Category Archives: Mental Health

Retraumatization: The Increased Risk of HIV Transmission among Abuse and Assault Victims

While the transmission of HIV and the causes of HIV-related death are actually more complicated—and even more nuanced—than public discussion would let on, a few presumptions about it remain fairly accurate.

For women who are marginalized in their communities, who are victims of abuse or assault, and who are economically or socially dependent on a spouse, the risk of them contracting HIV or dying from multiple complications from AIDS is simply greater than that of women fortunate enough to not be subjected to these circumstances. Take these scenarios:

  • The power dynamic in an abusive relationship may prohibit women from being able to protect herself from a partner who refuses to wear a condom
  • Women in poverty and those who need to rely on a partner for financial support may have greater risk of comorbid infections than women of economic independence. They are less likely to have the health insurance and relationship with a healthcare provider that would support HIV testing and provide the essential—and expensive—HIV medications to ensure a healthy life and lower the risk of co-morbid infections
  • People without social support, living in fear of what an HIV-positive diagnosis means, or those who have reason to fear stigma around personal behavior when seeking treatment are less likely to know where to access treatment or seek it out because of that fear, stigma and lack of support

Common sense would seem to support these statements. But until recently, the pathways of infection were not always clear, and while the conclusions above seemed certainly reasonable, specific data to support them had been difficult to collect. Two recent studies led by a UCSF-researcher have changed that. One synthesized what is known about PTSD and exposure to trauma among HIV-positive women, and the other explored the root of this relationship.

The results were remarkable. HIV-positive women had between two and six times the rates of childhood and adult physical and sexual abuse, and PTSD. The snapshot of risk behaviors among HIV-positive women was sobering:

  Sample size Number (%) of participants with each characteristic
Sexual activity
Any sexual activity in the past 6 months 113 61 (54.0%)
 With a main partnerMedian number of main partners (if any) 61 43 (70.5%)1 (range 1–2)
 With casual partnersMedian number of casual partners (if any)a 61 23 (37.7%)1 (range 1–25)
Sex with any HIV negative or unknown serostatus partners (if sexually active) in the last 6 months 61 51 (83.6%)
 Disclosure of HIV status less than all of the time with these partners 51 29 (56.9%)
 Using condoms less than all of the time with these partners 51 31 (60.8%)
 Detectable viral load 51 30 (58.8%)
 Disclosure of HIV status less than all of the time, and using condoms less than all of the time, and a detectable viral load 51 16 (31.4%)
Substance use (any, recent)
Cigarettes 110 71 (64.5%)
Alcohol 111 50 (45.0%)
Marijuana 111 39 (35.1%)
Crack/cocaine, heroin, and/or methamphetamines 111 45 (40.5%)
IDUb 112 11 (9.8%)
 IDU who share needles 11 5 (45.5%)
 IDU who have a detectable viral load 11 6 (54.5%)

aOne participant had a very high number of sexual partners (N = 250) and was excluded from the analysis; b IDU injection drug use; ©2012 Machtinger, et al. (retrieved December 16, 2012.)

There were striking findings in terms of both HIV treatment failure and the impact of the above risk behavior in these women, bringing us the first real data hoping to explain this relationship. Those who suffered from recent trauma had more than four times the odds of anti-retroviral (ART) failure while on treatment than HIV-positive non-victims—and this was seemingly not due to self-reported poor adherence to the medication. One potential explanation offered by the study authors is that abuse and trauma interfere with an individual’s ability to stay on a consistent medication schedule, which is essential for control of the virus. Other studies have confirmed that abuse manifest as control, in which a male partner prevents his HIV-positive female partner from accessing services at a clinic out of fear that the stigma of HIV would be attached to him.

HIV-positive victims of recent trauma also all reported experiencing what the study calls “coerced sex,” and have over three times the odds of un-traumatized women of having sex with HIV-negative or status-unknown individuals. They had greater than four times the odds of inconsistent condom use, potentially exposing those casual partners to the virus. While high-risk sex behavior is always a factor in HIV-transmission, HIV-positive individuals who adhere consistently to HIV treatments are significantly less likely to infect HIV-negative partners during sex. So the lack of treatment adherence among traumatized HIV-positive women combined with the risky sex behavior is a great concern.

Interestingly, these figures were only significant among women who experienced recent trauma, indicating that the ongoing—not merely one occurrence—circumstances of abuse are the key to the relationship between HIV-infection and HIV-related illness and death. This can actually be seen as a snapshot of hope—if we are able to offer abuse, assault, and PTSD victims the appropriate support to heal from the experiences, we may be able to weaken the HIV/trauma relationship.

These studies draw a clear line between victims of assault and trauma and both the spread of HIV within their communities and the increased risk of HIV-related illness and death. But interestingly, the risk goes much deeper than these socioeconomic circumstances. The conversation around HIV transmission is generally split into one of two categories: social and behavioral—risky activity, injection drug use, the prejudicial judgment of sex workers; and medical and clinical—how the virus infiltrates the immune system, takes over cells, and how it is and isn’t suppressed with antiretroviral medications. What isn’t usually discussed is the possible combination of these two categories and how together they create a perfect storm for potential infection.

Recent studies have shown that those individuals suffering from PTSD had significantly higher rates of cytomegalovirus (CMV) in their body. A virus that is found in between 50%-80% of adults in the United States, CMV remains largely undetected—latent, suppressed, unproblematic—in healthy individuals. It’s also seen as a marker of immune health and function, and of the body’s ability to control potential infections. Given that 30% of American women with HIV/AIDS have PTSD (five times the national average), the potential relationship between their HIV-status and even further compromised immune function could lead to a myriad of comorbid infections and premature death. Other research has also shown that additional biological mechanisms may prevent ART-treatment from being as effective as possible, including high cortisol (stress hormone) levels. Not only do these victims have to fight against abuse and assault, they have been left without the essential social support to decrease risky behaviors that may expose others to the virus, and their own bodies are in revolt.

Collecting this kind of information is difficult. It requires consistent and positive communication between women and providers, unobstructed access to medical care and uninterrupted ART treatment, and of course, in this example, most importantly—removal from an abusive environment.

The combination of immunosuppression due to PTSD, the detectable rates of HIV in traumatized women whose viral loads are not suppressed by consistent anti-retroviral treatments, and the concurrent risk behaviors of abused HIV-positive women, all contribute to higher rates of HIV-infection in communities, as well as the potential for co-morbid infections and HIV-related death. Until these women are able to find the essential social and community support, free from abuse and trauma, and until their access to care and preventative measures are fully realized, the relationship between trauma and HIV will only deepen.

Leave a comment

Filed under Epidemiology and Population Health, Feminism, Health Behavior, Mental Health, Public Health, Rape and Sexual Assault, Reproductive and Sexual Health, Violence Against Women, Women's Health

Juvenile Detention Centers Miss Key Health Indicators for Girls

I listened to a great NPR report this afternoon by Jenny Gold about juvenile detention centers and how they’re missing some key indicators of the health status of girls that enter into the system. As someone specializing in adolescent girls’ health, I was pretty fascinated – it detailed the personal experiences of a few girls being seen in a New Mexico facility and also tried to address ways it could be rectified. Detention centers can actually be helpful entry points for girls and young women to be connected to healthcare resources (we’re talking mental and physical health, so everything from counseling to substance abuse help to medical attention if they are victims of assault or violence or have seen physicians only irregularly).

One of the biggest issues facing these girls was confidential disclosure of their health status and any social, emotional, and physical issues they were facing. Developing rapport with a provider at a detention facility can be difficult in and of itself, but the girls reported having to answer personal questions in an open-door location, often with men and boys – staff or other teens – present; unsurprisingly, this made it difficult for many girls to feel that they could answer questions of a personal nature (sexual behavior, drug and alcohol use, history of assault, abuse or violence) honestly and openly. What we do know about these girls – 41% have vaginal injury consistent with sexual assault, 8% have positive skin tests for tuberculosis, and 30% need glasses but don’t have them – shows that getting all of this information early on is essential for appropriate and timely care.

One proposed solution to this – getting as much information as possible from these girls about their health status and the best ways to then help them, treat them, and connect them with resources – was to have them fill out a survey themselves. Currently, girls are asked 35 questions by an intake nurse when they arrive, that cover things like current medications, alcohol or drug use in the last 24 hours, and whether they have a history of self-destructive behavior. The proposed survey in the New Mexico facility is 132 questions, and according to one facility employee the time that would take is just not feasible given the traffic and business of the facility. Researchers and providers implemented a pilot study of the survey for 30 girls at the detention facility.

Of course, I can’t comment on the actual level of frantic activity in the specific facility at hand, but I can say that having a questionnaire that catches health issues which can be immediately and effectively addressed can prevent a host of issues from getting worse as time goes on without treatment – potential injuries from abuse or assault, needing STI screenings for victims of rape or girls who are sexually active without access to contraceptives or regular gynecological care, and of course mental health resources and immediate connection with social workers or therapists for those girls in need. Either having the girls fill out the survey via computer themselves or having a nurse help them would also be enormously helpful in the long run. This can also be a great way to track the care progress of these girls over the years, as many go in and out of detention centers. For girls who have experienced assault or abuse or multiple infections and injuries, this can be an easy way to follow-up with them without having to go through essentially baseline assessments of their well-being every time they enter a facility.

Some of the sobering stats about the girls from this particular New Mexico facility from this report: Of the 30 girls who participated in the piloting of implementing this survey, 12 needed immediate medical care, and 23 were coded as needing medical care within 24 hours, based on the survey’s questions. Intakes without this survey missed essential things, like burns on one girl’s torso and chest.

Check out the whole report here. I have no doubt that detention centers are in dire need of additional resources and likely way more staff than they have, for more than just this particular issue of adolescent girls’ health, but if the issue is there being one nurse for multiple intakes, having the girls fill out the survey on a computer themselves – when they’re more likely to be honest than in discussion with a nurse anyway, seems like the best solution to these kind of initial entry screenings. Especially since poor physical health is an indicator of recidivism, increasing the likelihood of girls ending up back in a facility.

Leave a comment

Filed under Child Development and Child Health, Health Behavior, Health Education, Mental Health, Women's Health

How Images and Ads Impact Self-Image and Human Development

I got a lot of traffic and messages about my recent post regarding Duke Nukem. People in the gaming community condemned it for its lack of originality, how it strayed from the original premise of apparently ostensibly mocking the ’80s action-hero genre, and how it overall disappointed those who are used to more complex and engaging videos. Some replies also included people needing to “get over it” when discussing images of coerced sexual activity or the game’s encouragement of merging violent and sexually explicit content together (I don’t post comments that are condescending or don’t encourage dialogue), something I found…disturbing. My initial argument, however, did not change – that is, that the imagery and the actions the gamer supposes in this video are tragically abusive and in fact detrimental to both men and women.

Many gamers also respond that they know when they are playing a game, and that their non-virtual socializing is not impacted by the game’s content. This, along with the recent news that the American Medical Association finally condemned the use of photoshopping in advertising campaigns and photo shoots, got me thinking about what repeated exposure to images and actions actually does to our brain and with who and what we identify.

A well-known study published in the Journal of Consumer Research found that repeated exposure to images and advertisements ultimately were processed in people the same way actual experiences were processed. That is, if you see or watch something enough times – in a video game, in a fashion magazine in which models are photoshopped to near obscurity, in a parent abusing your sibling – you begin to process it as though it was you yourself experiencing the act and identify with the “player” (model, game character) you are watching. You see enough pictures of a model like this:

Courtesy fashion-o-lic.com

And you begin to think you are supposed to align yourself with her, that this image is what is normal (the image on the right was criticized heavily in 2009 for being so drastically photoshopped). After so many exposures, you begin to mold yourself after her, to think that since this is how we project women for adoration in our culture, that you should begin appropriating yourself to match her image. Just like a gamer, after so many exposures, can begin to mold themselves after the image of the character they are impersonating in a game. And while they may not go out on a shooting spree, they are desensitized to the effects of that reality, just as they are desensitized to the effects of coerced sex in a game, which can lead to difficulty distinguishing that from a healthy sexual relationship.

As I have also discussed in previous posts, a foundational theory in behavioral science and education is the Social-Cognitive Theory, which has informed educators and psychologists for years in explaining that people learn by watching, and that even one observation of a behavior can influence perspective. It also importantly points out that while full on adoption of behaviors witnessed may not occur, the more we see, the more our attitudes and beliefs about them change. This can be good and bad. It can make us more accepting of others’ opinions and outlooks, and it can also desensitize and normalize the opinions and behaviors that are harmful.

We’re humans. We learn by watching, by then mimicking and imitating what we observe. It doesn’t happen all at once, which is why fashion moguls or game designers claim they have no real impact. Are girls entering periods of self-mandated starving as soon as they open this month’s Vogue? Are adolescent boys heading to the hills for a sawed off shotgun fight after the first round of Duke or stealing cars after playing the new Grand Theft Auto? No, of course not. But can it impact their sense of compassion, affect their interpersonal relationships? Can it make violence seem less threatening, less damaging, and less impacting than it is? Yes. Can that change the way people behave, from nuance to imitation? Sure. Even researchers who admit that it won’t necessarily turn children violent admit that’s likely true (and, interestingly, still disallow their children to play). Human development takes time – language acquisition, understanding of and the processing of visual messages, being able to comprehend meaning from a block of text – these are all cognitive functions that take years to develop and perfect, and their influence lies in the words and actions of children’s families, friends, teachers. Unfortunately, messages of gender have been largely commandeered by the media. And the repeated exposure, over years, to these specifics of models’ physical appearance has resulted in the erosion of self-confidence that many girls and women – and boys and men – experience as young children becoming adolescents. And the repeated exposure, over years, to the specifics of war, sexual violence, and the presentation of hyper-masculinity, can also result in the erosion of what kind of impact violence truly has, as they become desensitized, and what a healthy understanding of and relationship with the opposite sex is (as opposed to its portrayal in my Duke Nukem piece). As the study articulated, it’s about changing people over time, it’s about how perceptions and perspectives change when a new definition of the norm that is not contested or dissected – a Ralph Lauren model, a Duke Nukem – enters the picture. Women who suffer from eating disorders and body dysmorphia, while not blaming the fashion industry, have emphatically articulated that it certainly has had an impact as it normalized this destructive self-image and behavior.

I think it’s also relevant here to bring up the Supreme Court’s decision about a week ago to shoot down California’s attempt to ban the sale of violent video games to children. Timothy Egan, a Times columnist, had a great commentary on this, noting how ridiculous it seems for there to be a perpetual ban on nudity and sexually explicit images, but not on virtually dismembering a human or sexually assaulting a woman. It does seem…well, more than troubling, that a game in which a player can simulate murder and rape is protected by free speech but a bare breast is the height of vulgarity. (I found a great post from a female gamer about this kind of sexual violence in video games, and I agree with her assertion that sexual expression can in fact exist without it also involving violence and degradation.) I don’t think any of the representations of sexuality that I have seen in video games are appropriate for children because they overwhelmingly associate it with abuse and/or coercion (I’ve done a lot of viewing in the past couple days after my Duke Nukem post). To say that sexuality would have a more harmful impact than violence seems questionable, when representations of both are equally unhealthy.

It should also be said that I am far from someone who believes nudity and sexuality itself is vulgar. I celebrate and support healthy (and protected!) sexual expression in any way the individual consents and desires. I firmly believe that discussions of sex and sexuality should be brought up early on, so children can ask questions, be informed, protect themselves when they do engage in sex, and have an understanding of what a respectful, consensual sexual relationship is. I also believe that when these discussions in families don’t take place, and when sex is a taboo topic, that it is a disservice to these children, and that any confusion they have about sex or uncertainty about what a healthy sex life actually is will be magnified by the messages the media sends them.  I’m an advocate of early onset, comprehensive sexual health and reproductive health education. Sex shouldn’t be confusing, and it shouldn’t be stigmatized. Sexual violence, however, and a misappropriation of the presentation of sexual relationships that are abusive, coercive, and violent, should be condemned.

This is also why a diversity of exposures is important. It’s important to not be inundated with the same message over and over again. Advertisers know that repeated exposure is key to getting people to buy what they want to sell. If you see an image of a Coke bottle once, it won’t register with much impact. If you see it every time your favorite TV show breaks for commercial, when you’re leafing through the pages of a magazine, when you’re driving down a freeway and it’s up on a billboard, when you’re listening to the radio and it breaks for the Coke jingle – it adds up, as do afternoons in front of a game console, as do hours reading “women’s” magazines and fashion spreads, as do episodes of spousal or child abuse, (which we know increases the likelihood of the child being in an abusive relationship him/herself and hampers healthy development – the others are logical extensions, to a lesser degree). We have to have enough positive images, positive games, positive and healthy discourse about relationships to not just equal the stream of negative imagery and messaging, but to overtake it. Positive, healthy messages, not abusive, harmful, violent messages, have to be in the majority. The norm. It’s nice that the docs finally said so.

3 Comments

Filed under Advertising, Child Development and Child Health, Defining Gender, Feminism, Gender Stereotyping, Media, Mental Health, Pop Culture, Public Health, Sexism, Violence

Abortion Isn’t That Simple, Mr. Douthat

Ross Douthat, one of the NY Times conservative columnists whose pieces I occasionally force myself to read, wrote an article yesterday about sex-selective abortion. In short, he claimed that the reason 160 million women were “missing” (that is, the reason they were so outnumbered in many countries like India and China, as well as other nations in the Balkans and Central Asia) was because they were “killed” via sex-selective abortion. In his words, the women weren’t “missing,” they were “dead.” (He also claims that the author of the book he cites, Mara Hvistendahl of the book “Unnatural Selection: Choosing Boys Over Girls, and the Consequences of a World Full of Men,” appropriates the issue to one of patriarchy, of greater social issues and inequities – which I agree with. He then says that “the sense of outrage that pervades her story seems to have been inspired by the missing girls themselves, not the consequences of their absence,” saying that she is more upset by the idea of abortion itself than she is about the issues surrounding abortion. Don’t you think that’s for her to decide? And doesn’t it seem she’s already decided what she thinks based on her book?)

Douthat, however, manages to contradict the crux of his argument near the start of his column.

He begins by saying “female empowerment often seems to have led to more sex selection, not less.” He then quotes Hvistendahl as saying “women use their increased autonomy to select for sons,” because male offspring bring higher social status. In countries like India, sex selection began in “the urban, well-educated stratum of society,” before spreading down the income ladder.

If this were the case – if in fact women had become truly empowered in their respective lands – culturally, politically, economically – then why would they be aborting based on the opposite – that men in their communities are still holding the cards? Are they imagining that men still hold positions of power and wealth in their countries, or are they living the ramifications of that painful reality everyday? Women do have some increased autonomy in many of these regions. But guess what? This autonomy has likely served to highlight the still very real inequities and disparities that exist in their communities, which contributes to the rates of sex-selective abortion. If women see which sex has the higher status, and one of the few autonomous decisions they can make is to choose the sex of their baby – they are likely going to choose the one with more status. This upsetting power dynamic shows just how far away true empowerment is for many of these women and their communities. If they felt their children would have the same opportunities if they were female than if they were male, the sex selection abortion Douthat decries would actually decrease. It is not the responsibility of the female fetus to ensure she is treated with the same respect and equality as the male fetus. Douthat seems to really care about female fetuses – but seems less interested in addressing the massive social, political, and economic issues that create so many difficulties for them once born. (His colleagues Paul Krugman and Nick Kristof seem to have handles on that. Too bad they were off yesterday.)

It seems that Douthat wants to push for the feelings of regret and remorse about abortion itself, separate from the issues surrounding it. Does sex-selection abortion sadden me? Yes. Does aborting a fetus that indicates it will have Down Syndrome sadden me? Yes. You know what else makes me sad? That a woman cannot afford a baby because she is single and has no familial or community support; because she has an abusive partner (homicide is the number one cause of death for pregnant women); because she has a low-wage hourly job that offers no maternity leave which could help her stay well while carrying the baby if needed; because she has no health insurance meaning she can’t access quality pre-natal care to make sure her baby would be healthy since we are systematically closing down those facilities that offer services for women who are uninsured (and also help provide birth control to prevent pregnancy!); because she has no way to pay for day care and she may have to quit her low-wage job to care for her baby; because she would then have no money for all the supplies, food, and developmental tools her baby would need to thrive which can lead to malnutrition, behavioral problems, child depression; because she could then become part of the 29.9% of families in poverty that are headed by single women, and her child could become part of the 35% of those in poverty who are under 18 years of age – the poverty rate for households headed by single women is significantly higher than the overall poverty rate.

We’ve cut child welfare services that aid women by the tens of millions in the past few years. Georgia alone cut over $10 million in Child Welfare Services. We’ve also cut subsidies that support adoption agencies – the organizations that help women find families that may be able to care for her baby were she to carry it to term – and who make sure these families are actually fit to do so! TANF (Temporary Assistance for Needy Families) provides women and families with aid so that children can be raised in their own homes or with relatives, instead of being placed in foster care and becoming wards of the state. How much have we cut from TANF? 17 of the poorest states, with some of the highest poverty rates in the nation, have already stopped receiving funds.

Birth control, one might say? Sure – birth control is expensive, so if she doesn’t have health insurance, she isn’t likely to be able to afford birth control (hey, Planned Parenthood can help with that, too! Seeing a pattern?) And if her partner refuses to wear a condom? If she is in an abusive relationship, if she fears leaving her partner, if she relies on her partner for added economic security – she’s much less likely to argue with him about the condom use. Or even feel that she has the agency to begin a negotiation discussion at all.

These facts make me sad. And all of these facts might lead a woman to decide she can’t have a baby. And many things not listed here may lead a woman to decide that she will not have a baby. And that she will have an abortion. Is it my decision? No. It’s not. It’s not yours or Ross Douthat’s, either. Again, Douthat represents the contingent of pro-lifers who want to make it seem like pro-choicers are cheering the performing of abortions right and left. What we are cheering is the right for women and respect of women to make their own decision based on their very specific personal circumstances. And given the fact that the medical establishment has not agreed with the pro-life camp in claiming that fetuses before a month into the third trimester can feel pain (reacting to stimuli does not equal pain, to reiterate, and pain without a cerebral cortex is seen by physicians as not possible), which has most recently become the pro-life camp’s wildly off-base rationale for preventing a woman’s right to choose, and given the fetus’ place of residence in the woman’s uterus as a part of her body, not as a human, these issues that Douthat sees as “sideline” are actually very much at the center of the argument. Bottom line – it’s the woman’s body. It’s the woman’s choice. She will be the one carrying it, she will be the one birthing it. No one else. So why should anyone else decide?

Additionally, it is not a crime for a woman to not want children. Since she is able to give birth, it is her decision as to when and how that will happen. Everything about her life and future will change once she has a baby. So she needs to be sure she is ready for that. How can one disagree with that? Douthat may not like it, but “the sense of outrage that pervades his story” (see what I did there?😉 ) seems to me more rooted in his anger and frustration with his opinion not being considered by women in these decisions and not being able to control what a woman decides to do about what is going on in her body.

All of the things I listed – the job issues, the healthcare issues, the family and community issues, the issues that arise when a child doesn’t have access to food, clothing, and developmentally appropriate stimulation – are the causes. So why don’t we start figuring out how we can mitigate those facts and issues instead of attacking the effect – the abortion – which is a decision women come to after weighing all of those facts and issues just discussed. Douthat’s fear tactics of talking about female fetuses strewn across Indian hospitals is scary imagery. So is this:

Photo thanks to ehow.com

And this:

Photo via Captain Hope's Kids Blog

And this:

Photo property of streetkidnews.blogsome.com

Want less abortions? How about providing health insurance, that covers both birth control and pre-post natal care? How about equal pay for equal work, so women are more financially and economically secure, providing them with the resources to stay out of poverty and keep their children out of it, too? How about child care in work environments, helping women who cannot afford day care can stay in their jobs and remain a part of the economy? While we’re at it, how about great public schools and clean community centers, so women know their children are being intellectually fed and socially stimulated in safe environments that help keep them out of more dangerous and potentially life-threatening social circles? How about comprehensive sex education so men and women know how to protect themselves not only from pregnancies but from diseases that can endanger a fetus and create complications during birth and cause health issues for them and their children – creating more expense, particularly if one has no health insurance.

Let’s talk then. And how about you follow me on Twitter?

7 Comments

Filed under Child Development and Child Health, Education, Feminism, Health Education, Mental Health, Politics, Women's Health