Features
JANAC Vol. 12, No. 5, September/October 2001
Relf / Childhood Sexual Abuse in MSM
Childhood Sexual Abuse in Men Who
Have Sex With Men: The Current
State of the Science
Michael V. Relf, PhD, RNCS, ACRN, CCRN
The experience of childhood sexual abuse (CSA)
among men, particularly men who have sex with men
(MSM), is poorly understood. Consequently, the
long-term psychological and behavioral conse-
quences of this phenomenon are unclear. This article
provides a critique and synthesis of the existing litera-
ture on childhood sexual abuse in MSM. After an
examination of prevalence estimates reported in the
literature, the mental health and substance abuse
behaviors in MSM that were the victims of CSA will be
examined. In addition, the relationship between CSA
and sexual identity development and HIV risk behav-
iors is critically evaluated. Finally, implications for
nursing practice are explored.
Key words: childhood sexual abuse, gay men,
bisexual men, HIV/AIDS nursing
As the gay revolution of the last 25 years of the 20th
century unfolded, gay and bisexual men migrated to
large urban centers to live open lifestyles (Hays &
Peterson, 1994). These large cities offered gay neigh-
borhoods, or gay “ghettoes” as they are commonly
referred to in the gay community, where gay, lesbian,
and bisexual individuals could work, live, and love
openly without fear of harassment, abuse, and inten-
tional violence (Hays & Peterson, 1994; Paradis,
1997). Ironically, these gay urban centers that fostered
freedom, liberation, and sexual exploration for its resi-
dents and visitors also have served as the major AIDS
epicenters for gay and bisexual men throughout the
epidemic (Hays & Peterson, 1994).
Without a preventative HIV vaccine or medical
cure, interventions leading to and sustaining behavior
JOURNAL OF THE ASSOCIATION OF NURSES IN AIDS CARE, Vol. 12, No. 5, September/October 2001, 20-29
Copyright © 2001 Association of Nurses in AIDS Care
modification remain the only mechanisms to prevent
HIV infection (DiClemente & Peterson, 1994). Mod-
ifying HIV risk behaviors are a complex challenge in
the interpersonal relationships of individuals at risk.
Not only are there interpersonal challenges and life
experiences to overcome, but there are also social, psy-
chological, and cultural obstacles to surmount in order
to curtail the epidemic (DiClemente & Peterson,
1994). Although gay and bisexual men are among the
most knowledgeable about HIV prevention, the epi-
demic continues in this risk group (Centers for Disease
Control and Prevention [CDC], 2000). The current lit-
erature on HIV risk behaviors in gay and bisexual men
is starting to document the relationship between early
adverse life experiences such as childhood sexual
abuse and adult risk behaviors including alcohol and
drug use as well as sexual risk behaviors.
Method
To examine the literature for this critique and syn-
thesis, a computerized literature search was conducted
using CINAHL for nursing, MEDLINE for medicine
and public health, and PsychNet for psychology and
sociology. When identifying the literature for this state
of the science article, the period from 1966 through
Michael V. Relf, PhD, RNCS, ACRN, CCRN, is an assistant
professor of nursing at Georgetown University School of
Nursing and Health Studies.

June 2000 was searched. The key words searched
included child abuse, childhood sexual abuse, sexual
abuse, rape, forced sex, gay men, bisexual men, men
who have sex with men, homosexual, homosexuality,
HIV, AIDS, and nursing.
After obtaining the computer-search-identified arti-
cles, reference lists from the identified articles were
reviewed for nonidentified articles. Finally, a detailed
manual search was undertaken to identify any missing
literature from the following journals: Child Abuse
and Neglect, Violence and Victims, and AIDS Educa-
tion and Prevention.
Preventing HIV in Men
Who Have Sex With Men (MSM)
In response to the epidemic, gay and bisexual men
have significantly modified sexual behaviors to reduce
risk (Becker & Joseph, 1988; Hospers & Kok, 1995;
McKusick, Hoff, Stall, & Coates, 1991; Stall, Coates, &
Hoff, 1988). However, the modification of behavior is
inconsistent in MSM outside of the large AIDS epi-
centers (Kelly, St. Lawrence, Betts, Brasfield, &
Hood, 1990; Kelly, St. Lawrence, Brasfield, et al.,
1990), in young MSM (Kegeles, Hays, & Coates,
1996; Lemp et al., 1994; McAuliffe et al., 1999;
Osmond et al., 1994; Rotheram-Borus, Reid, &
Rosario, 1994), and in MSM of color (Carballo-
Dieguez & Dolezal, 1996; Peterson et al., 1992;
Ramirez, Suarez, de la Rosa, Castro, & Zimmerman,
1994). Furthermore, long-term maintenance of modi-
fied sexual behaviors is also a significant problem for
all MSM (Adib, Joseph, Ostrow, & James, 1991;
Ekstrand & Coates, 1990; Miller, 1995).
Although the demographics of the AIDS epidemic
are changing in the United States, the absolute number
and the highest percentage of AIDS cases still occur in
MSM—particularly among gay men in the large AIDS
epicenters (CDC, 2000). The current epidemiological
evidence clearly demonstrates the significant health
impact of HIV and AIDS in the gay and bisexual male
population. Twenty years into the epidemic, HIV dis-
ease continues unabated among MSM. In addition,
current epidemiological evidence suggests that the fol-
lowing two particularly vulnerable populations of
MSM exist: young MSM and MSM of color. Evalua-
tion of other empirical evidence suggests that the HIV
Relf / Childhood Sexual Abuse in MSM 21
prevention message does not always reach or meet the
health information or risk behavior modification needs
of bisexual MSM (Doll & Becker, 1996; Heckman et al.,
1995).
To reduce the years of potential life lost before the
age of 65 (YPLL–65) due to HIV and AIDS, HIV pre-
vention programs must continue to be funded, theoret-
ically designed, and empirically tested to meet the
needs of the intended audience. Prevention of HIV and
other sexually transmitted diseases (STDs) needs to be
based on the sexual behaviors that place persons at risk
for infection (CDC, 1998) as well as reflect the social,
economic, behavioral, life-experience-related, and
other factors associated with HIV transmission (CDC,
1996). Early adverse life experiences involving child-
hood physical abuse, parent-parent physical violence,
and drug use, as well as childhood sexual abuse,
requires screening and treatment when unresolved
issues are identified because these experiences are
associated with adult risk behaviors associated with
HIV.
Childhood Sexual Abuse
and HIV Risk in MSM
The empirical literature examining the long-term
psychological and behavioral outcomes of childhood
sexual abuse (CSA) in men, particularly in MSM, is
scant (Bartholow et al., 1994). Consequently, an accu-
rate understanding of the potential influences of CSA
in men as it relates to health behaviors is unclear. The
few studies examining this issue in men have identified
the outcomes of sexual abuse to include problems in
social adjustment; psychological disorders including
anxiety, depression, and substance use; and confusion
about sexual identity (Carballo-Dieguez & Dolezal,
1995). In addition, Zierler et al. (1991) identified an
increased probability of behaviors associated with the
risk for STDs, including HIV infection, in adult men
who were the victims of sexual abuse.
The sexual abuse of male children and adolescents
has historically been unmentionable and disbelieved
(Anderson, 1982). As a result, the victims have often
been underserved and neglected by clinicians, advo-
cates, and policy makers. The societal expectations of
men have significantly hindered the recognition of
men as victims of sexual abuse (Bartholow et al.,
22 JANAC Vol. 12, No. 5, September/October 2001
1994), partly due to the role expectations or typecast-
ing of males as dominant, competitive, aggressive, and
tough (Bolton, Morris, & MacEachron, 1989). This
critique and synthesis will examine the prevalence
rates and outcomes of CSA in males as well as its rela-
tionship to HIV risk behaviors.
Prevalence
Finklehor (1987) estimated that between 3% and
31% of American men have been sexually abused
before the age of 18. This estimation closely matches
the actual prevalence rates of CSA among men in the
empirical literature, which demonstrated rates
between 3% (Lodico & DiClemente, 1994) and 29%
(Zierler et al., 1991). In the studies examining CSA in
MSM, the prevalence rates were considerably higher
and varied from 11.8% (Duncan, 1990) to 37% (Doll
et al., 1992). In a national probability sample of men
with a history of same-sex cohabitation, 26.2% of the
sample (n = 65) reported a lifetime history of being
raped. In this sample, 15.4% experienced sexual abuse
before the age of 18, with the remaining 10.8% experi-
encing sexual abuse after age 18 (Tjaden, Thoennes, &
Allison, 1999).
In a sample of 1,001 ethnically diverse MSM
recruited from STD clinics in Chicago, San Francisco,
and Denver, 37% (n = 369) of the sample reported sex-
ual contact before the age of 19 in situations in which
they perceived the perpetrator as being older or more
powerful (Doll et al., 1992). On the first occasion when
the sexual contact occurred, 94% of the contacts were
with a male partner. The median age at time of contact
was 10 (range: 2 to 17). Most participants reported
engaging in oral-genital (39%) or anal-genital (33%)
sex during the contact. In this study, the Black and His-
panic participants were much more likely to report
sexual contact with an older or more powerful partner
than were White participants (Black, 52%; Hispanic,
50%; White, 32%; p < .0001).
In a sample of primarily White (94.8%), well-
educated (M = 16 years), middle-aged (M = 39.5 years)
homosexual men, a large percentage, 35% (n = 116),
reported at least one abusive childhood sexual experi-
ence (Lenderking et al., 1997). Similarly, Jinich et al.
(1998) identified the prevalence of CSA in a sample of
homosexual men to be 28%. In both samples, the per-
petrators were nearly always men (95.7% and 95.9%)
with the perpetrator being generally from outside of
the family (62.9% and 69.9%). In one sample
(Lenderking et al., 1997), 62.9% (n = 73) experienced
the abuse before age 13 and 37.1% (n = 43) between
ages 13 and 16; in the other sample, 71% (n = 379)
were abused before the age of 12, whereas 29% were
abused between the ages of 13 and 15.
Finally, among university students participating in a
study to examine the lifetime prevalence of sexual
abuse victimization, 11.8% of the male students who
self-identified as gay had a lifetime prevalence of sex-
ual victimization compared with 3.6% in the hetero-
sexual male sample (Duncan, 1990). The characteris-
tics of the abuse and the age and ethnicity of the study
participants were not included. Therefore, the applica-
bility of results from this study is limited.
Mental Health and Substance
Use Related to CSA
Among MSM who have experienced CSA, the feel-
ings of rage toward their assailants, toward society for
ignoring or condoning the victimization, and toward
the gay community for being insensitive to victims of
CSA often lead to negative emotional consequences,
including depression and chronic low self-esteem
(Anderson, 1982). Numerous studies have demon-
strated the negative emotional reactions of CSA in
men. These negative emotional reactions are varied
and include attempted suicide, depression, anxiety,
anger, guilt, detachment, and substance abuse disor-
ders (Briere, Evans, Runtz, & Wall, 1988; Dimock,
1988; Myers, 1989). In addition, problems with sexual
identity development (Dimock, 1988; Johnson &
Schrier, 1985; Myers, 1989) and high-risk sexual
behaviors as adults (Zierler et al., 1991) have been
identified as outcomes of CSA in MSM.
The relationship between CSA and mental health
outcomes is suggested in the literature by numerous
authors (Anderson, 1982; Bartholow et al., 1994;
Breire et al., 1988; Dimock, 1988; Finklehor, 1987;
Hunter, 1991; Kuhn, Arellano, & Chavez, 1998;
Lodico & DiClemente, 1994; Stein, Golding, Siegel,
Burnam, & Sorenson, 1988; Strathdee et al., 1998;
Zierler et al., 1991). However, only a limited number

of studies empirically examined mental health and
substance use as an outcome of CSA.
In the three identified studies of gay and bisexual
men who experienced CSA (Bartholow et al., 1994;
Jinich et al., 1998; Strathdee et al., 1998), the individu-
als who were abused as children or forced into
nonconsensual sex as adults were more likely than
nonabused men to have problems with alcohol, drug
use, and depression. Among young MSM, Strathdee
et al. (1998) identified that the abused men had higher
depression scores (odds ratio [OR] = 1.56; 95% confi-
dence interval [CI] = 1.02, 2.39) and were significantly
more likely to use several recreational drugs (OR =
2.30; CI = 1.53, 3.45) during the previous year.
Similarly, men who experienced CSA were more
likely to have been hospitalized for substance use
problems and depression than the nonabused control
participants (Bartholow et al., 1994). In this sample of
ethnically diverse MSM (27% of total sample), abused
men were more likely to have used cocaine (c2 = 4.19,
p = .04), crack (c2 = 8.76, p = .003), stimulants (c2 =
4.80, p = .028), hallucinogens (c2 = 7.51, p = .006), and
opiates (c2 = 16.06, p = .0001). In addition, the total
Michigan Alcohol Screening Test score indicating the
degree of alcohol-related impairment was signifi-
cantly higher for the abused MSM than for those who
were not abused. In another study, Jinich et al. (1998)
identified that men who experienced CSA involving
either strong coercion or physical force scored signifi-
cantly higher on depression symptoms (M = 6.42) than
did men who reported no coercion or mild coercion
(M = 5.22, p < .05) and those who were not abused (M =
5.12, p < .05).
In studies of CSA of men in which sexual orienta-
tion of participants was not identified, CSA was again
strongly associated with drinking before sex (Lodico &
DiClemente, 1994) and depression (Hunter, 1991;
Kuhn et al., 1998). In a small, cross-sectional study of
adolescent Mexican American (n = 37, mean age =
16.74) and non-Hispanic White men (n = 27, mean
age = 16.81), depression was significantly higher in
the sexual assault group, F = 6.46 (1, 1356), p < .01,
when compared with adolescents without a history of
sexual assault (Kuhn et al., 1998). However, because
the ethnicity demographics of the sample were not
included in one study (Lodico & DiClemente, 1994)
Relf / Childhood Sexual Abuse in MSM 23
and the sexual orientation of participants was not
included in any of the three studies (Hunter, 1991;
Kuhn et al., 1998; Lodico & DiClemente, 1994), the
generalizability of results to MSM and MSM of color
is limited.
CSA and Gay Identity
The relationship between CSA and sexual identity
confusion has been reported in the literature. It is not
to be assumed, nor does the following review of the
literature indicate, that childhood sexual abuse in
men “causes” them to grow up to be gay or bisexual.
Rather, as J. Catania (personal communication, May 18,
2000) suggests, the relationship among these factors
are complex and interactive. For instance, some ado-
lescent males who are exploring their sexual devel-
opment and questioning their sexual identities may
seek out and engage in sexual relations with older
men. Certainly, some of these encounters may be
coercive in nature. Yet, for many adolescent males,
this may have been the only venue for sexual explora-
tion. In the school or neighborhood environment,
attempts to initiate sexual exploration or contacts
with another adolescent male could lead to physical
violence and psychological harassment, which may
further complicate sexual identity issues. Therefore,
the following review does not examine CSA and gay
identity or sexual orientation from a cause-effect per-
spective but, rather, to present evidence to help expli-
cate the relationship between CSA and gay identity
development.
Among 14 adult heterosexual and homosexual ther-
apy patients in treatment for sexual abuse as boys or
young adults, 64% were conflicted regarding their sex-
ual orientation (Myers, 1989). Similarly, in a qualita-
tive study of 26 men who experienced childhood sex-
ual abuse and among the participants who were abused
by men (n = 7), issues surrounding their sexuality and
homosexuality were common (Lisak, 1994). In both
studies (Lisak, 1994; Myers, 1989), gay and hetero-
sexual participants who were abused by men were
intensely homophobic and fearful of homosexuals, as
manifested by an irrational dread, loathing of homo-
sexuality and homosexual behavior, or hostility
toward homosexuality. These findings are similar to
those of Marmor (1980). However, because these
24 JANAC Vol. 12, No. 5, September/October 2001
studies were based on clinical samples, the intensity of
homophobia may be exaggerated.
In several studies, CSA was associated with homo-
sexual behaviors during adolescence and in adulthood.
Among 40 males at an adolescent medical clinic who
reported sexual abuse, researchers found that in com-
parison with age-matched random controls, those indi-
viduals experiencing sexual abuse were 7 times more
likely to self-identify as homosexual and 6 times more
likely to identify as bisexual. Similarly, among men
sexually abused by older men during childhood,
Finklehor (1979) identified that the abused men were 4
times more likely than nonabused men to engage in
homosexual behaviors as adults. In a sample of abused
youth in 10 American cities, Cunningham, Stiffman,
Dore, and Earl (1994) found that after controlling for
race, the odds were significantly increased for youth
who had been raped to engage in homosexual activity
during adolescence and young adulthood.
This finding, however, is not consistent across the
literature. Fromuth and Burkhart (1989) found that
sexually abused male college students (n = 582) from
two different geographic locations in the United States
were no more likely to report a homosexual experience
than the nonabused men in the study. However, in this
study, nearly three quarters of the perpetrators were
female, and the abusive episode was generally not neg-
atively viewed. This contrasts to the other studies in
which a male was most commonly the perpetrator and
the abusive episode was frequently negatively
viewed.
Among gay and bisexual men, the process of gay
identity development was different in men who had
oral or anal sex prior to their sexual abuse experience
in comparison with men whose first sexual experience
with another man was related to sexual abuse
(Bartholow et al., 1994). An important outcome of this
study demonstrated that the relationship between CSA
and gay identity development differed based on the
timing of the CSA in relation to the first sexual activity.
In men whose first sexual experience with another man
was abuse related, the process of questioning gay iden-
tity occurred at an earlier age and proceeded differ-
ently than for nonabused men and men whose first
sexual experience was not abuse related.
CSA and HIV
Risk Behaviors
The negative psychological and behavioral mani-
festations of CSA increase the probability of behaviors
placing individuals at risk for STDs, including HIV,
according to Zierler et al. (1991). In a large, multicity
study of gay and bisexual men with 27% of the sample
representing men of color, sexually abused men were
more likely (OR = 1.36; 95% CI = 1.04 to 1.77) to have
engaged in at least one instance of unprotected anal
intercourse during the 4-month preinterview period
(Bartholow et al., 1994). Furthermore, abused men in
this study were significantly more likely to have been
paid for sex by another male partner and to have had an
increased rate of positive syphilis serology. They were
also more likely to report being HIV positive by
self-report and antibody data.
The relationship between CSA or forced-coercive
sex and HIV risk behaviors in adult MSM is consistent
in the literature. Similar to the above findings,
Hirozawa et al. (1993) found that young MSM with a
lifetime history of forced sex were significantly more
likely to have engaged in unprotected anal sex in the
6-month period prior to the interview than those with-
out a history of forced sex. Among Puerto Rican
MSM, CSA was also significantly associated with
unprotected receptive anal intercourse (Carballo-
Dieguez & Dolezal, 1995). Demonstrating a similar
finding, Lenderking et al. (1999) identified that, in a
sample of White (95%), well-educated (M = 16 years)
gay and bisexual men, the only significant predictor of
unprotected receptive anal intercourse was a history of
CSA (OR = 2.13; 95% CI = 1.15 to 3.9). Further illus-
trating this relationship, among 439 young HIV-nega-
tive gay and bisexual multiethnic men (29% of the
sample), individuals who had unprotected anal sex
with a casual partner during the past year were more
likely to report nonconsensual sex as a youth or adult
(Strathdee et al., 1998).
Similarly, Jinich et al. (1998) identified that men
who had been sexually abused as children were more
likely to engage in HIV transmission risk behaviors in
the previous 30 days than those who had not been
abused (9.5% vs. 5.7%; p < .005). This increased risk
taking included more sexual events, more male

partners, and more sexual episodes under the effects of
recreational drugs. In addition, ethnicity (Latino,
Asian/Pacific Islander, and Native American) and
level of education (having less than a college degree)
were associated with HIV risk behaviors (p < .005 and
p < .001, respectively). Education was also signifi-
cantly related to abuse (p < .00001).
In a retrospective clinical sample of 100 male
patients seeking clinical services for sexual assault as an
adult, 20 victims were threatened with HIV infections
by their assailants (Hillman, O’Mara, Taylor- Robin-
son, & William Harris, 1990). Of the participants, 12
of 17 (71%) who sought medical advice were found to
have an STD that the victim attributed to the attack.
The likelihood of HIV infection was also found to be
more prevalent by Zierler et al. (1991) in men who
were sexually abused. In this study, sexually abused men
were twice as likely to be HIV positive as their
nonabused peers. Other studies have found the conse-
quences of CSA among men to include an increased
likelihood (8 times more likely) to report a history of
prostitution (Zierler et al., 1991), engage in compul-
sive sexual patterns (Dimock, 1988), and have multiple
and anonymous sexual partners (Zierler et al., 1991).
Recent research by Paul, Catania, Pollack, and Stall
(in press) examined the mediators of childhood sex-
ual abuse and HIV risk behaviors in MSM. In this
study of 2,881 men from four major AIDS epicenters
(San Francisco, New York, Los Angeles, and Chi-
cago), multivariate analyses demonstrated that engag-
ing in a “one-night stand,” frequent substance use dur-
ing sex, and a recent experience with an abusive rela-
tionship mediated the relationship between CSA and
sexual risk. Two additional variables identified in the
literature, depression and adult sexual revictimization,
were not significant as mediators. Findings from this
study demonstrate not only the need to assess for a his-
tory of CSA but also to assess sexual behaviors, sub-
stance use patterns, and intimate partner violence in
same-sex relationships.
The relationships between CSA, high-risk behav-
iors, and personality characteristics—including
self-efficacy, self-esteem, and sexual sensation seek-
ing—were also identified in the literature. In a qualita-
tive study of 26 adult male survivors of sexual abuse,
the psychological consequences of CSA included
Relf / Childhood Sexual Abuse in MSM 25
helplessness, self-blame/guilt, and shame/humiliation
(Lisak, 1994). Learned helplessness may be the result
of loss of control associated with the CSA experience
(Paul et al., in press).
Perceived powerlessness and low self-efficacy can
lead to poor interpersonal regulation of adult sexual
experiences, limiting safer sexual behaviors, particu-
larly when the CSA perpetrator used coercive or con-
trolling techniques (Paul et al., in press). Conse-
quently, the cumulative effect of helplessness,
powerlessness, and low self-efficacy may manifest as
a negative self-concept or low self-esteem, impairing
the motivation and ability to successfully implement
risk-reduction intentions. In addition, high levels of
substance use in sexual situations may serve as coping
mechanisms to manage the negative emotions related
to the CSA history. Furthermore, engaging in
one-night stands was identified as a mediator between
CSA and HIV risk behaviors, possibly indicating sex-
ual preoccupation, low interpersonal regulatory abili-
ties, and poor risk appraisals as a consequence of the
CSA experience.
Summary and Problems
With the CSA Literature
The literature demonstrates a significant connec-
tion between CSA and HIV risk behaviors; problems
with social adjustment; psychological disorders,
including anxiety, depression, and substance use; and
confusion about sexual identity. Although the litera-
ture is consistent about the negative outcomes of CSA,
there are significant methodological concerns. First,
the definition of CSA varies across studies. Conse-
quently, what is included as CSA in one study may not
constitute CSA in another study. Some studies look at
the age difference between victim and perpetrator,
whereas others do not, and some studies automatically
classify coercive sex as abusive, whereas others do not
discuss the issue of force or coercion because the defi-
nition of CSA was not explicated. In the case of gay
and bisexual adolescents who are exploring their sex-
ual identities, these adolescents may seek sexual rela-
tions with an older man. In the schemata of Doll et al.
(1992), this would require classification as CSA.
26 JANAC Vol. 12, No. 5, September/October 2001
The second major methodological problem relates
to the sample of the men studied and the related sam-
pling methodologies. Most samples used a conve-
nience or clinical sample, which was generally small
in size. In the studies conducted in clinical settings, the
severity of mental health and behavioral outcomes
may be exaggerated. Consequently, the results of these
studies may not be representative of the MSM popula-
tion. In nearly all the studies, the sample demographics
were not included. Therefore, the similarities and dif-
ferences between gay, bisexual, and heterosexual men
are not clear. Third, without longitudinal analysis, it is
challenging to determine the long-term negative out-
comes related to the CSA experience. Consequently,
it is unclear if CSA causes negative mental health out-
comes and increased substance use, or if these phe-
nomenon are co-occurring due to the use of cross-
sectional designs.
Overall, the research examining the relationship
and outcomes of sexual abuse as a child or as an adult
male and its relationship to MSM and HIV risk behav-
ior is in its infancy. Although there is evidence of the
relationship between CSA and confusion in sexual
identity, mental health outcomes, and risk behaviors,
the results of these studies are limited due to small
sample sizes, convenience or clinical samples, the lack
of demographic information, and the use of cross-
sectional designs.
Implications for
HIV Nursing Practice
Because the literature demonstrates the linkages
between CSA, depression, substance use, intimate
partner battering, and HIV risk behaviors, there are
many indications for nurses and other providers to
assess for a history of CSA. Evidence from the
research literature demonstrates the importance of
assessing for a history of CSA when designing and
delivering HIV prevention interventions in MSM
(Paul et al., in press).
As Paul et al. (in press) suggest, “Substance abuse
treatment services, for example, may be a critical
point of entry to services for gay/bisexual men who
have been sexually coerced in childhood” (p. 21).
Therefore, nurses working with gay and bisexual men
seeking HIV testing and counseling and nurses
working in a variety of clinical settings, including
ambulatory care, mental health, and substance abuse
programs, need to assess for a history of sexual victim-
ization and be aware of the negative consequences of
CSA in this population.
In 1998, the CDC recommended that the prevention
of HIV needed to be placed in the context of the indi-
vidual’s risk-related behaviors. Without examining
the childhood experiences of men, the context of sex-
ual risk behaviors and the coping strategies used to
deal with those childhood experiences, such as sub-
stance use, will remain misunderstood. As nurses, we
must ensure that all needs of MSM are identified and
addressed. By assessing for a history of childhood sex-
ual abuse, it is possible to facilitate holistic health by ini-
tiating referrals for mental health and substance use
treatment while facilitating personalized strategies that
lead to HIV risk reduction in the context of sexual abuse
and aggression. The appendix suggests questions that
could be used by clinicians to screen for CSA.
In conclusion, the prevalence of a history of CSA in
MSM demonstrates the need for nurses and other
health care providers to address the long-term psycho-
logical and behavioral consequences of such experi-
ences. Through a heightened awareness of this prob-
lem, it is possible to design specialized interventions in
the context of the lives of many MSM. Consequently,
by assessing for a history of sexual abuse and initiating
referral and treatment, the many negative health conse-
quences, including substance use, depression, and sex-
ual risk behaviors, can be minimized.
Appendix
Childhood Sexual
Abuse Screening Questions
1. During your childhood and teenage years (before the
age of 18), were you ever forced or frightened by
someone into doing something sexually?
2. How many experiences of this kind did you experi-
ence before the age of 18?
3. Before the age of 18, how many different people
forced or frightened you into doing something
sexually?
4. How old were you when
a. the first experience occurred?
b. the last experience occurred?
5. Over how long a period did this occur?
6. What was the gender of the person(s)?

7. When it
a. first happened, how old was this person?
b. last happened, how old was this person?
8. Did the first person (last person) ever . . .
a. use weapons or physically force you?
b. threaten to harm you or others if you didn’t do
what they wanted?
c. put other kinds of pressure on you?
9. Did (he/she) . . .
a. force you to watch someone engage in sexual
activity?
b. force you to touch (him/her) or someone else
sexually?
c. fondle you sexually?
d. insert an object or finger into your anus?
e. perform oral sex on you?
f. force you to perform oral sex on (him/her)?
10. If the person was a male,
a. did he have anal intercourse with you, with you as
the receptive person?
b. attempt anal intercourse with you, with you as the
receptive person?
c. did you have anal intercourse with him with you
as the insertive person?
d. did he want you to have anal intercourse with him
with you as the insertive person?
11. If the person was a female, did you
a. have vaginal intercourse with her?
b. attempt vaginal intercourse with her?
SOURCE: Adapted from the Urban Men’s Health Study Question-
naire, Joe Catania, PhD, principal investigator (1996).
Acknowledgment
The author would like to thank Jacquelyn Campbell,
PhD, RN, FAAN, Johns Hopkins University, and Colleen
Thomas, MSN, RN, CS, ACRN, and Jeff O’Neill, BA, RN,
ACRN, Whitman-Walker Clinic, for their thoughtful insight
and critical review of this manuscript.
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