"Psychologically and emotionally, it affects me 'til this day": exploration of childhood sexual abuse perspectives among older adults living with HIV in South Carolina.

The influence of childhood sexual abuse (CSA) may be seen immediately or across the life course. CSA is also associated with increased HIV-risk behavior, and greater likelihood of an HIV/STI diagnosis. The aim of this study was to explore the perspectives of CSA among older adults living with HIV. Twenty-four adults living with HIV aged 50 to 67 years (mean age = 58.5 years), with a history of CSA, receiving care from an HIV clinic in South Carolina, participated in the study. In-depth semi-structured interviews were conducted, audio recorded and analyzed using a thematic analytic approach. The iterative analytic process included a three-step approach: discussion of initial thoughts and key concepts, identification and reconciliation of codes, and naming of emergent themes. Four themes emerged: Psychological issues due to CSA, relationship challenges due to CSA, self-blame, and reliving childhood trauma (subtheme: lack of influence of CSA today). Some participants reported feeling the influence of CSA several years after the event while others noted that that there was a lack of influence of CSA at present. Trauma-informed intervention programs are needed for older adults living with HIV who still experience the influence of their CSA experience. Future research should delve into the design and feasibility of implementing these programs.

Keywords: Childhood sexual abuse; HIV; older adults; abuse/neglect; qualitative methods; psychological and social aspects

Childhood sexual abuse (CSA) continues to be a national and global public health challenge. Recent estimates suggest that 20.4% of girls in North America have been sexually abused before 18 years of age (Moody et al., [26]). Two meta-analyses found that the prevalence of CSA globally ranged from 3 to 31%; and that the prevalence for men was 7.9% and 19.7% for women (Barth et al., [3]; Pereda et al., [31]). In the US, 1 in 5 girls and 1 in 20 boys have experienced CSA, while 20% of adult women and 5-10% of adult men have reported a history of CSA (National Center for Victimes of Crime, [28]).

CSA has pervasive deleterious effects on a variety of health and mental health outcomes. For example, CSA has been shown to be associated with increased risk for physical health outcomes such as lung disease, arthritis, peptic ulcer, pain, high cholesterol levels and low-density lipoproteins (Kamiya et al., [19]). Research has shown that the age of occurrence and severity of CSA may also play a role in its impact on health outcomes (Xavier Hall et al., [42]). CSA has also been linked to suicidal behavior (Steine et al., [37]; Xavier Hall et al., [42]), substance use, depression, HIV risk behaviors (such as condomless sex, more sexual partners), HIV and other sexually transmitted infections (STIs) (Peterson et al., [32]; Xavier Hall et al., [42]; Xu et al., [43]).

The intersection of CSA and living with HIV has been studied extensively. CSA rates among people living with HIV have been estimated to range from 30 to 53% (Henny et al., [14]; Kalichman et al., [18]; Markowitz et al., [22]). Among Haitian women living with HIV, CSA was associated with anxiety and alcohol use (Villalba et al., [41]). Individuals who reported CSA were more likely to report HIV risk behavior, a greater number of sexual partners, heroin use in the past month, and poorer adherence to HIV medication (Markowitz et al., [22]).

It is important to note that while CSA may occur in childhood, its effects may last into older adulthood. One study found that CSA was linked to adverse health outcomes, including greater medical illness burden, greater pain, and worse physical functioning (Talbot et al., [38]). Older adults who experienced sexual and/or physical abuse during childhood were more likely to experience poorer physical and mental health (Draper et al., [9]). Older adults with a CSA history were also more likely to have internalizing disorders (Sachs-Ericsson et al., [35]).

With the intersection of CSA, HIV and aging, this study aimed to explore the perspectives of CSA among older adults living with HIV with a CSA history using a qualitative approach. Mujumdar et al. examined a wide range of traumas but did not focus specifically on CSA and the unique perspectives of older adults (Mujumdar et al., [27]). To our knowledge, this is the first study to examine qualitatively how CSA and living with HIV may influence older adults.

Older CSA survivors living with HIV were recruited from an HIV clinic in South Carolina. Recruitment was done through flyers, and the clinic staff approached potential participants. To be included in the study, participants had to be living with HIV, at least 50 years of age (Centers for Disease Control & Prevention, [7]), self-reported CSA experiences prior to age 18, and lacked severe cognitive impairment, which was measured by a six-item screener (Callahan et al., [5]). For older adults living with HIV, age 50 years old and older is considered an appropriate age delineation as this population experiences comorbidities and geriatric conditions at younger ages compared to the general population (Greene, [13]). Furthermore, living with HIV/AIDS has been considered to contribute to premature aging (Pathai et al., [30]).

Fifty-five (55) participants expressed interest in the study. Thirty (30) participants were not eligible due to being younger than 50 and/or not reporting CSA before 18 years old. One participant did not show for the interview. Therefore, the final sample size was 24. Participants included 12 males, one transgender female and 11 females. Sixteen (16) participants identified as Black, six White, one Native Hawaiian/Pacific Islander, and one American Indian/Alaskan Native. Only one participant identified as Latinx/Hispanic (Brown et al., [4]).

Interview questions included a variety of topics from literature review and scholars' presumption including: aging with HIV, perspectives on HIV disclosure, childhood sexual trauma, general/overall health, psychosocial health, antiretroviral therapy (ART) adherence, and perspectives on U = U (Undetectable = Untransmissible). Questions on childhood sexual trauma asked about its influence on current mental health, relationships with others, and coping. Questions were administered using a semi-structured interview guide. Interviews were conducted in a private room, face-to-face, in English, were audio recorded, and ranged from 16 to 62 min with an average time of 31 min. Interviewers were trained in qualitative interviewing techniques.

Otter.ai (Los, Altos, CA) was used to transcribe interviews. Transcripts were reviewed to ensure they correctly represented participants' statements. The thematic content analysis approach was used to analyze data (Saldana, [36]). In this approach, we identified common themes in which we grouped and refined from the text common themes to provide expression to the commonality of voices among the participants (Anderson, [2]). Two team members independently crosschecked the accuracy of the transcripts. Line by line coding was used by four team members to code the interviews independently. During the coding process, the team met weekly to resolve any differences between codes that were identified. This resolution included discussing initial thoughts, assumptions, and understandings of key concepts. Four team members independently placed codes into themes and subthemes, discussed the links between themes and how well they reflected the participants' views on their CSA experiences as they age with HIV. Researchers who conducted the analysis included an epidemiologist, a nurse scientist and two doctoral students who received training in qualitative research. This study was guided by the Consolidated Criteria for Reporting Qualitative Research (Tong et al., [40]). The University of South Carolina Institutional Review Board approved the current study (Pro# 00084536).

Four main themes emerged: Psychological issues, relationship challenges, self-blame, and reliving childhood trauma. A subtheme under "reliving childhood trauma" was "lack of negative influence of CSA today". Each theme (and subtheme) and related quotes are discussed in detail below (some details on demographics have been changed to protect confidentiality):

Psychological challenges, such as feeling depressed, were reported by some study participants. There were participants who wondered why they had experienced the CSA event(s) and attributed their depressed feelings and poor mental health to their CSA history.

"My mental health ain't good when it comes down to this craziness. I'm wondering why this happened to me? I'm wondering why I can't live a life like I'm 52 years old" (52-year old Black female)

"Sometimes I get depressed for no apparent reason. And I really think it does stem back from when I was raped as a child." (51-year-old White transgender)

"I might feel depressed [due to CSA], you know sometimes, but I don't use nothing [substances]. You know, I may talk to somebody or something but just wait [for it] to pass" (56-year old Black male)

Participants were asked if they thought their CSA experience influenced their relationships with others. Relationship issues were also a challenge due to having a CSA history. For one female participant, the CSA event perpetuated a lack of trust in men to the extent that she did not want men talking to her and she was scared to talk to men. For another female participant, being a rape survivor resulted in rejection in relationships. For a few male participants, their CSA history resulted in trust issues with people in general. For example, if there were signs of aggression from others, there were challenges with that relationship.

"It [CSA] makes me scared of people. It makes me real scared to talk to men. I don't want no man talking to me. I just don't trust men, let's put it like that." (52-year old Black female)

"Yes, it [CSA] still affects me. Personally, I guess with relationships with other people, it does affect me...because if I see in another person, they're forcible or aggressive, that can be an issue with me because of what happened to me earlier in my life." (61-year-old White male)

"I mean, let's say a new person, the trust factor is there, okay. I'm not going to trust them until I get to know them." (55-year-old American Indian/Alaskan Native male).

"In a certain way, yes. In a certain way because some people don't want to take someone [if] they've been raped." (53-year-old Black female).

There were participants who also blamed themselves for the CSA event or stated that they had a role to play in what occurred. There were issues with forgiving oneself and thinking that the CSA event was their fault.

"Today, I still haven't forgiven myself for making some bad choices and today I know that was a bad choice...that was my beginning, but I've corrected a lot of those behaviors today...Anytime you get to a place where you can just open up or talk about it or be honest about it and get to the place to understand the part that you play in the event" (54-year-old Black male).

"I think that there is a way that could kind of resolve all of this. I almost still think that it's my fault. And I was told not to go down that street. And I did anyway." (54-year-old White female)

There were participants who stated that the CSA experience still affected them at present. Flashback and nightmares also resulted from reliving the CSA experience. Post-traumatic stress symptoms were also seen among CSA survivors, even at older ages. One participant still felt violated due to the CSA event.

"They haunt me, they haunt me as to why adults or you know, especially like a man of the church will do that to a child. Yeah, so psychologically and emotionally, yes, it still affects me to this day." (52-year-old Black male)

"I think it [CSA] does. I think I have emotional problems from it. And definitely flashbacks and nightmares sometimes. For a long time, I couldn't walk down the street without seeing a shadow and I would say someone's gonna hit me, you know with something or do harm to me. And I'm still that way today. I don't like people to get too close to me...Well, when I'm depressed, I'm having flashbacks. I think it would be beneficial for me to be able to talk [to] someone because even at 51, you do feel scared...just...hard to describe, feel violated." (51-year-old White transgender)

"I think about it [CSA]. I mean, when I'm alone or when I'm looking at TV, you know, death, sexual assault...I think about it a lot, it is boundless for me." (53-year-old Black male)

"Today it [CSA] gives me nightmares is causing me to not function being able to function. That's probably that's why I'm scared of people. I have nightmares about these people over and over...in a night time. I can't sleep at night for it's running me crazy. It's getting to me real bad." (52-year old Black female)

Nevertheless, the majority of participants stated that CSA did not have an influence on them today. They tried not to dwell or reflect on the CSA event as it was seen as something that happened in the past or when they were children, so with the passage of time they were better able to cope. Some viewed themselves as being older and wiser and in a better position to protect themselves from abuse, and some had suppressed the memories of the CSA event.

"It don't... you know I don't dwell on it [CSA]. I don't reflect on [it], it don't bother me. You know that was just something that happened when we was kids you know." (56 year old Black male)

"It [CSA] doesn't affect me today because...no one is coming at me against my will. Yeah. Nobody's coming at me against my will." (54-year old Black female).

"No, it [CSA] don't affect me because I'm more wiser now. I'm old, I'm older and more wiser, smarter and wiser now. And now I know how to protect myself now, so they don't bother me." (62-year old Black female)

To our knowledge, this is the first qualitative analysis of an exploration of how CSA influenced the lives of older adults living with HIV. The main findings of the study were that some CSA survivors experienced psychological issues due to CSA, relationship challenges due to CSA, self-blame, relived childhood trauma, while the majority stated there was a lack of influence of CSA today.

Research has shown that a variety of adverse childhood experiences, including childhood sexual trauma, can have a significant impact on survivors across the life course. In the current study, while a majority of participants stated there was a lack of effect of CSA at present, some participants stated varying challenges resulting from a CSA history. Experiencing any adverse childhood event was associated with having a psychiatric disorder or substance use disorder in the past year among adults aged 65 and older (Rhee et al., [34]). Repeated physical abuse and forced sexual intercourse during childhood was associated with late-life depression among adults aged 60 and older (Ege et al., [10]). As the number of adverse childhood experiences increased, prescription rates for psychotropic medications, such as antidepressants, antipsychotics and mood-stabilizing medications, also increased (Anda et al., [1]). Adverse childhood experiences may impact income in adulthood, social support and adult adversity, which may then impact health outcomes in adulthood (Jones et al., [17]). Our participants did not report any current effects on income in response to our queries, but it is possible that there could be an influence on social support due to the relationship challenges resulting from a CSA history.

In childhood, the effects of CSA may range from neurobiological changes, developmental delays to low self-esteem (Institut National de Sante Publique, [15]). In adolescence, the effects may range from high-risk sexual behavior, early sexual initiation, STIs, and intimate partner violence victimization and abuse. However, the influence of CSA may also be seen in adulthood and older adulthood by affecting sexual and physical health (including STIs and risky lifestyles); psychological health (depression, post-traumatic stress disorder, suicidal behavior); relational and marital challenges (less trusting of others, commitment challenges); parental challenges (parenting stress and troubled parent-child relationships); and when applicable, during the perinatal period (early motherhood, premature births, and postpartum depression) (Institut National de Sante Publique, 2021). In the current study, a history of CSA was found to be linked to psychological challenges such as feeling depressed. Specifically among older adults, loss of social support, declining function, and preoccupation with early adverse experiences were among the common vulnerabilities reported among older CSA survivors (Gagnon & Hersen, [11]). Gagnon and Hersen also found that dysfunction in adulthood may be due to the impact of CSA on childhood developmental tasks such as autonomy and forming healthy relationships. If the child does not develop adaptive coping strategies, maladaptive ways of coping may be used (into adulthood) when stressors exceed the available resources (Gagnon & Hersen, [11]). For example, some participants reported suppressing memories of the CSA event, which may be considered maladaptive coping.

The current study found that some CSA survivors had psychological issues associated with CSA and relived the traumatic experience. The link between CSA and mental health has been confirmed by previous studies, albeit quantitative and among international populations. A longitudinal quantitative study found that compared with experiencing no/low maltreatment, CSA was associated with twice the risk of having an internalizing disorder, and this elevated risk was also seen at older ages among urban New Zealand women (Rapsey et al., [33]). CSA has also been linked to depression, anxiety, worry, loneliness, and a poorer quality of life among older adults among an Irish population (Kamiya et al., [19]). Among a representative sample of community-dwelling adults in England, CSA was associated with mixed anxiety and depression, generalized anxiety disorder (GAD), eating disorders, posttraumatic stress disorder (PTSD) and suicidal ideation. Revictimization was also associated with mixed anxiety and depression, GAD, phobia, PTSD, and suicidal ideation. CSA and revictimization have been linked to increased psychiatric hospitalization (Chou, [8]). Another study found that depressed women who were aged 50 and older who had a history of CSA were more likely to report suicidal ideation and a history of multiple suicide attempts than those without such a history (Talbot et al., [39]). These studies and our current study highlight the intricate relationship between CSA and mental health.

Self-blame, which was seen in our study, is also a phenomenon that survivors may experience. Not many studies have assessed self-blame among older survivors of CSA. Nevertheless, self-blame has been shown to be associated with disclosure of CSA among children (Kellogg et al., [20]; McElvaney & Nixon, [23]). Among men who have sex with men, experiencing CSA during adolescence was associated with higher self-blame, which was then linked with PTSD symptoms (Ironson et al., [16]). Another study found that people are more likely to blame themselves for CSA when they have more conservative attitudes towards gender roles (Okur et al., [29]). Among CSA survivors, self-blame was found to be linked to revictimization (Mokma et al., [25]). Research has shown that compassion-focused therapy may be used as an intervention for adult survivors of sexual abuse, which should include reducing one's perception of self-blame (McLean et al., [24]).

The dichotomy seen in the current study, with some participants stating a lack of influence while others stating that the CSA experience was a challenge to deal with at present has also been seen in previous research. The majority of participants reported that CSA had nothing to do with their HIV acquisition. Graham et al. ([12]) conducted a qualitative study on women aged 60 and older who were victims of CSA. They found that there was a need for resolution for the women to move from the CSA event(s). While some women were able to reframe their experience and using "positive life philosophies", some women had negative feelings and memories associated with the experience (Graham et al., [12]). In the current study, there were some participants who relived the childhood trauma; however, the majority stated that there was no current influence of CSA. The effect of the CSA likely depends on the perception of the stressor (Lazarus & Folkman, [21]).

The study did have some limitations. For example, all participants were receiving care at an HIV clinic in the Southeastern US and their perspectives may not be reflective of older adults living with HIV who may not be in care and/or reside in different geographical regions. Future studies should endeavor to reach older adults living with HIV who may not be in care and also recruit from varying regions of the US and in other areas with growing numbers of older adults living with HIV such as sub-Saharan Africa. In addition, there may be selection bias where participants who may be willing to talk about their experience with CSA and self-select into the study may cope differently compared to older adults who are not willing to talk about their CSA history. Nevertheless, we found that some participants, who were willing to share their experience, still had a hard time coping with the CSA event. In addition, there could also be the potential of survival effect bias where individuals who suffered the most severely from HIV or CSA would not have participated in the study. It is also important to note that gender minority populations were underrepresented in the study with only one transgender person. Their experiences and perspectives may also differ compared to the majority and should be considered in future research.

Nevertheless, the study also had some strengths. According to our knowledge, this is the first study to explore the effect of CSA on older adults living with HIV. The study population was racially diverse with 67% of participants identifying as Black individuals. The study was also conducted in the southern US which is disproportionately affected by HIV.

A CSA history continues to affect some older adults living with HIV and this influence may be manifested through self-blame, psychological and relationship challenges, and reliving the trauma. It is important to note that experiencing CSA did not seem to affect some participants in the present time. Trauma-informed intervention programs are needed for these older adults who are still affected and should accentuate adaptive coping strategies for these older adults. There are promising studies suggesting effective interventions among older adults with broader experiences with adverse childhood experiences (Cameron et al., [6]) but the specific issues faced by survivors of CSA merit special attention. Future research should examine the development and feasibility of implementing these interventions. Quantitative studies should also examine the relationships between CSA and psychosocial outcomes among older adults living with HIV.

We would like to thank the participants who participated in the study.

No potential conflict of interest was reported by the authors.