Journal of Community Health

, Volume 38, Issue 5, pp 894–899

Sexual Risk Behavior and Symptoms of Historical Loss in American Indian Men

Original Paper

DOI: 10.1007/s10900-013-9695-8

Cite this article as:
Anastario, M.P., FourStar, K. & Rink, E. J Community Health (2013) 38: 894. doi:10.1007/s10900-013-9695-8

Abstract

Native Americans in the United States are not typically regarded as a most at-risk population for HIV or other sexually transmitted infections (STIs), despite emerging evidence which suggests otherwise. As a result, Native Americans lack access to key prevention services and programs. In planning prevention programs for this unique population, however, it is important to take into account the cultural factors that may be implicated in health risk behaviors. Historical Loss is a type of historical trauma that has been reported in Native Americans, and which may be related to health behaviors. We examined whether Historical Loss was associated with sexual risk behaviors in a sample of 120 American Indian men living in Fort Peck Reservation in northeastern Montana who completed questions regarding Historical Loss and sexual risk behaviors. Symptoms of Historical Loss that reflected Anxiety/Depression and Anger/Avoidance were associated with an increased likelihood of individuals’ having sex with multiple concurrent partners. Health interventions that aim to address HIV/STI prevention should take symptoms of Historical Loss into account, as Historical Loss could be a potential factor that will mitigate HIV, STI, and pregnancy prevention efforts in this population.

Keywords

Native American American Indian Sexual risk Historical Loss Men 

Introduction

Native Americans in the United States are not typically regarded as a most at-risk population for HIV or other sexually transmitted infections (STIs), despite emerging evidence which suggests otherwise [1, 2, 3]. As a result, Native Americans lack access to prevention services and programs. In beginning to plan prevention programs for this unique population, however, it is important to take into account unique cultural factors that may be implicated in health risk behaviors.

Environmental stressors may play a role in the logic of risk behaviors for at-risk individuals in Native American populations. For example, recent research has found that stressful life events were associated with risk behaviors in American Indian youth [4]. It is important to note that stressors typically observed in non-native cultures may be different from those perceived in native communities. Historical Loss is a type of intergenerational trauma that has been reported in Native American populations, where trauma that has been “passed down” through generations is experienced by the individual. For American Indians, Historical Loss may include experiencing the loss of land, language, traditional spiritual ways, and other culturally significant events that are part of the cognitive process, and where perceptions of these losses are linked with psychological symptoms [5].

As part of a greater perception of environmental and historical degradation, Historical Loss may play a role in the health behaviors of American Indians. In one study on Native American men, Historical Loss was found to be associated with the intention to use birth control [3]. It is possible that cultural loss may be a component of “the bodily and cultural logic of epidemiologically risky sexual activities”[6] that would be observed in Native American populations.

In this study, we examined whether symptoms of Historical Loss were associated with sexual risk behaviors in a sample of American Indian men. We hypothesized that Historical Loss associated symptoms would be associated with an increased likelihood of sexual risk behaviors. These findings have implications for planning prevention programs that address HIV, STIs, and pregnancy prevention in this population.

Methods

Sample

The target population for this project was 18–24 year old American Indian men, living on the Fort Peck Reservation in northeastern Montana. There are 12,000 enrolled members of the Assiniboine and Sioux tribes from the Fort Peck Reservation, total. Of the 578 enrolled tribal members between the ages of 18 and 24 years old, we aimed to obtain a sample of 120 individuals, or 20 % of the target population.

The participants were recruited using purposive sampling techniques. Community organizations assisted with recruitment. Flyers, posters, presentations, community gatherings, advertisement on the Indian Health Services marquee at Fort Peck, and word of mouth were also used to recruit study participants. Structured interviews were verbally administered by trained interviewers who were male tribal members, and who were slightly older than the study population. Interviews were approximately 45–90 min in length. Participants were provided a gift certificate as compensation for their time. The study was reviewed and approved by the Montana State University IRB, and local ethics approvals were also provided by the Indian Health Services—Billings, Montana, and the Fort Peck Tribal Council Executive Board.

Measures

Historical Loss

The Historical Loss Scale consists of 12 items that describe a specific type of loss that respondents may experience, with frequency response sets ranging from never (1) to several times a day (6) [5]. In our sample, The Historical Loss Scale exhibited a Chronbach’s α coefficient of 0.91. For the purposes of this analysis, we developed a mean score (K = 12) representing Historical Loss based on a one-factor solution that has been previously reported [5].

Items on the Historical Loss scale act as a primer on the survey instrument for The Historical Loss Associated Symptoms Scale, which consists of 12 items that each specify a potential symptom related to Historical Loss. Respondents are asked to evaluate the frequency with which they experience particular symptoms using response sets ranging from never (1) to always (5) [5]. In our sample, items in the Historical Loss Associated Symptoms Scale exhibited a Chronbach’s α of 0.88. Based on a two-factor solution that has been previously reported [5], we developed two separate mean scores representing Anxiety/Depression (K = 5, Chronbach’s α = 0.73) and Anger/Avoidance (K = 7, Chronbach’s α = 0.84).

Sexual Risk Behaviors

We examined two sexual risk behaviors for the purposes of this study: sex with multiple concurrent sexual partners (MCPs), and inconsistent condom use.

A respondent was classified as having sex with MCP’s if he self-reported ≥2 sexual partners during the 3 months preceding the survey. A dichotomous variable was created, where individuals with ≥2 sexual partners were coded as “1” and individuals with <2 sexual partners were coded as “0”. We also examined the number of sexual partners reported during the 3 months preceding the survey.

A respondent was classified as engaging in inconsistent condom use if he reported using a condom on fewer occasions than the frequency with which he engaged in sex during the past 3 months. This variable was only defined for the subpopulation of individuals who reported having sex during the 3 months preceding the survey. A dichotomous variable was created, where individuals with inconsistent condom use behavior were coded as “1” and individuals with consistent condom use behavior were coded as “0”. Individuals who did not engage in sex with a partner during the 3 months preceding the survey were treated as missing for this particular outcome variable.

Data Analysis

Stata 10 was used to conduct all statistical analyses [7]. In order to test for internal consistent reliability of select scales, we examined Chronbach’s α statistic. In order to test for mean differences in demographic variables between those engaging in (1) and not engaging in (0) each sexual risk behavior examined, we conducted two-tailed T tests, and for categorical variables we conducted the Pearson χ2 test. In order to examine the correlation of the number of sexual partners with mental health symptoms, we used the Pearson correlation coefficient. We used logistic regression to estimate the odds ratio for engaging in a given sexual risk behavior. Statistical significance was established at p < 0.05.

Results

On average, men in the sample were 21.1 years of age (standard deviation (SD) = 2.0), 31.2 % had completed less than a high school education, 36.1 % had at least one child, and 9 % were married. Demographic characteristics of men in the sample did not vary appreciably by the sexual risk behaviors measured (Table 1).
Table 1

Demographic characteristics and sexual risk behaviors in a sample of American Indian men, n = 120

 

≤1 sexual partner

≥2 sexual partners

P

Consistent condom usera

Inconsistent condom usera

P

(n = 97)

(n = 23)

(n = 40)

(n = 53)

Age

21.2 (2.1)

20.4 (1.8)

0.094

20.8 (2.1)

21.3 (2.1)

0.254

Education (less than high school)

30.9 %

34.8 %

0.721

42.5 %

26.4 %

0.103

Has children

36.1 %

34.8 %

0.907

27.5 %

37.7 %

0.300

Married

10.3 %

4.4 %

0.373

7.5 %

15.1 %

0.262

aAmong individuals with ≥1 sexual partner in the last 30 days

The Historical Loss scale had a potential range of 1–6, and respondents averaged a 3.4 (SD = 1.1) on the scale. The Historical Loss Associated Symptoms scales had a potential range of 1–5, and respondents averaged a 2.2 (SD = 0.84) on the scale measuring Anger/Avoidance, and 2.1 (SD = 0.71) on the scale measuring Anxiety/Depression. The Historical Loss scale, Anxiety/Depression and Anger/Avoidance subscales were each significantly associated with having sex with MCPs (Table 2), but not with inconsistent condom use (Table 3).
Table 2

Historical Loss associated symptoms subscale items and sex with multiple concurrent sexual partners in a sample of American Indian Men, n = 120

Historical Loss symptoms and items

≤1 sexual partner

≥2 sexual partners

Odds ratioa (95 % CI)

P

(n = 97)

(n = 23)

Anxiety/depression

2.0 (0.70)

2.4 (0.67)

2.3 (1.2–4.5)

0.013

Often feel sadness or depression

2.4 (0.99)

2.8 (1.1)

1.5 (0.95–2.4)

0.081

Often feel anxiety or nervousness

2.1 (1.1)

2.7 (1.3)

1.6 (1.1–2.4)

0.017

Loss of concentration

2.0 (0.9)

2.6 (1.3)

1.8 (1.2–2.8)

0.009

Feel isolated/distant when you think of these losses

2.0 (1.0)

2.0 (1.1)

1.1 (0.69–1.7)

0.752

A loss of sleep

1.6 (0.8)

1.9 (1.2)

1.4 (0.89–2.2)

0.147

Anger/avoidance

2.1 (0.85)

2.5 (0.69)

1.8 (1.1–3.2)

0.028

Often feel anger

2.8 (1.1)

3.0 (1.1)

1.2 (0.79–1.8)

0.384

Uncomfortable around white people when you think of these losses

2.0 (1.3)

2.3 (1.4)

1.2 (0.86–1.7)

0.287

Shame when you think of these losses

2.1 (1.2)

2.2 (1.1)

1.1 (0.7–1.6)

0.737

Rage

1.8 (1.0)

2.4 (1.1)

1.7 (1.1–2.7)

0.011

Fearful or distrustful of the intentions of white people

1.9 (1.1)

2.3 (1.2)

1.4 (0.92–2.0)

0.115

Feel like it is happening again

2.1 (1.2)

2.7 (1.1)

1.6 (1.1–2.3)

0.027

Feel like avoiding places or people that remind you of these losses

2.0 (1.2)

2.8 (1.5)

1.5 (1.1–2.1)

0.018

Historical Loss scale

3.3 (1.1)

3.8 (1.0)

2.3 (1.2–4.3)

0.014

aOdds ratios were derived from a logistic regression, and illustrate the odds of engaging in sex with multiple concurrent partners relative to a one-unit increase in the independent variable

Table 3

Historical Loss associated symptoms subscale items and inconsistent condom use in a sample of American Indian men reporting ≥1 sexual partner in the last 3 months, n = 93

Historical Loss symptoms and items

Consistent condom user

(n = 40)

Inconsistent condom user

(n = 53)

Odds ratio (95 % CI)

P

Anxiety/depression

2.2 (0.74)

1.9 (0.62)

0.59 (0.32–1.1)

0.096

Often feel sadness or depression

2.6 (1.1)

2.3 (0.94)

0.72 (0.47–1.1)

0.139

Often feel anxiety or nervousness

2.2 (1.1)

2.2 (1.0)

0.94 (0.64–1.4)

0.740

Loss of concentration

2.3 (1.2)

1.9 (0.9)

0.67 (0.45–1.0)

0.055

Feel isolated/distant when you think of these losses

2.1 (1.1)

1.9 (0.98)

0.86 (0.58–1.3)

0.478

A loss of sleep

1.7 (0.9)

1.4 (0.8)

0.72 (0.43–1.2)

0.208

Anger/avoidance

2.3 (0.81)

2.0 (0.80)

0.69 (0.41–1.2)

0.159

Often feel anger

3.0 (1.0)

2.7 (1.0)

0.73 (0.48–1.1)

0.148

Uncomfortable around white people when you think of these losses

2.2 (1.3)

1.9 (1.3)

0.84 (0.61–1.1)

0.267

Shame when you think of these losses

2.2 (1.2)

2.1 (1.2)

0.90 (0.64–1.3)

0.566

Rage

2.0 (1.0)

1.8 (1.0)

0.84 (0.56–1.3)

0.417

Fearful or distrustful of the intentions of white people

2.2 (1.1)

1.8 (1.1)

0.72 (0.49–1.1)

0.092

Feel like it is happening again

2.3 (1.1)

2.1 (1.1)

0.82 (0.57–1.2)

0.295

Feel like avoiding places or people that remind you of these losses

2.2 (1.2)

2.1 (1.4)

0.94 (0.69–1.3)

0.728

Historical Loss scale

3.6 (1.1)

3.3 (1.2)

0.61 (0.33–1.1)

0.105

aOdds ratios were derived from a logistic regression, and illustrate the odds of inconsistent condom use relative to a one-unit increase in the independent variable

The odds of sex with MCPs increased by 2.3 for every one point increase on the Historical Loss Anxiety/Depression subscale (95 % CI 1.2–4.5, p = 0.013) (Table 2). Individual symptoms that were particularly associated with sex with MCPs included feeling anxiety or nervousness (OR = 1.6, 95 % CI 1.1–2.4, p = 0.017) and loss of concentration (OR = 1.8, 95 % CI 1.2–2.8, p = 0.009).

For the Anger/Avoidance scale, the odds of sex with MCPs increased by 1.8 for every one-point increase on the scale (95 % CI 1.1–3.2, p = 0.028). Individual symptoms of Anger/Avoidance that were associated with MCPs included rage (OR = 1.7, 95 % CI 1.1–2.7, p = 0.011), feeling like it is happening again (OR = 1.6, 95 % CI 1.1–2.3, p = 0.027) and feeling like avoiding places or people that remind you of these losses (OR = 1.5, 95 % CI 1.1–2.1, p = 0.018).

Each of the Historical Loss Associated Symptoms was positively correlated with the number of sexual partners an individual had during the previous 3 months (Table 4).
Table 4

Correlation between Historical Loss associated symptoms subscale items and number of sexual partners during the last 3 months, n = 120

 

Corr.

P

Anxiety/depression

0.20

0.026

Often feel sadness or depression

0.18

0.045

Often feel anxiety or nervousness

0.21

0.021

Loss of concentration

0.18

0.046

Feel isolated/distant when you think of these losses

0.07

0.473

A loss of sleep

0.06

0.531

Anger/avoidance

0.23

0.013

Often feel anger

0.10

0.275

Uncomfortable around white people when you think of these losses

0.10

0.258

Shame when you think of these losses

0.05

0.594

Rage

0.25

0.005

Fearful or distrustful of the intentions of white people

0.18

0.055

Feel like it is happening again

0.19

0.040

Feel like avoiding places or people that remind you of these losses

0.26

0.004

Historical Loss scale

0.14

0.114

Discussion

In this study, we found that Historical Loss and Historical Loss Associated Symptoms of Anxiety/Depression and Anger/Avoidance were associated with sex with multiple concurrent partners, but not with inconsistent condom use in a sample of American Indian men. These results have several implications for STI, HIV, and pregnancy prevention efforts in addition to future studies of sexual risk in American Indian Men.

First, we documented that Historical Loss associated symptoms were associated with sex with MCPs. Health professionals working in Indian Health Services who provide services to American Indian men should be aware that Historical Loss may be underlying health behaviors, and that patients with Historical Loss may benefit from screening for risk behaviors. Further, HIV, STI, and pregnancy prevention programs targeting American Indian youth may benefit from screening youth for Historical Loss, or by incorporating Historical Loss into preventive programming modules.

In this study, we found a link between sex with multiple partners and symptoms of Historical Loss. These findings are similar to findings in other populations which have documented a link between poor mental health and sexual risk behaviors [8, 9, 10, 11, 12, 13, 14, 15], with several studies finding a link with an outcome in our study—sex with multiple partners. Psychological distress has been associated with an increase in the number of sexual partners in adolescence [16], and self-esteem has been associated with individuals’ likelihood of having multiple sex partners [17]. In one study of individuals who lost a friend following a major disaster, an increased likelihood of sex with multiple partners was observed [18]. While we cannot conjecture what mechanisms underlie the associations detected in our study, it is possible that the trauma of Historical Loss drives individuals to seek intimacy through sex with more than one partner. Future research should examine this potential mechanism more closely.

The lack of significant associations and the direction of effects between inconsistent condom use and symptoms of Historical Loss were notable (Table 3). Although findings were not significant, the odds of inconsistent condom use decreased as symptoms of Historical Loss increased. Thus, our findings suggest that while Historical Loss was associated with having multiple partners, it was not associated with practicing unsafe sex. We again conjecture that the mechanism underlying the association with sex with MCPs may be driven by a search for intimacy.

Given the associations of symptoms of Historical Loss with sex with MCPs identified in this study, it is also important to understand whether subjects themselves perceive this link. In order to examine respondent-level awareness of this association, we conducted a post hoc analysis to analyze a statement that was appended to the Historical Loss Associated Symptoms items: “when thinking about these losses and how they make you feel, do you think they influence decisions you make in your life about sex?” Of respondents sampled, 19 % responded positively to this statement. Although the link between Historical Loss and sexual behavior does not have to be apparent to the individual for providers to screen at-risk individuals, it is possible that providers and prevention counselors could miss an important prevention opportunity, and opportunity for alignment with patients, by ignoring this relationship.

Limitations

This study has several limitations. First, it was based on a cross-sectional sample of American Indian men living in Fort Peck, Montana, and results cannot be generalized to other populations. However, the similarity in the internal consistency reliability of our scale measures with that of a previous study, as well as the associations detected, may be replicable in other Native American populations. Further, our study was only based on self-report of the respondent, and issues concerning social desirability bias could always impact responders’ willingness to disclose sensitive information. In the context of this study, other data collection modalities were not feasible and self-reported survey measures were the best option. Further, this study did not seek to determine the whether there was convergent or divergent validity between Historical Loss and symptoms of other mental health conditions in this population, thus it is possible that a spurious mental health condition could be driving the association. However, an examination of convergent/divergent validity of the Historical Loss measure would be far beyond the scope and resources of the present study, and findings can still inform prevention efforts that may seek to screen individuals for, or incorporate, Historical Loss. Finally, questions regarding the number of sexual partners were hetero-normative and did not ask males to report on same-sex sexual encounters or condom use. It is possible that we missed a subset of respondents who may have same-sex contact by limiting our measures of sexual behaviors, however this would have likely produced more noise and thus weaker effect sizes than those detected in the study. Future research should account for potential same sex contact and the role that this may have on effect sizes and directions.

Conclusion

In this study of American Indian Men in Fort Peck, Montana, we found that symptoms of Historical Loss were associated with sex with MCPs, a sexual risk behavior that may increase the risk of STIs, HIV, and/or unintended pregnancy throughout the life course. Interventions that aim to address prevention in this population should take symptoms of Historical Loss into account, and future research should further explore the mechanisms underlying the association between symptoms of Historical Loss and sexual risk behavior in Native American populations.

Acknowledgments

This research was funded by the US Office of Population Affairs (R03—#FPRPA006028-01-01, Principal Investigator—Elizabeth Rink).

Copyright information

© Springer Science+Business Media New York 2013

Authors and Affiliations

  1. 1.Behavioral Health and Criminal Justice Research DivisionRTI InternationalNew YorkUSA
  2. 2.Montana State UniversityBozemanUSA

Personalised recommendations