AIDS and Behavior, Vol. 8, No. 4, December 2004 (C ?2004)
Women, Trauma, and HIV: An Overview
Gail E. Wyatt,1,2Hector F. Myers,1and Tamra B. Loeb1
Women and other vulnerable populations con-
tinue to be disproportionately affected by the
HIV/AIDS epidemic. There are an estimated
800,000–900,000 people currently living with HIV
in the US, with ∼40,000 new HIV infections each
year (CDC, 2004). This steady increase in rates of
HIV/AIDS is a challenge to clinicians, behavioral
scientists, and policy analysts, who are responsible
for the development of treatment approaches, in-
terventions, and services that focus on minimizing
the behaviors that contribute to these growing num-
bers.This section isdevoted todiverse populations of
women who are at risk for or living with HIV. Eco-
nomic, relationship, lifestyle, and immigration fac-
tors, along with substance abuse and risky relation-
ships increase risk for HIV transmission and disease
progression. While high-risk behaviors have been the
primary focus of prevention efforts, increasing atten-
tion is being directed to how trauma may contribute
to both HIV risk behaviors and disease sequelae.
The research in this section goes beyond describing
women’s risky behaviors and examines the contribu-
tions of personal and interpersonal sexual and physi-
cal abuse trauma as independent risk factors (Wyatt
et al., 2002). Past and current sexual risk-taking can
develop into a template for future behaviors that are
ultimately AIDS related.
The likelihood of sexual or physical abuse oc-
curring in a woman’s life is not uncommon. Personal
trauma, specifically childhood sexual abuse (CSA)
before the age of 18, is defined as sexual activity that
may or may not involve physical force ranging from
unwanted touch to sexual penetration with an object,
and/or sexual intercourse (Kruttschnitt et al., 2004).
One out of every three girls is sexually abused by age
18 (Finkelhor, 1994; Kohn, 1987; Loeb et al., 2002;
1Neuropsychiatric Institute, UniversityofCalifornia, LosAngeles.
2Correspondence should be directed to Gail E. Wyatt, Depart-
ment of Psychology, University of California, Los Angeles;
Wyatt et al., 1992; Wyatt et al., 1999). Intimate part-
ner violence, including actual or threatened physi-
cal or sexual violence or psychological and emotional
abuse directed toward a spouse or intimate partners
affects as many as one in four women in the US
(Tjaden and Thoennes, 2000). Young adult lifetime
exposure rates to community level violence range
from 76% to 82% for victimization, specifically expo-
sure to traumatic violence and the general milieu of
a harsh or dangerous environment (McLeer and An-
war, 1989; Scarpa, 2003). Indeed, a woman is more
likely to be exposed to risks for HIV and to expe-
rience sexual or physical harm in her lifetime than
she is to complete college (US Bureau of the Cen-
sus, 2002). These risks are even greater for women
from diverse ethnic and socioeconomic groups. Re-
search has shown that histories of physical and sexual
trauma can affect the decisions women make with re-
gard to risks for sexually transmitted infections and
HIV, including the choice of partners and the ability
to negotiate the use of barrier methods of protection
with them. Therefore, it is important to understand
the relationship between trauma and HIV for women
and the context in which risks and protective factors
The studies in this section document findings
from various data sources funded by NIH and other
sources. Some studies use shared datasets with sam-
ples from AIDS epicenters, while other studies in-
clude samples from understudied groups. Paxton
et al. (2004) and Newcomb and Carmona (2004) use
data from the Los Angeles County Women and Fam-
ily dataset, a longitudinal study of a multi-ethnic
sample of HIV-positive and negative women. El-
Bassel and associates utilize a New York sample.
Galvan et al. (2004) use the HIV Cost and Ser-
vices Utilization Study (HCSUS), a national study
of women and men of diverse ethnicities and sex-
ual orientations. Wyatt et al. (2004) use data from
the Los Angeles County Women’s Health Project
dataset, one of the first risk-reduction interventions
1090-7165/04/1200-0401/0 C ?2004 Springer Science+Business Media, Inc.
402Wyatt, Myers, and Loeb
specifically designed for multi-ethnic samples of
HIV-positive women with histories of CSA.
The samples included in this section target pop-
ulations of women and their sexual partners that
are diverse with respect to ethnicity, gender, age,
socio-economic status, sexual orientation, primary
language, HIV serostatus, and cultural background.
These studies address the effects of a range of trau-
matic experiences, including sexual, physical, and
community level violence on mental and physical
health outcomes. The studies range in sample size,
with large samples of African American, Latina, and
European American women (see Galvan et al. (2004)
and Tucker et al. (2004)), and a smaller sample of
Asian Pacific Islander women (Nemoto et al., 2004).
These samples are also diverse with respect to risk
categories, ranging from sex workers (Nemoto et al.,
women living in shelters (Tucker et al., 2004). Three
Tucker et al., 2004; Wyatt et al., 2004)—one in-
cludes HIV-negative women at risk (El-Bassel et al.,
2004), and the three studies compare HIV-positive
and HIV-negative women (Paxton et al., 2004; New-
comb and Carmona, 2004). Finally, one study reports
the initial results of the first risk-reduction interven-
tion for HIV-positive women with trauma histories
(Wyatt et al., 2004).
The focus on outcomes includes a variety of risk
factors (i.e., substance use, poverty, homelessness, a
history of trauma, risky relationships, language bar-
riers, risky behaviors). Ethnicity and cultural values
and beliefs are used as a lens through which risks and
decision-making are filtered. The following are de-
scriptions of the specific papers:
Nemoto et al. (2004) examined high-risk behav-
iors of 43 Asian female massage parlor workers in
San Francisco. With regard to STIs and HIV risks,
they found that frequent exposure to physical or ver-
bal abuse and persistent HIV risk behaviors was as-
tus, and legal factors related to their work, and the
nature of their employment. The findings call for
individualized and community-level interventions to
improve women’s health and decrease prolonged ex-
posure to risks for STIs and violence.
Galvan et al. (2004) used the HCSUS dataset in-
cluding 1421 HIV-positive men and women who are
diverse with respect to sexual orientation to identify
characteristics of those most at-risk for intimate part-
ner violence (IPV). They report that women did not
differ from gay men in the likelihood of being per-
petrators or victims of IPV. The findings highlight
the need for interventions to address the presence of
abuse in close relationships in all risk groups.
Other studies focused on men on methadone
and the effects on their female partners. El-Bassel
et al. (2004) used structural equation modeling to
examine the validity of a model that assessed male
gender role beliefs, substance use, and couple drug
involvement in a random sample of 322 men on
methadone. Their findings confirmed that drug in-
volvement and psychological dominance increased
risks for IPV and sexual risk behavior. The need for
interventions that target drug involved men and their
sexual partners to include interpersonal violence-
reduction skills in their curriculum is apparent.
Paxton et al. (2004) examined CSA, other life
traumas, and other psychosocial variables as pre-
dictors of risk behaviors in the multi-ethnic sample
of HIV-positive and -negative women enrolled in
the UCLA–Charles R. Drew University Women and
Family Project. They found that a history of trauma,
which increased the likelihood of engaging in high-
risk behaviors by 5.1%, ethnicity, drug and alcohol
use, homelessness, and being HIV positive were all
independent predictors of frequency of high-risk sex-
ual behavior. They call for more specialized services
for HIV-positive women to address sexual trauma
Newcomb and Carmona (2004) examined cul-
tural factors that contribute to poorer psychologi-
cal adjustment in a community sample of 87 HIV-
positive and 34 HIV-negative Latinas over a year.
Findings indicated that both acculturation and HIV-
status were related to poorer psychological adjust-
ment and substance use; however, these findings did
not hold over time. Education was a protective fac-
tor in reducing HIV risks, depression, and interper-
sonal violence, but increased risks for illicit drug use.
Tucker et al. (2004) conducted a 6-month prospec-
tive study of 810 women residing in shelters and
low-income housing. The study investigated asso-
ciations of recent violence and substance use with
HIV-related sexual behaviors and cognitions. Find-
ings point to the importance of conducting prospec-
tive studies in order to better understand the short-
and long-term impact of violence and substance use
on women’s HIV-related outcomes.
Finally, Wyatt et al. (2004) report the results
of a randomized Phase I clinical trial testing the ef-
ficacy of a culturally congruent psycho-educational
intervention that was designed to reduce sexual
risks and increase medication adherence among 147
Women, Trauma, and HIV403 Download full-text
HIV-positive African American and Latina women
with histories of CSA. Findings provide initial sup-
port for the efficacy of the Enhanced Sexual Health
Intervention in reducing sexual risk behaviors com-
pared to attention controls. Results also indicated a
dose–response relationship with medication adher-
ence, such that only women who attended eight or
more sessions evidenced greater adherence to their
HIV-medication regimen than those who attended
fewer sessions. The next step for this intervention is
to test its efficacy on larger and more representative
samples, with the ultimate goal of preparing this in-
tervention for delivery in community-based organi-
In summary, the studies together indicate that
traumatic experiences are prevalent among HIV pos-
itive women and men and among those at risk for this
disease. These studies also note that much of this vio-
posure (e.g., CSA) and current exposure and perpe-
tration exacerbate risk by affecting sexual decision-
making and psychological adjustment. Finally, one
study demonstrates the utility of addressing skills for
coping with traumatic past experiences into a behav-
ioral risk reduction intervention. The fact that these
results were obtained in samples that were diverse
with respect to ethnicity, gender, socio-economic sta-
tus, sexual orientation, and HIV serostatus supports
the conclusion that violence and trauma in the con-
text of close personal relationships is an important
and understudied riskfactor in HIV transmissionand
disease sequelae. This is especially true for women of
color and from lower SES backgrounds. Preliminary
results of one study also suggest that intervening with
women who carry the double burden of living with
HIV and having a history of early sexual trauma can
be effective in increasing safer sexual practices and
improving HIV medication compliance. Hopefully,
these findings will help to move the field of HIV pre-
vention and intervention forward.
Centers for Disease Control (CDC). (2004). Recommendations
for incorporating Human Immunodeficiency Virus (HIV)
prevention into the medical care of persons living with HIV.
Clinical Infectious Diseases, 38, 104–121.
El-Bassel, N., Gilbert, L., Golder, S., Wu, E., Chang, M.,
Fontdevila, J., and Sanders, G. (2004). Deconstructing the
relationship between intimate partner violence and sexual
AIDS and Behavior, 8(4), 429–440.
Finkelhor, D. (1994). Current information on the scope and nature
of child sexual abuse. Future of Children, 4(2), 31–53.
Galvan, F., Collins, R., Kanouse, D., Burnam, A., Paddock, S.,
Beckman, R., and Mitchell, S. (2004). Abuse in the close rela-
tionships of people with HIV. AIDS and Behavior, 8(4), 441–
Kohn, A. (1987). Shattered innocence. Psychology Today, 21, 54–
Loeb, T., Williams, J. K., Carmona, J. V., Rivkin, I. D., Wyatt, G.,
Chin, D., and Asuan-O’Brien, A. (2002). Child sexual abuse
associations with the sexual functioning of adolescents and
adults. Annual Review of Sex Research, 8.
McLeer, S. V., and Anwar, R. (1989). A study of battered women
presenting in an emergency department. American Journal of
Public Health, 79(1), 65–66.
Nemoto, T., Iwamoto, M., Wong, S., Le, M. N., and Operario, D.
(2004). Social factors related to risk for violence and sexually
transmitted diseases/HIV among Asian massage parlor
workers in San Francisco. AIDS and Behavior, 8(4), 475–483.
Newcomb, M. D., and Carmona, J. V. (2004). Adult trauma and
HIV status among Latinas: Effects upon psychological adjust-
ment and substance use. AIDS and Behavior, 8(4), 417–428.
Paxton, K. C., Myers, H. F., Hall, N. M., and Javanbakht, M.
(2004). Ethnicity, serostatus and psychosocial difference
in sexual risk behavior among HIV-seropositive and HIV-
seronegative women. AIDS and Behavior, 8(4), 405–416.
of male-to-female and female-to-male intimate partner vio-
lence as measured by the National Violence Against Women
Survey. Violence Against Women, 6(2), 142–161.
Tucker, J. S., Wenzel, S. L., Elliott, M. N., Marshall, G. N., and
Williamson, S. (2004). Interpersonal violence, substance use,
and HIV-related behavior and cognitions: A prospective
study of impoverished women in Los Angeles County. AIDS
and Behavior, 8(4), 463–474.
U.S. Bureau of the Census. (2002). The United States in inter-
national context: 2000 Census brief. Retrieved, 2004, from
the World Wide Web: http://www.census.gov/prod/2002pubs/
Wyatt, G. E., Carmona, J. V., Loeb, T. B., Ayala, A., and
Chin, D. (2002). Sexual abuse. In G. M. Wingood and R. J.
DiClemente (Eds.), Handbook of women’s sexual and repro-
ductive health. Issues in women health (pp. 195–216). New
York: Kluwer Academic/Plenum Publishers.
Wyatt, G. E., Guthrie, D., and Notgrass, C. M. (1992). Differ-
ential effects of women’s child sexual abuse and subsequent
sexual revictimization. Journal of Consulting and Clinical
Psychology, 60(2), 167–173.
Wyatt, G. E., Loeb, T. B., Solis, B., Carmona, J. V., and Romero,
G. (1999). The prevalence and circumstances of child sexual
abuse: Changes across a decade. Child Abuse and Neglect,
Wyatt, G. E., Longshore, D., Chin, D., Carmona, J. V., Loeb,
T. B., Myers, H. F., Warda, U., Liu, H., and Rivkin, I. (2004).
The efficacy of an integrated risk reduction intervention for
HIV-positive women with child sexual abuse histories. AIDS
and Behavior, 8(4), 453–474.