Prenatal cocaine exposure and age of sexual initiation: Direct and indirect effects
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).
References (70)
- et al.
Adolescent risk-taking as a function of prenatal cocaine exposure and biological sex
Neurotoxicol. Teratol.
(2014) - et al.
Reliability of the 1999 Youth Risk Behavior Survey Questionnaire
J. Adolesc. Health
(2002) - et al.
The effects of prenatal cocaine exposure and gender on inhibitory control and attention
Neurotoxicol. Teratol.
(2011) - et al.
Pubertal timing and its link to behavioral and emotional problems among ‘at-risk’ African American adolescent girls
J. Adolesc.
(2009) - et al.
Age of sexual debut among US adolescents
Contraception
(2009) - et al.
Alcohol, tobacco and marijuana use among pregnant teenagers: 6-year follow-up of offspring growth effects
Neurotoxicol. Teratol.
(2002) - et al.
Prenatal marijuana use and neonatal outcome
Neurotoxicol. Teratol.
(1991) - et al.
Prenatal and postnatal cocaine exposure predict teen cocaine use
Neurotoxicol. Teratol.
(2011) - et al.
Substance use and sexual intercourse onsets in adolescence: a genetically informative discordant twin design
J. Adolesc. Health
(2014) - et al.
Adolescent initiation of licit and illicit substance use: impact of intrauterine exposures and post-natal exposure to violence
Neurotoxicol. Teratol.
(2011)
White matter microstructure abnormalities and executive function in adolescents with prenatal cocaine exposure
Psychiatry Res.
Early adolescent sexual initiation as a problem behavior: a comparative study of five nations
J. Adolesc. Health
Caregiver and self-report of mental health symptoms in 9-year old children with prenatal cocaine exposure
Neurotoxicol. Teratol.
Examining the association between parenting and childhood depression: a meta-analysis
Clin. Psychol. Rev.
Externalizing behavior and substance use related problems at 15 years in prenatally cocaine exposed adolescents
J. Adolesc.
The effects of prenatal cocaine exposure on problem behavior in children 4–10 years
Neurotoxicol. Teratol.
Effects of prenatal cocaine/polydrug exposure on substance use by age 15
Drug Alcohol Depend.
Ten-year research update review: child sexual abuse
J. Am. Acad. Child Adolesc. Psychiatry
Prenatal cocaine exposure and gray matter volume in adolescent boys and girls: relationship to substance use initiation
Biol. Psychiatry
Effects of prenatal cocaine exposure on child behavior and growth at 10 years of age
Neurotoxicol. Teratol.
Prenatal cocaine exposure: effects on mother- and teacher-rated behavior problems and growth in school-age children
Neurotoxicol. Teratol.
The effects of prenatal cocaine use on infant development
Neurotoxicol. Teratol.
Adolescent initiation of drug use: effects of prenatal cocaine exposure
J. Am. Acad. Child Adolesc. Psychiatry
Contrasts between admitters and deniers of drug use
J. Subst. Abuse Treat.
Associations between forced sex, sexual and protective practices, and sexually transmitted diseases among a national sample of adolescent girls
Womens Health Issues
Ten years of longitudinal research on U.S. adolescent sexual behavior: developmental correlates of sexual intercourse, and the importance of age, gender and ethnic background
Dev. Rev.
Manual for the Child Behavior Checklist/4-18 and 1991 Profile
A review of the effects of prenatal cocaine exposure among school-aged children
Pediatrics
Prevalence of positive urine drug screens in a prenatal clinic: correlation with patients’ self-report of drug use
R. I. Med.
Psychological adjustment, substance use, HIV knowledge, and risky sexual behavior in at-risk minority females: developmental differences during adolescence
J. Pediatr. Psychol.
Protective factors can mitigate behavior problems after prenatal cocaine and other drug exposures
Pediatrics
Preadolescent health risk behavior as a function of prenatal cocaine exposure and gender
J. Dev. Behav. Pediatr.
Externalizing problems in late childhood as a function of prenatal cocaine exposure and environmental risk
J. Pediatr. Psychol.
Exposure to violence and associated health-risk behaviors among adolescent girls
Arch. Pediatr. Adolesc. Med.
Childhood Trauma Questionnaire: A Retrospective Self-Report
Cited by (13)
Pathways from prenatal cocaine exposure to adult substance use and behavior
2024, Neurotoxicology and TeratologyPrenatal cocaine exposure, early cannabis use, and risky sexual behavior at age 25
2022, Neurotoxicology and TeratologyCitation Excerpt :The additional item for male participants asked about their concerns that a new partner would interpret condom use as a sign that they had previously had sex with other males. Based on the literature (De Genna et al., 2014; Frank et al., 2011; Lambert et al., 2013; Lester et al., 2012; Min et al., 2014; Richardson et al., 2013b, 2019), we tested indirect pathways between PCE and adult risky sex via childhood externalizing behavior problems, experiences of child abuse, early initiation of cannabis use, and age of sexual initiation. Childhood externalizing behavior problems were assessed by the Child Behavior Checklist completed by caregivers at the age 10 assessment (CBCL; Achenbach and Edelbrock, 1991).
Longitudinal studies of the effects of prenatal cocaine exposure on development and behavior
2018, Handbook of Developmental NeurotoxicologyAssociation of prenatal cocaine exposure, childhood maltreatment, and responses to stress in adolescence
2017, Drug and Alcohol DependenceThe association of prenatal cocaine exposure, externalizing behavior and adolescent substance use
2017, Drug and Alcohol DependenceCitation Excerpt :Problems with poor inhibitory control can manifest in behaviors that show impulsivity and poor judgment for adolescents with PCE. Examples of such behavior include earlier initiation of sexual activity (De Genna et al., 2014; Min et al., 2015), more engagement in risky sexual behavior (Min et al., 2016), and more damage, theft, and status offenses by age 15 (Richardson et al., 2015) than non-exposed adolescents. Relatively few studies have examined the mediating effect of externalizing behavior in the relationship between prenatal cocaine exposure and teen substance use.
Impact of Prenatal Cocaine Exposure on Adolescent Behavior
2017, The Neuroscience of Cocaine: Mechanisms and Treatment