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Journal of Child Sexual Abuse Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/wcsa20
Caregiver–Youth Communication about Sex in South Africa: The Role of Maternal Child Sexual Abuse History a
b
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Elizabeth R. Anthony , Tracy N. Hipp , Doyanne A. Darnell , Lisa b
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Armistead , Sarah L. Cook & Donald Skinner a
Case Western Reserve University, Cleveland, Ohio, USA
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Georgia State University, Atlanta, Georgia, USA
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University of Washington, Seattle, Washington, USA
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University of Stellenbosch, Stellenbosch, South Africa Published online: 12 Aug 2014.
Click for updates To cite this article: Elizabeth R. Anthony, Tracy N. Hipp, Doyanne A. Darnell, Lisa Armistead, Sarah L. Cook & Donald Skinner (2014) Caregiver–Youth Communication about Sex in South Africa: The Role of Maternal Child Sexual Abuse History, Journal of Child Sexual Abuse, 23:6, 657-673, DOI: 10.1080/10538712.2014.932877 To link to this article: http://dx.doi.org/10.1080/10538712.2014.932877
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Journal of Child Sexual Abuse, 23:657–673, 2014 Copyright © Taylor & Francis Group, LLC ISSN: 1053-8712 print/1547-0679 online DOI: 10.1080/10538712.2014.932877
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SEX EDUCATION AND COMMUNICATION
Caregiver–Youth Communication about Sex in South Africa: The Role of Maternal Child Sexual Abuse History ELIZABETH R. ANTHONY Case Western Reserve University, Cleveland, Ohio, USA
TRACY N. HIPP Georgia State University, Atlanta, Georgia, USA
DOYANNE A. DARNELL University of Washington, Seattle, Washington, USA
LISA ARMISTEAD and SARAH L. COOK Georgia State University, Atlanta, Georgia, USA
DONALD SKINNER University of Stellenbosch, Stellenbosch, South Africa
Much of the research on child sexual abuse focuses on negative outcomes. This brief report explores a potentially protective parenting behavior among black South African female caregivers with and without a child sexual abuse history. Using cross-sectional baseline data, we hypothesized that caregiver child sexual abuse history would be positively associated with caregiver–youth sex communication and this relationship would be strongest for girls. Youth whose caregiver experienced child sexual abuse were more likely to report communicating with their caregiver about sex than youth whose caregivers did not experience child sexual abuse; however, this relation did not hold for caregiver reported
Received 26 March 2013; revised 10 September 2013; accepted 15 November 2013. Address correspondence to Elizabeth R. Anthony, Center on Urban Poverty and Community Development, Jack, Joseph and Morton Mandel School of Applied Social Sciences, Case Western Reserve University, 10900 Euclid Avenue, Cleveland, OH 44106. E-mail: exa136@ case.edu 657
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communication. Child sexual abuse survivors’ ability and decision to discuss sex with their youth has the potential to protect youth from sexual risk and demonstrates resilience among a group rarely acknowledged for positive parenting practices.
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KEYWORDS child sexual abuse, parent–child communication, HIV prevention, South Africa, youth, parenting, sexual risk behavior
Child sexual abuse (CSA) is associated with a host of negative sequelae for survivors (Paolucci, Genuis, & Violato, 2001; Carey, Walker, Rossouw, Seedat, & Stein, 2008), and researchers investigating the long-term consequences of CSA have identified a number of domains of functioning affected by abuse history, one of which is parenting (DiLillo, Tremblay, & Peterson, 2000). For example, CSA history has been associated with the use of parenting techniques (i.e., punitive parenting) shown to negatively affect children of CSA survivors (DiLillo & Damashek, 2003). However, outcomes, including parenting behaviors, among CSA survivors are diverse and variable (Walsh, Fortier, DiLillo, 2010). This pilot study explores the relationship between CSA history and a protective parenting practice, parent–child communication about sex, a variable consistently shown to decrease youth sexual risk taking behavior (Dittus, Miller, Kotchick, & Forehand, 2004). Most data underlying the relationship between parenting and youth sexual risk reduction are from the United States and other industrialized countries. For example, in U.S. samples, parents who provide accurate information about risks, consequences, and responsibilities related to sexual behavior have adolescents who are more likely to make responsible decisions about health and sexuality (Dittus, Jaccard, & Gordon, 1999; Karofsky, Zeng, & Kosorok, 2000). Emerging research from South Africa demonstrates a similar relationship between caregiver–youth sex communication and reduced youth sexual risk behavior. Boys and girls who reported talking to their parents about HIV/AIDS were more likely than youth who had not talked with parents about sex to report having been tested for HIV (MacPhail, Pettifor, Moyo, Rees, 2009). Beyond its direct effects on adolescent sexual behavior, female caregiver/parent–adolescent communication about sex has also been linked to several variables that bear on sexual risk such as attitudes about HIV (Seligman, Mukai, Woods, & Alfeld, 1995), abstinence values (Miller, Norton, Fan, & Christopherson, 1998), and intentions to abstain (Miller, Clark, & Moore, 1997). Given ample evidence supporting the benefits of parent–child communication about sex, research that explores factors affecting sex communication may provide insight into promoting such communication.
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Caregiver communication with youth about sex may play a particularly important role in the prevention of HIV among South African youth. Sub-Saharan Africa suffers the highest rate of HIV, with an estimated one in 20 adults (4.9%) living with HIV, accounting for 69% of the people living with HIV worldwide (UNAIDS, 2012). In South Africa alone, 11.9% of young women (ages 15–24) and 5.3% of young men (ages 15–24) were living with HIV in 2011 (UNAIDS, 2012). Currently, young adult women are most at risk for infection, spread largely through heterosexual sex (Shisana et al., 2010). Prevalence estimates of CSA vary depending on the definition and methodology used to estimate the scope of the problem. Although evidence suggests rates of CSA in South Africa are comparable to those from Australia, Austria, Costa Rica, Switzerland, and the Unites States (Pereda, Guilera, Forns, & Gomez-Benito, 2009; Finkelhor, 1994), CSA is an all too common event in South African girls’ lives. For example, among a sample of 216 adolescent girls surveyed about their experiences of CSA before age 17, 47.2% reported sexual kissing, 31.0% reported sexual touching, and 17.6% reported sexual intercourse (Madu & Peltzer, 2000). Retrospective reports provided by college women suggest as many as one in three have experienced at least one incident of contact CSA including sexual kissing, sexual touching, genital and breast fondling, and oral, anal, and vaginal penetration (Collings, 1997). Deleterious outcomes dominate the CSA research literature. For example, CSA has been linked to maladaptive parenting behaviors including physical abuse, punitive discipline strategies, and physical discipline (DiLillo & Damashek, 2003; DiLillo, Tremblay, & Peterson, 2000; Schuetze & Das Eiden, 2005; Cohen, Hien, & Batchelder, 2008). However, adaptive responses can also emerge from negative life experiences. McMillen, Zuravin, and Rideout (1995) explored perceived adaptive responses following CSA. In their study, 29.2% of mothers with a history of CSA reported that as a result of their personal childhood victimization, they felt better equipped to protect their children from sexual victimization by teaching them about sexual abuse, exercising more caution, controlling their child’s contact with other adults, and establishing a more open relationship with their child. In this brief report, we explore the relationship between female caregivers’ CSA history and caregiver–youth communication about sex among caregiver–youth dyads in South Africa using previously collected data from a larger study. Given evidence indicating caregivers talk about sex-related topics with daughters more than sons (Regnerus, 2005; Nolin & Petersen, 1992) and female caregivers provide more sex-related communication than male caregivers (Jaccard, Dittus, & Gordon, 2000), we hypothesized that female caregiver CSA history would be positively associated with caregiver–youth communication about sex and that this relationship would be stronger for adolescent girls than boys after controlling for theoretically
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related demographic variables and other forms of the caregivers’ childhood and adult victimization experiences.
METHOD
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The current project uses cross-sectional baseline data from a longitudinal intervention study intended to decrease youths’ HIV risk by improving parenting practices including caregiver–youth communication about sex.
Participants Data were collected from N = 99 black South African female caregivers (M age = 42.7 years, SD = 12.0 years) and their 10- to 14-year-old youth (M age = 11.7 years, SD = 1.4 years). Approximately 53% of youth were female. Caregivers were biological mothers (68.7%), grandmothers (15.2%), aunts (7.1%), great-grandmothers (2.0%), and female cousins (2.0%). Approximately 61% of caregivers had never been married; however, 58.6% identified another adult who helped them raise their child, and 63.8% of identified co-caregivers were female (e.g., grandmothers and aunts). To illustrate the ethnic diversity in our sample, caregivers and youth identified as Xhosa (83.8%), Zulu (11%), Sotho (3%), or other (2%). Participants were given the option of completing measures in Xhosa or English. Sixty percent of caregivers chose Xhosa, while 70% of youth choose to complete the assessment in English. Caregivers with (n = 26) and without (n = 73) a CSA history did not differ based on several demographic variables including the age, t(97) = –0.75, p = .45, and gender of their child χ 2 (1, N = 99) = 0.09, p = .76; their age t(96) = –1.11, p = .27; ethnicity t(97) = 1.44, p = .16; family material resources χ 2 (1, N = 99) = 1.99, p = .16; presence of a co-caregiver χ 2 (1, N = 99) = 0.48, p = .49; or marital status χ 2 (1, N = 99) = 0.84, p = .36.
Measures We collaborated with our South African colleagues and community-based service providers to ensure our measures were culturally relevant, sensitive, and valid. When applicable, we selected instruments previously administered with South African samples. Where no appropriate measures existed, we modified measures not previously used with samples similar to our own, drawing from the literature and the cultural knowledge of South Africabased researchers and staff. Measures were created in English, translated to Xhosa, and then back translated into English by independent sets of native Xhosa speakers. We reviewed back translations to ensure content equivalency (Chavez & Canino, 2005).
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FAMILY
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MATERIAL RESOURCES
We measured family material resources with 17 items about material welfare from the Household Economic and Social Status Index (HESSI), a measure developed in South Africa (Barbarin & Khomo, 1997; Barbarin & Richter, 2007). Thirteen of the 17 items were dichotomous questions (0 = no, 1 = yes); a sample item is, “Does your home have a separate kitchen?” Remaining items had ordinal response sets; a sample item is, “In what type of house do you and your child live?” Scores ranged from 0 to 5. Items were reversed scored when necessary so that higher scores consistently indicated the presence, rather than absence, of resources. We created a scale score by summing across all 17 items. Scale scores ranged from 0 to 28. Cronbach’s alpha was 0.67. As this variable was significantly negatively skewed, we dichotomized the scale at the median, creating a low and high resources group. CHILDHOOD
PHYSICAL AND EMOTIONAL TRAUMA HISTORY
Caregivers completed a modified version of the Childhood Trauma Questionnaire Short Form (CTQ-SF; Bernstein et al., 2003), a retrospective account of child abuse and neglect. The 28-item CTQ-SF has been used previously in South Africa (Jewkes et al., 2006). To control for physical and emotional childhood trauma so that we could examine the unique influence of CSA on caregiver–youth communication, we summed across four of the five CTQ-SF subscales (excluding Sexual Abuse): Physical Abuse (4 items), Physical Neglect (5 items), Emotional Abuse (5 items), and Emotional Neglect (5 items). To be more culturally relevant, two items, one from the Physical Abuse subscale (“I was punished with hard objects”) and one from the Physical Neglect subscale (“I wore dirty clothes”) were reworded (“I was punished with a sjambok or some other hard object”; “I did not have proper shoes”) from the original version of the CTQ-SF. One item was created for the Physical Neglect subscale: “My family left me with adults who hurt me.” Caregivers answered each question on a Likert-type scale ranging from 0 (never true) to 4 (very often true). Items were reverse scored as needed so that higher scores consistently indicated more childhood trauma. Items were summed across each subscale to yield a total score of childhood trauma. Cronbach’s alpha was .78. LIFETIME
PREVALENCE OF INTIMATE PARTNER VIOLENCE
We measured caregivers’ history of intimate partner violence (IPV) using 10 items from the World Health Organization’s (WHO) Violence Against Women (VAW) Instrument (WHO, 2003). A sample item is, “Has a partner ever kicked you, dragged you, or beat you up?” In an effort to ensure participants completed the entire assessment for the larger study of which these measures are just a subset, we omitted items when they seemed both
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redundant and likely to yield possible low-base rates. As a result, we did not administer three items from the WHO VAW instrument (“Did you ever have sexual intercourse you did not want to because you were afraid of what your partner or any other partner might do?” “Has he or any other partner ever choked or burnt you on purpose?” “Has he or any other partner ever threatened to use or actually used a gun, knife, or other weapon against you?”). Respondents answered no (0); yes, in the last year (1); or yes, but not in the last year (2). To create a lifetime prevalence variable, we combined all reports of victimization experiences in the past year and victimization experiences prior to the past year. Cronbach’s alpha was .92. The resulting count was dichotomized with 0 = no IPV and 1 = at least one experience of IPV. CHILD
SEXUAL ABUSE HISTORY
We used three of the five items from the Sexual Abuse subscale of the CTQ-SF to index female caregivers’ retrospective accounts of sexual abuse experienced during childhood (“I believe that I was sexually abused,” “Someone tried to touch me in a sexual way or tried to make me touch them,” “Someone threatened to hurt me or tell lies about me unless I did something sexual with them”). The remaining two items, assessing for sexual molestation and whether the respondent was made to do sexual things, were removed to keep our assessment as brief as possible and because we perceived them as repetitive. Participants responded on a five-point Likerttype scale ranging from 0 (never true) to 4 (very often true). As we were interested in potential differences in caregiver–youth communication about sex between women with and without a history of CSA, we summed across the three items and dichotomized the resulting sum score so that 0 = no CSA history and 1 = any experience of CSA. CAREGIVER–YOUTH
COMMUNICATION ABOUT SEX
We used a single item previously used by Wyckoff et al. (2008) to assess our outcome: “Has your parent ever talked to you about what sex is?” for children and “Have you ever talked to your child about what sex is?” for caregivers. Caregivers responded using a 0 (no), 1 (yes) response option. Youth responded using a four-point Likert-type scale ranging from 1 (no, never) to 4 (three or more times). We dichotomized this item to be consistent with caregiver report, 0 = never and 1 = at least once.
Procedures Fieldworkers recruited caregiver–youth dyads by going door to door in Langa, a black township near Cape Town with a population of approximately
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50,000. To be eligible to participate, caregivers had to respond yes when asked if they had lived in Langa for at least one year and had a child between the ages of 10 and 14 with whom they spent at least four nights per week. Caregivers did not necessarily have to be the biological parent of the participating child but were legally responsible for providing primary care and supervision to the child. If more than one child in the household between the ages of 10 and 14 was present, the child with the birthday closest to the informational meeting was selected. Interested caregivers were invited to an informational session about the study. One hundred and six female caregivers attended the informational meeting where project staff reviewed details of the study and scheduled baseline assessment appointments. Seven caregivers attended the informational session but did not participate in the study. Four were determined to be ineligible, and three withdrew after the consent procedures, citing the length of the baseline assessment as problematic. Institutional review boards in the United States and South Africa approved all study procedures. Data collection took place at two sites within Langa. Before deploying into the field, U.S. investigators trained two black South African women to administer the assessments by conducting mock assessment administrations. Both women spoke Xhosa and English. During the first week of assessments, U.S. investigators were on site to provide support. Throughout the study, assessment administrators were supervised through regular meetings by masters and doctoral-level South Africa–based staff with extensive research training and experience. At the baseline assessment, informed consent and assent were obtained from caregivers and youth, respectively, in English or Xhosa based on participants’ preference. All measures were administered through audio computer-assisted self-interview (ACASI) technology. The complete assessment battery included the measures described previously as well as measures assessing general health, parenting, and youth behavior. Measures were not counterbalanced. Youth and caregivers were assessed separately. Caregivers were compensated with R70 (approximately $10 USD). Youth received a small gift for their time.
Statistical Analyses We used independent samples t-tests and chi-square tests for independence to ensure caregivers with and without a history of CSA were demographically equivalent (e.g., age, youth gender, family material resources). We then ran two binary logistic regressions. In the first we regressed youthreported caregiver–youth communication about sex onto dichotomously coded caregiver CSA history. In the second, we regressed caregiver-reported caregiver–youth communication onto the same predictor variable. For both models we controlled for several theoretically related covariates, specifically
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youth age and gender and other forms of caregiver trauma to identify the unique effect of maternal CSA history on communication.
RESULTS In our sample, 26.3% of caregivers experienced CSA. Approximately 38% of youth whose caregivers did not experience CSA reported talking to their caregiver about sex at least once compared with 73.1% of youth whose caregiver experienced CSA (see Figure 1). Approximately 30% of caregivers without a CSA history reported talking to their youth about sex at least once compared with 42.3% of caregivers who had experienced CSA (see Figure 1). Youth gender and sex communication were correlated according to youth report but not caregiver report (see Table 1). Similarly, caregiver CSA history and sex communication were correlated according to youth report but not caregiver report (see Table 1).
CSA as a Predictor of Caregiver–Youth Sex Communication We hypothesized that caregiver CSA history would be positively associated with caregiver–youth sex communication and that this relationship would be stronger for girls than boys after controlling for theoretically related demographic variables and other forms of the caregivers’ childhood and 100 % of Sample that Reported Talking about Sex
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Descriptive Statistics
Caregivers without a CSA history Caregivers with a CSA history
90 80 70 60 50 40 30 20 10 0 Caregiver Report
Youth Report
FIGURE 1 Percent of youth and caregivers reporting caregiver–youth communication about sex by caregiver CSA history.
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Youth reported agea Youth reported gendera Caregiver physical and emotional trauma historya Caregiver lifetime prevalence of IPVb Caregiver CSA historya Youth reported sex communicationb Caregiver reported sex communicationa 11.72 0.53 0.93 0.66 0.26 0.47 0.33
(1.39) (0.50) (0.55) (0.48) (0.44) (0.50) (0.47)
— — — — — — —
1. 0.08 — — — — — —
2. 0.04 0.19 — — — — —
3.
5. 0.08 −0.03 ∗ 0.25 0.17 — — —
4. −0.08 0.01 0.06 — — — —
0.10 0.27 0.06 −0.01 ∗ 0.32 — — ∗
6.
0.12 0.11 −0.07 −0.09 0.11 ∗ 0.24 —
7.
Note. Youth gender, 0 = male, 1 = female; caregiver CSA history, 0 = no, 1 = yes; both youth report and caregiver report of communication, 0 = no, 1 = yes. a = N is 99; b = N is 98. ∗ p < .05.
1. 2. 3. 4. 5. 6. 7.
M (SD)
TABLE 1 Means, Standard Deviations, and Correlations among Covariates, Independent and Outcomes Variables
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adult victimization experiences. The data did not support a moderation hypothesis (see Table 2). Rather, we found separate main effects for caregiver CSA history and youth gender on youth reported sex communication (see Table 2). Youth whose caregiver experienced CSA were over seven times more likely to report talking to their caregiver about sex than youth whose caregiver did not experience CSA. Adolescent girls were four times more likely to report that their caregiver spoke to them about sex than boys.
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DISCUSSION The purpose of our secondary data analysis was to explore a parenting behavior known to protect youth from sexual risk among a sample of black South African female caregivers, many of whom experienced CSA. According to youth reports, caregiver CSA history increased the likelihood that caregivers and youth talked about sex. We were surprised this relationship did not hold for caregiver report of outcome; however, studies of family communication regularly find disagreement between parent and youth report. For example, Newcomer and Udry (1985) found that U.S. parents and youth in their study contradicted one another about what kind of sex-related communication they had. Whereas mothers were more likely to report having talked to their high school aged son or daughter about using birth control, teens were more likely to report that their mother had talked to them about sex before marriage and the teens’ own sexual behavior. Miller, Kotchick, Dorsey, Forehand, and Ham (1998) similarly noted discrepancies between parent and youth reported sex-related communication. In their study, mothers were more likely than youth to report they had discussed 10 different topics about sex including birth control, condoms, and HIV/AIDS. From a U.S. cultural perspective, we assumed that parents, as compared with their children, would report more parent–youth sex-related communication. However, we do not yet know if this parent–child dynamic can be applied to South African families. Through our cultural lens, findings like Newcomer and Udry’s (1985) and the one we report in this paper are challenging to explain. It is possible that the female caregivers with a CSA history in our sample underestimated their parenting skills, believing they did not talk enough or as well as they should have to sufficiently protect their children. Or maybe youth interpreted more general health and safety communication through a sex-related lens knowing, explicitly or implicitly, of their caregiver’s CSA history. While these hypotheses have yet to be explored, we believe youths’ perceptions of the occurrence of sex communication may be more important to sexual risk prevention than caregivers’ as our ultimate goal is to improve youth health outcomes. Our results and causal inferences are limited by the cross-sectional nature of this pilot study as well as the small convenience sample from which
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−1.04 0.09 ∗ 1.40 −0.43 −0.19 ∗ 1.96 −0.17 (0.67) (0.17) (0.55) (0.44) (0.49) (0.74) (1.11) 0.79 1.38 0.28 0.32 1.67 0.10
Lower 0.35 1.10 4.05 0.65 0.83 7.06 0.84
Odds Ratio 1.51 11.87 1.55 2.17 29.85 7.48
Upper −0.82 0.18 0.76 −0.51 −0.53 1.00 −0.24
(0.65) (0.16) (0.55) (0.45) (0.48) (0.73) (0.99)
β (SE)
0.87 0.73 0.25 0.23 0.65 0.11
Lower
0.44 1.20 2.14 0.60 0.59 2.72 0.79
Odds Ratio
1.64 6.23 1.46 1.50 11.43 5.51
Upper
95% CI for odds ratio
Caregiver report
Note. N = 96 for youth-report model; N = 97 for caregiver-report model; youth gender, 0 = male, 1 = female; caregiver CSA history, 0 = no, 1 = yes; both youth report and caregiver report of communication, 0 = no, 1 = yes. ∗ p < .05.
Constant Youth age Youth gender Caregiver trauma history Caregiver IPV history Caregiver CSA history Youth gender X CSA
β (SE)
95% CI for odds ratio
Youth report
TABLE 2 Results of Youth and Caregiver Report of Caregiver CSA History on Caregiver–Youth Communication about Sex
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we collected our data. Approximately a quarter of the female caregivers in our sample reported CSA. While this is 26 women too many, we recognize that an n of this size, in statistical terms, constitutes a relatively small sample. However, we believe our findings are noteworthy even with this limitation given our research question and novel research approach. Furthermore, Reid-Cunningham (2009) explored the effect of maternal CSA history and maternal childhood rape on the parent–child relationship with an n of 40 and 11, respectively. Given a sizable body of research that supports a protective effect of caregiver–child sexual communication on youth sexual risk, in this article we assume such communication is a positive and protective feature for youth sexual development in South Africa. We are not alone in this assumption; Let’s Talk, an HIV prevention parenting program implemented at workplaces in South Africa (Bogart et al., 2013); loveLife, an HIV prevention initiative targeting young people in South Africa (loveLife, 2000a, 2000b; Wilbraham, 2009); and the larger study from which these data were drawn (Armistead et al., 2014) all recognize the potential of parent–child communication as a mechanism through which to reduce youths’ sexual risk. As a result, we did not determine if the sex-related communication that youth reported getting actually was protective. We recognize that not all caregiver–youth sex communication is protective. For example, fear-based messages delivered in a threatening context likely produce different outcomes from more didactic, educational conversation. Our inability to determine the tone of caregiver–youth sexual communication is a limitation of this study. Our results warrant further study of the relationship between CSA history and caregiver–youth communication about sex. Most needed is qualitative information about the nature of caregiver–youth sex communication to contextualize the results obtained from a single item assessing the occurrence of caregiver–youth communication about sex. Future research on this topic could employ multiple closed-ended items to measure the breadth or scope of sex communication but potentially more rich would be research using content analysis techniques to gain insight into the verbal and nonverbal aspects of caregiver–youth sex communication that are otherwise missed in survey research. We do not know if the caregivers and youth in our study who engaged in sex communication did so as a bidirectional discussion or a threatening monologue about the dangers of sex. Furthermore, longitudinal research is needed to identify mediating processes that may influence the relationship between CSA history and caregiver–youth sex communication as well as link sex communication to youth behavioral outcomes. Our findings demonstrate a potentially positive parenting practice among a group often characterized as deficient parents. As our focus was on caregiver–youth sex communication and not negative parenting practices, we cannot say that these behaviors were not also co-occurring with increased sex communication among our sample. However, as parenting is complex
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and likely characterized by strengths and weaknesses, we feel additional research with a larger sample of female caregivers with a CSA history is warranted, as any intervention programming designed to improve parenting practices among this population may perhaps more successfully alter maladaptive behavior by acknowledging and building on an existing strength. In addition, better understanding the motivations and processes involved in CSA survivors’ communication with their youth may hold benefit for all caregivers and parenting interventionists. If future research supports the finding we present in this brief report, incorporating this strengthsbased perspective into prevention programming may increase the efficacy of interventions among all caregivers, including those with and without a CSA trauma history. Last, given the prevalence of CSA as well as other forms of victimization and its documented effects on parenting, parenting interventions must be trauma-informed.
ACKNOWLEDGMENTS We wish to acknowledge Katherine Colmer, Georgia State University; Gillian Sibiya, Namafu Jayiya, and Annemie Stewart, Stellenbosch University; Ina Vermulen, Desiree Uys, Nolitha Lekoma, and Gertrude Gwenzi, Cape Town Child Welfare; Cat Rieper, Resources Aimed at the Prevention of Child Abuse and Neglect (RAPCAN); Fouzia Rykleft and Marjorie Feni, the Parent Centre; Ndileka Xameni, Anele Ghasana, and Siyabonga Mgwabala, Siyaphambili Orphan Village; Khulani Chiliza, “KC,” LoveLife; and Nomakhosi Magalakanqa, Mbulelo Mapele, and Nokwanda Matanda and the families from Langa who participated in the study for their contributions to this project.
FUNDING This study was funded by the Eunice K. Shriver National Institute of Child Health and Human Development (Grant 5R21HD058483).
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AUTHOR NOTES Elizabeth R. Anthony, PhD, is a senior research associate at the Center on Urban Poverty and Community Development, Jack, Joseph and Morton Mandel School of Applied Social Sciences, Case Western Reserve University. Her current research focuses on the evaluation of early childhood interventions for young children living in poverty. She received her PhD from Georgia State University in Community Psychology. Tracy N. Hipp, MA, is a doctoral candidate of community psychology at Georgia State University. Her current research focuses on the intersections of sexuality, human rights violations, and sexual assault. She received her MA from Georgia State University in Community Psychology. Doyanne A. Darnell, PhD, is a National Institutes of Mental Health T32 postdoctoral fellow with the Center for Healthcare Improvement for Addictions, Mental Illness, and Medically Vulnerable Populations (CHAMMP) at the University of Washington Department of Psychiatry and Behavioral Sciences. Her current research focuses on population-based approaches to screening and intervention with victims of rape trauma seeking acute care to address posttraumatic stress disorder and related comorbidities such as depression, suicidality, and risk behaviors (e.g., substance misuse, risky sexual behaviors). She received her PhD from Georgia State University in clinical and community psychology. Lisa Armistead, PhD, is professor and chair of the Department of Psychology at Georgia State University. Her research focuses on the intersection of HIV
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and families. She received her PhD in clinical psychology from the University of Georgia.
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Sarah L. Cook, PhD, is professor of psychology and associate dean of the Honors College. Her research focuses on how science conceptualizes and measures violence against women, ethical issues in researching it, how to prevent it, and how it intersects with other problems such as HIV/AIDS in South Africa. She received her PhD in community psychology from the University of Virginia. Donald Skinner, PhD, is the director of research on health and society at the Faculty of Medicine and Health Sciences, Stellenbosch University. He focuses on research looking at the social aspects of health with particular interests in HIV and AIDS and tuberculosis prevention and treatment, substance abuse, and violence. He has particular expertise in qualitative and community participatory research approaches.
Journal of Child Sexual Abuse Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/wcsa20
Caregiver–Youth Communication about Sex in South Africa: The Role of Maternal Child Sexual Abuse History a
b
c
Elizabeth R. Anthony , Tracy N. Hipp , Doyanne A. Darnell , Lisa b
b
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Armistead , Sarah L. Cook & Donald Skinner a
Case Western Reserve University, Cleveland, Ohio, USA
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Georgia State University, Atlanta, Georgia, USA
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University of Washington, Seattle, Washington, USA
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University of Stellenbosch, Stellenbosch, South Africa Published online: 12 Aug 2014.
Click for updates To cite this article: Elizabeth R. Anthony, Tracy N. Hipp, Doyanne A. Darnell, Lisa Armistead, Sarah L. Cook & Donald Skinner (2014) Caregiver–Youth Communication about Sex in South Africa: The Role of Maternal Child Sexual Abuse History, Journal of Child Sexual Abuse, 23:6, 657-673, DOI: 10.1080/10538712.2014.932877 To link to this article: http://dx.doi.org/10.1080/10538712.2014.932877
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Journal of Child Sexual Abuse, 23:657–673, 2014 Copyright © Taylor & Francis Group, LLC ISSN: 1053-8712 print/1547-0679 online DOI: 10.1080/10538712.2014.932877
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SEX EDUCATION AND COMMUNICATION
Caregiver–Youth Communication about Sex in South Africa: The Role of Maternal Child Sexual Abuse History ELIZABETH R. ANTHONY Case Western Reserve University, Cleveland, Ohio, USA
TRACY N. HIPP Georgia State University, Atlanta, Georgia, USA
DOYANNE A. DARNELL University of Washington, Seattle, Washington, USA
LISA ARMISTEAD and SARAH L. COOK Georgia State University, Atlanta, Georgia, USA
DONALD SKINNER University of Stellenbosch, Stellenbosch, South Africa
Much of the research on child sexual abuse focuses on negative outcomes. This brief report explores a potentially protective parenting behavior among black South African female caregivers with and without a child sexual abuse history. Using cross-sectional baseline data, we hypothesized that caregiver child sexual abuse history would be positively associated with caregiver–youth sex communication and this relationship would be strongest for girls. Youth whose caregiver experienced child sexual abuse were more likely to report communicating with their caregiver about sex than youth whose caregivers did not experience child sexual abuse; however, this relation did not hold for caregiver reported
Received 26 March 2013; revised 10 September 2013; accepted 15 November 2013. Address correspondence to Elizabeth R. Anthony, Center on Urban Poverty and Community Development, Jack, Joseph and Morton Mandel School of Applied Social Sciences, Case Western Reserve University, 10900 Euclid Avenue, Cleveland, OH 44106. E-mail: exa136@ case.edu 657
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communication. Child sexual abuse survivors’ ability and decision to discuss sex with their youth has the potential to protect youth from sexual risk and demonstrates resilience among a group rarely acknowledged for positive parenting practices.
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KEYWORDS child sexual abuse, parent–child communication, HIV prevention, South Africa, youth, parenting, sexual risk behavior
Child sexual abuse (CSA) is associated with a host of negative sequelae for survivors (Paolucci, Genuis, & Violato, 2001; Carey, Walker, Rossouw, Seedat, & Stein, 2008), and researchers investigating the long-term consequences of CSA have identified a number of domains of functioning affected by abuse history, one of which is parenting (DiLillo, Tremblay, & Peterson, 2000). For example, CSA history has been associated with the use of parenting techniques (i.e., punitive parenting) shown to negatively affect children of CSA survivors (DiLillo & Damashek, 2003). However, outcomes, including parenting behaviors, among CSA survivors are diverse and variable (Walsh, Fortier, DiLillo, 2010). This pilot study explores the relationship between CSA history and a protective parenting practice, parent–child communication about sex, a variable consistently shown to decrease youth sexual risk taking behavior (Dittus, Miller, Kotchick, & Forehand, 2004). Most data underlying the relationship between parenting and youth sexual risk reduction are from the United States and other industrialized countries. For example, in U.S. samples, parents who provide accurate information about risks, consequences, and responsibilities related to sexual behavior have adolescents who are more likely to make responsible decisions about health and sexuality (Dittus, Jaccard, & Gordon, 1999; Karofsky, Zeng, & Kosorok, 2000). Emerging research from South Africa demonstrates a similar relationship between caregiver–youth sex communication and reduced youth sexual risk behavior. Boys and girls who reported talking to their parents about HIV/AIDS were more likely than youth who had not talked with parents about sex to report having been tested for HIV (MacPhail, Pettifor, Moyo, Rees, 2009). Beyond its direct effects on adolescent sexual behavior, female caregiver/parent–adolescent communication about sex has also been linked to several variables that bear on sexual risk such as attitudes about HIV (Seligman, Mukai, Woods, & Alfeld, 1995), abstinence values (Miller, Norton, Fan, & Christopherson, 1998), and intentions to abstain (Miller, Clark, & Moore, 1997). Given ample evidence supporting the benefits of parent–child communication about sex, research that explores factors affecting sex communication may provide insight into promoting such communication.
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Caregiver communication with youth about sex may play a particularly important role in the prevention of HIV among South African youth. Sub-Saharan Africa suffers the highest rate of HIV, with an estimated one in 20 adults (4.9%) living with HIV, accounting for 69% of the people living with HIV worldwide (UNAIDS, 2012). In South Africa alone, 11.9% of young women (ages 15–24) and 5.3% of young men (ages 15–24) were living with HIV in 2011 (UNAIDS, 2012). Currently, young adult women are most at risk for infection, spread largely through heterosexual sex (Shisana et al., 2010). Prevalence estimates of CSA vary depending on the definition and methodology used to estimate the scope of the problem. Although evidence suggests rates of CSA in South Africa are comparable to those from Australia, Austria, Costa Rica, Switzerland, and the Unites States (Pereda, Guilera, Forns, & Gomez-Benito, 2009; Finkelhor, 1994), CSA is an all too common event in South African girls’ lives. For example, among a sample of 216 adolescent girls surveyed about their experiences of CSA before age 17, 47.2% reported sexual kissing, 31.0% reported sexual touching, and 17.6% reported sexual intercourse (Madu & Peltzer, 2000). Retrospective reports provided by college women suggest as many as one in three have experienced at least one incident of contact CSA including sexual kissing, sexual touching, genital and breast fondling, and oral, anal, and vaginal penetration (Collings, 1997). Deleterious outcomes dominate the CSA research literature. For example, CSA has been linked to maladaptive parenting behaviors including physical abuse, punitive discipline strategies, and physical discipline (DiLillo & Damashek, 2003; DiLillo, Tremblay, & Peterson, 2000; Schuetze & Das Eiden, 2005; Cohen, Hien, & Batchelder, 2008). However, adaptive responses can also emerge from negative life experiences. McMillen, Zuravin, and Rideout (1995) explored perceived adaptive responses following CSA. In their study, 29.2% of mothers with a history of CSA reported that as a result of their personal childhood victimization, they felt better equipped to protect their children from sexual victimization by teaching them about sexual abuse, exercising more caution, controlling their child’s contact with other adults, and establishing a more open relationship with their child. In this brief report, we explore the relationship between female caregivers’ CSA history and caregiver–youth communication about sex among caregiver–youth dyads in South Africa using previously collected data from a larger study. Given evidence indicating caregivers talk about sex-related topics with daughters more than sons (Regnerus, 2005; Nolin & Petersen, 1992) and female caregivers provide more sex-related communication than male caregivers (Jaccard, Dittus, & Gordon, 2000), we hypothesized that female caregiver CSA history would be positively associated with caregiver–youth communication about sex and that this relationship would be stronger for adolescent girls than boys after controlling for theoretically
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related demographic variables and other forms of the caregivers’ childhood and adult victimization experiences.
METHOD
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The current project uses cross-sectional baseline data from a longitudinal intervention study intended to decrease youths’ HIV risk by improving parenting practices including caregiver–youth communication about sex.
Participants Data were collected from N = 99 black South African female caregivers (M age = 42.7 years, SD = 12.0 years) and their 10- to 14-year-old youth (M age = 11.7 years, SD = 1.4 years). Approximately 53% of youth were female. Caregivers were biological mothers (68.7%), grandmothers (15.2%), aunts (7.1%), great-grandmothers (2.0%), and female cousins (2.0%). Approximately 61% of caregivers had never been married; however, 58.6% identified another adult who helped them raise their child, and 63.8% of identified co-caregivers were female (e.g., grandmothers and aunts). To illustrate the ethnic diversity in our sample, caregivers and youth identified as Xhosa (83.8%), Zulu (11%), Sotho (3%), or other (2%). Participants were given the option of completing measures in Xhosa or English. Sixty percent of caregivers chose Xhosa, while 70% of youth choose to complete the assessment in English. Caregivers with (n = 26) and without (n = 73) a CSA history did not differ based on several demographic variables including the age, t(97) = –0.75, p = .45, and gender of their child χ 2 (1, N = 99) = 0.09, p = .76; their age t(96) = –1.11, p = .27; ethnicity t(97) = 1.44, p = .16; family material resources χ 2 (1, N = 99) = 1.99, p = .16; presence of a co-caregiver χ 2 (1, N = 99) = 0.48, p = .49; or marital status χ 2 (1, N = 99) = 0.84, p = .36.
Measures We collaborated with our South African colleagues and community-based service providers to ensure our measures were culturally relevant, sensitive, and valid. When applicable, we selected instruments previously administered with South African samples. Where no appropriate measures existed, we modified measures not previously used with samples similar to our own, drawing from the literature and the cultural knowledge of South Africabased researchers and staff. Measures were created in English, translated to Xhosa, and then back translated into English by independent sets of native Xhosa speakers. We reviewed back translations to ensure content equivalency (Chavez & Canino, 2005).
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MATERIAL RESOURCES
We measured family material resources with 17 items about material welfare from the Household Economic and Social Status Index (HESSI), a measure developed in South Africa (Barbarin & Khomo, 1997; Barbarin & Richter, 2007). Thirteen of the 17 items were dichotomous questions (0 = no, 1 = yes); a sample item is, “Does your home have a separate kitchen?” Remaining items had ordinal response sets; a sample item is, “In what type of house do you and your child live?” Scores ranged from 0 to 5. Items were reversed scored when necessary so that higher scores consistently indicated the presence, rather than absence, of resources. We created a scale score by summing across all 17 items. Scale scores ranged from 0 to 28. Cronbach’s alpha was 0.67. As this variable was significantly negatively skewed, we dichotomized the scale at the median, creating a low and high resources group. CHILDHOOD
PHYSICAL AND EMOTIONAL TRAUMA HISTORY
Caregivers completed a modified version of the Childhood Trauma Questionnaire Short Form (CTQ-SF; Bernstein et al., 2003), a retrospective account of child abuse and neglect. The 28-item CTQ-SF has been used previously in South Africa (Jewkes et al., 2006). To control for physical and emotional childhood trauma so that we could examine the unique influence of CSA on caregiver–youth communication, we summed across four of the five CTQ-SF subscales (excluding Sexual Abuse): Physical Abuse (4 items), Physical Neglect (5 items), Emotional Abuse (5 items), and Emotional Neglect (5 items). To be more culturally relevant, two items, one from the Physical Abuse subscale (“I was punished with hard objects”) and one from the Physical Neglect subscale (“I wore dirty clothes”) were reworded (“I was punished with a sjambok or some other hard object”; “I did not have proper shoes”) from the original version of the CTQ-SF. One item was created for the Physical Neglect subscale: “My family left me with adults who hurt me.” Caregivers answered each question on a Likert-type scale ranging from 0 (never true) to 4 (very often true). Items were reverse scored as needed so that higher scores consistently indicated more childhood trauma. Items were summed across each subscale to yield a total score of childhood trauma. Cronbach’s alpha was .78. LIFETIME
PREVALENCE OF INTIMATE PARTNER VIOLENCE
We measured caregivers’ history of intimate partner violence (IPV) using 10 items from the World Health Organization’s (WHO) Violence Against Women (VAW) Instrument (WHO, 2003). A sample item is, “Has a partner ever kicked you, dragged you, or beat you up?” In an effort to ensure participants completed the entire assessment for the larger study of which these measures are just a subset, we omitted items when they seemed both
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redundant and likely to yield possible low-base rates. As a result, we did not administer three items from the WHO VAW instrument (“Did you ever have sexual intercourse you did not want to because you were afraid of what your partner or any other partner might do?” “Has he or any other partner ever choked or burnt you on purpose?” “Has he or any other partner ever threatened to use or actually used a gun, knife, or other weapon against you?”). Respondents answered no (0); yes, in the last year (1); or yes, but not in the last year (2). To create a lifetime prevalence variable, we combined all reports of victimization experiences in the past year and victimization experiences prior to the past year. Cronbach’s alpha was .92. The resulting count was dichotomized with 0 = no IPV and 1 = at least one experience of IPV. CHILD
SEXUAL ABUSE HISTORY
We used three of the five items from the Sexual Abuse subscale of the CTQ-SF to index female caregivers’ retrospective accounts of sexual abuse experienced during childhood (“I believe that I was sexually abused,” “Someone tried to touch me in a sexual way or tried to make me touch them,” “Someone threatened to hurt me or tell lies about me unless I did something sexual with them”). The remaining two items, assessing for sexual molestation and whether the respondent was made to do sexual things, were removed to keep our assessment as brief as possible and because we perceived them as repetitive. Participants responded on a five-point Likerttype scale ranging from 0 (never true) to 4 (very often true). As we were interested in potential differences in caregiver–youth communication about sex between women with and without a history of CSA, we summed across the three items and dichotomized the resulting sum score so that 0 = no CSA history and 1 = any experience of CSA. CAREGIVER–YOUTH
COMMUNICATION ABOUT SEX
We used a single item previously used by Wyckoff et al. (2008) to assess our outcome: “Has your parent ever talked to you about what sex is?” for children and “Have you ever talked to your child about what sex is?” for caregivers. Caregivers responded using a 0 (no), 1 (yes) response option. Youth responded using a four-point Likert-type scale ranging from 1 (no, never) to 4 (three or more times). We dichotomized this item to be consistent with caregiver report, 0 = never and 1 = at least once.
Procedures Fieldworkers recruited caregiver–youth dyads by going door to door in Langa, a black township near Cape Town with a population of approximately
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50,000. To be eligible to participate, caregivers had to respond yes when asked if they had lived in Langa for at least one year and had a child between the ages of 10 and 14 with whom they spent at least four nights per week. Caregivers did not necessarily have to be the biological parent of the participating child but were legally responsible for providing primary care and supervision to the child. If more than one child in the household between the ages of 10 and 14 was present, the child with the birthday closest to the informational meeting was selected. Interested caregivers were invited to an informational session about the study. One hundred and six female caregivers attended the informational meeting where project staff reviewed details of the study and scheduled baseline assessment appointments. Seven caregivers attended the informational session but did not participate in the study. Four were determined to be ineligible, and three withdrew after the consent procedures, citing the length of the baseline assessment as problematic. Institutional review boards in the United States and South Africa approved all study procedures. Data collection took place at two sites within Langa. Before deploying into the field, U.S. investigators trained two black South African women to administer the assessments by conducting mock assessment administrations. Both women spoke Xhosa and English. During the first week of assessments, U.S. investigators were on site to provide support. Throughout the study, assessment administrators were supervised through regular meetings by masters and doctoral-level South Africa–based staff with extensive research training and experience. At the baseline assessment, informed consent and assent were obtained from caregivers and youth, respectively, in English or Xhosa based on participants’ preference. All measures were administered through audio computer-assisted self-interview (ACASI) technology. The complete assessment battery included the measures described previously as well as measures assessing general health, parenting, and youth behavior. Measures were not counterbalanced. Youth and caregivers were assessed separately. Caregivers were compensated with R70 (approximately $10 USD). Youth received a small gift for their time.
Statistical Analyses We used independent samples t-tests and chi-square tests for independence to ensure caregivers with and without a history of CSA were demographically equivalent (e.g., age, youth gender, family material resources). We then ran two binary logistic regressions. In the first we regressed youthreported caregiver–youth communication about sex onto dichotomously coded caregiver CSA history. In the second, we regressed caregiver-reported caregiver–youth communication onto the same predictor variable. For both models we controlled for several theoretically related covariates, specifically
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youth age and gender and other forms of caregiver trauma to identify the unique effect of maternal CSA history on communication.
RESULTS In our sample, 26.3% of caregivers experienced CSA. Approximately 38% of youth whose caregivers did not experience CSA reported talking to their caregiver about sex at least once compared with 73.1% of youth whose caregiver experienced CSA (see Figure 1). Approximately 30% of caregivers without a CSA history reported talking to their youth about sex at least once compared with 42.3% of caregivers who had experienced CSA (see Figure 1). Youth gender and sex communication were correlated according to youth report but not caregiver report (see Table 1). Similarly, caregiver CSA history and sex communication were correlated according to youth report but not caregiver report (see Table 1).
CSA as a Predictor of Caregiver–Youth Sex Communication We hypothesized that caregiver CSA history would be positively associated with caregiver–youth sex communication and that this relationship would be stronger for girls than boys after controlling for theoretically related demographic variables and other forms of the caregivers’ childhood and 100 % of Sample that Reported Talking about Sex
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Descriptive Statistics
Caregivers without a CSA history Caregivers with a CSA history
90 80 70 60 50 40 30 20 10 0 Caregiver Report
Youth Report
FIGURE 1 Percent of youth and caregivers reporting caregiver–youth communication about sex by caregiver CSA history.
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Youth reported agea Youth reported gendera Caregiver physical and emotional trauma historya Caregiver lifetime prevalence of IPVb Caregiver CSA historya Youth reported sex communicationb Caregiver reported sex communicationa 11.72 0.53 0.93 0.66 0.26 0.47 0.33
(1.39) (0.50) (0.55) (0.48) (0.44) (0.50) (0.47)
— — — — — — —
1. 0.08 — — — — — —
2. 0.04 0.19 — — — — —
3.
5. 0.08 −0.03 ∗ 0.25 0.17 — — —
4. −0.08 0.01 0.06 — — — —
0.10 0.27 0.06 −0.01 ∗ 0.32 — — ∗
6.
0.12 0.11 −0.07 −0.09 0.11 ∗ 0.24 —
7.
Note. Youth gender, 0 = male, 1 = female; caregiver CSA history, 0 = no, 1 = yes; both youth report and caregiver report of communication, 0 = no, 1 = yes. a = N is 99; b = N is 98. ∗ p < .05.
1. 2. 3. 4. 5. 6. 7.
M (SD)
TABLE 1 Means, Standard Deviations, and Correlations among Covariates, Independent and Outcomes Variables
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adult victimization experiences. The data did not support a moderation hypothesis (see Table 2). Rather, we found separate main effects for caregiver CSA history and youth gender on youth reported sex communication (see Table 2). Youth whose caregiver experienced CSA were over seven times more likely to report talking to their caregiver about sex than youth whose caregiver did not experience CSA. Adolescent girls were four times more likely to report that their caregiver spoke to them about sex than boys.
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DISCUSSION The purpose of our secondary data analysis was to explore a parenting behavior known to protect youth from sexual risk among a sample of black South African female caregivers, many of whom experienced CSA. According to youth reports, caregiver CSA history increased the likelihood that caregivers and youth talked about sex. We were surprised this relationship did not hold for caregiver report of outcome; however, studies of family communication regularly find disagreement between parent and youth report. For example, Newcomer and Udry (1985) found that U.S. parents and youth in their study contradicted one another about what kind of sex-related communication they had. Whereas mothers were more likely to report having talked to their high school aged son or daughter about using birth control, teens were more likely to report that their mother had talked to them about sex before marriage and the teens’ own sexual behavior. Miller, Kotchick, Dorsey, Forehand, and Ham (1998) similarly noted discrepancies between parent and youth reported sex-related communication. In their study, mothers were more likely than youth to report they had discussed 10 different topics about sex including birth control, condoms, and HIV/AIDS. From a U.S. cultural perspective, we assumed that parents, as compared with their children, would report more parent–youth sex-related communication. However, we do not yet know if this parent–child dynamic can be applied to South African families. Through our cultural lens, findings like Newcomer and Udry’s (1985) and the one we report in this paper are challenging to explain. It is possible that the female caregivers with a CSA history in our sample underestimated their parenting skills, believing they did not talk enough or as well as they should have to sufficiently protect their children. Or maybe youth interpreted more general health and safety communication through a sex-related lens knowing, explicitly or implicitly, of their caregiver’s CSA history. While these hypotheses have yet to be explored, we believe youths’ perceptions of the occurrence of sex communication may be more important to sexual risk prevention than caregivers’ as our ultimate goal is to improve youth health outcomes. Our results and causal inferences are limited by the cross-sectional nature of this pilot study as well as the small convenience sample from which
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−1.04 0.09 ∗ 1.40 −0.43 −0.19 ∗ 1.96 −0.17 (0.67) (0.17) (0.55) (0.44) (0.49) (0.74) (1.11) 0.79 1.38 0.28 0.32 1.67 0.10
Lower 0.35 1.10 4.05 0.65 0.83 7.06 0.84
Odds Ratio 1.51 11.87 1.55 2.17 29.85 7.48
Upper −0.82 0.18 0.76 −0.51 −0.53 1.00 −0.24
(0.65) (0.16) (0.55) (0.45) (0.48) (0.73) (0.99)
β (SE)
0.87 0.73 0.25 0.23 0.65 0.11
Lower
0.44 1.20 2.14 0.60 0.59 2.72 0.79
Odds Ratio
1.64 6.23 1.46 1.50 11.43 5.51
Upper
95% CI for odds ratio
Caregiver report
Note. N = 96 for youth-report model; N = 97 for caregiver-report model; youth gender, 0 = male, 1 = female; caregiver CSA history, 0 = no, 1 = yes; both youth report and caregiver report of communication, 0 = no, 1 = yes. ∗ p < .05.
Constant Youth age Youth gender Caregiver trauma history Caregiver IPV history Caregiver CSA history Youth gender X CSA
β (SE)
95% CI for odds ratio
Youth report
TABLE 2 Results of Youth and Caregiver Report of Caregiver CSA History on Caregiver–Youth Communication about Sex
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we collected our data. Approximately a quarter of the female caregivers in our sample reported CSA. While this is 26 women too many, we recognize that an n of this size, in statistical terms, constitutes a relatively small sample. However, we believe our findings are noteworthy even with this limitation given our research question and novel research approach. Furthermore, Reid-Cunningham (2009) explored the effect of maternal CSA history and maternal childhood rape on the parent–child relationship with an n of 40 and 11, respectively. Given a sizable body of research that supports a protective effect of caregiver–child sexual communication on youth sexual risk, in this article we assume such communication is a positive and protective feature for youth sexual development in South Africa. We are not alone in this assumption; Let’s Talk, an HIV prevention parenting program implemented at workplaces in South Africa (Bogart et al., 2013); loveLife, an HIV prevention initiative targeting young people in South Africa (loveLife, 2000a, 2000b; Wilbraham, 2009); and the larger study from which these data were drawn (Armistead et al., 2014) all recognize the potential of parent–child communication as a mechanism through which to reduce youths’ sexual risk. As a result, we did not determine if the sex-related communication that youth reported getting actually was protective. We recognize that not all caregiver–youth sex communication is protective. For example, fear-based messages delivered in a threatening context likely produce different outcomes from more didactic, educational conversation. Our inability to determine the tone of caregiver–youth sexual communication is a limitation of this study. Our results warrant further study of the relationship between CSA history and caregiver–youth communication about sex. Most needed is qualitative information about the nature of caregiver–youth sex communication to contextualize the results obtained from a single item assessing the occurrence of caregiver–youth communication about sex. Future research on this topic could employ multiple closed-ended items to measure the breadth or scope of sex communication but potentially more rich would be research using content analysis techniques to gain insight into the verbal and nonverbal aspects of caregiver–youth sex communication that are otherwise missed in survey research. We do not know if the caregivers and youth in our study who engaged in sex communication did so as a bidirectional discussion or a threatening monologue about the dangers of sex. Furthermore, longitudinal research is needed to identify mediating processes that may influence the relationship between CSA history and caregiver–youth sex communication as well as link sex communication to youth behavioral outcomes. Our findings demonstrate a potentially positive parenting practice among a group often characterized as deficient parents. As our focus was on caregiver–youth sex communication and not negative parenting practices, we cannot say that these behaviors were not also co-occurring with increased sex communication among our sample. However, as parenting is complex
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and likely characterized by strengths and weaknesses, we feel additional research with a larger sample of female caregivers with a CSA history is warranted, as any intervention programming designed to improve parenting practices among this population may perhaps more successfully alter maladaptive behavior by acknowledging and building on an existing strength. In addition, better understanding the motivations and processes involved in CSA survivors’ communication with their youth may hold benefit for all caregivers and parenting interventionists. If future research supports the finding we present in this brief report, incorporating this strengthsbased perspective into prevention programming may increase the efficacy of interventions among all caregivers, including those with and without a CSA trauma history. Last, given the prevalence of CSA as well as other forms of victimization and its documented effects on parenting, parenting interventions must be trauma-informed.
ACKNOWLEDGMENTS We wish to acknowledge Katherine Colmer, Georgia State University; Gillian Sibiya, Namafu Jayiya, and Annemie Stewart, Stellenbosch University; Ina Vermulen, Desiree Uys, Nolitha Lekoma, and Gertrude Gwenzi, Cape Town Child Welfare; Cat Rieper, Resources Aimed at the Prevention of Child Abuse and Neglect (RAPCAN); Fouzia Rykleft and Marjorie Feni, the Parent Centre; Ndileka Xameni, Anele Ghasana, and Siyabonga Mgwabala, Siyaphambili Orphan Village; Khulani Chiliza, “KC,” LoveLife; and Nomakhosi Magalakanqa, Mbulelo Mapele, and Nokwanda Matanda and the families from Langa who participated in the study for their contributions to this project.
FUNDING This study was funded by the Eunice K. Shriver National Institute of Child Health and Human Development (Grant 5R21HD058483).
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AUTHOR NOTES Elizabeth R. Anthony, PhD, is a senior research associate at the Center on Urban Poverty and Community Development, Jack, Joseph and Morton Mandel School of Applied Social Sciences, Case Western Reserve University. Her current research focuses on the evaluation of early childhood interventions for young children living in poverty. She received her PhD from Georgia State University in Community Psychology. Tracy N. Hipp, MA, is a doctoral candidate of community psychology at Georgia State University. Her current research focuses on the intersections of sexuality, human rights violations, and sexual assault. She received her MA from Georgia State University in Community Psychology. Doyanne A. Darnell, PhD, is a National Institutes of Mental Health T32 postdoctoral fellow with the Center for Healthcare Improvement for Addictions, Mental Illness, and Medically Vulnerable Populations (CHAMMP) at the University of Washington Department of Psychiatry and Behavioral Sciences. Her current research focuses on population-based approaches to screening and intervention with victims of rape trauma seeking acute care to address posttraumatic stress disorder and related comorbidities such as depression, suicidality, and risk behaviors (e.g., substance misuse, risky sexual behaviors). She received her PhD from Georgia State University in clinical and community psychology. Lisa Armistead, PhD, is professor and chair of the Department of Psychology at Georgia State University. Her research focuses on the intersection of HIV
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and families. She received her PhD in clinical psychology from the University of Georgia.
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Sarah L. Cook, PhD, is professor of psychology and associate dean of the Honors College. Her research focuses on how science conceptualizes and measures violence against women, ethical issues in researching it, how to prevent it, and how it intersects with other problems such as HIV/AIDS in South Africa. She received her PhD in community psychology from the University of Virginia. Donald Skinner, PhD, is the director of research on health and society at the Faculty of Medicine and Health Sciences, Stellenbosch University. He focuses on research looking at the social aspects of health with particular interests in HIV and AIDS and tuberculosis prevention and treatment, substance abuse, and violence. He has particular expertise in qualitative and community participatory research approaches.
