Introduction 2003 2003 2005 1996 1998 2003 1996 force 2003 1998 penetrative 2003 1997 2005 1987 1993 1998 1991 1998 The primary purpose of this study was to determine whether use of force and type of sexual act was associated with sexual risk behavior in a group of patients receiving outpatient care from a sexually transmitted disease (STD) clinic. Based on previous research, we hypothesized that: (1) the use of force; and (2) sexual abuse involving penetration would be associated with greater sexual risk behavior. The secondary purpose of this study was to determine whether the effects of abuse characteristics on adult sexual behavior differed by gender. Method Participants n n n= n n 2000 n n n n n n n SD Procedure 2003 Measures Childhood/adolescent sexual abuse 1979 1 n Current sexual behavior 1997 2000 2004 Table 1 Sexual abuse characteristics by gender  n n n  n % of men n % of women n % of total No sexual abuse 227 35 182 34 409 35 Sexual abuse without force and without penetration 100 16 59 11 159 14 Sexual abuse with penetration only (no force) 208 32 105 20 313 27 Sexual abuse with both force and penetration 108 17 188 35 296 25 Table 2 Demographic characteristics of sexual abuse groups formed by force and penetration  a n b n c n d n  n % n % n % n % Sex (male) c,d 56 d 63 a,d 66 a,b,c 36 Race (minority) b,c,d 66 a,c 75 a,b,d 89 a,c 77 Education (high school or less) b,c,d 52 a,c 63 a,b,d 78 a,c 65  M SD M SD M SD M SD Age (in years) d 9.6 28.7 9.5 29.2 9.8 a 9.7 a p b p c p d p Statistical analyses 10 x 2001 Exploratory analyses were conducted to investigate whether gender moderated the relations between the sexual abuse characteristics and later sexual behavior. ANOVAs were conducted including demographic covariates, a main effect of abuse, and the interaction of abuse and gender. Results n N 1 Table 3 Sexual risk behaviors of participants who reported sexual abuse with force, sexual abuse without force, and no sexual abuse (raw data)  a n b n c n d n  M SD M SD M SD M SD Sexual partners (number, lifetime) c,d 80.9 c,d 28.2 a,b 211.5 a,b 172.4 Sexual partners (number, past 3 months) c,d 2.1 2.7 2.2 a 2.7 a 4.0 Unprotected sex (number of events, past 3 months) c,d 24.3 17.0 26.8 a 30.1 a 38.2 Unprotected sex (proportion, past 3 months) 0.68 0.32 0.64 0.33 0.70 0.30 0.67 0.33 Exchanged sex for money or drugs (number, lifetime) c,d 55.9 d 42.0 a,d 42.4 a,b,c 89.6 STD diagnoses (number, lifetime) c,d 3.0 c,d 3.2 a,b 3.6 a,b 4.1 a p b p c p d p Demographic differences 2 2 Relation between sexual abuse characteristics and sexual behavior F p F p F p F p F p 3 d d d d d p d d d d d p d d p d d d p d p p Gender as a moderator of the relation between sexual abuse characteristics and sexual behavior To determine whether gender moderated the relation between sexual abuse characteristics and sexual behavior, gender-by-sexual abuse interactions were included in the ANOVAs. Relevant demographic covariates were included. F p p 1 Fig. 1 The effect of the interaction of gender and sexual abuse status on the number of episodes of sex trading  Discussion 2003 2001 1998 1997 2003 2001 2003 1997 2006 Penetration by itself (i.e., without force) and penetration in combination with force were associated with increased sexual risk behavior relative to those who were abused without force and without penetration, and those who were not abused. The sole difference between the penetration only and the penetration plus force groups involved sex trading, where those who experienced sexual abuse with force and penetration reported engaging in a greater frequency of sex trading, relative to those who experienced sexual abuse with penetration and no force. However, this finding was qualified by a significant gender-by-abuse interaction. Because only a very small number of participants reported sexual abuse with force but without penetration (i.e., forced kissing or fondling), we were unable to investigate the impact of force only. A somewhat unexpected finding was that the group that reported sexual abuse without force and without penetration did not differ significantly from the nonabused group on any of the sexual behavior outcomes. Future investigation of the relation between sexual abuse and adult sexual behavior might find it fruitful to conduct more fine-grained assessments of the sexual experiences that involve only large age differentials to determine how these experiences are perceived by both men and women, and whether such experiences influence subsequent sexual behavior. 1990 2006 2003 1997 1985 2003 1997 2004 1998 1996 2003 2003 2003 1990 1999 Cook et al. 2006 These results have implications for both practice and research. Regarding public health and clinical practice, they suggest that a thorough sexual health assessment should include inquiry about the nature of the sexual abuse, particularly whether force was involved and what type of sexual act occurred. Given the likely impact of sexual abuse on sexual risk behavior (as well as other health outcomes), we recommend a more comprehensive approach to sexual health assessment, education, counseling, and/or therapy. Indeed, these findings highlight the need to develop interventions tailored to the unique needs of persons with a history of sexual abuse to promote (and restore) sexual health and reduce sexual risk. With respect to research, these findings raise many questions about the conditions under which sexual abuse impairs healthy sexual development and expression, and about the mechanisms by which sexual abuse influences sexual development, behavior, and adjustment. This work will require sophisticated methods and analyses to overcome the limitations of what is inherently retrospective and correlational research.