1. Experience of Childhood Abuse and STI Prevalence Among Young Ukrainian Women Annie Dude University of Chicago anniemd@uchicago.edu American Public Health Association Washington, DC November 6 th, 2007

2. What is Child Abuse? While the precise legal definition of what constitutes child abuse varies between states and nations, the United Nations defines child abuse as the physical, sexual, or emotional maltreatment of children by parents, guardians, or others who have positions of responsibility or authority in relation to the child. These acts can include: Physical abuse: burning, shaking, punching, shaking, restraining, beating, or otherwise inflicting physical harm on the child. Sexual abuse: fondling a child’s genitals, making the child fondle an adult’s genitals, intercourse, sodomy, or exploitation, including forcing the child into sex acts with others or using the child for explicit photographs or films.

3. What is Child Abuse? Emotional abuse: belittlement, blaming, or scapegoating of the child; extreme punishments such as restraining the child to a chair or in a closet; emotional rejection; other forms of verbal or psychological maltreatment. Neglect: the failure to provide for the child’s basic needs, including food, shelter, medical care, adequate clothing, or supervision. The definition of neglect can also extend to failing to provide for a child’s education, allowing the child to engage in alcohol or drug abuse, or failure to provide love and emotional support.

4. Sexually Transmitted Infections in Ukraine: HIV Incidence rates of HIV are the highest in the world: the number of those infected with HIV increased by a factor of 1.5 in Ukraine between 2001 and 2003. 1.4% of the adult Ukrainian population is infected with HIV (2005). Originally, HIV was concentrated in IV drug users (IDUs) and commercial sex workers in large cities. Sexual transmission of HIV is increasingly common, as are new infections among women and children – in 2004, 30% of infections in Ukraine were due to unprotected sex. Many of those newly infected were the non-drug-using partners of IDUs.

5. Sexually Transmitted Infections in Ukraine: Other STIs Ukraine also has very high rates of other STIs – syphilis, gonorrhea, chlamydia, and HSV. These diseases, previously nearly eradicated via treatment in the public health system, made a dramatic resurgence throughout the 1990s. In addition to the morbidity associated with these other sexually transmitted infections, including PID and infertility, co – infection with another STI is a risk factor for HIV transmission (Oster 2005).

6. Previous Research on Childhood Abuse and STIs Girls who are sexually abused as children often contract STIs as a consequence of abuse itself. These women are also more likely to exhibit risky sexual behaviors as adolescents and adults. Previous research shows that they are: 1. more likely to engage in multiple sexual partnerships. 2. more likely to have sex in exchange for gifts or money. 3. more likely to initiate sexual activity at earlier ages than women who did not experience abuse. 4. more likely to select into abusive intimate relationships as adults.

7. Research Questions 1. Are women who report experience of child abuse more likely to report a lifetime STI infection? 2. Did women who experienced abuse as children debut sexually at younger ages than those who did not? 3. Are women who experienced abuse as children also more likely to have experienced abuse from an intimate partner as adolescents or adults?

8. Data The data come from the 1999 Ukrainian Reproductive Health Survey, a nationally – representative survey of women aged 15 – 44. Analysis sample: women aged 30 or under who have been married at least once, with complete data on outcome and predictor variables [N = 1,765]. Main independent variable: ‘Were you physically abused as a child?’ Outcomes: self-reported lifetime prevalence of STIs, age at sexual debut, whether the woman reports a physically abusive relationship in adulthood.

9. Sample Summary Statistics Abused as a child: 33.9% Reports a lifetime STI:46.0% Reports adult abuse: 17.8% Mean age at first sex:18.2 years [N = 1,765]

10. Methods – Lifetime STI Infection Women self-report whether they have ever been diagnosed with syphilis, gonorrhea, chlamydia, herpes, HPV, or had a genital ulcer. Logistic regression on a binary variable indicating a lifetime self- reported infection. Control variables: current age, ethnicity, education, marital status, urban residence, household wealth, perceived risk of having a STI, age of sexual debut, employment status, number of marriages, number of children, whether actively seeking pregnancy.

11. Results – Lifetime STI Prevalence [odds ratios] Women who report childhood abuse are 1.33 times as likely to report a lifetime STI infection [p = 0.012]. Other significant covariates: variableodds ratio p – value education 1.15 0.000 age at first sex 0.87 0.000 perceived STI risk 1.16 0.018 current age 1.09 0.000

12. Methods – Age at Sexual Debut Women self – report the age [in years] at which they first had sexual intercourse. OLS regression predicting age at first sex. Control variables: current age, ethnicity, education, marital status, urban residence, household wealth, age of first marriage, employment status, number of marriages, number of children.

13. Results – Age at Sexual Debut [OLS coefficients] Women who were abused as children report debuting sexually 0.15 years earlier than women who were not abused as children. This result, however, is only marginally significant [p = 0.060] Other significant covariates: variable coefficient p – value Russian ethnicity -0.34 0.004 education 0.11 0.000 household wealth -0.11 0.043 current age 0.62 0.000 divorced-0.29 0.016 urban residence -0.34 0.000 employed 0.18 0.047 age at first marriage 0.05 0.000 number of marriages-0.43 0.000

14. Methods – Adult Experience of Abuse Women self – report whether they have ever been kicked, slapped, punched, or threatened with a knife or other weapon by an intimate partner in their lifetimes. Logistic regression on a binary variable indicating whether women report any of the above abusive acts. Control variables: ever witnessed parents engaging in abuse, ethnicity, education, household wealth, current age, marital status, age at first sex, urban residence, employment status, number of marriages, number of children.

15. Results – Adult Experience of Abuse [odds ratios] Women who were abused as children are 2.58 times as likely to report abuse from an intimate partner as an adult [p = 0.000]. Other significant covariates: variableodds ratio p – value witnessed parental abuse 0.52 0.000 household wealth 0.79 0.031 current age 1.04 0.004 divorced 5.16 0.000 age at first sex 0.86 0.001 number of marriages 2.45 0.000

16. Conclusions Women who report being abused as children are significantly more likely to report a lifetime STI. While a younger age at sexual debut is an important risk factor for increased lifetime STI risk, childhood abuse experience is only marginally associated with a younger age at sexual debut. Other factors are stronger predictors of age at sexual debut. Childhood abuse experience, however, is strongly associated with selecting into physically abusive intimate relationships as adults, which has been shown in other studies to be a strong predictor of HIV and other STI infections.