Psychosocial Pathways to Sexually Transmitted Infection (STI) Risk Among Youth Transitioning Out of Foster Care: Evidence From a Longitudinal Cohort Study

Background and Purpose:  Among other health disparities, adolescents in foster care are at a disproportionately high risk of sexually transmitted infections (STIs) compared with their peers. We sought to determine overall fit and identify important pathways to STI risk for foster youth using a theoretically-driven conceptual model which included: 1) historical abuse and foster care experiences, 2) mental health and attachment style in late adolescence, and 3) STI risk in young adulthood.

Methods:  We used path analysis to analyze data from a longitudinal study of 732 youth transitioning out of foster care. Exposure variables (retrospectively measured at Waves 1-2) included: history of physical/sexual abuse, total, group, and kinship care placements, and whether the participant ever had very close relationship with foster caregiver. Mediators (Wave 1) included: current symptoms of post-traumatic stress disorder, depression, and/or substance use, delinquency behaviors, attachment style, and whether the youth participated in extended care past age 18. Outcomes (Waves 2-5) included inconsistent condom use, having 5 or more partners, and/or having sex for money in the past year at any wave, and report of STI diagnosis in partner or self. Covariates included gender and race.  Maximum likelihood missing values methodology and an inverse probability weight were used to address missing data.  We also performed moderation analyses comparing models constrained and unconstrained by gender.

Results: Thirty percent reported they or a partner had been diagnosed with an STI. Probability of other measured STI risk behaviors ranged from 9% (having sex for money) to 79% (inconsistent condom use).  Overall model fit was good (Standardized Root Mean Squared Residual = 0.026; Coefficient of Determination = 0.501).  Increased risk of oppositional/delinquent behaviors mediated an association between abuse history and STI risk, via increased inconsistent condom use.  There was also a borderline association with having greater than 5 partners. Having a very close relationship with a caregiver and remaining in foster care beyond age 18 decreased STI risk.  Moderation analysis revealed better model fit when coefficients were allowed to vary by gender versus a constrained model, but few significant differences in individual path coefficients were found between male and female-only models.

Conclusions and Implications: Findings suggest that among foster youth, abuse history is associated with increased oppositional/delinquent behaviors in adolescence, which are, in turn, associated with inconsistent condom use and STI risk in young adulthood. Interventions/policies that: 1) address externalizing trauma sequelae, 2) promote close, stable substitute caregiver relationships, and 3) extend care to age 21 years have the potential to decrease STI risk in this population.