HIV and Sexually Transmitted Diseases: Implications for Juvenile Sexual Offenders and their Victims

1. HIV and Sexually Transmitted Diseases: Implications for Juvenile Sexual Offenders and their Victims Tiffany Chenneville, Ph.D. Florida Psychological Association November, 2005

2. Objectives • Discuss estimated rates of HIV and STDs among juvenile sexual offenders • Discuss risk factors associated with HIV-risk taking behavior among juvenile sex offenders • Discuss legal and ethical issues associated with juvenile sexual offenders known or suspected to be HIV positive or the carrier of an STD • Discuss intervention strategies for working with juvenile sexual offenders to prevent the spread of HIV and other STDs

3. Epidemiology of HIV Disease in General Population • AIDS cases globally • CDC Surveillance Report (United States) • Current cases • Total deaths • Trends based on age, gender, and ethnicity • AIDS cases in Florida • Adult • Pediatric

4. Epidemiology of HIV Disease in General Population • Problems with epidemiological data • Changing definitions • Adolescents grouped with adults (15-24 year olds) • Anonymous testing/HIV home test kits • Undiagnosed cases • HIV tracking vs. AIDS tracking • Conclusion: Estimates are gross underestimate!!

5. Estimating the Prevalence of HIV and STDs among Juvenile Offenders • Elevated rates of HIV and STDs among correctional populations (including juvenile correctional facilities) worldwide • In some countries, 20-40% or correctional populations are infected with HIV or STDs (Seal, 2005) • Estimated that AIDS cases in prison population is 5 times that in US general population (Braithwaite, Hammett, & Jacob Arriola, 2002) • African American incarcerated youth are considered to be at even greater risk for HIV infection (Gary, Yarandi, Verbosky, Lopez, Campbell, & Scruggs, 2000)

6. Risk Factors associated with HIV and STDs among Juvenile Offenders • Drug/alcohol use • Injection drug use • Mental illness • Infectious disease co-morbidity (e.g., hepatitis) • Relationship between adolescent psychopathology and HIV-risk behaviors (Donenberg et al., 2001) • Delinquency linked to drug/alcohol use • Aggression related to risky sexual behavior • Leads to hypotheses about juvenile sexual offenders and estimated rates of HIV (Donenberg, Emerson, Bryant, Wilson, & Weber-Shifrin, 2001; Seal, 2005)

7. HIV Knowledge and Safe Sex Practices among Juvenile Sexual Offenders and Juvenile Offenders • Juvenile Sexual Offenders (limited data available) • Comparison of juvenile sexual offenders to a group of runaways (Rotheram-Borus, Becker, Koopman, & Kaplan, 1991) • Juvenile sex offenders found to be less knowledgeable about HIV and less likely to engage in safe sex practices

8. HIV Knowledge and Safe Sex Practices among Juvenile Sexual Offenders and Juvenile Offenders • Juvenile Sexual Offenders • Factors Associated with HIV Knowledge and Attitudes towards Safer Sex in a Population of Juvenile Sexual Offenders(Trisdale, 1999) • Male adolescent juvenile sex offenders • Variables • Measures • AIDS Knowledge Questionnaire • Views about Sex Questionnaire • Beck Depression Inventory • Ethnicity • Sexual orientation • Total lifetime number of sexual partners

9. HIV Knowledge and Safe Sex Practices among Juvenile Sexual Offenders and Juvenile Offenders • Results • In general, this group had… • Very low scores on test of HIV knowledge • Low intent to engage in safer sex in the future • Negative correlation between HIV knowledge, intent to engage in safer sex in the future, and scores on the BDI • As depression increased, HIV knowledge and intent to engage in safe sex decreased

10. HIV Knowledge and Safe Sex Practices among Juvenile Sexual Offenders and Juvenile Offenders • Juvenile Offenders • Most report… (Robertson & Levin, 1990) • Being sexually active • Early onset of sexual activity • Unsafe sexual practices • Low intent to engage in safer sex in the future (Trisdale, 1999)

11. Legal/Ethical IssuesMandatory Testing of Juvenile Sexual Offenders • Do you think HIV testing should be legally mandated for sexual offenders? • What about for juvenile sexual offenders? • Why or why not?

12. Legal/Ethical IssuesMandatory Testing of Juvenile Sexual Offenders • Arguments in Favor of Mandatory Testing • Reduce the incidence of HIV • Allows for treatment of HIV for victim and offender • Reduce anxiety among victims of sexual crimes • Arguments Against Mandatory Testing • Fourth Amendment protection against unreasonable search and seizure/privacy rights • Victims can/should be tested themselves to ensure negative status due to window period between HIV infection and development of HIV antibodies, which can be diagnosed on the basis of an HIV test

13. Legal/Ethical IssuesMandatory Testing of Juvenile Sexual Offenders • Washington Supreme Court (1993) ruled that a state statute requiring HIV testing for all sexual offenders applied to juvenile sexual offenders • The court ruled that… • Benefits to society outweighed possible intrusion into juveniles’ privacy interests • Intent of the law is to reduce the incidence of STDs, which is consistent with public health policies • Law beneficial to juveniles, victims, and society by making HIV status known so that all concerned can receive treatment, if necessary, and to prevent infection of others

14. Legal/Ethical IssuesMandatory Testing of Juvenile Sexual Offenders • People v. Benjamin G. (2004) • In 2002, Benjamin (a minor child) admittedly committed a lewd and lascivious act against his younger brother (a minor child under the age of 14) • Benjamin was placed on probation and was adjudged a ward of the court and was placed in a group home, and imposed a $100 restitution fine • In 2003, Benjamin came before the court on similar charges • Court terminated probation, committed Benjamin to the California Youth Authority, imposed a second $100 restitution fine, and ordered an HIV test • Benjamin appealed the fine and the HIV test, claiming that penetration had not taken place • The court ruled that, according to CA law, every person convicted of a sexual offense must submit to a blood test for HIV

15. Legal/Ethical IssuesMandatory Testing of Juvenile Sexual Offenders • State of New Jersey v. J.G. • Initially, trial court refused to order HIV test of three juveniles charged with raping a girl • Medical testimony showed that best way for victim to learn HIV status would be for her to under HIV test herself • New Jersey Superior Court Appellate Division reversed the trial judge • Mandatory testing may ease victim’s anxiety about HIV status

16. Legal/Ethical IssuesMandatory Testing of Juvenile Sexual Offenders • State of Arizona v. Superior Court (1995) • Law forcing juvenile sex offenders to submit to HIV antibody test does not violate 4th Amendment protection against unreasonable search and seizure • However, neither judges nor prosecutors can order the tests at their own initiative • Rather, only the victim’s parents or guardians can request the tests • Applies to adjudicated delinquents who either • Committed a sexual offense or • “Significantly exposed” a victim to the offender’s blood or body fluids (other than saliva, tears, or perspiration)

17. Legal/Ethical IssuesMandatory Testing of Juvenile Sexual OffendersFlorida Law • Florida Statute 960.003 (2005): “HIV testing for persons charged with or alleged by petition for delinquency to have committed certain offenses; disclosure of results to victim” • (1) Legislative Intent • Victims have a right to know if the alleged offender is infected with HIV • Denying victims such information such information causes “unnecessary mental anguish in persons who already have suffered trauma” • Early diagnosis and intervention beneficial to both victim and offender

18. Legal/Ethical IssuesMandatory Testing of Juvenile Sexual OffendersFlorida Law • (2) Testing of Person Charged with or Alleged by Petition for Delinquency to Have Committed Certain Offenses • (a) Court shall order HIV testing for the alleged offender if • Offense involves the transmission of bodily fluids from one person to another AND • The victim or the victims parent or legal guardian, if the victim is a minor, requests the HIV testing • (b) However, if, at the time of the offense, the victim is a minor, a disabled adult, or an elderly person, then the condition that the offense involve the transmission of bodily fluids need not be present • Testing must be performed under direction of Dept. of Health • Testing performed on a defendant or juvenile offender will not be admissible in any criminal or juvenile proceeding arising out of the alleged offense

19. Legal/Ethical IssuesMandatory Testing of Juvenile Sexual OffendersFlorida Law • (3) Disclosure of Results • (a) Results must be disclosed within 2 weeks of receipt, under direction of Dept of Health • Victim • Alleged offender • Parent of alleged offender (if positive) • Public health agencies (if positive) • Results are otherwise confidential • (b) Opportunity for face-to-face counseling must be made available at the time of disclosure of results, pursuant to Florida Statute 381.004(3)

20. Legal/Ethical IssuesMandatory Testing of Juvenile Sexual OffendersFlorida Law • (4) Postconviction Testing • HIV testing can be court order postconviction, if it has not been ordered prior, consistent with the guidelines in (1)-(3). • (5) Exceptions • (a) Alleged offender has undergone voluntary HIV testing and • (b) Results were provided to the victim and, if the victim is a minor, his/her parents or legal guardians

21. Legal/Ethical IssuesMandatory Testing of Juvenile Sexual OffendersFlorida Law • (6) Testing During Incarceration, Detention, or Placement; Disclosure • If a juvenile offender has not been tested under the conditions of subsection (2), but undergoes HIV testing during incarceration, detention or placement • Results shall be disclosed in accordance with subsection (3) • Requests for disclosure shall be considered a “standing request for any subsequent HIV test results obtained within 1 year of the initial HIV test performed • i.e., Request for disclosure need not be repeated after each test administration performed within 1 year of the initial test

22. Intervention Strategies • Sex education listed as an important content area to be included in treatment (Righthand & Welch, 2001) • Other Areas: • Cognitive restructuring • Empathy training • Values clarification • Abusive vs. nonabusive sexual behavior • Impulsivity control training • Social skills training • Reduction of deviant arousal • Relapse prevention • No sex education programs designed specifically for juvenile sexual offenders • Number of sex education programs designed for juvenile offenders

23. Intervention Strategies • Sexual Risk Reduction Skills Training (ST) vs. Anger Management (AM) Interventions for Incarcerated Male Adolescents (St. Lawrence, Crosby, Belcher, Yazdani, & Brasfield, 1999) • 428 male juvenile offenders enrolled in a state reformatory • Randomly assigned to 6-week session (ST or AM) • Pre/Post test design • Cognitive mediating measures • AIDS knowledge • Condom attitudes • Self-efficacy with regard to condom use • Perceived risk • Conflict tactics • Anger management • Impulsivity • Behavioral skills in condom use assessed at baseline and 6 months post-release • Results • ST participants reported greater AIDS knowledge, self-efficacy, positive attitudes about condoms, and significantly greater condom use than AM participants • AM participants reported no changes in attitudes or knowledge following the intervention • Both groups showed significant decreases in sexual risk behaviors and drug use upon follow-up

24. Intervention Strategies • HIV and STD Prevention Program for Adolescents in Juvenile Rehabilitation Centers (Godin, Michaud, Alary, Otis, Masse, Fortin, Gagnon, & Gagnon, 2003) • HIV/STD prevention program designed for adolescents with social adaptation difficulties • Pre-test/Post-test quasi-experimental design • Experimental group • 296 adolescents (12-18 year old males and females) • Participated in the prevention program • Control group • 240 adolescents (12-18 year old males and females) • Did not participate in the prevention program

25. Intervention Strategies • Intervention Program • Theoretical Basis (Theory of Reasoned Action, Theory of Planned Behavior, Theory of Interpersonal Behavior, & Social Cognitive Theory ) • 10 sessions (each 75-90 minutes in length) • Meaning of sexual intercourse • Unsafe and safer sexual activities • Pros and cons of condom use • Values and sexuality • Negotiation of safer sex • Communication skills • Self-affirmation • Arguing to overcome obstacles to safer sex behavior

26. Intervention Strategies • Learning Activities • Group discussions • Brainstorming • Role playing • Problem solving • Demonstrations • Condom manipulation • Improvisation • Audiovisual documents

27. Intervention Strategies • Variables measured • Intention to use condom • Ex. “I have the intention to use a condom each time if I have sex with a new partner during the next 3 months” • Attitude toward condom use (using rating on paired adjectives) • Ex. “useless/useful, unpleasant/pleasant, shameful/honorable, etc” • Perceived behavioral control about condom use (using rating on paired adjectives) • Ex. “For me, using a condom each time that I might have sexual intercourse with a new partner during the next 3 months would be….very difficult/very easy.” • Personal/normative belief (Likert scale…strongly agree/disagree) • Ex. “If I had sexual intercourse with a new partner during the next 3 months, I would feel guilty about not using a condom each time.” • Knowledge about transmission modes and prevention of HIV and other STDS • Habit of using condoms • Assessed by asking respondents to evaluate how often they used condoms in the last 3 months when having intercourse with a new partner

28. Intervention Strategies • Results • No significant differences between groups at baselines in terms of variables measured • Significant findings for adolescents in experimental group • Intention to use condoms • Increased self-efficacy • Personal normative beliefs toward using a condom was higher • Attitude toward using condoms was higher • Behavioral beliefs were higher • Perceived behavioral control was higher • Knowledge about HIV/STDs was higher

29. Intervention Strategies • What problems might you foresee in attempting to apply an HIV prevention program designed for a “juvenile offender” to a “juvenile sexual offender”?

30. Intervention Strategies • Implications of Research Findings for Practice • Need to individual interventions • Determine function of sexual behavior • Assess HIV knowledge, intentions, behavior skill level with regard prevention efforts • Assess for emotional factors which may impede HIV prevention

31. Conclusion • More research is needed in this area • Epidemiological information about rates of HIV among population of juvenile sexual offenders • HIV prevention programs specifically designed for this population • Contact Information • Tiffany Chenneville, Ph.D. University of South Florida Department of Psychological and Social Foundations 4202 East Fowler Avenue, EDU 162 Tampa, Florida 33620 813-974-9499 727-644-5911 chennevi@coedu.usf.edu or chenneville@juno.com