AIDS Care, 2014 Vol. 26, No. 7, 827–834, http://dx.doi.org/10.1080/09540121.2013.861571
Experiences of community and parental violence among HIV-positive young racial/ethnic minority men who have sex with men Gregory Phillips IIa*, Lisa B. Hightow-Weidmanb, Sheldon D. Fieldsc, Thomas P. Giordanod, Angulique Y. Outlawe, Bonnie Halpern-Felsherf and Amy R. Wohlg a
Department of Epidemiology and Biostatistics, The George Washington University School of Public Health and Health Services, Washington, DC, USA; bDivision of Infectious Diseases, University of North Carolina, Chapel Hill, NC, USA; cCollege of Nursing and Health Sciences, Florida International University, Miami, FL, USA; dBaylor College of Medicine and the Michael E. DeBakey VA Medical Center, Houston Health Services Research and Development (HSR&D) Center of Excellence, Houston, TX, USA; e Horizons Project, Wayne State University, Detroit, MI, USA; fDivision of Adolescent and Young Adult Medicine, University of California, San Francisco, CA, USA; gLos Angeles County Department of Public Health, HIV Epidemiology Program, Los Angeles, CA, USA (Received 8 March 2013; final version received 29 October 2013) Adolescents and young adults (ages 13–24) in the USA are frequently exposed to violence in their community and home. While studies have examined the prevalence and impact of violence exposure among adolescents, there is a lack of data focusing specifically on adolescent men of color who have sex with men. Eight demonstration sites funded through a Special Projects of National Significance (SPNS) Initiative recruited 363 HIV-positive racial/ethnic minority young men who have sex with men (YMSM) for a longitudinal study between 2006 and 2009. Over two-thirds of participants (83.8%) had witnessed community violence, 55.1% in the prior three months. Witnessing violence committed with a deadly weapon was significantly associated with being African-American, having ever used drugs, and drinking alcohol in the prior two weeks. Fear of violence in the community was significantly associated with depressive symptomatology, having less than a high school degree, not possessing health insurance, and site of enrollment. Having been emotionally or physically abused by a parent or caretaker was significantly associated with depressive symptomatology, attempting suicide, site of enrollment, and increased age. Witnessing violence with a deadly weapon was significantly associated with alcohol and drug use but not with high-risk sexual behaviors. As this was one of the first studies on the prevalence and correlates of violence exposure among racial/ethnic minority YMSM living with HIV, the findings can be used to inform the development of culturally appropriate resilience-focused interventions to address the aftereffects of violence exposures and help develop social support systems outside of the family. Keywords: violence; community violence; parental violence; HIV; MSM
Background Adolescents and young adults ages 13–24 (referred to in this manuscript as youth) in the USA are frequently exposed to violence in their community and home, with national studies indicating that more than one-third have witnessed violence in their community (Finkelhor, Turner, Ormrod, & Hamby, 2009; Zinzow et al., 2009). Exposure to community violence has been shown to be significantly higher among male, urban, low socioeconomic status, and minority youth than in the general population, with the prevalence ranging from 50% to 96% (McCart et al., 2007; Spriggs, Halpern, & Martin, 2009; Voisin et al., 2007). African-American and Hispanic youth were significantly more likely to have witnessed violence than their Caucasian counterparts (57.2% and 50.0%, respectively, vs. 34.3%) (Crouch, Hanson, Saunders, Kilpatrick, & Resnick, 2000). A national study of 4549 children under the age of 18
*Corresponding author. Email: [email protected] © 2013 Taylor & Francis
showed that 60.3% of males had experienced some form of physical assault in their lifetime and 4.1% were the victim of an attack based on their race/ethnicity or perceived sexual identity (Finkelhor et al., 2009). Youth exposure to violence is not limited to experiences in the community – it can include being the victim of a violent attack at the hands of parents, guardians, or relatives. Compared to Caucasian youth, African-American youth were significantly more likely to report physical abuse (15.4% vs. 7.9%), physical assault (24.2% vs. 15.5%), and sexual assault (13.1% vs. 6.7%) (Crouch et al., 2000). In a study of 526 young men who have sex with men (YMSM) aged 18–24, researchers found that 20% experienced physical violence in their home (Wong, Weiss, Ayala, & Kipke, 2010). Compared with heterosexual peers, gay/lesbian adolescents were 1.89 times as likely to experience physical abuse at the hands of a parent (Friedman et al., 2011).
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Youth who have not explicitly witnessed violence may still fear violence in their neighborhood. To date, most research has focused on the direct consequences of experiencing violence without accounting for the possible mediating factor of fear of violence. One study of youth aged 9–15 in Chicago found that fear of violence in one’s neighborhood was associated with negative selfperceptions, which can affect mental health (Dupere, Leventhal, & Vitaro, 2012). Exposure to community and/or family violence has been tied to a number of negative mental health outcomes in youth, such as depression (Buka, Stichick, Birdthistle, & Earls, 2001; Russell, Springer, & Greenfield, 2010) and post-traumatic stress disorder (PTSD). Violence exposure can lead to truancy and poor school performance (Mathews, Dempsey, & Overstreet, 2009), as well as to the perpetration of violence (Buka et al., 2001; Spriggs et al., 2009). Additionally, experience with violence has been shown to be associated with a number of HIV risk behaviors, including substance use (Brady, 2006; Buka et al., 2001; Melander & Tyler, 2010; Voisin et al., 2007) and engaging in high-risk sexual encounters (Brady, 2006; Melander & Tyler, 2010; Voisin, 2005; Voisin et al., 2007). Studies focusing on violence exposure among HIV-positive youth found an association between witnessing or experiencing violence and mental health disorders and substance abuse (Martinez, Hosek, & Carleton, 2009), and that HIVpositive adolescents who experienced physical abuse at home were 5.4 times more likely to have unstable housing (Eastwood & Birnbaum, 2007). Many studies have looked at the prevalence and impact of exposure to violence among youth, but few have focused specifically on YMSM of color. Most research on violence among YMSM has focused on childhood sexual abuse (Fields, Malebranche, & FeistPrice, 2008; Outlaw et al., 2011) and sexuality-based bullying (Hightow-Weidman et al., 2011). Therefore, we sought to characterize the experiences of community and parental violence among a multi-site cohort of HIVpositive racial/ethnic minority YMSM. We hypothesized that there would be a high prevalence of experiences with violence within this sample, and that these experiences would be associated with substance use, mental health disorders, and high-risk sexual behaviors.
Methods Participants A total of 363 participants were enrolled across eight demonstration sites (Bronx, NY; Chapel Hill, NC; Chicago, IL; Detroit, MI; Houston, TX; Los Angeles, CA; Oakland, CA; and Rochester, NY) funded by the Health Resources and Services Administration (HRSA)
HIV/AIDS Bureau’s (HAB) Special Projects of National Significance (SPNS) Initiative. The focus of the initiative was to provide outreach to HIV-positive racial/ethnic minority YMSM, and link them to and retain them in HIV-related care. Methods for this study have been described elsewhere (Hightow-Weidman et al., 2011; Magnus et al., 2010; Outlaw et al., 2011; Phillips et al., 2011). Eligibility criteria were: born male; HIV-positive and not currently in care; have sex with men or the intent to have sex with men; self-identify as non-White; be between the ages of 13 and 24 years at the time of first interview; and be willing and able to provide full written informed consent/assent and a release of information to obtain medical records.
Procedures Eligible participants were administered a standardized questionnaire by trained interviewers at each site at baseline and every three months thereafter for up to two years or until study closure, whichever occurred first. Data were collected between 1 June 2006 and 31 August 2009. Only baseline data were used for these analyses. All data were entered into a secure web-based data portal maintained by an evaluation center at The George Washington University (GWU). All instruments and protocols were approved by institutional review boards (IRBs) at each site and by the GWU IRB.
Measures Participants reported demographic characteristics such as age, race/ethnicity, sexual orientation, and education. Participants were asked if they had observed violence using the following questions: “Have you ever seen someone: (1) yelled at; (2) shoved, kicked, or punched; (3) attacked with a knife; (4) killed with a knife; (5) attacked with a gun; (6) killed with a gun?” If they answered “yes” to one of these questions, they were also asked if they had witnessed that form of violence in the last three months. For the purposes of this paper, having seen someone yelled at was not included in the composite measures of witnessing violence. Fear of violence was assessed by the question, “Are you afraid of violence in your neighborhood?” Parental violence was measured by the question: Parents use many different ways of trying to settle differences they may have between themselves and their children. We are interested in approaches your parent or primary caretaker might use with you. When your parent or primary caretaker has disagreements with you, do they ever: (1) hurt your feelings/emotionally abuse you; (2) kick, bite, or hit you with a fist; (3) beat you up; (4) burn or scald you; (5) threaten you with a knife; (6) threaten you with a gun; (7) touch you in a way that
AIDS Care made you uncomfortable; (8) threaten your life in some other way; (9) other?
Participants were able to choose one or all the options from this list that applied to their situation. If they responded “yes” to any of the options, they were asked, “Did you ever have cuts, burns, or any broken bones as a result of those incidents?” Depressive symptomatology was measured using the Center for Epidemiologic Studies Depression Scale (CES-D), a self-report scale consisting of 20 items, each of which was rated based on a four-point scale (Radloff, 1977). CES-D scores range from 0 to 60, with a score of 16 or greater considered indicative of significant depression. Measures to assess high-risk sexual behavior, substance/alcohol use, and suicidal thoughts/attempts have been previously presented (Hightow-Weidman et al., 2011; Outlaw et al., 2011; Phillips et al., 2011). Statistical analysis Univariate analyses were conducted on all violence variables. In order to characterize correlates of violence experiences, bivariable analyses were conducted for (1) witnessing a crime committed with a knife or a gun, (2) seeing someone be killed with a knife or a gun, (3) experiencing parental violence, and (4) fear of violence in the neighborhood. Significant associations were assessed using χ2 tests for categorical variables and t-tests for continuous variables, both at α = 0.05; additionally, unadjusted odds ratios (ORs) and 95% confidence intervals (CIs) were generated for all categorical variables. Four multivariable logistic regression models were created to look at the four outcomes of interest. Variables associated with the outcome with p-value
Experiences of community and parental violence among HIV-positive young racial/ethnic minority men who have sex with men Gregory Phillips IIa*, Lisa B. Hightow-Weidmanb, Sheldon D. Fieldsc, Thomas P. Giordanod, Angulique Y. Outlawe, Bonnie Halpern-Felsherf and Amy R. Wohlg a
Department of Epidemiology and Biostatistics, The George Washington University School of Public Health and Health Services, Washington, DC, USA; bDivision of Infectious Diseases, University of North Carolina, Chapel Hill, NC, USA; cCollege of Nursing and Health Sciences, Florida International University, Miami, FL, USA; dBaylor College of Medicine and the Michael E. DeBakey VA Medical Center, Houston Health Services Research and Development (HSR&D) Center of Excellence, Houston, TX, USA; e Horizons Project, Wayne State University, Detroit, MI, USA; fDivision of Adolescent and Young Adult Medicine, University of California, San Francisco, CA, USA; gLos Angeles County Department of Public Health, HIV Epidemiology Program, Los Angeles, CA, USA (Received 8 March 2013; final version received 29 October 2013) Adolescents and young adults (ages 13–24) in the USA are frequently exposed to violence in their community and home. While studies have examined the prevalence and impact of violence exposure among adolescents, there is a lack of data focusing specifically on adolescent men of color who have sex with men. Eight demonstration sites funded through a Special Projects of National Significance (SPNS) Initiative recruited 363 HIV-positive racial/ethnic minority young men who have sex with men (YMSM) for a longitudinal study between 2006 and 2009. Over two-thirds of participants (83.8%) had witnessed community violence, 55.1% in the prior three months. Witnessing violence committed with a deadly weapon was significantly associated with being African-American, having ever used drugs, and drinking alcohol in the prior two weeks. Fear of violence in the community was significantly associated with depressive symptomatology, having less than a high school degree, not possessing health insurance, and site of enrollment. Having been emotionally or physically abused by a parent or caretaker was significantly associated with depressive symptomatology, attempting suicide, site of enrollment, and increased age. Witnessing violence with a deadly weapon was significantly associated with alcohol and drug use but not with high-risk sexual behaviors. As this was one of the first studies on the prevalence and correlates of violence exposure among racial/ethnic minority YMSM living with HIV, the findings can be used to inform the development of culturally appropriate resilience-focused interventions to address the aftereffects of violence exposures and help develop social support systems outside of the family. Keywords: violence; community violence; parental violence; HIV; MSM
Background Adolescents and young adults ages 13–24 (referred to in this manuscript as youth) in the USA are frequently exposed to violence in their community and home, with national studies indicating that more than one-third have witnessed violence in their community (Finkelhor, Turner, Ormrod, & Hamby, 2009; Zinzow et al., 2009). Exposure to community violence has been shown to be significantly higher among male, urban, low socioeconomic status, and minority youth than in the general population, with the prevalence ranging from 50% to 96% (McCart et al., 2007; Spriggs, Halpern, & Martin, 2009; Voisin et al., 2007). African-American and Hispanic youth were significantly more likely to have witnessed violence than their Caucasian counterparts (57.2% and 50.0%, respectively, vs. 34.3%) (Crouch, Hanson, Saunders, Kilpatrick, & Resnick, 2000). A national study of 4549 children under the age of 18
*Corresponding author. Email: [email protected] © 2013 Taylor & Francis
showed that 60.3% of males had experienced some form of physical assault in their lifetime and 4.1% were the victim of an attack based on their race/ethnicity or perceived sexual identity (Finkelhor et al., 2009). Youth exposure to violence is not limited to experiences in the community – it can include being the victim of a violent attack at the hands of parents, guardians, or relatives. Compared to Caucasian youth, African-American youth were significantly more likely to report physical abuse (15.4% vs. 7.9%), physical assault (24.2% vs. 15.5%), and sexual assault (13.1% vs. 6.7%) (Crouch et al., 2000). In a study of 526 young men who have sex with men (YMSM) aged 18–24, researchers found that 20% experienced physical violence in their home (Wong, Weiss, Ayala, & Kipke, 2010). Compared with heterosexual peers, gay/lesbian adolescents were 1.89 times as likely to experience physical abuse at the hands of a parent (Friedman et al., 2011).
828
G. Phillips II et al.
Youth who have not explicitly witnessed violence may still fear violence in their neighborhood. To date, most research has focused on the direct consequences of experiencing violence without accounting for the possible mediating factor of fear of violence. One study of youth aged 9–15 in Chicago found that fear of violence in one’s neighborhood was associated with negative selfperceptions, which can affect mental health (Dupere, Leventhal, & Vitaro, 2012). Exposure to community and/or family violence has been tied to a number of negative mental health outcomes in youth, such as depression (Buka, Stichick, Birdthistle, & Earls, 2001; Russell, Springer, & Greenfield, 2010) and post-traumatic stress disorder (PTSD). Violence exposure can lead to truancy and poor school performance (Mathews, Dempsey, & Overstreet, 2009), as well as to the perpetration of violence (Buka et al., 2001; Spriggs et al., 2009). Additionally, experience with violence has been shown to be associated with a number of HIV risk behaviors, including substance use (Brady, 2006; Buka et al., 2001; Melander & Tyler, 2010; Voisin et al., 2007) and engaging in high-risk sexual encounters (Brady, 2006; Melander & Tyler, 2010; Voisin, 2005; Voisin et al., 2007). Studies focusing on violence exposure among HIV-positive youth found an association between witnessing or experiencing violence and mental health disorders and substance abuse (Martinez, Hosek, & Carleton, 2009), and that HIVpositive adolescents who experienced physical abuse at home were 5.4 times more likely to have unstable housing (Eastwood & Birnbaum, 2007). Many studies have looked at the prevalence and impact of exposure to violence among youth, but few have focused specifically on YMSM of color. Most research on violence among YMSM has focused on childhood sexual abuse (Fields, Malebranche, & FeistPrice, 2008; Outlaw et al., 2011) and sexuality-based bullying (Hightow-Weidman et al., 2011). Therefore, we sought to characterize the experiences of community and parental violence among a multi-site cohort of HIVpositive racial/ethnic minority YMSM. We hypothesized that there would be a high prevalence of experiences with violence within this sample, and that these experiences would be associated with substance use, mental health disorders, and high-risk sexual behaviors.
Methods Participants A total of 363 participants were enrolled across eight demonstration sites (Bronx, NY; Chapel Hill, NC; Chicago, IL; Detroit, MI; Houston, TX; Los Angeles, CA; Oakland, CA; and Rochester, NY) funded by the Health Resources and Services Administration (HRSA)
HIV/AIDS Bureau’s (HAB) Special Projects of National Significance (SPNS) Initiative. The focus of the initiative was to provide outreach to HIV-positive racial/ethnic minority YMSM, and link them to and retain them in HIV-related care. Methods for this study have been described elsewhere (Hightow-Weidman et al., 2011; Magnus et al., 2010; Outlaw et al., 2011; Phillips et al., 2011). Eligibility criteria were: born male; HIV-positive and not currently in care; have sex with men or the intent to have sex with men; self-identify as non-White; be between the ages of 13 and 24 years at the time of first interview; and be willing and able to provide full written informed consent/assent and a release of information to obtain medical records.
Procedures Eligible participants were administered a standardized questionnaire by trained interviewers at each site at baseline and every three months thereafter for up to two years or until study closure, whichever occurred first. Data were collected between 1 June 2006 and 31 August 2009. Only baseline data were used for these analyses. All data were entered into a secure web-based data portal maintained by an evaluation center at The George Washington University (GWU). All instruments and protocols were approved by institutional review boards (IRBs) at each site and by the GWU IRB.
Measures Participants reported demographic characteristics such as age, race/ethnicity, sexual orientation, and education. Participants were asked if they had observed violence using the following questions: “Have you ever seen someone: (1) yelled at; (2) shoved, kicked, or punched; (3) attacked with a knife; (4) killed with a knife; (5) attacked with a gun; (6) killed with a gun?” If they answered “yes” to one of these questions, they were also asked if they had witnessed that form of violence in the last three months. For the purposes of this paper, having seen someone yelled at was not included in the composite measures of witnessing violence. Fear of violence was assessed by the question, “Are you afraid of violence in your neighborhood?” Parental violence was measured by the question: Parents use many different ways of trying to settle differences they may have between themselves and their children. We are interested in approaches your parent or primary caretaker might use with you. When your parent or primary caretaker has disagreements with you, do they ever: (1) hurt your feelings/emotionally abuse you; (2) kick, bite, or hit you with a fist; (3) beat you up; (4) burn or scald you; (5) threaten you with a knife; (6) threaten you with a gun; (7) touch you in a way that
AIDS Care made you uncomfortable; (8) threaten your life in some other way; (9) other?
Participants were able to choose one or all the options from this list that applied to their situation. If they responded “yes” to any of the options, they were asked, “Did you ever have cuts, burns, or any broken bones as a result of those incidents?” Depressive symptomatology was measured using the Center for Epidemiologic Studies Depression Scale (CES-D), a self-report scale consisting of 20 items, each of which was rated based on a four-point scale (Radloff, 1977). CES-D scores range from 0 to 60, with a score of 16 or greater considered indicative of significant depression. Measures to assess high-risk sexual behavior, substance/alcohol use, and suicidal thoughts/attempts have been previously presented (Hightow-Weidman et al., 2011; Outlaw et al., 2011; Phillips et al., 2011). Statistical analysis Univariate analyses were conducted on all violence variables. In order to characterize correlates of violence experiences, bivariable analyses were conducted for (1) witnessing a crime committed with a knife or a gun, (2) seeing someone be killed with a knife or a gun, (3) experiencing parental violence, and (4) fear of violence in the neighborhood. Significant associations were assessed using χ2 tests for categorical variables and t-tests for continuous variables, both at α = 0.05; additionally, unadjusted odds ratios (ORs) and 95% confidence intervals (CIs) were generated for all categorical variables. Four multivariable logistic regression models were created to look at the four outcomes of interest. Variables associated with the outcome with p-value
