Elsevier

Drug and Alcohol Dependence

Volume 145, 1 December 2014, Pages 194-200
Drug and Alcohol Dependence

Prenatal cocaine exposure and age of sexual initiation: Direct and indirect effects

https://doi.org/10.1016/j.drugalcdep.2014.10.011Get rights and content

Highlights

  • Direct and indirect effects of prenatal cocaine exposure on sexual behavior were explored.

  • Participants were enrolled prenatally and followed through childhood, adolescence, and young adulthood.

  • First trimester cocaine exposure predicted earlier age at first intercourse, with control for important covariates.

  • This relationship was mediated by early adolescent substance use.

  • The findings have implications for identification of exposed offspring at greatest risk of risky sexual behaviors.

Abstract

Background

Prenatal cocaine exposure (PCE) has been linked to child behavior problems and risky behavior during adolescence such as early substance use. Behavior problems and early substance use are associated with earlier initiation of sexual behavior. The goal of this study was to examine the direct and indirect effects of PCE on sexual initiation in a longitudinal birth cohort, about half of whom were exposed to cocaine in utero.

Methods

Women were interviewed twice prenatally, at delivery, and 1, 3, 7, 10, 15, and 21 years postpartum. Offspring (52% female, 54% African American) were assessed at delivery and at each follow-up phase with age-appropriate assessments. At age 21, 225 offspring reported on their substance use and sexual behavior.

Results

First trimester cocaine exposure was a significant predictor of earlier age of first intercourse in a survival analysis, after controlling for race, sociodemographic characteristics, caregiver pre- and postnatal substance use, parental supervision, and child's pubertal timing. However, the association between PCE and age of first sexual intercourse was mediated by adolescent marijuana and alcohol use prior to age 15.

Conclusions

Most of the effect of PCE on age of sexual initiation occurred between the ages of 13–18, when rates of initiation were approximately 10% higher among exposed offspring. This effect was mediated by early adolescent substance use. These results have implications for identification of the exposed offspring at greatest risk of HIV risk behaviors and early, unplanned pregnancy.

Introduction

In the medical literature on sexual behavior, a primary focus has been on the debut of sexual intercourse because earlier initiation of sex is a powerful predictor of HIV risk behaviors, sexually transmitted infections (STIs), as well as early and unintended pregnancy (Bachanas et al., 2002, Melchert and Burnett, 1990, Smith, 1997). One of the strongest correlates of early sex is substance use (Madkour et al., 2010, Zimmer-Gembeck and Helfand, 2008). A review of 35 longitudinal studies confirmed that substance use is linked to earlier sexual intercourse (Zimmer-Gembeck and Helfand, 2008). In a comparative study, substance use was significantly and positively associated with early sexual behavior in each country, even though age of initiation and rates of substance use and sexual behavior varied by country (Madkour et al., 2010). And in a genetically informed design, Australian twins who experienced drunkenness earlier had sexual intercourse earlier than their co-twins who experienced drunkenness later (Deutsch et al., 2014).

In addition to substance use, there are other important correlates of early sexual intercourse. Boys report having sex earlier than girls (Nkansah-Amankra et al., 2011), and African American youth, on average, engage in intercourse earlier than White youth (Cavazos-Rehg et al., 2009, De Rosa et al., 2010, Upchurch et al., 1998). Other child characteristics associated with early sexual initiation include behavior problems, earlier pubertal timing, and depressive symptoms (Epstein et al., 2013, Longmore et al., 2004, Oberlander et al., 2011, Zimmer-Gembeck and Helfand, 2008). The environment is also an important predictor of sexual behavior including exposure to child abuse and neglect (Putnam, 2003, Upchurch and Kusunoki, 2004), violence (Berenson et al., 2001), and lower levels of parental supervision (Huang et al., 2011, Zimmer-Gembeck and Helfand, 2008).

Many of these correlates of age of sexual initiation have also been documented in youth with prenatal cocaine exposure (PCE). For example, PCE is associated with increased child behavior problems (Ackerman et al., 2010, Bada et al., 2012, Bennett et al., 2013, Delaney-Black et al., 2004, McLaughlin et al., 2011, Minnes et al., 2010, Richardson et al., 2011, Whitaker et al., 2011). Children with PCE are often raised in less than optimal environments that are also linked to poor behavioral outcomes (Bradley and Corwyn, 2002, McLeod et al., 2007). Nonetheless, recent reviews evaluating studies that control for many factors in the postnatal environment have found a consistent relationship between PCE and child behavior problems (Ackerman et al., 2010, Buckingham-Howes et al., 2013).

Findings from longitudinal studies show that the effects of PCE continue into adolescence, involving new problem behaviors that emerge during this developmental period (Buckingham-Howes et al., 2013). For example, adolescents with PCE are more likely to initiate substance use at a younger age than non-exposed adolescents. Delaney-Black et al. (2011) reported that youth with PCE were more likely to initiate cocaine use by age 14 than non-exposed youth. PCE has also been associated with the early onset of alcohol and/or marijuana use (Frank et al., 2011, Minnes et al., 2014, Richardson et al., 2013b), and with substance use related problems (Min et al., 2014). Further, some researchers have reported a gender by PCE interaction, with boys with PCE having poorer inhibitory control (Carmody et al., 2011), a greater propensity for risk-taking (Allen et al., 2014), more behavior problems (Bennett et al., 2007, Delaney-Black et al., 2004), earlier initiation of substance use (Bennett et al., 2007), and increased frequency of sex without a condom (Lambert et al., 2013) than girls with PCE. Thus, it is possible that gender may moderate the effect of PCE on age at sexual initiation and interaction effects should be considered in analyses.

To our knowledge, sexual behavior as a function of PCE has only been examined in one other sample. Lambert et al. (2013) assessed adolescent sexual behavior at the 15-year follow-up of the Maternal Lifestyle Study of prenatal cocaine and/or opiate exposure. At delivery, the mothers reported on their cocaine use during pregnancy. Adolescents with any PCE were slightly more likely to report sexual intercourse by age 14 than non-exposed adolescents (37% versus 30%, respectively), but this was not statistically significant in multivariate models controlling for child gender, prenatal marijuana exposure, parental involvement, and community violence. PCE did significantly predict oral sex by age 14 in multivariate models: 31% of adolescents with PCE reported oral sex by this age compared to 22% of adolescents without PCE. Lambert et al. (2013) found no moderating effect of gender on oral sex by age 14. In another study of the same cohort, Conradt et al. (2014) found that boys, but not girls, prenatally exposed to multiple substances displayed physiological signs of neurobehavioral dysregulation that predicted sexual intercourse by age 16. It is not known if these findings are replicable in other cohorts of PCE individuals, or if they will apply to the initiation of sexual behavior after age 16.

This report is from a longitudinal, prospective study of PCE in which African American and White women were enrolled early in pregnancy and seen with their offspring at several time points across childhood, adolescence, and at 21 years post-partum. Extensive data on the mothers, offspring, and the home environment were collected at these phases. The purpose of these analyses was to examine the direct and indirect effects of PCE on the initiation of sexual behavior in offspring. We investigated whether there was a direct effect of PCE on sexual behavior, while controlling for other correlates of sexual behavior (e.g., race, gender, early puberty, lower parental monitoring). We also investigated whether the earlier effects of PCE on child behavior problems and early substance use, as summarized above, would mediate any direct effects on sexual behavior. A Gender × PCE interaction term was also entered into the direct and indirect models to determine if gender moderated the effect of PCE on age at sexual initiation.

Section snippets

Study design

Women attending the Magee-Womens Hospital (MWH) prenatal clinic who were at least 18 years of age were approached by research staff. Written informed consent was obtained prior to interviewing the women. Ninety percent of the women approached agreed to participate. Medical chart reviews were conducted on a random sample of the women who refused to participate and only 5% had a history of drug use during the current pregnancy. The University of Pittsburgh's Institutional Review Board and the

Results

Maternal prenatal cocaine use was moderate, with most users decreasing or discontinuing use after the first trimester. This represents the most common pattern of drug use in non-treatment samples (Cornelius et al., 2002, Day et al., 1989, Day et al., 1991, Substance Abuse, 1998). In the first trimester of pregnancy, 41% of the women reported using cocaine. This proportion decreased over pregnancy: 8% and 11% of the women reported use of cocaine during the second and third trimesters of

Discussion

This study provided initial evidence for a direct effect of first trimester cocaine exposure on age at first intercourse, controlling for other prenatal drug exposure, race, gender, earlier pubertal timing, lower levels of parental supervision, exposure to child abuse/neglect, and greater exposure to violence. We were able to determine via survival analysis that most of the effect of PCE on age of sexual initiation occurred between the ages of 13–18, when rates of initiation were approximately

Role of funding source

Nothing declared.

Contributors

Dr. Richardson designed the study and wrote the protocol. Dr. Richardson and Dr. De Genna managed the literature searches and summaries of previous related work. Dr. Goldschmidt undertook the statistical analysis, and Dr. De Genna wrote the first draft of the manuscript. All authors contributed to the writing of the manuscript and have approved the final manuscript.

Conflict of interest

No conflict declared.

Acknowledgements

Funding provided by National Institute on Drug Abuse: DA025734 (PI: De Genna); DA05460, DA06839, DA08916, DA12401 (PI: Richardson).

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