Childhood abuse and neglect and the risk of STDs in early adulthood.

Approximately 19 million STD diagnoses are made each year in the United States,1 and the public health burden they impose is staggering. STDs are implicated in a range of serious health outcomes, including pelvic inflammatory disease,2 infertility3 and increased risk of HIV transmission.4 Adolescents and young adults are particularly vulnerable to STDs and their sequelae; nearly half of all new infections occur among 15–24-year-olds.1 Accordingly, identifying childhood factors that predict STD risk in adolescence and early adulthood is a priority. One prevalent and important potential predictor of STD risk is childhood maltreatment by parents and other adult caregivers. Each year, at least 1–4% of all U.S. children are victims of maltreatment,5,6 and this experience has been associated with a number of adverse sexual health outcomes in adolescence and early adulthood, including sexual victimization, inconsistent contraceptive use, prostitution and multiple sexual partners.7-13 Despite this apparent association, however, evidence linking maltreatment to future STD risk is equivocal at best and characterized by a number of key gaps and limitations. First, because many findings come from clinical samples8,14 or other special populations (e.g., homeless or detained youth),15 their generalizability to the broader population is uncertain.16 Further hampering efforts to compare findings, the measurement of past and current STD status has been inconsistent across studies. Third, some studies may have overestimated the strength of the relationship between maltreatment and STD risk by reporting only bivariate associations17,18 or adjusting for a limited set of potential socioeconomic confounders.19 Fourth, despite evidence that the predictors of STD may differ by sex20 and race or ethnicity,21 few studies have evaluated these characteristics as potential moderators of the association between maltreatment and STD risk. Finally, although neglect accounts for more than half of all cases of maltreatment,5,6 it is rarely examined in relation to STD risk. In analyses of one of the few prospective data sets to include information on experiences of neglect and subsequent STD risk, Wilson and Widom found no association between childhood neglect and increased risk of self-reported lifetime diagnoses of herpes, syphilis, human papillomavirus, gonorrhea or chlamydia by middle adulthood.22 The prevalence of test-identified HIV infection appeared to be approximately twice as high among individuals with a history of neglect as among those with no history of maltreatment, but the difference did not reach statistical significance (perhaps partly because HIV prevalence in the sample was low).11 As a result of these limitations, our understanding of the association between maltreatment and STD risk is derived largely from studies based on select samples and focused exclusively on childhood sexual abuse.7,8,14,15,18,23-27 In this article, we address these gaps and limitations in the following ways. We study the link between maltreatment by a parent or other adult caregiver during childhood and STD risk in early adulthood using a national probability sample to obtain population-level estimates, and we model both self-reported and test-identified measures of STD status. Our analysis adjusts for an expanded set of possible confounders and evaluates potential moderators and mediators of the relationship between maltreatment and STD risk. Lastly, we evaluate childhood and adolescent exposure to four major types of maltreatment—including two forms of neglect—to estimate their individual and shared association with STD risk.