Childhood Maltreatment, Psychological Dysregulation, and Risky
Sexual Behaviors in Female Adolescents
Jennie G. Noll, PHD, Katherine J. Haralson, BA, Erica M. Butler, BA, and Chad E. Shenk, PHD
University of Cincinnati College of Medicine, Cincinnati Children’s Hospital Medical Center
All correspondence concerning this article should be addressed to Jennie Noll, PhD, Cincinnati Children’s
Hospital Medical Center, Division of Behavioral Medicine and Clinical Psychology, 3333 Burnet Ave., MLC
3015, Cincinnati, OH, 45229-3039, USA. E-mail: [email protected]
Received October 12, 2010; revisions received January 7, 2011; accepted January 8, 2011
Objective Maltreated female adolescents are at risk for engaging in sexual behaviors consistent with HIV
infection and teen pregnancy. The current study applied a model positing the key role of psychological
dysregulation in the development of adolescent females’ sexual behavior. Methods The sample consisted of adolescent females aged 14–17 years who had experienced substantiated childhood maltreatment
(n ¼ 275) and a demographically matched, non-maltreated comparison group (n ¼ 210). Results Multiple
mediator analysis revealed that, when in company with a host of plausible mechanisms, sexual preoccupation mediated the relationship between psychological dysregulation and risky sexual behaviors.
Conclusion Maltreated females may have difficulty regulating emotions, cognitions, and behaviors, which,
when coupled with a propensity to entertain sexual thoughts and consume sexually explicit materials, may
increase the likelihood that they act on sexual impulses and engage in high-risk sexual behaviors.
Key words
adolescent sexual behavior; maltreatment; psychological dysregulation; structural modeling.
Introduction
Over 1.2 million children are determined to be victims of
childhood maltreatment, including neglect, physical abuse,
and sexual abuse, each year in the United States (Sedlak
et al., 2010). Research on the short- and long-term effects
of childhood maltreatment suggests that it may play a role
in the development of adverse sexual outcomes in pediatric
and adult populations. For instance, childhood maltreatment has been associated with several risky sexual behaviors, including early coital initiation, sexual engagement
without contraceptives, and prostitution (Houck, Nugent,
Lescano, Peters, & Brown, 2010; Jones et al., 2010;
Noll, Trickett, & Putnam, 2003) as well as the contraction
of sexually transmitted infections and HIV (Wilson &
Widom, 2008; Wingood & DiClemente, 1997). Although
this risk applies to both males and females who have been
maltreated (Jones et al., 2010), females are at risk for
additional sexual health outcomes including teenage pregnancy and motherhood (Noll, Shenk, & Putnam, 2009).
There is scant research aimed at explicating specific
mechanistic processes involved in high-risk sexual behaviors for maltreated females. There is some evidence that
childhood maltreatment may result in a breakdown in
global regulatory processes associated with pediatric outcomes. For instance, childhood maltreatment has been
linked to disruptions in the hypothalamic–pituitary adrenal
axis (Trickett, Noll, Susman, Shenk, & Putnam, 2010),
neurological structures responsible for behavior regulation
(De Bellis & Kuchibhatla, 2006), and systems involved in
affect regulation (Shipman, Zeman, Penza, & Champion,
2000). Maltreated females also report significantly higher
levels of sexual preoccupation, such as intrusive sexual
thoughts, pornography consumption, and frequent masturbation, which have accounted for individual differences
in subsequent HIV-risk behaviors and teen pregnancy
(Noll et al., 2003). This breakdown in regulatory processes
is thought to be indicative of further disruption, especially
in the face of other risk factors such as peer influences and
Journal of Pediatric Psychology 36(7) pp. 743–752, 2011
doi:10.1093/jpepsy/jsr003
Advance Access publication February 19, 2011
Journal of Pediatric Psychology vol. 36 no. 7 ß The Author 2011. Published by Oxford University Press on behalf of the Society of Pediatric Psychology.
All rights reserved. For permissions, please e-mail: [email protected]
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Noll, Haralson, Butler, and Shenk
substance use that are common in adolescence (Crockett,
Raffaelli, & Shen, 2006).
The bulk of research tying regulatory deficits to risky
adolescent behaviors has been done in the substance use
field where global regulatory deficits have been operationalized in terms of ‘‘psychological dysregulation’’ comprising
three distinct but related components: cognitive dysfunction, behavioral impulsivity, and emotional lability (Tarter
et al., 2003). At the broadest level, psychological dysregulation is the inability to optimally and willfully control
and guide one’s cognitions, behaviors, and emotional
responses in a goal-directed manner (Thatcher & Clark,
2008). There are several aspects of psychological dysregulation which are often studied separately including:
(a) cognitive self-regulation defined as attentional focus,
inhibitory control or the suppression of off-task cognitions,
planning and organizing, and effortful control or the ability
to exert the effort needed to achieve goal-directed action
(Murray & Kochanska, 2002); (b) behavior self-regulation
defined as control of behavioral impulses in social contexts, delayed gratification or enacting patience, refraining
from impulsivity and weighing options in social contexts
(Sprague & Walker, 2000); and (c) emotion self-regulation
defined as modulating internal feeling states and emotionrelated physiological and attentional processes in the
service managing volatile social and emotional states
(Eisenberg & Spinrad, 2004). Albeit inclusive of many
components, the warp of psychological dysregulation is
comprised of several threads which have very specific implications for the development of problematic behaviors in
adolescence. Woven through this warp is a large social
component wherein it is recognized that social contexts
offer unique challenges to self-regulatory capacities.
Adolescence is arguably one of the most difficult periods
to navigate with respect to self-regulation as there are
ample social challenges, such as engagement in romantic
and sexual relationships, which prompt the use of these
developing capacities. If self-regulatory capacities are disrupted or inadequately developed in the presence of such
challenges, adolescent health can be affected.
Within the larger adolescent development literature,
there is convincing evidence to support models that
place risky sexual behaviors within the framework of general problem behaviors that interact with one another to
impact optimal development. For example, involvement in
a deviant peer group has been shown to be particularly
pronounced and detrimental for female adolescent sexual
development (Caspi, Lynam, Moffitt, & Silva, 1993).
Experimentation with alcohol and drugs often first occurs
within a peer group and can result in sexual enhancement
expectancies and remove inhibitions that disrupt
adolescents’ decision-making around sexual activity
(Mason et al., 2010). In addition to alcohol and drug
use, more general delinquency and conduct problems
have been shown to be prognostic of later adverse outcomes including risky sexual behaviors (Fergusson,
Horwood, & Ridder, 2005). Conversely, parenting practices can be powerful protective factors in the family-peer
mesosystem (Bronfenbrenner & Crouter, 1983) buffering
against the harmful effects of problematic behaviors and
peer influences during adolescence (O’Donnell et al.,
2006). Adolescents who report being emotionally connected and supported by parents (Crosby et al., 2001)
and whose parents are present and monitor their whereabouts and activities (Miller, Benson, & Galbraith, 2001)
have reported lower rates of risky sexual behaviors.
Parental influences have been shown to be especially effective in curtailing risky sexual behaviors in females
(Hutchinson, Jemmott, Jemmott, Braverman, & Fong,
2003). Hence, models of adolescent female risky sexual
behaviors should simultaneously consider various interrelated behavioral processes and contexts.
Although a comprehensive picture of the myriad of
psychosocial risk factors associated with adolescent
female risky sexual behaviors is beginning to be painted,
key variables are too often studied in isolation and are
rarely incorporated on the same canvass. This makes it
difficult to discern the unique contribution of each risk
and protective factor and precludes our ability to articulate
important pathways to risky sexual behavior that will bolster prevention and intervention efforts. The purpose of
this article is to: (a) test a comprehensive model where
childhood maltreatment is associated with higher rates of
psychological dysregulation which in turn is associated
with risky sexual behaviors in adolescent females; and
(b) isolate indirect pathways to risky sexual behaviors that
function independently from one another while taking
into account simultaneously occurring alternative pathways. The present study focuses on pathways to risky
sexual behaviors for adolescent females aged 14–17 years
and explicitly tests associations between risky sexual activities and a circumscribed set of the most often cited and
developmentally relevant risk factors.
Methods
Sample
Maltreated adolescents (n ¼ 275) were recruited from local
child protective service (CPS) agencies and had experienced substantiated incidences of physical neglect, physical abuse, or sexual abuse via state and local standards.
Abuse type was distributed as follows: sexual abuse (47%),
Child Maltreatment and Risky Sexual Behaviors
physical abuse (32%), physical neglect (16%), with 51% of
the sample experiencing multiple types. Because of this
high overlap among types of maltreatment, discrete categories of abuse types were not examined. Hence, sexual
abuse, physical abuse and physical neglect were combined
into a single category and analyzed as such. Assessments
were scheduled 3–12 months after disclosure of abuse.
Comparison females (n ¼ 239) were recruited from a
hospital-based, primary care teen health center and were
matched to at least one abused female regarding race/ethnicity, family income level, age, and family constellation
(one or two parent households). To obtain mutually exclusive groups, comparison females were screened for CPS
involvement prior to enrollment. In addition, a validated
instrument assessing prior trauma histories (Barnes, Noll,
Putnam, & Trickett, 2009) was administered to both adolescents and caregivers. As a result, 29 comparison females
were excluded because of reports of childhood maltreatment resulting in a final comparison sample of 210.
The total sample was mean age of 15.74 years
(SD ¼ 1.10), had a median family income level of
$20,000–$29,000, was 53% single-parent households,
and had a racial make-up at 46% Caucasian, 45%
African-American, 8% Bi- or Multi-racial, 0.5% Hispanic,
and 0.5% Native American.
Procedures
Participants resided in the catchment area of a Children’s
Hospital located in the Mid-west region of the US.
Non-maltreating caregivers accompanied adolescents to
the lab session to provide informed consent and information about adolescents’ well-being. Adolescents provided
assent and then completed questionnaires and
semi-structured interviews regarding sexual attitudes and
activities, substance use, peer involvement, and parental
connectedness. High-risk behaviors and attitudes (e.g.,
sexual behaviors, substance use, and high-risk peer affiliations) were assessed via multimedia computers to provide
an atmosphere of anonymity without embarrassment or
fear of offending a live interviewer. Caregivers completed
the behavior problems questionnaire and the trauma history reports in a separate testing area. The study received
approval from the Institutional Review Board.
Measures
Maltreatment
Based on substantiated caseworker reports, maltreatment
was quantified as 1 ¼ ‘‘maltreated’’, 0 ¼ ‘‘comparison’’.
We did not conduct analyses by type of maltreatment
due to sample size limitations, but performed post hoc
exploratory analyses to ascertain if type of maltreatment
contributed meaningfully to the understanding of the
multivariate system.
Risky Sexual Behaviors
The Sexual Attitudes and Activities Questionnaire (SAAQ;
Noll et al., 2003) was administered to assess high-risk
sexual behaviors. We defined the latent variable, ‘‘risky
sexual behaviors’’ for structural equation modeling (SEM)
analyses using the following five compellations: (a) number
of HIV risk behaviors including ‘‘yes’’ ¼ 1 or ‘‘no’’ ¼ 0 to
having ever had intercourse without a condom, condoms
failing during intercourse, intercourse or oral sex with an
intravenous drug user, used intravenous drugs, shared
needles, intercourse or oral sex with a bisexual partner,
unprotected intercourse with a homosexual male, multiple
concurrent intercourse partners, one night stands, and
intercourse while drunk or high; (b) age at first voluntary
intercourse was scored according to risk level in that lower
ages received high scores [i.e., (age at first intercourse)*-1]
and those who had never had intercourse were given the
lowest risk score; (c) number of sexually transmitted diseases including ‘‘yes’’ ¼ 1 or ‘‘no’’ ¼ 0 to having ever had
chlamydia, gonorrhea, syphilis, pelvic inflammatory disease, genital warts, genital herpes, HIV, or hepatitis B or
C; (d) number of sexual intercourse partners in the past
year; and (e) number of additional risky sexual behaviors
including the number of lifetime partners with whom the
following occurred: oral sex, one night stands, unprotected
sex, and sex while under the influence of alcohol or drugs.
Psychological Dysregulation
The Dysregulation Inventory (DI; Mezzich, Tarter,
Giancola, & Kirisci, 2001) is a 92-item adolescent
self-report measure assessing difficulties in modulating
problematic cognitions, affect, and behaviors. The DI is
comprised of three subscales which we used to define
the 3-indicator latent construct, ‘‘psychological dysregulation,’’ for SEM analyses: affective (a ¼ .87), cognitive
(a ¼ .83) and behavioral (a ¼ .91) dysregulation.
Sexual Preoccupation
The SAAQ measures risky sexual attitudes such as sexual
preoccupation (Noll et al., 2003) which is comprised of
15 items (a ¼ .91) including frequent masturbation, pornography consumption, intrusive sexual thoughts, and
being turned-on by sexual themes and fantasies. We split
the items into three even groups (1–5, 6–10, and 11–15)
to define the three-indictor latent construct, ‘‘sexual
preoccupation,’’ included in SEM analyses.
745
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Noll, Haralson, Butler, and Shenk
Substance Use
Substance use was defined as smoking, drinking, and illicit
drug use during the past year via items excerpted from
the Monitoring the Future (MTF) national survey questionnaires (Johnston, O’Malley, Bachman, & Schulenberg,
2005). Smoking was defined as frequency of smoking
cigarettes (from 0 ¼ ‘‘none’’ to 4 ¼ ‘‘four time or more’’).
Drinking was defined by two items reflecting the number
of occasions (from 0 ¼ ‘‘none’’ to 6 ¼ ‘‘40 or more’’) adolescents had ‘‘more than just a few sips of alcohol’’ and
were ‘‘drunk or very high from drinking’’. Illicit drug
use was defined as the number of occasions adolescents
used a variety of illicit substances including marijuana,
lysergic acid diethylamide (LSD), cocaine, amphetamines,
barbiturates, tranquilizers, and other narcotics. These compilations were included in the SEM analysis to define the
three-indicator latent construct, ‘‘substance use.’’
Risky Peers
Affiliation with high-risk peers was defined via two broad
aspects of risk: (a) peer substance use (a ¼ .79)—a compellation MTF items measuring how many close friends
(0 ¼ ‘‘none,’’ 1 ¼ ‘‘a few,’’ 2 ¼ ‘‘some,’’ 3 ¼ ‘‘most,’’
4 ¼ ‘all’’) smoke cigarettes, drink alcohol, get drunk,
smoke marijuana, use illegal drugs; and (b) peer sexual
involvement (a ¼ .88)—a compellation of SAAQ items
measuring whether or not (from 0 ¼ ‘‘definitely no’’ to
5 ¼ ‘‘definitely yes’’) adolescents’ best friend has had oral
sex, intercourse, multiple partners, one night stands, intercourse while drinking or high, or unprotected sex. These
aspects of high-risk peer behaviors were included in the
SEM analysis to define the 2-indicator latent construct,
‘‘risky peers.’’
Parental Connectedness
This construct was measured in two ways to define a
three-indicator latent construct. The first was ‘‘parental
warmth’’ as measured by the 10-item subscale of the
Children’s Report of Parent Behaviors Inventory-30
(Schluderman & Schluderman, 1988) which is a wellestablished measure with strong psychometric properties
(Schwarz, Barton-Henry, & Pruzinsky, 1985). Internal
consistency for the warmth scale in the current sample
is (a ¼ .88). The second was ‘‘caregiver presence’’ as
measured by a composite scale of 12 items (a ¼ .91) derived from the Add Health survey (Chandy, Blum, &
Resnick, 1996) and includes the frequency of caregiver
presence at mealtimes, before school, after school, and at
bedtime.
Behavior Problems
Internalizing and externalizing behavior problems were assessed via caregiver reports on the Child Behavior Checklist
(Achenbach, 1991). The CBCL is a widely used, valid measure for assessing internalizing and externalizing behaviors.
Internal consistencies for internalizing (a ¼ .89) and externalizing (a ¼ .91) scales are excellent in the current
sample. Given their high inter-correlation (r ¼ .69), the
internalizing and externalizing scales were used to define
the two-indicator latent construct, ‘‘behavior problems,’’
for the SEM.
Analytic Plan
Using a mediational framework, we first conducted an
individual mediator analysis to test whether psychological
dysregulation mediated the relationship between maltreatment and risky sexual behaviors using the Sobel test
(Sobel, 1982) to evaluate the significance of the indirect
effect and the degree of mediation (i.e., full vs. partial). If
partial mediation were to emerge, we sought to further
understand the role of dysregulation by using Mplus to
perform a multiple mediator test of the extent to which
other associated risk factors would further mediate the relationship between dysregulation and risky sexual behaviors. SEM is a sound and state-of-the-art approach to
error-free parameter estimation and the use of Mplus
(Muthen & Muthen, 2007; Los Angeles, CA) allows us
to test multiple pathways simultaneously. Although a
host of alternative models could have been tested, we adhered to strong a priori hypotheses and theoretical parsimony in selecting the resultant model and identified
pathways. For each latent variable, individual indicators
were standard scores prior to inclusion in SEM analysis.
Variables defining unit-weighted linear composites of constructs included in the SEM were contrasted via an overall,
omnibus multivariate analysis of variance (MANOVA)
model followed by individual post hoc F-tests to discern
group differences (Table I).
Results
Descriptives
There were no demographic differences across maltreated
versus comparison groups. To control for Type I error, we
conducted an overall omnibus MANOVA model to test
group differences in all other variables included in analyses.
The overall F-test for the MANOVA was significant,
F (7, 447) ¼ 9.98, p < .01. Post hoc analyses revealed that
maltreated adolescents scored significantly higher than
comparison females regarding risky sexual behaviors,
Child Maltreatment and Risky Sexual Behaviors
Table I. Group Differences for Variables Used in Mediational Analyses
Variables
Total M (SD)
Comparison M (SD)
Maltreated M (SD)
Sexual preoccupation
0 (1)
0.03 (0.99)
0.02 (0.99)
Behavioral problems
Parental connectedness
0 (1)
0 (1)
0.32 (0.89)
0.13 (0.97)
0.26 (0.99)
0.12 (1.02)
F
d
1.00
.09
24.78**
7.95**
.61
.25
Risky peers
0 (1)
0.14 (0.94)
0.09 (1.03)
6.14**
.23
Substance use
0 (1)
0.24 (0.85)
0.17 (1.08)
19.46**
.41
Psychological dysregulation
0 (1)
0.26 (0.94)
0.20 (1.01)
23.49**
.46
Risky sexual behaviors
0 (1)
0.28 (0.91)
0.16 (1.01)
20.90**
.45
Note. Degrees of freedom are 1,483 for all contrasts shown except for behavioral problems which is 1,469. Standard scores (M ¼ 0; SD ¼ 1) were calculated from
unit-weighted linear combinations of indicators described in the ‘Measure’ section.
*p < .05, **p < .01.
psychological dysregulation, substance use, risky peers, lack
of parental connectedness, and behavior problems (Table I).
Psychological Dysregulation as an
Individual Mediator
An individual mediator analysis was conducted to assess
whether the indirect pathway between maltreatment,
psychological dysregulation, and risky sexual behaviors
significantly accounted for the relationship between maltreatment and risky sexual behaviors. The Sobel statistic
was Z ¼ 3.12, p < .01, indicating significance for the indirect pathway. However, as can be seen in Figure 1, even in
the company of psychological dysregulation, maltreatment
continued to be a significant predictor of risky sexual behaviors, b ¼ .16, p < .01, indicating that psychological dysregulation functions only as a partial mediator in the
proposed system. However, the associational and squared
associational effect sizes for the relationship between psychological dysregulation and risky sexual behaviors were
relatively small, r ¼ .18 and R2 ¼ .07, respectively. Small
effects indicate that shared variance is minimal and that
there is ample variability in the constructs of interest that
has been left unexplained (Ferguson, 2009).
Multiple Mediator Model
A multiple mediator analysis using Mplus was then conducted to further account for the relationship between
psychological dysregulation and risky sexual behaviors
(Figure 2). Fit indices suggest that the proposed model
fits the observed data well; w2 (188) ¼ 470.95,
Comparative Fit Index ¼ 0.95, and Root Mean Square
Error of Approximation ¼ 0.05. The fit indices indicate
that the measurement model is sound and that the proposed paths are specified such that latent variable interrelationships are accounted for, and that the observed
covariance matrix is adequately reproduced. Results indicated that childhood maltreatment was significantly and
positively related to psychological dysregulation, suggesting
Figure 1. Individual mediator analysis showing partial mediation for
psychological dysregulation. Standardized b parameter estimates
shown. *p < .05, **p < .01.
that various forms of abuse may disrupt cognitive, affective,
and behavioral processes. Psychological dysregulation was,
in turn, significantly related to all of the additional risk
factors of interest including sexual preoccupation, behavior
problems, parental connectedness, risky peers, and substance use. Taken together, these results suggest that,
while psychological dysregulation does not fully mediate
the relationship between maltreatment and risky sexual
behaviors, it indeed plays a role in additional hypothesized
processes that might contribute to risky sexual behaviors.
To test whether psychological dysregulation plays a
role in additional processes that are associated with risky
sexual behaviors, simultaneous tests of indirect pathways
were conducted. The sum of the total indirect effects was
significant, Z ¼ 5.47, p < .001, indicating that the set of
mediators explained the relationship between psychological dysregulation and risky sexual behaviors. Although all
risk factors were correlated with risky sexual behaviors at
the zero-order level (Table II), only sexual preoccupation
and risky peers emerged as independent predictors of risky
sexual behaviors when in company with the entire set.
Moreover, Figure 2 shows that the b-values from psychological dysregulation to risky sexual behaviors is not significantly different from 0, b ¼ .03, p ¼ .26, indicating that
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Noll, Haralson, Butler, and Shenk
Sexual
Preoccupation
.27**
.21**
Behavior
Problems
.07
.50**
R 2 = .62**
Maltreatment
.29*
Parental
Connectedness
-.16**
Psychological
Dysregulation
-.10
Risky Sexual
Behaviors
.03
.52*
.30**
Risky Peers
.32**
.15
Substance
Use
Figure 2. Multiple mediator analysis showing a total indirect effect by the set of risk factors modeled. Sexual preoccupation emerged as a unique
indirect pathway between psychological dysregulation and risky sexual behaviors. Inter-correlations among risk factors were freely estimated and
are reported in Table II but are not shown in order to simplify the figure. Standardized b parameter estimates shown. *p < .05, **p < .01.
Table II. Inter-correlations among Variables Included in Analyses
Variables
1. Sexual preoccupation
2. Behavioral problems
3. Parental connectedness
1
2
3
4
5
6
7
8
1.0
.07
.05
1.0
.28**
1.0
4. Risky peers
5. Substance use
.19**
.22**
.16**
.21**
.11*
.10*
1.0
.40**
6. Psychological dysregulation
.19**
.44**
.17**
.15**
.27**
7. Risky sexual behaviors
.36**
.21**
.13*
.41**
.48**
.18**
8. Maltreatment
.08
.30**
.15**
.11*
.20**
.23**
1.0
1.0
1.0
.22**
1.0
Note. Pearson product–moment correlations shown except in the case of correlations with maltreatment status which is scored as a dichotomous variable
(1 ¼ maltreated, 0 ¼ comparison) warranting the presentation of point-biserial correlations.
*p < .05, **p < .01.
the set of risk factors fully mediated the relationship
between psychological dysregulation and risky sexual
behaviors. Indeed, when the entire set of independent variables was included, the R2 for risky sexual behaviors was
.62 which constitutes a strong effect size indicating a
relatively high practical impact of the findings reported
(Ferguson, 2009).
Specific indirect effects for each mediator were then
examined to ascertain whether any proposed pathway
significantly accounted for the relationship between
Child Maltreatment and Risky Sexual Behaviors
psychological dysregulation and risky sexual behaviors
while simultaneously estimating other plausible mediators.
As can be seen in Figure 2, the only significant indirect
pathway was that from dysregulation, through sexual preoccupation, to risky sexual behaviors, Z ¼ 3.33, p < .01.
Using effect size calculations for mediational/indirect
effects (MacKinnon, 2008), the significant indirect effect
accounted for 38% of the total zero-order direct effect.
Although there are no guidelines yet available to judge
the relative magnitude of indirect effect sizes, the proportion of variation accounted for by this indirect effect corresponds to a moderate to strong squared associational
effect (Ferguson, 2009). Although the b-values from psychological dysregulation to risky peers and from risky peers
to risky sexual behaviors were both significant, the indirect
effect was not significant.
Discussion
This study tested indirect pathways of a host of risk factors
in an effort to better understand the links between maltreatment, psychological dysregulation, and risky sexual
behaviors. The results support an association between psychological dysregulation and a host of key variables that
can place adolescent females at risk for further developmental disruption. These include behavior problems, lack
of parental connectedness, risky peer affiliations, substance
use, and sexual preoccupation. All of these variables were
associated with risky sexual behaviors at the zero-order,
correlation level. These associational patterns suggest that
dysregulation likely plays an important role in the development of risky sexual behaviors at the level of affective,
behavioral and cognitive processing.
Associated risk factors were then simultaneously
assessed in a multiple mediator analysis to determine
unique pathways to risk sexual behaviors. Sexual preoccupation was the most potent predictor of sexual risk-taking
when evaluated along with risky peers, parental connectedness, behavior problems, substance use. Out of all these
risk factors, only sexual preoccupation helped explain the
process by which psychological dysregulation operates
on adolescent risky sexual behavior. Indeed, the results
suggest that psychological dysregulation and sexual preoccupation function together to illuminate an important
indirect pathway to sexual risk-taking above and beyond
other plausible avenues. Female adolescents who have difficulty regulating their emotions, cognitions, and behaviors
may be unable to effectively compartmentalize these preoccupations to a degree that keeps them from acting on
sexual impulses and resisting the propensity to engage in
sexual behaviors.
The inability to effectively regulate emotions, cognitions, and behaviors, coupled with a preoccupation with
sexual thoughts and stimuli, can help explain why maltreated adolescent females are at risk for engaging in
risky sexual behaviors. According to the Traumagenics
Dynamics model (Finkelhor & Browne, 1986), childhood
maltreatment may result in cognitive distortions around
sexuality stemming from the severe boundary violations,
betrayal, stigma, shame, and powerlessness that characterize extreme traumatization. Hence, when faced with sexual
impulses, especially those that are difficult to regulate, maltreated adolescents may act accordingly and adopt risky
sexual behaviors. Theses results suggest that maltreatment
might dysregulate one’s ability to modify or alter cognitions, putting those who have higher sexual preoccupation—a cognitive process itself—at risk for further
disruption and for engagement in risky sexual behaviors.
As such, this study offers potential implications for
prevention efforts and clinical interventions in the pediatric
setting. These data suggest that psychological dysregulation
increases the risk for engagement in risky sexual behavior.
However, further examination of this relationship indicated
that sexual preoccupation, including frequent masturbation, pornography consumption, and intrusive sexual
thoughts, fully mediated the relationship between psychological dysregulation and risky sexual behavior even when
accounting for other associated risk factors. Pediatric psychologists should assess the presence of psychological dysregulation, sexual preoccupation, and sexual activity when
working with female adolescents with a maltreatment history. In turn, interventions should focus on addressing
current sexual thoughts, attitudes, and behaviors in order
to reduce engagement in risky sexual activity. This can be
accomplished through cognitive-behavioral interventions
or even education about safe sex hygiene for those not
yet engaging in sexual activity. Parents and pediatric practitioners should emphasize ways in which adolescents can
field sexual thoughts and feelings and should discuss various healthy means of sexual expression. Being especially
vulnerable, female adolescents who have been maltreated
may need augmented interventions regarding effective
strategies to deal with sexual thoughts and warding-off
sexual advances.
These findings are considered in light of several limitations of the current study. First, the cross-sectional
nature of the data precludes strong causal inferences and
the indirect pathways reported should not be interpreted as
temporally-ordered mediation. The testing of indirect pathways is one approach to parsing out variability according to
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sound theory. The model tested provides a means by which
we can examine a theoretically plausible representation of a
multivariate system of interrelationships and pathways
that, when included in the same equation, can advance
knowledge by allowing variability to be parsed in meaningful ways that are not possible when these variables are
examined in isolation. Second, although there is some
good evidence and sound theory to suggest that, due to
its explicit nature, sexual abuse would constitute the highest risk for aberrant development, we are unable to speak
to whether or not the model we tested fits the data better
for one specific type of abuse versus another. Sub-sample
size limitations preclude multiple group SEM, however we
did examine, on an experimental basis, zero-order correlations for sexually abused, physically abused and neglected
adolescents separately. Although interrelationships among
key constructs were generally stronger for the sexual abuse
sub-sample, no obvious appreciable differences across
sub-samples were found. Future research should be
aimed at articulating (a) the unique roles that different
forms of childhood maltreatment might play in the development of adolescent sexuality; and (b) how the experience of multiple types of maltreatment might exacerbate
vulnerability for risky behavior. Third, we utilized a sample
of victims with substantiated maltreatment. While this
method constitutes rigor in terms of objective confirmation
of maltreatment, it may inherently decrease sensitivity by
excluding cases of unreported or unsubstantiated maltreatment and, accordingly, may limit generalizability. Fourth,
we are unable to comment on how effects might be different for males as compared to females. Although there is
some recent evidence to suggest that trajectories to risky
sexual behaviors do not necessarily differ for males versus
females (Jones et al., 2010), male sexual development has
been largely understudied (Senn, Carey, & Vanable, 2008)
and we recognize that moderation analyses would be preferable to simply controlling for gender. Such a design
would require relatively large samples of both male and
female adolescents in order to adequately describe the
unique pathways to risky sexual behaviors experienced
by both. Finally, we are unable to speak to emerging evidence that dysregulation in maltreated adolescents may be
in part due to the dynamic interplay of multiple physiological systems. Studies have linked various childhood maltreatment and violence exposures to changes in the
hypothalamic–pituitary–adrenal
axis
(Cicchetti
&
Rogosch, 2001), cardiovascular (Cooley-Quille, Boyd,
Frantz,
&
Walsh,
2001),
and
sympathetic-adrenomedullary
systems
(El-Sheik,
Cummings, & Goetsch, 1989), as well as dysfunctional
coordination among multiple physiological systems
(Gordis, Granger, Susman, & Trickett, 2008) all of which
have implications for stress modulation, vigilance and
action-oriented behaviors.
Female victims of childhood maltreatment exhibit a
host of behaviors and attitudes with consistent deviations
in normal sexual development such as early coital initiations, (Fergusson, Horwood, & Lynskey, 1997) more
sexual partners, (Luster & Small, 1997) risky sexual behavior, (Chandy et al., 1996), and teen pregnancy (Noll et al.,
2009). Although one longitudinal, prospective study
reported how sexual preoccupation played a key role in
later risky sexual behaviors (Noll et al., 2003), there has
been scant empirical devotion to the mechanisms and processes by which sexual preoccupation operates to place
victims at inordinate risk. These results suggest that the
concept of psychological dysregulation may be a key
element that should be included in future permutations
of mechanistic research and in models of aberrant sexual
development.
Acknowledgment
The authors would like to acknowledge Paul Succop, PhD.,
Mimi L. Boheme, and Amy S. Taylor, MFA, for their instructional elegance.
Funding
This article was supported in part by National Institutes of
Health grant R01HD052533.
Conflicts of interest: None declared.
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