According to a recent study published by Yale researchers, the collective effects of substance abuse, depression, hazardous drinking and post-traumatic stress disorder on women facing violent personal relationships decreases their likelihood of negotiating condom use with a partner. This conclusion supports the greater implementation of condom-negotiation skills training in programs designed to help women experiencing intimate partner violence.

Courtney Peasant, Tami P. Sullivan, Nicole H. Weiss, Isabel Martinez and Jamie P. Meyer, professors and researchers at the Yale School of Medicine and Yale School of Public Health, authored the study, which was published in AIDS Care on Sept. 2, 2016. The study utilized a syndemic framework -— an aggregation of two or more diseases, disorders or illnesses in which the combination exacerbates the negative health effects on the person — to gauge the multiple epidemics affecting women exposed to intimate partner violence. First utilized in the 1990s as an anthropological device to outline urban health concerns, syndemic frameworks have remained an effective tool for researchers hoping to acknowledge the scope of modern health issues. Condom negotiation was defined in the study as the number of times a participant asked their partner to wear a condom divided by the number of times they had sexual intercourse with one another.

“The idea initially was that there are certain populations that disproportionately experience substance abuse, HIV and violence, and that those things collectively make health outcomes worse in terms of morbidity and mortality. Since then syndemics research has exploded, and you can use it to describe anything that intersects,” explained Meyer, a medical school professor in the infectious diseases section in the Department of Internal Medicine.

One of the challenges in publishing the study was the relevance of condom negotiations in light of new strategies for HIV/AIDS prevention. Pre-exposure prophylaxis, or PrEP, is a daily HIV medicine that lowers the chance of contracting HIV from sex by more than 90 percent. PrEP was legalized by the FDA in July 2012.

“There were questions as to why condom negotiations are important given that we have PrEP now, given that we should not be encouraging women who are in violent relationships to negotiate condom use because that can be dangerous,” said Peasant, primary author of the study, on the complexity of condom negotiation in violent relationships. Traditionally, public health officials will urge women in nonviolent relationships to continually impress upon their partner the necessity of using a condom. However, in violent relationships this can become a bit trickier.

Peasant believes, however, that condom use is still crucial to women’s health. Condom negotiation skills, she added, help prevent the spread of sexually transmitted infections, which PrEP does not defend against. She also signaled a concern that not all women are either aware of or able to easily access PrEP.

The study examined data collected from interviews performed with 158 women currently experiencing some degree of intimate partner violence. Criteria for eligibility included a household income of less than or equal to $4,200 per month, physical victimization from a current male partner in the past six months, less than two weeks apart from their partner in the last month and face-to-face contact with their partner at least twice a week. Flyers posted in community establishments throughout greater New Haven were used to find study participants, and many Yale students participated in the study.

“The fact that this is a study of women in the community who are currently being abused is really important. It gets at a population of people that are not often represented in the research because it is easier to recruit people in a shelter or the criminal justice system because you have a point of contact,” said Sullivan, who collected the study’s data.

Participants sat down with an experienced interviewer for roughly two hours of questions regarding mental health, general well-being and their experiences with partner abuse. Sixty-five percent of the sample identified as African-American, 25 percent identified as white, 8 percent as Hispanic and 3 percent as other races and ethnicities. The average age of the participants was 36.59, and the each participant’s current relationship had lasted an average of 6.74 years. Fifty-eight percent of the participants reported having experienced sexual violence. Substance abuse, hazardous drinking, depression and PTSD were incorporated as syndemic variables to determine their collective effect on sexual risk.

The research found that women facing a more severe syndemic became significantly more prone to fear the negotiation of condom use with their partner. These results can help inform the services available for women who are in abusive relationships and at risk of contracting HIV or sexually transmitted infections.

The study also elaborates on the often-overlooked nature of sexual misconduct in intimate relationships.

“The rate of sexual assaults on campuses, including Yale’s, is high and unacceptable,” Sullivan said. “But we don’t think about that in the context of intimate relationships. When you’re with someone you’re supposed to care about and trust, and in some situations love, the thought of other people thinking about sexual safety being a challenge is unheard of.”

The National Institute on Drug Abuse and the National Institute of Mental Health were the main funders of this study. Sullivan noted that resources are still a challenge when it comes to research projects on partner violence such as this one. Partner violence is not regarded in it of itself as a health problem akin to suicide, depression, alcoholism, PTSD or substance abuse, and, consequentially, researchers working on projects related to partner violence generally struggle to access traditional streams of funding from research organizations such as the National Institutes of Health.

According to the National Intimate Partner and Sexual Violence Survey 2010 Summary Report, nearly half of all women in the United States have experienced psychological aggression by an intimate partner in their lifetime. Nearly one in 10 women in the United States has been raped by an intimate partner in her lifetime, and about one in four women in the United States have experienced severe physical violence by an intimate partner.