Strong association between earlier abuse and revictimization in youth

Youth violence is recognized as a significant public health problem [1] and the strong associations between violence exposure and health risk behaviours and physical and psychological ill health are well documented [1–3].The WHO categorizes violence victimization into self-inflicted, interpersonal, and community violence [4]. Interpersonal violence victimization in adolescents and young adults is high and the prevalence varies according to type of violence and perpetrator [1, 4–9] with prevalence rates for physical violence victimization during the past year varying from 18-20% for women and 25-27% for men [5, 10]. Dating violence, often described as physical and sometimes sexual violence in a dating relationship, is most often used in American literature [8, 9] while in other reports, the perpetrator is not the focus, only the violence exposure per se [5, 7]. To understand risk factors for interpersonal violence victimization, different explanatory levels, including societal, community, relationship and individual factors, may be addressed [4, 6]. The examination of risk factors for violence victimization may provide an opportunity to identify individuals with possible risk factors eligible for prevention strategies.

Young men have a higher prevalence of physical violence exposure than young women [4, 5, 10], while experience of sexual abuse consistently shows a higher prevalence in young women [5, 11, 12]. It is well-known that low age is a risk factor for exposure to violence in both young men and women [6, 10, 13], although in adolescence and young adulthood, it is unclear at which age the violence exposure declines. A longitudinal U.S. study on high school students identified living in a single-parent household as predictive for physical violence victimization in young women but not in young men [14].

The American experience is that parents’ education and socioeconomic status may be more strongly associated with violence exposure than ethnicity [15]. One U.S. study suggests immigration status to be protective for dating violence among adolescent girls [16]. The association between violence victimization among youth and immigration status in a European context is not known.

Individual risk factors for violence victimization may include health risk behaviors and negative life experiences. Hazardous alcohol use or binge drinking are sometimes found to be associated with violence exposure in youths [8, 17], but not always [2, 12, 18, 19]. Smoking and drug use are more constantly associated with violence victimization [2, 8, 19]. It has been shown that people with childhood victimization are more likely to take part in high-risk behaviours [20, 21]. Although numerous studies have identified exposure to childhood physical and/or sexual abuse as significantly increasing the risk for later violence exposure in adult women [7, 22], sometimes including adult men [23, 24] and young adults [18, 25, 26], little attention has been paid to exposure to emotional abuse during childhood and later abuse.

WHO applies the public health perspective in the ecological model as a theoretical approach to understand causes of interpersonal violence. This theory includes different explanatory levels a) societal, b) community, c) relationship- and d) individual factors [4, 6]. Societal factors can be social and cultural norms regarding gender roles, endorsement of violence as a normal method to resolve conflicts and honour-based-violence. The community context represents institutions and social structures – such as attitudes in peer groups, neighbourhood and poverty. Relationship can include family factors such as witnessing domestic violence, parental substance abuse and parental mental illness. Individual level identifies biological and personal factors for each individual including previous trauma and substance abuse.

In criminology research the current explanatory hypotheses on the links between victimization and revictimization are the population heterogeneity hypothesis, that focus on stable individual characteristics that make the person more accessible to violence , and the state dependent hypothesis, that focus on changes in behaviour after victimization [27].

In an earlier study, we showed that young men and women visiting youth health centers in Sweden have a high and gendered exposure to violence. Young women were more exposed to emotional and sexual violence, while young men were more exposed to physical violence. The overlap between emotional, sexual, and physical abuse was considerable, specifically concerning sexual abuse [5].

In studies on childhood and young adolescence (age 2 to 17 years) the poly-victimization (experience of victimization in several contexts e.g. sexual victimization, maltreatment, property crime, physical assault, peer/sibling victimization and witnessed/indirect victimization), indicates an elevated risk for additional victimization [28]. The different pathways for being a poly-victim include residing in a dangerous community, living in a dangerous family, having a multiproblem family environment or having emotional problems that increase risk behaviour [29]. The research on victimization in childhood indicates that victimization may, in some children, be more seen as condition with multiple victimization, rather than an isolated event [20].

The objective of this study was to analyze the risk pattern of exposure to emotional, physical, or sexual abuse during the past 12 months by gender, sociodemographic factors, health risk behaviors, and exposure to violence before the age of 15, among young men and women attending youth health centers in Sweden.

A consistent and strong association was noted between exposure to violence during the past 12 months and victimization before the age of 15 for both women and men (Tables 3, 4 and 5). For the women, the adjusted odds ratios for exposure <15 to emotional, physical, or sexual violence and exposure past year were 1.4-2.8, 1.8-2.3, and 1.4-2.3, respectively. For the men, the adjusted odds ratios for exposure <15 to emotional or physical violence and exposure past year were 1.9-3.5 and 1.6-2.3, respectively, while exposure to sexual violence <15 was not associated with abuse past year (Tables 2, 3, 4 and 5).

In women exposed to emotional violence during the past 12 months, there was also an association to smoking and drug use (Table 3). A similar risk profile was found in women who had been subjected to physical violence during the past 12 months, but there was also an association with hazardous alcohol consumption (Table 4) and not living with parents. For young women with experience of sexual violence, there were associations to hazardous alcohol use, drug use, not living with parents, partnered, and living in big cities with more than 300,000 inhabitants) (Table 5).

In men, besides childhood experience of violence, physical abuse past year was associated with not being partnered, hazardous alcohol consumption, and drug use (Table 4), while smoking and living in big cities showed increased risk for sexual violence (Table 5). Immigration status had no association with exposure to violence past year after adjustment for all other risk factors.

The odd ratios for the young women (n = 393) and men (n = 114) exposed to more than one type of violence during the past 12 months were calculated. A similar risk profile for multi-abused as for single-abused young women was seen with raised AORs for younger age, exposure to violence before the age of 15, and drug use. In the men exposed to more than one type of violence, the only raised AOR was for exposure to emotional violence before the age of 15.

There was a strong and consistent association between exposure to different forms of abuse during the past 12 months and exposure to violence before the age of 15 in both men and women. Lower age was a risk factor for all abuse in the young women; in men only for emotional abuse. Only a small number of associations with sociodemographic characteristics were noted, with the exception of sexual abuse and living in big cities for both young men and women. Immigrant status did not show any associations with violence exposure during the past 12 months. As for health risk behaviors, hazardous alcohol use was associated with physical and sexual abuse in women; in men, only with physical abuse. Smoking was moderately associated with emotional and physical abuse in women; in men, only with sexual abuse. Drug use was moderately associated with all violence exposures among women, but for men, only with physical abuse.

Having experienced emotional, physical, or sexual violence before the age of 15 was highly associated with abuse during the past 12 months, regardless of type, even though the odds ratios were highest for the same type of violence. In the young men, there was no significant association with exposure to sexual violence before the age of 15, regardless of type of abuse during the past 12 months. Since only few young men were exposed to sexual violence, the interpretation must be cautious [5]. Several studies have demonstrated a strong association between violence victimization as a child and violence exposure among adult women and young adult women and men [7, 19, 38–40]. Most often, the studied violence exposure, both as an adult/young adult and as a child, has been restricted to sexual violence, but sometimes physical violence is included [7, 39]. In our study, sexual, physical, and emotional violence are included for both periods. Also, in our study, the violence exposure for the young adults is controlled for sociodemographic factors and health risk behaviors.

In this study we have used violence exposure before the age of 15 to describe childhood victimization [26]. The cut-off ages for childhood victimization varies in other studies, from prior to the initiation of dating [24] to being <18 years [22, 23], being <14 [40], being 16 years [7] and sometimes no specific age limit [38]. In our study, neither the study design nor the questionnaire were devised to answer the question of when the violence before the age of 15 occurred. Consequently, it is not possible to know whether the violence was distant or close in time in the men and women exposed to violence during the past year. Some of the experiences of violence in the young men and women might be a continuum from before and after 15 years. This possibility might be one reason for the consistently strong association found between exposure to violence during the past 12 months and exposure before 15 years of age. It is also probable that some young men and women may have been repeatedly victimized, or even poly-victimized according to Finkelhor, but this was neither possible to analyze.[20, 29].

In a previous article on the same material, we accounted for perpetrators of the violence among the adolescents’ violence exposure during the past 12 months [5]. Parents contributed to a small proportion of the perpetrators, while peers, strangers, and present or former partners were more often stated.

The strong association between earlier abuse and later violence exposure, found in our study, are in line with the literature [7, 23, 25, 26, 28, 38–40]. The complexity of victimization in childhood and young adolescence [11, 20], implicates the importance of addressing a broad spectra on violence exposures. By taking into account different types of abuse in a study population including adolescents and young adults, this study adds insights to the importance of not being restricted to an isolated violence exposure [20, 21].

A strong association between emotional violence before the age of 15 and principally all types of abuse among the young men and women was found. Exposure to emotional violence before the age of 15 had strong associations in the multi-bused men compared to single-exposed men. There are only a few studies on earlier emotional abuse as a risk factor. In an American prospective study on college women, verbal abuse by parents was a significant predictor for adolescent dating violence [40].

The association between hazardous alcohol consumption/drug use and physical/sexual abuse in the young women found in this study is consistent with one study [41], although another did not find strong relationships [18]. The association between violence exposure and alcohol is complex. One population-based longitudinal study found that accumulation of violence exposures had an negative impact on adolescent alcohol use three years after the abuse [42] Another population based longitudinal study found strong links between victimization and alcohol/drug use, with gendered differences regarding bi- or uni-directional relationship [43].

Cigarette smoking has been studied as one of several risk behaviors in some studies and is most often found to be associated with violence in both young men and women [2, 12], although after adjusting for other risk factors, the association in one study of high school students remained only in the young women [12]. In our study, daily smoking was weakly correlated with emotional and physical abuse in young women and strongly with sexual abuse in young men. Low economic status of the family has been demonstrated to be associated with higher exposure in youth violence in some studies [4, 44]. In our study, no variable for socioeconomic status was available. Smoking could be regarded as a proxy for low socioeconomic status [45], thus indicating a relationship between violence exposure and low socioeconomic status.

Few clearly gendered differences were seen in the association between exposure to any violence before the age of 15 and abuse during the past 12 months, except for sexual violence. This data must be interpreted with caution, due to the few young men exposed to sexual violence [5]. In both genders, hazardous alcohol consumption, daily smoking, and drug use were associated with exposure to physical violence, although daily smoking was not significant in the young men. The association in the young women between drug use/daily smoking and sexual abuse during the past 12 months is consistent with one study [19] but inconsistent with another [12].

The major strengths of our study are the validated questionnaire on abuse, the national setup, the high participation rate in combination with a low internal dropout rate, and the fact that both young men and women were included. In many studies, only women are studied [6, 7]. In addition, we addressed the complexity of violence victimization by including different types of violence exposure.

There are several weaknesses to our study. First, the study was cross-sectional, so conclusions about causality cannot be made. Second, we had no variable for environmental risk factors, including parents’ education, socioeconomic status, substance abuse and health, or other maltreatments during childhood besides abuse. Also, we decided not to control for the young people’s education, since the variable encoding for enrollment in a vocational or theoretical program in upper secondary school was found not to be reliable.

In many youth health centers in Sweden, questions about health-risk behaviors, including hazardous alcohol consumption and use of tobacco and drugs, have been routinely included for several years. In addition, screening for intimate partner violence during maternity care has become routine in Sweden. The National Center for Knowledge on Men’s Violence Against Women put forth in 2010 that there is strong evidence that all women seeking medical care should be routinely asked about earlier experience of violence [46]. Still, today there is no consensus for asking routine questions about abuse in the health care system in Sweden. An U.S. review recommends adolescent health care providers to screening efforts [1]. A meta-analysis on screening for intimate partner violence in healthcare settings indicates that screening does not seem to cause harm in the short term, although the evidence for improved outcome after screening was still considered insufficient [47]. On the basis of our study, we find it essential to discuss the use of questions dealing with earlier and current violence exposure for all staff members meeting both young men and women in their work. This would give young adults the opportunity to take a position on what they have gone through and learn how to deal with it so they could get on with their lives.

Violence victimization in young men and women is not a single experience. Findings underline the importance of early interventions. Exposure to violence before 15 years of age is strongly associated with exposure to emotional, physical, and sexual abuse during the past 12 months in both young men and women, even after adjusting for sociodemographic factors and health risk behaviors such as hazardous drinking patterns, drug use, and daily smoking. It is time to consider routine questions on violence exposure for all staff meeting both young men and women in medical and social settings.