Qualitative Assessment of the Cognitive Qualitative Assessment of the Cognitive Difference Among Abused and Difference Among Abused and

Nonabused Minority Women with STD: Nonabused Minority Women with STD: Implications for Behavioral InterventionsImplications for Behavioral Interventions

JD ChampionJD Champion, A Longoria, D Reid , A Longoria, D Reid RN Shain, JM Piper, S Perdue RN Shain, JM Piper, S Perdue

The University of Texas Health Science Center The University of Texas Health Science Center San Antonio, TXSan Antonio, TX

BackgroundBackground

Research has identified the need for Research has identified the need for modification of standardized STD behavioral modification of standardized STD behavioral interventions for minority women with a interventions for minority women with a history of sexual or physical abuse.history of sexual or physical abuse.

ObjectiveObjective

The objective was to obtain qualitative data to The objective was to obtain qualitative data to provide more in-depth understanding of the provide more in-depth understanding of the configuration of psychosocial and situational configuration of psychosocial and situational factors associated with high-risk sexual factors associated with high-risk sexual behavior, substance use, health seeking behavior, substance use, health seeking behavior, contraceptive use and treatment behavior, contraceptive use and treatment compliance among minority women with STD compliance among minority women with STD and sexual or physical abuse history.and sexual or physical abuse history.

MethodsMethods

Participants included Mexican-and African-Participants included Mexican-and African-American women, aged 15-45 years enrolled American women, aged 15-45 years enrolled in a randomized study of behavioral in a randomized study of behavioral intervention to reduce STD recurrence. intervention to reduce STD recurrence. Individual, open-ended, semi-structured Individual, open-ended, semi-structured interviews lasting approximately 30 -45 interviews lasting approximately 30 -45 minutes were conducted with 513 participants. minutes were conducted with 513 participants.

MethodsMethods

These interviews focused on participants’ These interviews focused on participants’ perceptions of their sexual risk, sexual perceptions of their sexual risk, sexual relationships, individual histories of sexual, relationships, individual histories of sexual, physical or psychological abuse and factors physical or psychological abuse and factors influencing their sexual behaviors. influencing their sexual behaviors. Additionally, participants were asked about Additionally, participants were asked about health-seeking behavior, contraceptive use and health-seeking behavior, contraceptive use and STD treatment compliance. STD treatment compliance.

ResultsResults

Key categories and themes from qualitative data Key categories and themes from qualitative data provided the context for interpretation of the data. provided the context for interpretation of the data. The interview data was searched for elaboration of The interview data was searched for elaboration of associations found in prior statistical analysis. The associations found in prior statistical analysis. The words of participants were used to corroborate, words of participants were used to corroborate, refute, substantiate and supplement previous refute, substantiate and supplement previous quantitative results, comparing responses by history quantitative results, comparing responses by history of abuse. Examining results of survey data in context of abuse. Examining results of survey data in context of participants’ own words provided alternative of participants’ own words provided alternative explanations and conclusions. explanations and conclusions.

DemographicsDemographics

NON ABUSED WOMEN RESPONSES

ABUSED WOMEN RESPONSES

Average Age 1st Willing Sex: 15.67 Average Age 1st Willing Sex: 15.18

Average Age Overall Group: 24 Average Age Overall Group: 25

““What do women want from men?”What do women want from men?”  NON ABUSED WOMEN RESPONSES   ABUSED WOMEN RESPONSES

1 Good Looks 1 Emotional Support

2 Has a Good Job, Financially Stable 2 Respect for Me

3 Honesty, Good Character 3 Good Looks

4 Emotional Support 4 Job, Employed

5 Financial Support 5 Financial Support

6 Accepts My Kids, treats them well 6 Accepts My Kids

7 Treats Me well, Has Respect for Me 7 Honesty

8 Sense of Humor, Fun 8 Love

9 Faithful 9 Fidelity, Faithfulness, Loyalty

10 Loving, Caring, understanding 10 Humor

11 Trust 11 Personality

12 Companion/Friend 12 No Violence/No criticizing

13 Intelligent, Educated 13 Trust

14 Moral Support, Comfort 14 Financially Stable Man

15 Love 15 Good Sex

““Why do women have sex?”Why do women have sex?”  NON ABUSED WOMEN RESPONSES   ABUSED WOMEN RESPONSES

1 For Fun, Pleasure, I like it, It Feels Good, I Get Turned On, I Want It, Satisfaction

1 For Pleasure, It feels Good, He turns Me on

2 To Share Our Love, I Love Him, We Have a Longterm/Mutual Relationship, We have a Monogamous Relationship, To Share Our Love, To Be Close to one Another, To Bond, Because he is my Love/My Companion

2 It is an Expression of Our Love, I love Him, To Show him I love Him, Intimacy with someone you love, To share Closeness, To Express Our Love, We Care about each other, To show each other our love

3 I t is a necessity, A Part of Life, I Have To because It is A Part of Being Married,

3 I just like it/ I get horny, I just like sex

4 To Feel Beautiful, To Feel Loved 4 To shut him up, He wants it, So he can stop bugging me, To please him, To make him happy, To Keep him around, To satisfy him or he'll get it from somewhere else

5 He Wants it, To Make HIM feel Like I want him, I only Have sex because and when he wants to

5 To relax me, so I forget about things, Emotional and Physical Escape, I Need it, It is Natural, To Relive Stress

6 Just for the sport/recreation, I don't want to be tied to one man, Because I can

6 To feel Loved, To be comforted, To feel Secure, Not to be Lonely, For attention, To get a relationship

7 I have sex to keep my man at home- So he won't get it nowhere else, I have sex to keep him happy/pleased, "If I give it to him, he won't leave me."

7 I/He wants to have a baby

8 Because I was Drunk/high 8 Bored- Just to do

9 Money, Drugs, I was drunk Or I was high

I just like sex / Bisexuality/Couple Swapping/Group Sex/Experimentation

I have already been with him for a while, I am used to him, He is my baby's Daddy

““Women who use drugs = more partners?”Women who use drugs = more partners?”

NON ABUSED WOMEN RESPONSES   ABUSED WOMEN RESPONSES

Don't care about anything, They are "high" or under the influence, no respect, not thinking

Women/Girls use sex for drugs, Sex=Money, They get paid for sex to buy drugs, Girls are with guys for drugs, sex partners give drugs, do drugs together, you get what you want on drugs

Use sex as money , To get more drugs, exchange drugs for sex

High, under the influence, crazy lifestyle on drugs, too high to care, don't know what they are doing, they "Black-out,"

Drugs make you want sex more, More wild, crave sex, fun, more exciting when high, get more aroused, relaxed, have a higher sex drive

Enhance pleasure, increase urge to have sex, want sex more, careless with sex, crave sex, sex makes you feel important, easy to have sex w/someone else who uses drugs, will sleep with anyone, everyone looks good when high, want attention, get hornier, feel sexier, feel powerful, because not good at relationships

More vulnerable, want attention Have multiple partners, Have more than one partner, Unstable relationships, not committed in relationships, Not satisfied with one partner, Don't care about the # of partners they have

Not a big deal to them Don't have anybody, trying to impress, makes them feel prettier or feel better about themselves, to raise self-esteem, because they feel worthless, to get control in their life, to feel comfort, not to feel lonely anymore

Riskier when high, willing to take more risks when you're high

I do not agree with this

Men use drugs to get woman/Offer drugs for sex when they're hooked

““Don’t want to marry” Don’t want to marry” NON ABUSED   ABUSED WOMEN

1 Not ready for that commitment, I am too young, He is ready I am not, I am not stable, I want to finish school, I want to do things for Myself, Not now, maybe in the future

1 Marriage is not a big deal, It's just a piece of paper, It makes no difference if you are married or not if you are going to be with the same person forever, You don’t have to be married, It is too much hassle to be married, too many problems, If I want him to leave I'll just tell him

2 Marriage is just a fantasy, there is no such thing, It is just a piece of paper, You'll be divorced in a year, why get married, No One that I know that is married is happy

2 I am still too young, I am not ready yet, I want to make sure that it is going to work out with him, I need to be more stable in my life, I am not ready to settle down, I don’t have time for marriage now, I want a career

3 All men Cheat, I don't think he'll be faithful, I can't trust anyone, I don't want to be controlled, Afraid commitment won’t last

3 I can come and go as I want to, A man will think that he owns you, A man takes you over-asks too much from you, If I am married then I can't go out, I lose my freedom, I am having too much fun now, I will become someone's property, I don’t want to be bossed around, I want to do my own thing, Marriage is a lifetime contract-You are Trapped, I don't want to be stuck with the same man forever

4 It is fine as it is now, we are living together, we are common law married anyway- it is the same thing

4 I haven't found the right man yet, I don't want to get married to him, I don't see myself with him forever, I can't trust men , I don't trust men, It never works out with a guy

5 I am scared of making the same mistake twice, Marriage is too hard, I am married but separated

5 I am recently divorced, I have been Married and Divorced 2 times, I am separated, I didn't like being married when I was, I don't believe in marriage after my last one, Got married for wrong reasons- To leave my parents- it didn't work out

6 He is not the right guy, He is bad-has HIV, I am waiting for him to change, I haven't met the right guy yet

6 Abusive Marriages, All my relationships have been abusive, Too much fighting and abuse, I have had bad relationships

7 Too much paperwork, Too much hassle to get a Divorce

7 Scared it won’t work out, Afraid marriage will fail, Don’t ever want to go through a divorce or him cheating on you

8 My boyfriend is in jail, we are getting married when he gets out

8 I want to stay single forever, I don’t think I will ever find a "right" man

““I don’t think I can get pregnant”I don’t think I can get pregnant”

  NON ABUSED WOMEN RESPONSES   ABUSED WOMEN RESPONSES

1 Stupid/Dumb, Naïve, Ignorant 1 Don't care; Don't think it can happen to them; Think are unable to/cannot get pregnant

2 Laziness 2 Stupid, Dumb, Naïve, Ignorant

3 Side effects (Weight gain, headaches, etc..) 3 Really want to have a Baby

4 Afraid of what man will say, he may get mad, might reject her, He may want a baby from her and not want her to use BC 4 Laziness/Carelessness, Depend on Guy to Use Something

5 Heat of the moment, Just want to have sex, mess around, take a risk 5 Heat of Moment, Not thinking," If it happens, it happens, if it doesn't even better."

6 No Money for BC 6 Side effects of Birth Control (weight gain, headaches, etc..)

7 Irresponsible 7

Guy won't allow to use birth control, he wants a baby, He'll think she's being unfaithful or sleeping around. Woman just does what guy wants, chooses not to take responsibility.

8 Don't think it can happen to them. Think they cannot/unable to get pregnant 8 No Money for Birth Control

9 Really Want a Baby 9 Hate/Don't like using condoms

10 Don't like using condoms Just don't like BCP, Depo, Condoms or using any type of BCM. More natural without

““My Baby’s Dad”My Baby’s Dad”

 NON ABUSED WOMEN RESPONSES

 

ABUSED WOMEN RESPONSES

Yes, I would go back because... Yes, I would go back because...

1 We are still together now 1 We are still together

2 I still love him, we are Soul Mates 2 I still love him ,I miss him

3 He is my Baby Daddy, For the sake of our kids, So he can support me and my kids

3 So he can be there for my kids, He is my baby Daddy

4 If he would divorce his wife and kids 4 If he changed, He has changed

5 If he were still alive, He is dead now

““My Baby’s Dad”My Baby’s Dad”  NON ABUSED WOMEN RESPONSES   ABUSED WOMEN RESPONSES

NO, I would not go back because... NO, I would not go back because…

1 He was abusive, He was too controlling, He had a Bad temper

1 He is too selfish, He is not Responsible, He has not changed, He is not Good For me, He is no good, He is bad

2 I do not love him, There is no future with him, We just grew apart

2 I do not love him anymore, I don't want to be with him

3 He is in Prison, He is Dead, He is Re-Married 3 He is abusive, Assaulted me, It was a Bad Relationship

4 I do not Trust him at all 4 He is married, He has another woman, He is in Prison, He is Dead, He is Out Of The Country

5 He does drugs, Risky Sexual Behavior, He has a drinking Problem

5 He cheated on Me, He left Me While I was Pregnant, He got another Girl Pregnant

6 We fought too much 6 We had too many problems, We fought too much, It wouldn't be the same

7 I want to be by myself for a while, I am happy now 7 Because he gave me an STD or STD's

8 He uses Drugs, Gets High, He is in A Gang, He has Alcohol Problems

9 I am gay now

““Why a woman stays with a man after a STD?”Why a woman stays with a man after a STD?”  NON ABUSED WOMEN RESPONSES   ABUSED WOMEN RESPONSES

1 She loves/needs him, Can't let him go, Not ready to Leave Him, Doesn't want to start over, Does not want to lose him

1 Wants to Stay in relationship, Thinks she Loves Him , She's Used to Him, She is obsessed with him, Only wants him in her life, She loves him, She has been with him for a long while, Feels he is the only one for her, Feels rejected by another man

2 Give him a Second Chance "Everyone Makes Mistakes," Gave him the benefit of the doubt, Believe that he will change, Believes that he will not do it again, Forgive him, Made a commitment so just stay together no matter what, Thinks he'll change

2 She is stupid, afraid to be alone, Scared to find someone else, Does not want to Start over, Does not want to leave him, Does not want to let go, Thinks can't find anyone else, no one wants them

3 Dumb, Stupid, Believe whatever a man tells them, They are Brainwashed, Sweet-Talked, They are in Denial, Think, : It was probably not his fault, Don’t want to accept or believe that he is out with another woman or cheating

3 Wants to work things out, Wants to give him a Second Chance, He promises he won’t do it again, She trusts him again, Forgave him, He promises to change and be faithful

4 Maybe had STD before got together, Not sure who gave it to who, Both gave it to each other

4 Just doesn’t care about herself, Has no Self-Confidence, Low Self-esteem, Insecure, feels Worthless

5 Because she is not strong enough to leave, Insecurity about leaving just because of an STD, She is afraid to be alone, Scared to Leave, Doesn't know how to leave, "Wants a man at any Cost," doesn't want to start over

5 Because they have kids or she is pregnant, they have a steady relationship, or Have been together through a lot, "That is just a part of having a relationship," They have a commitment, They want to keep their family together

6 Don't Know or Have no Idea 6 They both gave it to each other, Had it before they both got together, It is no one's fault- just the beginning of a relationship, they are both Treated

““Why a woman stays after STD?”Why a woman stays after STD?”

  NON ABUSED WOMEN RESPONSES   ABUSED WOMEN RESPONSES

Nonabused Abused

7 Feels helpless, ashamed, Thinks no man would want her with an STD, Feels can't get or find anyone else- he's the only one for her

7 Man Lies to her, Brainwashes her, Manipulates her, Convinces her to stay, She believes him

8 She might be physically or verbally threatened, She might feel threatened by him, He might get mad and blame her for the STD, Doesn't want to confront him.

8 He may hit her or hurt her if she leaves him, He threatens her, She is scared of what he may do

9 Doesn't Love herself, Has low self esteem 9 Because she needs him for money

10 She's Pregnant, They have Kids together, He's the Father of the Baby, They are married, "Just deal with it! You stick with a Man no matter what!!!)"

10 Both are cured, It was really No Big Deal, Stays with him because doesn't want to get something else form someone else both infected both cured

11 He got cured, Both were cured- ok to stay together 11 They have an emotional attachment, they are there to support and comfort one another

12 Because he gives her Money, For Financial Reasons, He's the provider, Feels she can't make it on her own, Feels Dependent on Him

12 Is in denial, think it wasn't him who gave it to her, Naïve, wants to Believe him, feel guilty because he accuses her

13 It's just an STD- It's not AIDS or anything like that- ok to stay It's not really important until you have kids

13 She like the sex

14 She didn't tell him she had an STD- He'll never find out 14 She has no where else to go, He is the only family that I have, I have no one to turn to

15 She likes the sex, She likes the attention/ affection 15 Thinks it is her fault

““I didn’t tell my man about STD”I didn’t tell my man about STD”  NON ABUSED WOMEN RESPONSES   ABUSED WOMEN RESPONSES

1 Embarrassed to Ask a Guy to come in 1 She is afraid to get blamed, She doesn't want to be accused, He'll accuse her of messing around or giving him an STD

2 He might accuse her of messing around, Guys always blame the woman

2 Embarrassed to Ask a Guy/ Shy to bring it up/ Doesn't feel comfortable asking him, Ashamed to ask

3 Nothing should stop her from asking 3 Afraid of his reaction,, Don't want to get him mad, "Men don't like to be cornered or accused of anything,", He may get mad for even saying that he had or might have anything

4 She is scared to lose him, He may not WANT HER with an STD, He might Leave her

4 He'll Leave, Fear of Losing Him, Afraid of Rejection

5 She doesn't want to get him mad, He will think she is accusing him, Ha may get upset, She has no control

He'll think she has something or was with someone else, He'll accuse her of cheating, He'd think bad of her, He would get suspicious, She doesn't want him to think that she is cheating, or thin kthat she is dirty with something

6 She doesn't want to make him feel like he is dirty, Afraid of what he would say or think of her if she brought it up, Afraid of how he will react

Abused, Afraid to get beat up, He'll get violent

7 She may not want to get beat up, She might get physically/mentally abused

5 She is scared of him

8 She is cheating and doesn't want him to know, She is ashamed that she got it from someone else, not him, doesn't want to tell him

6 Nothing should stop her

9 He refuses 7 She is cheating and doesn't want him to know

10 She, herself, doesn't want to know the results, She is scared to know the truth, May be afraid that he will confess

8 It will embarrass him, He'll get embarrassed, It will make him feel uncomfortable, "If she loved and trusted him, she wouldn't ask," He might get offended, He might think that she doesn't trust him

9 She is afraid to get the results, If he gets checked he would be confessing to infidelity/jealousy/wants to avoid confrontation

13 Revenge- to get back at him (n=1)

14 HE lied and told her he already got checked (n=1)

““Did STD affect my body?”Did STD affect my body?”  NON ABUSED WOMEN RESPONSES

 ABUSED WOMEN RESPONSES

NO, STD has Not Affected my Body NO, STD has Not Affected my Body

Reasons: Reasons:

1 Got it treated early before it could harm me, My STD is cured

1 Got it treated right away, It was cured

2 Have not had any problems since, no signs of damage, I feel the same

2 No symptoms since, I feel healthy, there are no changes in my body, I feel normal, I haven't had any side effects or problems

3 I am able to have kids with no problem 3 I am still able to get pregnant, Still fertile, I delivered my kids with no problems

4 I was told by the doctor or nurse that I was ok, Doctor or Nurse would have told me if there was something wrong

4 Doctor or Nurse would have told me something, They always say that everything is ok

5 I Don't Know 5 I get checked

6 God restored and healed my body 6 I have not had anything else (STD's) since then, I only had it one time

““Did STD affect your body?”Did STD affect your body?”

YES, STD HAS AFFECTED MY BODY NONABUSEDYES, STD HAS AFFECTED MY BODY

ABUSED

Reasons: Reasons:

1 I am unable to get pregnant, I miscarried, It took a long time for me to become pregnant

1 I am unable to get pregnant, It took a long time for me to become pregnant, It is harder for me to get pregnant, I haven't been able to get pregnant, I had a miscarriage

2 HPV, HSV, Got a virus that will never go away 2 I feel that my insides are damages, I have scarring now

3 Not sure how, but I feel that it did affect my insides in some way, I have scarring inside of me

3 HPV, HSV. I now have a virus that will never go away

4 Makes me feel like I am dirty 4 It is just bad for your health and it weakens your immune system, You always feel sick and weak, Your body never feels the same again

5 I am not at risk for cervical cancer 5 I always have pain, odor or frequent discharge since I had that STD

6 Now, I have pain associated with sex, I have symptoms, I think I will always have it

6 Never thought about it, I really do not know

7 Mental effects, It has affected me emotionally, It makes me not want to have sex, I can't believe I let it happen

8 Makes it easier to get and pass HIV or another STD

9 I am increased risk of cancer and HIV

I have abnormal pap smears and Abnormal periods since then

It makes me feel impure

ConclusionsConclusions

Context for modification of risk-reduction Context for modification of risk-reduction interventions specifically designed for abused interventions specifically designed for abused minority women to realize a reduction in minority women to realize a reduction in sexual risk behaviors, abuse and STD re-sexual risk behaviors, abuse and STD re-infection rates is identified. infection rates is identified.

ImplicationsImplications

Incorporation of results to modify existing Incorporation of results to modify existing STD prevention programs STD prevention programs