Research articleThe impact of childhood gender expression on childhood sexual abuse and psychopathology among young men who have sex with men☆
Introduction
Similar to other sexual minorities, men who have sex with men (MSM) (including those who identify as gay/bisexual) are more likely than heterosexuals to exhibit lifetime psychopathology (Cochran et al., 2003, Mustanski et al., 2010). Childhood sexual abuse and childhood gender nonconformity, two factors found to be more common among gay/bisexual men than their heterosexual counterparts (Friedman et al., 2011, Zucker and Lawrence, 2009), are worthy of examination as they are both associated with the development of later psychopathology in heterosexual as well as lesbian, gay, bisexual, and transgender populations (Benoit and Downing, 2013, D’Augelli et al., 2006, Roberts et al., 2012b). Moreover, childhood sexual abuse (Lloyd & Operario, 2012), and psychiatric disorders such as depression (Alvy et al., 2011) and post-traumatic stress disorder (PTSD) are associated with sexual risk behavior in adult (Reisner, Mimiaga, Safren, & Mayer, 2009) and young MSM (Beidas, Birkett, Newcomb, & Mustanski, 2012) – groups already disproportionately vulnerable to HIV infection due to risk associated with condomless anal intercourse and a high concentration of HIV in MSM communities (CDC, 2012a, CDC, 2012b). Thus, for multiple reasons, it is imperative to examine the factors associated with the development of psychopathology including childhood sexual abuse and childhood gender expression.
Childhood sexual abuse has been defined as any unwanted or inappropriate form of sexual contact between a child and a person at least 5 years older, and it can consist of genital touching or fondling, vaginal, anal, or oral intercourse (or attempted intercourse) (Andrews, Corry, Slade, Issakidis, & Swanston, 2004). Individuals who experience these severe forms of CSA are at increased odds of experiencing psychiatric conditions (Andrews et al., 2004, Maniglio, 2010). For example, according to one recent meta-analysis, CSA was associated with lifetime diagnosis of a psychiatric disorder including depression, anxiety, and posttraumatic stress disorder (PTSD), as well as suicide attempts (Chen et al., 2010). Trait impulsivity, a risk factor for suicidal behavior (Maser et al., 2002), substance use (Li et al., 2012) and sexual risk (Dir, Coskunpinar, & Cyders, 2014), is also associated with CSA (Roy, 2005). The aspects of impulsivity most strongly associated with CSA include negative urgency (i.e., tendency to act hastily in response to negative affect) (Gagnon, Daelman, McDuff, & Kocka, 2013) and a lack of both premeditation (i.e., tendency to act without thinking) and perseverance (i.e., inability to sustain focus on a task) (Sujan, Humphreys, Ray, & Lee, 2014).
In the United States, CSA is experienced by approximately ten percent of youth 18 and under, with the majority of cases (25–75%) experienced by females and 16–25% among males (CDC, 1997, Pérez-Fuentes et al., 2013). While CSA prevalence rates are yet to be examined in young MSM, adult gay/bisexual men report disproportionately high rates of CSA that range between 4 and 59% (Paul et al., 2001, Rothman et al., 2011). Since it is likely that gay/bisexual men (including some MSM) exhibit greater gender nonconformity in childhood than do their heterosexual counterparts, the presence of childhood gender nonconformity may be an important attribute that explains the disproportionately high rates of CSA in MSM (Zucker & Lawrence, 2009).
Gender identity refers to an individual's psychologically rooted “personal sense of self as male or female” (Adelson, 2012, p. 5). By the age of 3 years, most children reared in western culture understand their gender identity to be either male or female and, by age 5 or 6 years, most children identify with a life-long male or female gender identity consistent with their natal sex (Martin, Ruble, & Szkrybalo, 2002). Gender expression refers to the way in which an individual communicates their gender identity to others most notably through their behavior (e.g., how they dress, behave), self-reference (e.g., use of “she”, “he”, “they”), and/or (non-)adherence to culturally dictated gender roles (American Psychological Association, 2009). In western culture, sociocultural norms dictate that natal males and natal females conform to masculine and feminine gender roles, respectively. Gender nonconformity is the “extent to which a person's gender identity, role, or expression differs from the cultural norms prescribed for people of a particular sex” (Coleman et al., 2012, p. 168). Given that children begin exhibiting gender-related phenomena in early childhood, gender nonconformity may occur as young as age 3 years (Martin et al., 2002). Findings from clinic-referred samples of prepubertal children with gender nonconformity infer that in the majority of cases these children develop to be cisgender (i.e., non-transgender) individuals who identify as gay or lesbian (Zucker & Lawrence, 2009).
Compared to children who conform to gender role expectations, gender-nonconforming children are at greater risk of experiencing ridicule, discrimination or violence from family or peers, and these factors increase their susceptibility to psychopathology in adolescence including depression, anxiety, posttraumatic stress disorder and suicidality (D’Augelli et al., 2006, Haas et al., 2011, Skidmore et al., 2006, Toomey et al., 2010, Travers et al., 2012). Moreover, recent studies support associations between childhood gender nonconformity and childhood sexual abuse (Bandini et al., 2011). Findings from retrospective case-controlled studies among adults indicate that childhood gender nonconformity moderates the relationship between CSA and adulthood PTSD risk (Roberts, Rosario, Corliss, Koenen, & Bryn Austin, 2012a). This research suggests that, compared with children who have no history of gender nonconformity, greater associations of CSA and psychopathology are found among those with gender nonconformity. No known studies have examined gender nonconformity as a mediator in the association between CSA and psychopathology perhaps because study findings to date are inconclusive regarding any psychological or biological precipitants of gender nonconformity, including that it manifests as a result of adverse childhood experiences including CSA (for a review see Sánchez & Vilain, 2013). However, no known studies have examined a similar moderating relationship in young MSM.
This study examined whether or not incidents of CSA were associated with current psychiatric symptomology in a sample of young adult MSM aged 16–20. This study also examined how recalled childhood gender nonconformity influenced the likelihood of CSA, as well as the likelihood of current psychiatric symptomology. Given extant literature characterizing CSA as often predictive of psychopathology, we hypothesized that those with histories of CSA would demonstrate an increased likelihood of developing symptomology consistent with Major Depressive Disorder, PTSD, and suicide risk factors (e.g., impulsivity, suicidal ideation, suicide attempts) in our sample of young men (hypothesis 1). We also hypothesized that young MSM with childhood gender nonconformity would report greater experiences of CSA consistent with extant literature regarding increased susceptibility of CSA among gender-nonconforming children (hypothesis 2). Last, we hypothesized that, compared to young MSM without childhood gender nonconformity, experiences of CSA in those with childhood gender nonconformity would contribute to an increased likelihood of psychiatric symptomology including suicide risk factors; in other words that gender nonconformity would moderate the CSA-psychopathology relationship (hypothesis 3).
Section snippets
Sample Characteristics
This analysis was conducted from data gathered in Crew450, a longitudinal cohort study examining the prevalence, course, and predictors of syndemic psychosocial health issues associated with HIV infection in a multiethnic sample of 450 young MSM, aged 16–20, and residing in a large Midwestern metropolitan area. The mean age in the sample was 18.9 years (SD = 1.3), with 26% of the sample under age 18. The sample was largely racial/ethnic minority (82%). In terms of sexual orientation, 73%
Results
The analysis included 449 participants, excluding one participant who did not respond to the ESE Checklist. All participants completed at least 7 valid answers for the gender expression scale. The Cronbach alpha for negative urgency, lack of premeditation, lack of perseverance, positive urgency, sensation-seeking, and gender nonconformity scales, was 0.80, 0.85, 0.64, 0.92, 0.82, and 0.88, respectively.
Sociodemographic characteristics and psychopathology are summarized overall and by number of
Discussion
This study examined the relationship of early childhood sexual abuse to current psychiatric problems (including suicidality and impulsivity) among young MSM and the degree to which childhood gender nonconformity moderated this relationship. Overall, a high proportion of young men in this sample reported ESE (45.6%). These rates are similar to, yet slightly higher than, rates recorded previously among adult MSM (20–39.7%) (Paul et al., 2001) and nearly double the CSA rates reported among
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This work was supported by the National Institute on Drug Abuse under grant R01DA025548.