse.
Lynn Blinn-Pike and colleagues ask a very different question about abuse: whether it can be causally linked to adolescent pregnancy [see article]. In a search of the literature in three relevant disciplines, they found 15 studies published between 1990 and 2000 that addressed the relationship between sexual maltreatment, alone or in combination with other types of maltreatment, and adolescent pregnancy. As Blinn-Pike and her coauthors note, results of the studies show little agreement: Ten studies supported a causal link, and five either did not support a link or qualified the relationship. In addition, the studies were weakened by methodological flaws and a lack of theoretical grounding, and comparisons across studies are difficult to make because they did not rely on consistent definitions of maltreatment. The bottom line, according to the authors of the review, is that the evidence is insufficient to conclusively establish or deny a causal relationship between abuse and teenage pregnancy.
Also in This Issue
• How do women view HIV testing, and what governs their decisions about whether to be tested? Theresa M. Exner and colleagues address these questions through a longitudinal study of women attending a family planning clinic in New York City [see article]. To a certain degree, they find, women accurately assess their lifetime risk factors and choose to be tested to allay their anxiety and determine their infection status. Some women, however, forgo testing because they do not want to know if they are infected. Perhaps the most disconcerting finding is that 40% of women believed that testing may prevent HIV infection. Furthermore, a negative test result provided reassurance but did not appear to influence women's protective behaviors. The authors urge a rethinking of policies that promote testing as a positive intervention without adequately considering the motivations and perceptions of those being tested.
• In a register-based study of Finnish births occurring between 1987 and 1998, Andres Vikat and coauthors find that pregnancies starting within eight months after a birth were more likely than those starting later to end in abortion [see article]. Moreover, within the first eight months, the less time that passed between a birth and a conception, the more likely the pregnancy was to end in abortion. The researchers conclude that many Finnish women may not use contraceptives effectively in the months after they give birth and that prenatal and postpartum counseling have room for improvement.
• To be successful, programs aimed at reducing HIV risk must be grounded in an accurate understanding of the factors that influence or determine at-risk populations' knowledge, norms, beliefs and access to services. They also must be appropriate for and acceptable to the targeted population. Anthony J. Silvestre and colleagues describe a model for program planning, initiated in Pennsylvania in 1995, that brings young people fully into the process [page 91]. As the authors document in their special report, youth roundtables, organized along the principles of focus groups, have had a major impact on state HIV policy, as well as other state programs. Roundtable members also have become a presence at the national level, and the roundtable model is being adapted in other states.
• For years, American women have by and large been loath to use the IUD. From David Hubacher's perspective [see article], this reluctance is unfortunate, particularly given the clear need to reduce levels of unintended childbearing in the United States. Hubacher outlines the uniquely American series of events that led to the IUD's virtual disappearance from the U.S. market, as well as the factors that could help redeem its image and reestablish its popularity.