Correlates of sexual self-esteem in a sample of substance-abusing women.
Article Type: Report
Subject: Sexual abuse (Research)
Sexual abuse (Risk factors)
Women (Psychological aspects)
Women (Health aspects)
Substance abuse (Care and treatment)
Substance abuse (Research)
Author: James, Raven
Pub Date: 09/01/2011
Publication: Name: Journal of Psychoactive Drugs Publisher: Taylor & Francis Ltd. Audience: Academic Format: Magazine/Journal Subject: Health Copyright: COPYRIGHT 2011 Taylor & Francis Ltd. ISSN: 0279-1072
Issue: Date: Sept, 2011 Source Volume: 43 Source Issue: 3
Topic: Event Code: 310 Science & research
Geographic: Geographic Scope: New York; Australia Geographic Code: 1U2NY New York; 8AUST Australia
Accession Number: 274114001
Full Text: Abstract--An exploratory study was conducted to investigate the construct of sexual self-esteem of women in substance abuse (SA) treatment. Demographical and abuse data were collected from 99 women in SA treatment centers in New York State in 2006 to explore relationships between demographic, addiction, abuse, and treatment variables and sexual self-esteem. Correlation of scores from the SSEI-W and its subscales and abuse variables were conducted to examine relationships between variables. T-tests showed significant differences between the mean scores of the physical abuse and physical/sexual abuse variables, relationship variables and sexual orientation. Regression analyses examined the effects of abuse, sexual orientation, relationship variables and treatment characteristics. Abuse and sexual orientation remained significant in all of the models and their affect is not influenced by controlling for the other variables. The results are discussed with regard to treatment implications. This study provides evidence of the reliability of this measure in a female substance-abusing population and contributes to the knowledge of sexual self-esteem as it relates to an adult female population of women in SA treatment. Limitations and future directions are discussed, along with proposed clinical use and assessment.

Keywords--abuse, sexual self-esteem, substance abuse, treatment, women

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The concept of sexual sell-esteem is relatively recent and understudied. Gaynor and Underwood (1995: 334) describe sexual self-esteem as "the tendency to value, versus devalue, one's own sexuality, thereby being able to approach rather than avoid sexual experiences both with self and others." These authors note that family background, peer group influence and personal experience all contribute to acquiring positive or negative sexual self-esteem. Zeanah and Schwarz (1996: 3) define sexual self-esteem as "one's affective reactions to one's sexual thoughts, feelings and behaviors," These researchers maintain that in order to effectively link self-perceptions with sexual behaviors, the affective realm of individuals' cognitive appraisals must be addressed in the sexual domain. Affective realms refer to the individual's feeling good or bad as a result of these cognitive appraisals. Positive reactions include feelings of pride, satisfaction or security. Negative feelings might include disappointment, dissatisfaction, confusion, or a sense of vulnerability or insecurity.

Sexual sell-esteem appears to be a distinguishable aspect of sexuality, and as a result, may offer a promising focus for identifying possible links between sexuality and the recovery process for substance-abusing women. These links include relapse triggers such as past sexual abuse or sexual assault, risky sexual behavior, sexual orientation, low body image and sexual dysfunction, to name a few. If individuals have acquired negative sexual self-esteem, this may contribute to their substance abuse, addiction and relapse if not addressed in treatment. Damaged sexual self-esteem can be viewed as a type of disability and has also been linked with sexual revictimization and child sexual abuse (Van Bruggen, Runtz & Kadlec 2006; Mayers, Heller & Heller 2003). Exploring the etiology of low sexual self-esteem in substance-abusing women may provide new links for future treatment interventions.

The purpose of this study was to explore the construct of sexual self-esteem with women in SA treatment, to establish reliability and validity of the Sexual Self-Esteem Inventory for Women (SSEI-W) as a measurement instrument with women in treatment, and to examine the effects of identified predictor variables. This study examined relationships among demographic, addiction, abuse, and treatment variables and sexual self-esteem in this population.

BACKGROUND

Numerous studies conducted with substance abusing women have found correlations to trauma, with estimates of lifetime physical or sexual abuse ranging from 39% to over 90%, a much higher prevalence rate than in the general population (James 2007; Brems et al. 2004; Liebschutz et al. 2002; Medrano et al. 1999; Grice et al. 1995; Triffleman et al. 1995). Experiencing physical and sexual abuse is considered to be a risk factor for the development of alcohol and drug use disorders (Abbey et al. 2001; Morril et al. 2001; Widom & Hiller-Sturmhofel 2001; GehrenbeckShim 1998; Kinzl & Biebl 1997). Risks for sexual assault and physical abuse may also increase for women with substance abuse disorders (Simpson & Miller 2002; Abbey et al. 2001).

Research on sexual and physical abuse suggests that women with such histories are more likely to report higher levels of alcohol consumption (Rosen et al. 2002). They report a higher level of general psychological distress than do their nonabused counterparts (Rosen et al. 2002). Victims of sexual and physical abuse exhibit poor interpersonal relationship functioning, which can be linked to risk for relapse (Ashley, Marden & Brady 2003).

A large-scale, ten-year project (National Study of Health and Life Experiences of Women) investigated a number of correlates of women's drinking behavior and concluded that "those variables related to sexuality were among the strongest predictors of drinking behavior" (Wilsnack 1991:147). These variables included expectancies about alcohol and sexuality, effects of drinking on sexual behavior, sexual dysfunction and childhood sexual abuse. Miller (1991) found that healthy connections are crucial for women; their psychological problems can be traced to disconnection and violations within relationships--familial, personal, or society at large. When a woman is disconnected from others or involved in abusive relationships, she experiences disempowerment, confusion and diminished self-worth. These experiences promote an environment conducive to addiction as women often use substances to self-medicate in order to cope.

THEORETICAL FRAMEWORK

A theoretical framework for understanding stigmatization from sexual abuse is Finklehor and Browne's (1985) traumagenic dynamics model. The concept of traumatic sexualization refers "to a process in which a child's sexuality, including both sexual feelings and sexual attitudes, is shaped in a developmentally inappropriate and interpersonally dysfunctional fashion as a result of sexual abuse" Negative sexual scripts may be developed in response to abuse, which in turn, can foster negative sexual self-concept and influence future sexual behaviors. Another component of this model includes stigmatization, which reflects "badness, shame, and guilt" that can be integrated into the woman's psyche (Finklehor & Browne 1985: 531). Lowered sexual self-esteem and vulnerability to guilt and shame may result from abuse, and this vulnerability can influence her introduction to substance abuse. This is critical to understanding the dynamics of her sexual behaviors, which often result in responses to past abuse situations.

Sexual Self-Esteem and Women

Zeanah and Schwarz (1996) found a relationship between sexual self-esteem and sexual activity. In general, young women who scored high on the SSEI-W had experienced more sexual activity within stable and committed relationships. The women who had fewer sexual experiences had lower scores. Sexual sellZesteem in women was found to be lower in women who were prone to guilt and who had high levels of sexual activity that took place outside committed relationships. This research was not able to determine the causal direction of these relationships.

A study assessing the affects of date rape by Shapiro and Schwarz (1997) used the SSEI-W. Almost two hundred female undergraduates participated in the study, answering questions that assessed dating and sexual activity, sexual self-esteem, trauma symptoms and unwanted sexual experiences. The women who did not report date rape experiences scored higher on the Moral Judgement, Control and Adaptiveness subscales than the women who reported experiences of date rape. The study indicated that women who had a higher frequency of sexual intercourse had higher sexual self-esteem in all five domains. Involvement in sexual relationships and the greater amount of sexual experience overall was associated with higher sexual self-esteem. The study proposes that high sexual self-esteem in women could increase the likelihood of a woman becoming involved in sexual relationships. The authors (Shapiro & Schwarz 1997) suggested a combination of the two. These findings support the previously mentioned relationship between sexual experience and sexual self-esteem.

Van Bruggen and colleagues (2006) conducted a study utilizing the SSEI-W that examined sexual self-esteem, sexual concerns and behaviors and sexual revictimization in a university sample of 402 women. The study examined the relationships between child maltreatment before age 14 and sexual assault alter age 14. Structural equation modeling was used to explore the role of sexual attitudes and behaviors as possible mediators between child sexual abuse (CSA) and later sexual assault. CSA was associated with lower sexual sell-esteem, greater sexual concerns and subsequent sexual assault. The relationship between child maltreatment (i.e., CSA and psychological maltreatment) and revictimization was partially mediated by sexual self-esteem and dysfunctional sexual behaviors. The results illustrated the need for increased prevention efforts to educate young women about risk factors for sexual assault, self-protection, and acknowledging that the perpetrator is responsible for the sexual victimization. It also recommended assisting women in becoming aware of their sexual feelings and the resulting influence on sexual behaviors (i.e., low sexual self-esteem may be related to dysfunctional sexual behaviors, such as multiple sexual partners and indiscriminant sexual behaviors).

Because the construct of sexual self-esteem is still being researched and explored, definitions of this construct are not consistent. Of the five measures that have been developed, only three of them have been utilized with women. As a result, the reliable measurement of sexual self-esteem remains uncertain. This study adds to the validity of the construct of sexual self-esteem in women and explores its use in addiction studies.

The sexual-esteem subscale that has been used most frequently (Snell & Papini 1989) is limited by its narrow definition of sexual self-esteem, which only concerns a person's ability to relate sexually to another person. Lacking in this definition and measure are components that correspond to previous definitions of self-esteem, such as virtue and power. Both Zeanah and Schwarz (1996) and Gaynor and Underwood (1995) describe and measure more specific domains of sexual self-esteem.

Gaynor and Underwood's (1995) construct of sexual self-esteem is rather broad, measuring behaviors, values and needs. Optimal sexuality is viewed as including reciprocal pleasure and exchanges, with the ideal development proceeding from self to partner context. One problem with this measure is it appears to neglect a positive view of sexual development for individuals who choose not to engage in sexual behaviors with a partner.

The Sexual Sell-Esteem Inventory for Women (Zeanah 1992) is appealing for use with a broad scope of the population since (a) sexuality is given a relatively liberal definition, (b) both women who are sexually experienced and inexperienced are included, and (c) it includes a positive view of sexual development for individuals who choose not to engage in sexual behaviors with a partner. Because the SSEI-W seems to be more firmly grounded in theories of self-esteem, has been developed exclusively to measure sexual self-esteem in women, and has been tested in many samples of women, it was chosen for use in this study.

METHODS

Sampling and Participants

This research utilized a cross-sectional sample of women being treated in drug and alcohol agencies in upstate New York. Information regarding location, services provided and contact information was obtained from a state website. Agencies were selected for solicitation based on equal distribution of rural and urban locations across the state in attempts to elicit a more diverse sample of women (Table 1). After calling several dozen agencies to elicit interest, invitations were mailed to 20 potential agencies. The mailings included descriptions of the study, survey contents, debriefing information, and return acceptance letters. Eight agencies agreed to participate in the study. Surveys were anonymously coded to track the agency they were administered in and number of participants. Surveys were distributed to participants by agency representatives in the facilities over a six-month period in 2006. Agency representatives were designated by each program's director. Four of the agencies were strictly inpatient facilities and four of the agencies provided outpatient treatment. Information on which types of treatment groups the outpatient sample attended was not tracked, limiting the analysis of treatment variables. IRB approval was granted by the governing University as well as the one hospital-based agency.

Instrumentation

Assessment of abuse instrument. The assessment of abuse questions were based on the Abuse Assessment Screen (AAS), an instrument used to identify abuse in women (Parker & McFarlane 1991). Women checked off whether an event had happened to them or not and were placed into an abuse category based on the type of reported abuse.

Sexual Self-Esteem Inventory for Women (SSEI-W). The SSEI-W was utilized to measure women's sexual self-esteem. Items require rating on a six-point Likert scale (with responses ranging from "strongly disagree" to "strongly agree"), with the highest total score calculated at 486. The SSEI-W is comprised of five subscales:

1. Skill and Experience: an individual's ability to please, or be pleased by, a sexual partner and the opportunities to engage in sexual activity. Examples of items from this subscale are "I wish I were better at sex," "I feel disappointed with my sex life," and "After a sexual encounter, I feel like something is missing."

2. Attractiveness: an individual's sense of sexual attractiveness, regardless of how others may perceive them. The Attractiveness subscale has 17 items, e.g., "I am pleased with my physical appearance," "I wish I were sexier," and "I like my body."

3. Control: the ability to direct or manage one's own sexual thoughts, feelings and interactions. The Control subscale has 16 items, e.g., "I am sure of what I want sexually," "I feel emotionally vulnerable in a sexual encounter," and "I am afraid of losing control sexually."

4. Moral Judgment: congruence of one's sexual thoughts, feelings and behaviors with one's own moral standards. The Moral Judgment subscale has 15 items, e.g., "I feel guilty about my sexual thoughts and feelings," "I don't think there's anything wrong with my sexual feelings," and, "My sexual behaviors are in line with my moral values."

5. Adaptiveness: the congruence or compatibility of one's sexual experience or behavior with other personal goals or aspirations. The Adaptiveness subscale has 15 items, e.g., "I wish things were different for me sexually," "I am where I want to be sexually at this point in my life," and "I feel good about the place of sex in my life."

Analysis

For the current study, measures of frequency distributions and central tendency were conducted on the raw data in order to tabulate descriptive statistics. These descriptive analyses were utilized to study and identify patterns in the data set. Comparisons between the groupings of abuse, treatment, and addiction variables utilized bivariate and multivariate statistical procedures. T-tests were used to examine SSEI-W total and subscale score differences for women who reported different types of abuse history, education levels, types of treatments, length of time in relationships, and sexual orientations. Multivariate regression analysis was used to explore a regression model with the moral judgment subscale based on significant results on this subscale.

RESULTS

A total of 295 surveys were mailed to the agencies and 99 completed surveys were returned during the data collection period, yielding a return rate of approximately 33%. Agency representatives administered surveys to participants. The return rate represented the number of surveys administered by agency staff, not the refusal of women to participate. One of the participants did not complete more

than half of the items on the SSEI and was eliminated from the sample. No other missing data was noted with regard to SSEI-W items. The women who participated in this study (n = 98) represented a broad range of demographic characteristics in age, ethnicity, education, and sexual experience (Table 1). Multiple numbers of SA treatments and mean age (34.5) indicated that many of these women have probably been using substances a large percentage of their lives.

Four Hypotheses were developed.

Hypothesis 1. Differences in sexual self-esteem scores will be found based on abuse variables; women with no abuse histories will have higher sexual self-esteem than women who report physical, emotional and/or sexual abuse. While it was assumed that a high percentage of women in this study would report experiences of abuse, the fact that 93.9% of this sample (an increase of 58.9% over that of the general population and 18.9% over the high range estimate of SA women) had experienced physical and sexual abuse was much higher than expected and adds to the existing literature. The fact that only two of 98 women reported no abuse is noteworthy, and due to the low number of nonabused women, this hypothesis could not be measured.

Hypothesis 2. Women with sexual abuse histories will have lower sexual self-esteem than other abuse groups. Although there were four abuse variables, two of the variables did not have a large enough n for statistical significance, so ANOVA was not utilized for the analyses. The two independent variables that were analyzed were physical abuse (n = 31) and physical and sexual abuse (n = 56) scores. Women who reported physical and sexual abuse scored significantly lower than women who reported only physical abuse on total SSEI-W scores (t = 2.03, df = 84, p = .045), Skill/Experience Subscale scores (t = 2.04, df = 84, p = .044) and Moral Judgment Subscale scores (t = 2.27, df = 84, p = .026). This was expected based on the results of previous research on sexual self-esteem and sexual abuse (e.g. Van Bruggen, Runtz & Kadlec 2006; Shapiro & Schwartz 1997).

It is noteworthy that 96 of 98 women in this sample reported emotional abuse along with physical and sexual abuse. Because nearly all respondents reported emotional abuse (n = 96) in addition to other types of abuse, it was not possible to compare women who had experienced only emotional abuse (n = 4). Based on differences in means and pooled standard deviations of the groups that were compared, the effect sizes for Total scores (d = .46); Skill/Experience scores (d = .46); and Moral Judgment scores (d = .51), are classified as medium, according to Cohen's (1988) convention.

Hypothesis 3. Higher sexual self-esteem scores will be found for women in long- term relationships (more than one year) versus women in short-term relationships or no relationships. Women who reported being in a relationship (n = 50) scored significantly higher than those women who reported not being in a relationship (n = 48) as predicted. Significant mean rankings were noted in SSEI-W total scores (t = 2.09, df = 96, p = .039), Control Subscale scores (t = 2.79, df : 96, p = .006), Moral Judgment Subscale scores (t = 2.12, df : 96, p = .037) and Adaptiveness Subscale scores (t = 2.28, df = 96, p = .025). Based on differences in means and pooled standard deviations of the groups that were compared, the effect sizes for Total scores (d = .42), Moral Judgment scores (d = .43), Control scores (d = .56) and Adaptiveness scores (d = .46) are classified as medium, according to Cohen's (1988) convention.

Hypothesis 4. Higher sexual self-esteem scores will be found in heterosexual women versus lesbian or bisexual women. No respondents reported being exclusively in a lesbian relationship, so the sexual orientation variables that were analyzed were heterosexual (n = 83) and bisexual (n = 15). Significant differences were noted in Total SSEI scores (t = 2.41, df = 92, p = .018), Moral Judgment Subscale scores (t = 2.68, df = 92, p = .009), Control (t = 2.62, df = 92, p = .01) and Adaptiveness (t = 2.69, df = 92, p = .009), with heterosexual women scoring higher then bisexual women as predicted. Based on differences in means and pooled standard deviations of the groups that were compared, the effect size for Moral Judgment and Adaptiveness scores (d = .32) and Control (d = .34) is classified as small to medium, according to Cohen's (1988) convention.

The regression analyses examined the effects of abuse, sexual orientation, relationship variables and treatment characteristics on the Moral Judgment subscale (Table 2). The first partial regression model indicated that abuse is significantly related to moral judgment (t = 2.33, p < .02). The next partial regression model indicated that controlling for abuse, sexual orientation is significantly related to low moral judgment (t =-2.4, p < 02). Bisexual women have moral judgment scores that are 8.31 points lower than those of heterosexual women. In the third model, alter adjusting for relationship variables, abuse and sexual orientation remain significantly related to moral judgment (t = 2.12, p < .04; t = -2.37, p < .02).

The full model is statistically significant (F = 2.13, p < .03) and explains approximately 23% of the variance in moral judgment scores. Abuse and sexual orientation remain significant in all of the models and their effect is not influenced by controlling for the other variables. Other factors that may explain variation in moral judgment may include religious affiliation and strength, ethnicity, age and education.

Cronbach's alpha for the SSEI-W total score was .96 for the sample in this study. The magnitude of correlates among the subscales was moderate to high (.50 to .81) and all correlations were statistically significant at the .01 level (Table 3). High internal consistency reliability (Cronbach's alpha) was found for all of the subscales: Skill and Experience (.87); Attractiveness (.77); Control (.85); Moral Judgment (.84); and Adaptiveness (.87).

DISCUSSION

The fact the almost 94% of this sample reported past abuse is significant. The experience of being sexually assaulted, abused or victimized contributes to feelings of guilt and shame about one's sexual self-esteem (James 2007). This is directly related to a person's moral standards and perceptions of oneself. Direct effects of sexual abuse (in relationship to a chemically-dependent woman's experience in SA treatment and the lowered sexual sell-esteem related to the abuse) may contribute to relapse rates in these women (Rubin, Stout & Longabaugh 1996).

Women who were involved in sexual relationships had higher sexual self-esteem on the SSEI-W Control domain than women who were not in sexual relationships. Length of time in sexual relationships had a positive correlation on average with higher sexual self-esteem scores. The longer women were in sexual relationships, the higher their sexual self-esteem. The Control domain includes the ability to direct or manage one's own sexual thoughts, feelings and interactions. Low scores on the Control subscale could translate to a woman's inability to make sound sexual decisions with regard to relationships.

Women who were involved in sexual relationships had higher scores on the SSEI-W Adaptiveness domain than women who were not in sexual relationships. It is a common treatment practice for clinicians to recommend that clients who are not currently in relationships to avoid involvement in romantic relationships during their first year of recovery (in order to focus on staying clean and sober). Pressure from the culture to be in a relationship, along with stigma associated with not being in a relationship, may influence the uninvolved women to resort to previous sexual behavior in order to find a partner, and if the previous sexual behavior was associated with substance abuse it could lead to relapse. Women involved in sexual relationships would not be subject to this risk factor.

Women who were not involved in sexual relationships had lower scores on the SSEI-W Moral Judgment domain than women who were in sexual relationships. Low scores on Moral Judgment directly reflect on the concept of guilt and shame. Guilt and shame are important issues for addicted women. Not examining the origin of these issues with regard to relationships may lead to relapse (Rubin, Stout & Longabaugh 1996). As reported in the literature, women experience higher levels of guilt, shame, depression, and anxiety about their addictions than do men (Covington & Surrey 1997).

Several other analyses were conducted on the data to explore other variables with one significant result. African American women scored significantly lower than Caucasian woman on the Attractiveness scale. With regard to body image, it would be purely conjecture to draw any conclusions as to the relevance as specific variables related to self-perceptions of attractiveness were not examined. Further investigation of this difference is needed in order to determine correlations.

Regression analysis was conducted with regard to Moral Judgment as this subscale was signiticant in all the analyses. Examining the variables related in the model (Table 2) provided information regarding the relevance of abuse and sexual orientation on Moral Judgment. Heterosexual women reported higher scores than bisexual women on the Moral Judgment, Control and Adaptiveness subscales. Bisexual women perceived lower feelings of congruence with their moral standards, perceptions of control and ability to adapt with regard to society's sexual standards. Of 16 large-scale studies that focused on the prevalence of substance abuse in lesbian, gay, bisexual, transgender (LGBT) communities, there is a general consensus that gay men and lesbians have greater substance abuse and health problems than non-LGBT men and women, due in part to lack of institutional supports, increased isolation due to lack of opportunities and fear of coming out (CSAT 2001). The lesbian or bisexual woman who is chemically addicted must deal with three types of stigma: (1) those associated with addiction, (2) sexism and (3) homophobia and heterosexism. There are significant differences between each of these stigmas, but each share a common thread of guilt and shame. The effects of homophobia can be extremely damaging. Certainly, women who struggle with addiction and the oppression of homophobia experience a sense of helplessness and feelings of shame, guilt and self-blame as a result.

Implications

Several implications should be considered as a result of this study. The prevalence of abusive experiences in chemically-dependent women suggests a need for all SA treatment facilities to assess women for physical and sexual abuse and other comorbid disorders, such as depression and PTSD. Along with the need for assessment is the ability to provide appropriate interventions, education and referrals regarding sexuality issues such as sexual abuse, sexual assault and sexual orientation. Extensive empirical studies with women have shown positive results with regard to self-esteem, psychosocial functioning and changes in anxiety and depression (Rao, Czuchry & Dansereau 2009; Covington et al. 2008; Simpson & Joe 2004).

Examining SSE in women may provide more targeted guidelines for developing sexual health interventions in relation to sexuality and subsequent relapse. Women need to be able to work through the trauma of being shamed and stigmatized by these issues in order to transform their stigmatized identity into a positive one (Van Bruggen, Runtz & Kadlee 2006). Utilizing SSE as an assessment tool for women in treatment may assist clinicians in developing appropriate treatment planning strategies. Experiential topic areas recommended as part of a sexual health intervention include those to (1) increase body awareness, (2) examine abusive relationship topics, (3) develop skills involving dialogue in relationships, (4) identify personal sexual relapse triggers, and (5) reexamine gender and the messages learned and internalized from it. Body image can affect intimacy, sexual response and sexual sell-esteem. The goal here is to begin a reversal process of a negative belief system, enabling women to focus on what they like about themselves and why sexual messages get skewed by media and society. Sexuality programming that only addresses sexual risk in terms of HIV prevention does not provide a holistic approach that incorporates relevant elements, such as self-efficacy, relational issues, skills-building and communication.

Limitations

The data were collected as part of the author's dissertation research, thus financial constraints and access to larger samples were limited as well as the ability to conduct personal interviews. This study was limited to a female substance-abusing population in New York State and larger studies need to be conducted in order for generalizations to be made. Efforts were made to solicit a representative sample in terms of racial/ethnic background. Some of the women had previous treatment experience and this may have impacted test scores. Specific treatment approaches and types of educational and clinical interventions were not known, so there was no way to control for or compare the effects of specific programming on the results of the SSEI-W.

Some researchers consider self-reported behavioral measures to be less reliable than biological measures (e.g., pregnancy tests, blood work, HIV results), especially with regard to sexual behavior. Catania and colleagues (1990) state that embarrassment, privacy, and fear of reprisals all motivate people to conceal their true sexual behavior. In addition, many subjects have difficulty in recalling past behaviors, particularly traumatic experiences.

Relationships between child sexual abuse (CSA) and adolescent or adult sexual and physical abuse were not examined. Data regarding the duration, age of victimization, intensity and perpetrator information were not included. The fact that this research was quantitative precluded data that could add valuable information regarding women's treatment and sexual experiences.

Future Directions

Having established the reliability of the SSEI-W in a female substance-abusing sample, further validation of the instrument can be established by implementing larger studies. Although numerous sexuality variables have been linked to substance abuse, sexual victimization and relapse risk for women, no sexuality-specific interventions have been developed for use in clinical settings. Exploring women's sexuality issues related to their substance abuse could provide vital information for developing behavioral interventions to improve sexual health. Interventions for substance-abusing women need to be developed and tested with regard to sex differences in order to determine their effects on SSE. Further studies utilizing the construct of sexual self-esteem coupled with a qualitative component will provide crucial data on treatment outcomes related to the construct. Utilizing the construct of SSE for substance-abusing women may provide new ways to predict and measure outcomes related to sexual health in SA treatment.

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Raven James, Ph.D. (a)

The contents of this manuscript were developed under a grant from the Department of Education, NIDRR grant number HI 33P070004. However, those contents do not necessarily represent the policy of the Department of Education, and endorsement by the federal government should not be assumed.

(a) Assistant Professor, Addictions Studies, Governors State University, University Park, IL.

Please address correspondence and reprint requests to Raven James, Ph.D., Assistant Professor, Governors State University, Addictions Studies, One University Place, University Park, IL 60466; phone: (708) 235-2160, fax: (708) 235-2196, email: rjames@govst.edu

DOI: 10.1080/02791072.2011.605700
TABLE 1
Demographics

Variable                      N      %   Range    Mean

Age                                      18-69    34.73

Race/Ethnicity
  Caucasian                   69   70.4
  African American            22   22.4
  Latino/Hispanic              4    4.1
  Native American              3    3.1

Education
  Bachelors                   10   10.2
  Associates                  15   15.3
  High School Education       65   66.3
  Less than High School        8    8.2

Relationship Status (1)
  Single                      52   53.6
  Divorced/Separated/         28   28.8
    Widowed
  Married                      8    8.2
  Living Together              9    9.3

Time in Relationship
  Less than One Year          63   64.3
  More than One Year          35   35.7

Sexual Orientation
  Heterosexual                80   81.6
  Bisexual                    15   15.3
  Lesbian                      0      0
  Not Identified               3    3.1

Treatment Characteristics
  More than Three             20   20.4
    Months
  Less than Three             78   79.6
    Months

  Inpatient                   56   57.1
  Outpatient                  42   42.9

  Mixed Gender                33   33.7
    Treatment Only
  Same Gender                 29   29.6
    Treatment Only
  Both Gender                 36   36.7
    Treatment Groups

  Times in Treatment                      1-10

Reported Abuse
  Physical and Emotional      31   31.6
  Sexual and Emotional (2)     6    6.1
  Physical, Sexual and        55   56.1
    Emotional
  Emotional Only (2)           4    4.1
  None (2)                     2    2.0

(1) Missing case

(2) Excluded from abuse analysis clue to low statistical power.

TABLE 2
Relationship Between Sexual Abuse and Moral Judgment Scale Before and
After Adjustment for Covariates

                                              Model 1

Variable                                    b           [beta]

Physical Abuse (1)                    6.262 (2.693)     .238 *
Sexual Orientation (2)
Relationship Characteristics  (3)
  Married or Living Together
  Widowed, Separated or Divorced
  Time in Relationship
Treatment Characteristics
  Number of Treatments
  Drug of Choice--Cocaine4
  Drug of Choice--Opiates
  Length of Treatment
  Treatment Type
  Group Type
Constant                             69.737
F                                     5.41 *
[R.sup.2]                              .056
Adjusted [R.sup.2]                     .046

                                               Model 2

Variable                                    b           [beta]

Physical Abuse (1)                    5.972 (2.627)     .227 *
Sexual Orientation (2)               -8.305 (3.457)    -.240 *
Relationship Characteristics  (3)
  Married or Living Together
  Widowed, Separated or Divorced
  Time in Relationship
Treatment Characteristics
  Number of Treatments
  Drug of Choice--Cocaine4
  Drug of Choice--Opiates
  Length of Treatment
  Treatment Type
  Group Type
Constant                             71.099
F                                     5.73 *
[R.sup.2]                              .114
Adjusted [R.sup.2]                     .094

                                               Model 3

Variable                                    b           [beta]

Physical Abuse (1)                    5.621 (2.655)     .214 *
Sexual Orientation (2)               -8.303 (3.498)    -.240 *
Relationship Characteristics  (3)
  Married or Living Together         -1.723 (3.685)    -.054
  Widowed, Separated or Divorced     -1.852 (2.874)    -.068
  Time in Relationship                4.029 (2.879)     .154
Treatment Characteristics
  Number of Treatments
  Drug of Choice--Cocaine (4)
  Drug of Choice--Opiates
  Length of Treatment
  Treatment Type
  Group Type
Constant                             70.697
F                                     2.80 *
[R.sup.2]                              .140
Adjusted [R.sup.2]                     .090

                                              Model 4

Variable                                    b           [beta]

Physical Abuse (1)                    6.557 (2.698)     .249 *
Sexual Orientation (2)               -7.083 (3.576)    -.205 *
Relationship Characteristics  (3)
  Married or Living Together         -1.436 (3.846)    -.045
  Widowed, Separated or Divorced     -2.289 (2.893)    -.085
  Time in Relationship                4.604 (2.924)     .176
Treatment Characteristics
  Number of Treatments                 .950 (.637)      .158
  Drug of Choice--Cocaine (4)         3.962 (2.949)     .149
  Drug of Choice--Opiates             3.127 (1.578)     .218 *
  Length of Treatment                 1.786 (3.249)     .058
  Treatment Type                      3.903 (2.732)     .155
  Group Type                          1.246 (2.906)     .045
Constant                             62.210
F                                     2.13 *
[R.sup.2]                              .226
Adjusted [R.sup.2]                     .120

Note: Standard errors are shown in parentheses

(1) The reference group is sexual abuse.

(2) The reference group is heterosexual.

(3) The reference group is single.

(4) The reference group is alcohol.

* p < .05

TABLE 3

Intercorrelations Between Total SSEI Scores and All Subscale Scores

Subscale                 M       SD      1       2         3

1. Skill/Experience     86.2    13.9    --      .58 *    .80 *
2. Attractiveness       76.1    11.8    --       --      .59 *
3. Control              75.1    10.5    --       --        --
4. Moral Judgment       71.9    12.3    --       --        --
5. Adaptiveness         72      12.3    --       --        --
6. Total Scores        386.7    52.7    --       --        --

Subscale                 4        5        6

1. Skill/Experience    .64 *    .80 *    .90 *
2. Attractiveness      .50 *    .52 *    .73 *
3. Control             .69 *    .81 *    .90 *
4. Moral Judgment        --     .81 *    .85 *
5. Adaptiveness          --       --     .92 *
6. Total Scores          --       --       --

* Correlation is significant at the 0.01 level (two-tailed).
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