573075 research-article2015
APHXXX10.1177/1010539515573075Asia-Pacific Journal of Public HealthZhu et al
Original Article
Child Sexual Abuse and Its Relationship With Health Risk Behaviors Among Adolescents and Young Adults in Taipei
Asia-Pacific Journal of Public Health 1–9 © 2015 APJPH Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1010539515573075 aph.sagepub.com
Qianqian Zhu, BS1,2, Ersheng Gao, MD2, Yan Cheng, PhD2, Yi-Li Chuang, MA3, Laurie S. Zabin, PhD4, Mark R. Emerson, BS4, and Chaohua Lou, MD2
Abstract This study explores the association of child sexual abuse (CSA) with subsequent health risk behaviors among a cross-section of 4354 adolescents and young adults surveyed in urban and rural Taipei. Descriptive analysis and logistic regressions were employed. The overall proportion of CSA was 5.15%, with more females (6.14%) than males (4.16%) likely to experience CSA. CSA was differently associated with multiple adverse health outcomes, after adjusting other factors, such as age, residence, economic status, education, employment status, and household instability. Both males and females with CSA experience were more likely to report drinking, gambling, and suicidal ideation compared with those who had no history of CSA. However, the significant association between CSA and smoking, fighting, and suicidal attempt was not observed among females. Effective interventions are needed to reduce CSA and its adverse effects on adolescent well-being. Keywords child abuse, sexual, health behaviors, adolescent, Taipei
Child sexual abuse (CSA) is a problem of epidemic proportions, affecting children of all ages, socioeconomic levels, and cultural backgrounds.1 Two recent meta-analyses consistently showed the prevalence of CSA was 18% to 20% for women and 8% for men worldwide.2,3 According to the definition of the World Health Organization,4 CSA is the involvement of a child in sexual activity that he or she does not fully comprehend, is unable to give informed consent to, or for which the child is not developmentally prepared and can not give consent, or that violates the laws or social taboos of society. Sexual abuse involves both contact and non-contact behaviors. These behaviors include, but are not limited to, fondling of breasts, genitals directly or through 1Fudan
University, Shanghai, People’s Republic of China Institute of Planned Parenthood Research, Shanghai, People’s Republic of China 3Bureau of Health Promotion, Department of Health, Taipei, Taiwan 4Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA 2Shanghai
Corresponding Author: Chaohua Lou, Department of Epidemiology and Social Science, Shanghai Institute of Planned Parenthood Research, 779 Lao Hu Min Road, Shanghai 200237, People’s Republic of China. Email: [email protected]
Downloaded from aph.sagepub.com at Bobst Library, New York University on May 19, 2015
2
Asia-Pacific Journal of Public Health
clothing, intercourse, attempted intercourse, oral-genital contact, exhibitionism or exposing children to adult sexual activity or pornography, and the use of children for prostitution or pornography. CSA is a serious infringement of a child’s rights to health and protection. Although a growing number of studies on CSA have appeared over the past decades, little is known about the prevalence of CSA in Taiwan. Taiwan has been dominated by Confucianism for thousands of years, which is an ethical and philosophical system established by the Chinese philosopher Confucius. There are some aspects of traditional Confucian culture that act as protective factors to CSA. First, Confucianism emphasizes the importance of family ties, family responsibility for promoting security and protection,5 and filial piety. In this light, children receive a high level of supervision and monitoring from their parents, and appear to be highly obedient, in comparison to children in Western culture.6 Second, in a Confucian cultural environment interpersonal relations are governed by moral and ethical codes of loyalty, obligation, and reciprocity, which may avoid or minimize inappropriate interpersonal behaviors, including CSA.7 In some aspects, however, Confucian culture could be conductive to CSA. The suppression of sexuality in traditional Confucian culture makes it difficult for children to talk about their sexual abuse experiences.6 In addition, in Confucian culture the needs of a family tend to be considered more important than those of an individual, which results in ignoring the abuse experiences of an individual family member in order to protect the family from the shame associated with its report.2 These may give potential offenders some leeway because they may be confident that neither children nor families will disclose the sexual abuse, thus indirectly encouraging such behavior. On the other hand, Taiwan has been one of the most developed regions in Asia and is undergoing marked sociocultural changes in the wake of modernization, rapid industrialization, and contemporary globalization. With increased Western influence, Confucian values have begun to weaken, and the social norms associated with love and sex have been changing among adolescents and young adults. Whether these changes can affect the prevalence of CSA in Taiwan is a question that needs to be explored. From a child-development perspective, sexual abuse in childhood and adolescence is considered as imposing disruption to the self-development process, which could cause adverse psychological and physical effects. Many studies have suggested that CSA is associated with health risk behaviors (eg, smoking, drinking, drug use, suicide ideation and suicide attempt, and risky sexual behaviors) as well as a number of adverse mental health outcomes, including depression, anxiety, or post-traumatic stress disorder.8-11 However, the majority of existing studies are conducted in Western nations and mainland China; data are limited regarding the association of CSA with health behavior problems in Taiwan. The current study will focus on CSA in Taipei; its aims are to estimate the prevalence of CSA and investigate the relationship between CSA and health risk behaviors. According to the results of previous studies,12 demographic characteristics such as employment status are significantly associated with adolescent health risk behaviors. Therefore, in exploring the association of CSA with health risk behaviors, we will control for several demographic characteristics including age, economic status, education, employment status, and household instability.
Methods Sample and Procedures Data for this article came from the Three-City Collaborative Study of Adolescent Health. This study was conducted in Taipei, Shanghai, and Hanoi among young people aged 15 to 24 in 2006. A 2-part random sampling strategy was adopted in Taipei. The first part was a school approach: 3773 urban and rural students were selected from a 2-stage sample of schools, colleges, and universities. For the students, the primary sampling unit was the school, with careful stratification for sample size and systematic random sampling for the selection of classes within the schools and individuals within the classes. The second part was the sampling of non-students from community Downloaded from aph.sagepub.com at Bobst Library, New York University on May 19, 2015
3
Zhu et al
dwellings: 581 urban and rural youth were identified based on a prior screening enumeration of households. These households included young people who were not attending school, but whose ages qualified them for inclusion. The 4354 youth were thus a representative sample of young people in Taipei. The sampling methodology has been described in detail by Zabin et al.13 Computer-assisted self-interviews were used for sensitive questions. All aspects of this study received approval from the Committee on Human Research at the Johns Hopkins University as well as the collaborating local organizations. Because of the small sample size (n = 27), we eliminated those who were married, and restricted the sample to 4327 individuals who were unmarried in this article. All respondents were asked about their CSA experience. Among them, 226 respondents refused to answer, and 1 had missing data, and after eliminating those, we had 4100 respondents for analyses.
Measures The questions about health risk behaviors in this article were developed based on items used in the Youth Risk Behavior Survey14 and the Global School-based Student Health Survey.15 As the definition of sexual abuse and the criteria for classifying the victim as a child differ from study to study,3 we developed a few questions to screen the experience of sexual abuse before 14 years based on previous literature.7,9,16 The questionnaire was reviewed and validated by adolescent health experts from the Johns Hopkins Bloomberg School of Public Health, the Population and Health Research Center in Taiwan’s Bureau of Health Promotion, and the Shanghai Institute for Planned Parenthood Research. It was pilot-tested in Taipei, and its appropriateness and feasibility were also assessed through focus groups. Demographic Variables. Basic demographic characteristics included respondents’ sex, age, urban/ rural residence, economic status, education, employment status, and household instability. Education was based on the respondents’ highest level of education completed. Economic status was based on the number of listed appliances the family currently owns, coded as 3 categories (low, middle, or high). Household instability was measured by the number of dwellings in which respondents have lived before age 14 years; those having lived in more than 4 different dwellings were coded as having household instability. Child Sexual Abuses. Respondents were asked whether they experienced any of the following sexual abuse before the age of 14. The sexual abuse here included non-contact CSA (eg, someone exposed their bodies to you or watched you while you were unclothed) and contact CSA (eg, made you touch or fondle their genitals/breasts, touched or fondled your genitals/breasts, had their genitals touch you, and had oral sex or had vaginal/anal sexual intercourse with you). Age of the first CSA and the relationship of the victim with the perpetrator were also asked. Health Risk Behaviors. Health risk behaviors included smoking, drinking, gambling, fighting, suicidal ideation, and suicidal attempt. They were defined as follows: (a) smoking on one or more days in the past 30 days; (b) drinking alcohol in the past 30 days; (c) ever having gambled for money; (d) fighting—being in a physical fight with anyone for any reason in the past 12 months; (e) suicidal ideation—thinking about hurting yourself physically or killing yourself during the past 12 months; (f) suicidal attempt—attempting suicide during the past 12 months.
Statistical Analyses Data were analyzed with SAS software 9.2 (SAS Institute, Inc, Cary, NC). All analyses were stratified by sex. Bivariate analyses were used to describe the distributions of demographic characteristics, characteristics of CSA, and the association of CSA with health risk behaviors. Logistic Downloaded from aph.sagepub.com at Bobst Library, New York University on May 19, 2015
4
Asia-Pacific Journal of Public Health
Table 1. Characteristics of the Study Population by Sex, Taipei. Characteristics
Males (n = 2065), n (%)
Age (years) 15-17 18-20 21-24 Residence Urban Rural Economic status Below average Average Above average Education Senior high school or lower College/university or higher Employment status Only in school Both in school and employed Only employed Neither in school nor employed Household instability Yes No Child sexual abuse experience
Females (n = 2035), n (%)
All (N = 4100), n (%)
606 (29.35) 701 (33.95) 758 (36.71)
633 (31.11)* 732 (35.97) 670 (32.92)
1239 (30.22) 1433 (34.95) 1428 (34.83)
1803 (87.31) 262 (12.69)
1819 (89.39)* 216 (10.61)
3622 (88.34) 478 (11.66)
763 (36.95) 855 (41.40) 447 (21.65)
759 (37.30) 812 (39.90) 464 (22.80)
1522 (37.12) 1667 (40.66) 911 (22.22)
941 (45.57)
908 (44.62)
1849 (45.10)
1124 (54.43)
1127 (55.38)
2251 (54.90)
1268 (61.40) 645 (31.23)
1205 (59.21) 692 (34.00)
2473 (60.32) 1337 (32.61)
109 (5.28) 43 (2.08)
101 (4.96) 37 (1.82)
210 (5.12) 80 (1.95)
182 (8.81) 1883 (91.19) 86 (4.16)
178 (8.75) 1857 (91.25) 125 (6.14)**
360 (8.78) 3740 (91.22) 211 (5.15)
*P < .05. **P < .01. ***P < .001.
regression analyses were used to explore the association between CSA experience and health risk behaviors, adjusting for the effects of demographic variables (age, residence, economic status, education, employment status, and household instability).
Results The description of demographic characteristics by sex is presented in Table 1. The overall proportion of CSA was 5.15%, with more females than males likely to report having experienced CSA before 14 years of age (6.14% vs 4.16%, P < .01). Among males and females, significant differences were observed in terms of age and residence (P < .05). More than 80% of the respondents lived in urban areas. About half of the respondents’ education level was college/university or higher. Most respondents were in school and not employed and a majority lived in stable households. These variables were adjusted for in the multivariate analysis.
Experience of CSA As shown in Table 2, although a large proportion of victims could not remember the exact age of their first CSA experience, a total of 7 victims (3.32%) reported their first experience of sexual abuse before age 6. Among those who reported CSA, 55.81% of males and 39.20% of females Downloaded from aph.sagepub.com at Bobst Library, New York University on May 19, 2015
5
Zhu et al Table 2. Characteristics of Child Sexual Abuse (CSA), by Sex, Taipei.
Age of first CSA (years) ≤6 7 8 9 10 11 12 13 Don’t remember Type of CSA Noncontact CSA Contact CSA Sexual intercourse Relationship of first perpetrator Stranger Relative Supervisor/teacher Classmate/friend/neighbor
Males (n = 86), n (%)
Females (n = 125), n (%)
All (N = 211), n (%)
0 2 (2.33) 2 (2.33) 1 (1.16) 3 (3.49) 5 (5.81) 8 (9.30) 18 (20.93) 47 (54.65)
7 (5.60) 7 (5.60) 9 (7.20) 3 (2.40) 13 (10.40) 10 (8.00) 11 (8.80) 12 (9.60) 53 (42.40)
7 (3.32) 9 (4.27) 11 (5.21) 4 (1.90) 16 (7.58) 15 (7.11) 19 (9.00) 30 (14.22) 100 (47.39)
33 (38.37) 48 (55.81) 10 (11.63)
62 (49.60) 49 (39.20) 9 (7.20)
95 (45.02) 97 (45.97) 19 (9.00)
6 (6.98) 40 (46.51) 1 (1.16) 39 (45.35)
56 (44.80) 40 (32.00) 2 (1.60) 27 (21.60)
62 (29.38) 80 (37.91) 3 (1.42) 66 (31.28)
experienced contact CSA, and about 11.63% of males and 7.20% of females reported having oral/vaginal/anal sexual intercourse. Regarding the relationship between the victims and the first perpetrators, a majority of the perpetrators were known to the victims and only 29.38% were strangers. Males were more likely to be abused by relatives, whereas females were much more likely to be abused by strangers.
Relationship Between CSA and Health Risk Behaviors The results of bivariate analyses about the association between CSA and health risk behaviors are shown in Table 3. Higher rates of drinking, gambling, and suicidal ideation were found among respondents who had experienced CSA than those who had not among both males and females. In addition, males with a history of CSA before the age of 14 reported a higher rate of smoking, fighting, and suicidal attempt compared to those who had not experienced. However, these associations were not found in females. Multiple logistic regression analysis was also used to explore the relationship between CSA and health risk behaviors, adjusting for age, residence, economic status, education, employment status, and household instability (Table 4). The relationship between CSA and each of those health risk behaviors is so strong that even adjusting for these demographic factors had no effect on the direction of the relationship or on which were significant. Males with CSA experience were more likely to engage in smoking, drinking, gambling, fighting, suicidal ideation, and suicidal attempt (adjusted odds ratio [AOR] range = 1.87-3.19). Females who had a history of sexual abuse before 14 years of age were more likely to engage in drinking, gambling, and suicidal ideation (AOR range = 1.84-2.17). The significant association between CSA and smoking, fighting, and suicidal attempt was not observed among females. Respondents with a lower education level reported higher rates of smoking, gambling, fighting, suicidal ideation, and suicidal attempt. Females with household instability were more likely to report smoking, drinking, gambling, suicidal ideation, and suicidal attempt compared with those reporting household stability. Downloaded from aph.sagepub.com at Bobst Library, New York University on May 19, 2015
6
Asia-Pacific Journal of Public Health
Table 3. Comparisons of Health Risk Behaviors by Child Sexual Abuse (CSA) Experience and Sex, Taipei. Males Health Risk Behaviors Smoking Drinking Gambling Fighting Suicidal ideation Suicidal attempt
Females
CSA (n = 86), n (%)
No CSA (n = 1979), n (%)
CSA (n = 125), n (%)
32 (37.21) 47 (54.65) 46 (53.49) 29 (33.72) 23 (26.74) 10 (11.63)
434 (21.93)*** 687 (34.71)*** 730 (36.89)** 300 (15.16)*** 252 (12.73)*** 90 (4.55)**
15 (12.00) 53 (42.40) 29 (23.20) 13 (10.40) 38 (30.40) 13 (10.40)
No CSA (n = 1910), n (%) 149 (7.80) 497 (26.02)*** 229 (11.99)*** 153 (8.01) 381 (19.95)** 145 (7.59)
*P < .05. **P < .01. ***P < .001.
Discussion This study estimated the proportion of sexual abuse before 14 years of age and examined its relationship with health risk behaviors among adolescents and young adults in Taipei. Several findings of this study could contribute to our understanding of CSA in Taipei. In this study, 5.15% of respondents experienced sexual abuse prior to 14 years of age—4.16% for males and 6.14% for females. Compared with the prevalence of 18% to 20% for women and 8% for men worldwide,2,3 these proportions are low in Taipei. This difference may be interpreted as related to the traditional Confucian culture—suppression of sexuality, patriarchal familism, the moral and ethical codes of loyalty, and obligation, which govern the interpersonal relations, and emphasize the moral importance of female virginity and chastity. On the one hand, as protective factors, these traditions could reduce the prevalence of CSA to some extent; on the other hand, these traditions could cause the family to conceal the sexual victimization of a family member for fear of losing face or being laughed at by the neighbors. Even as all are influenced by the traditional Confucian culture, results of the current study were different from other studies. The percentage of CSA we report is higher than the study by Luo et al,7 which reported the overall percentage of CSA as 3.3% for women in mainland China. It is lower than some other studies, for example, Chen et al9,17 reported the prevalence of any unwanted sexual experience at 10.5% for males and 16.7% for females among students in 4 secondary schools in 4 provinces of mainland China and 21.9% for female students in a medical secondary school.9,17 The differences in results of these studies may reflect real differences in the prevalence of CSA or just a differential effect of research methodology (eg, child abuse definition, data gathering techniques, populations sampled, the use of broad or more behaviorally specific questions).18 Further studies should be conducted to identify the factors contributing to those differences. In the current study, more females than males reported experiencing CSA (6.7% vs 4.1%), which is consistent with the findings from studies in the West and mainland China.3,9,19,20 The comparatively low prevalence of CSA for males has been discussed by some authors,3,21 who proposed that one of the most important problems is the methodology used in many studies. It is argued that either the experiences of men are not sufficiently captured by the definition of sexual abuse employed or that men fail to identify themselves with the questions asked.3,21 Males’ reluctance to disclose their victimization may also play a role in the lower reported prevalence of CSA. Sexually victimized males may consider it unmanly to seek help, because they believe their victimization occurred because of their own weakness and failure as males.18,21 The traditional social stigma of homosexuality, associated with the finding that most boys are abused by male perpetrators, may also contribute to males’ reluctance to report sexual victimization.21 Moreover, even male victims disclose their CSA experiences, and they tend to do so later than female victims.2,22,23 On average, it would take most male CSA victims more than 10 years before they start to discuss their CSA experiences. For Downloaded from aph.sagepub.com at Bobst Library, New York University on May 19, 2015
7
Downloaded from aph.sagepub.com at Bobst Library, New York University on May 19, 2015
In school and employed Only employed Neither in school nor employed Yes
Yes 18-20 21-24 Rural Average Above average College/university or higher
In school and employed Only employed Neither in school nor employed Yes
Yes 18-20 21-24 Rural Average Above average College/university or higher
Comparative Group
No
Senior high school or lower Only in school
Urban Below average
No 15-17
No
Senior high school or lower Only in school
Urban Below average
No 15-17
Reference Group
2.58 (1.65-4.04)***
3.10 (2.11-4.58) 4.44 (2.25-8.78)* 3.72 (1.45-9.55)
1.38 (0.76-2.48) 2.34 (1.45-3.77)** 1.71 (0.92-3.18) 1.86 (1.28-2.69)** 0.96 (0.62-1.48) 0.96 (0.62-1.49) 0.32 (0.20-0.50)***
1.67 (1.18-2.38)**
1.92 (1.51-2.44) 3.52 (2.19-5.67)** 2.58 (1.33-4.98)
2.15 (1.34-3.44)** 2.22 (1.59-3.09)* 2.98 (1.97-4.50)*** 1.35 (1.02-1.78)* 0.95 (0.71-1.29) 1.29 (0.96-1.72)* 0.39 (0.28-0.54)***
Smoking
Abbreviations: CSA, child sexual abuse; OR, odds ratio; CI, confidence interval. *P < .05. **P < .01. ***P < .001.
Household instability
Employment status
Household instability Females CSA Age (years) Residence Economic status Education
Employment status
Males CSA Age (years) Residence Economic status Education
Variables
1.57 (1.13-2.19)**
1.77 (1.41-2.22) 2.05 (1.29-3.25) 1.55 (0.75-3.20)
1.86 (1.27-2.72)** 1.56 (1.11-2.18) 1.86 (1.24-2.78)** 0.87 (0.67-1.12) 0.81 (0.62-1.07)* 1.08 (0.83-1.40) 0.99 (0.73-1.35)
1.58 (1.15-2.18)**
1.44 (1.17-1.77) 3.03 (1.91-4.80)** 1.85 (0.98-3.51)
2.35 (1.49-3.70)*** 1.39 (1.01-1.92) 1.69 (1.16-2.47)** 1.10 (0.86-1.41) 0.79 (0.61-1.02)** 1.18 (0.92-1.51)** 1.66 (1.22-2.25)**
Drinking
1.56 (1.03-2.36)*
1.01 (0.74-1.36) 0.81 (0.41-1.61) 1.42 (0.60-3.39)
2.17 (1.39-3.37)*** 1.08 (0.71-1.64) 1.33 (0.79-2.23) 1.19 (0.86-1.63) 1.09 (0.76-1.57) 1.23 (0.86-1.76) 0.82 (0.54-1.23)
1.39 (1.01-1.90)*
1.59 (1.30-1.95)*** 0.81 (0.51-1.28) 0.89 (0.46-1.70)
1.87 (1.20-2.90)** 1.26 (0.94-1.68) 1.63 (1.14-2.33)** 0.92 (0.73-1.18) 1.15 (0.90-1.48) 1.19 (0.93-1.52) 0.64 (0.48-0.86)**
Gambling
Table 4. Multivariate Logistic Regression of the Effect of CSA on Health Risk Behaviors (OR, 95% CI), Taipei.
1.61 (0.98-2.64)
1.86 (1.28-2.72) 1.81 (0.74-4.47) 2.67 (0.96-7.46)
1.37 (0.74-2.54) 0.69 (0.44-1.09) 0.41 (0.21-0.80)* 1.14 (0.77-1.68) 0.81 (0.52-1.26) 0.89 (0.58-1.37) 0.40 (0.24-0.67)***
1.02 (0.62-1.66)
1.47 (1.10-1.96)* 0.79 (0.39-1.61) 0.92 (0.34-2.55)
3.19 (1.93-5.28)*** 0.60 (0.43-0.84) 0.35 (0.21-0.59)*** 0.96 (0.69-1.34) 1.25 (0.85-1.83) 1.39 (0.95-2.03) 0.32 (0.21-0.49)***
Fighting
2.34 (1.65-3.30)***
1.17 (0.90-1.53) 0.89 (0.49-1.63) 1.14 (0.50-2.59)
1.84 (1.21-2.80)** 1.29 (0.94-1.76) 1.07 (0.69-1.65) 0.81 (0.60-1.08) 1.21 (0.89-1.63) 0.96 (0.70-1.30) 0.28 (0.20-0.39)***
1.46 (0.95-2.24)
0.85 (0.63-1.15) 0.72 (0.36-1.44) 1.27 (0.54-3.00)
2.49 (1.51-4.12)*** 1.13 (0.78-1.63) 0.82 (0.50-1.34) 1.00 (0.71-1.41) 0.93 (0.65-1.33) 0.94 (0.66-1.34) 0.58 (0.39-0.86)**
Suicidal Ideation
2.27 (1.44-3.57)***
1.85 (1.26-2.72) 1.49 (0.67-3.32) 1.58 (0.52-4.81)
1.32 (0.71-2.45) 1.31 (0.84-2.07) 1.44 (0.77-2.69) 0.91 (0.59-1.40) 0.87 (0.56-1.35) 0.82 (0.53-1.28) 0.25 (0.15-0.40)***
1.23 (0.60-2.53)
0.74 (0.45-1.24) 0.79 (0.27-2.24) 1.43 (0.41-4.99)
2.82 (1.40-5.70)** 1.09 (0.63-1.90) 0.76 (0.35-1.67) 1.37 (0.83-2.25) 0.98 (0.54-1.77) 1.14 (0.64-2.03) 0.51 (0.27-0.95)*
Suicidal Attempt
8
Asia-Pacific Journal of Public Health
women, the average period between the CSA experiences and disclosure was found to be much shorter.2 Even the report of about 4% of males experiencing CSA in the current study indicates that it is not rare; attention to sexual victimization should not neglect young males. Child sexual abuse can have both immediate and long-term adverse effects. In line with previous studies,17,24 we also found a significant positive association of CSA with drinking, gambling, and suicidal ideation among male and female adolescents and young adults. Experiencing sexual abuse may leave children with little sense of control over what happens to them, and leave feelings of helplessness, powerlessness, stigmatization, guilt, and negative self-image.25 Victims may adopt substance abuse and behavior patterns to escape or dissociate from the negative feelings that CSA engenders. In addition, males experiencing CSA also are more likely to engage in smoking, fighting, and suicidal attempt, an association not significant among females. Further study should explore the moderators and mechanisms by which CSA could result in negative health outcomes. In the current study, we also found females with household instability had a higher incidence of health risk behaviors. A possible explanation is that adolescents and young adults who lived in unstable households may get inadequate supervision or inadequate education about these risks from their parents. They may engage in these behaviors just out of curiosity, or to draw the attention of parents. In addition, adolescents with household instability were more likely to come from economically disadvantaged homes; thus, socioeconomic characteristics may also affect their behaviors. Several potential limitations of the study should be noted. First, the current study relied on selfreports of CSA and health risk behaviors, raising questions about the accuracy of retrospective recall, and the validity of self-reporting on sensitive and socially undesirable behaviors. However, computer-assisted interviews were used for the sensitive parts of the interview to minimize biased reports. Second, this study was cross-sectional, which limited our ability to establish causality between CSA and health risk behaviors. However, as defined here CSA was before age 14, the health risk behaviors were largely in the last 12 months and thus had to have occurred after CSA. Third, because respondents experiencing sexual intercourse prior to 14 years were relatively few, we could not analyze deeply the effects of different severity levels of CSA on health behaviors. Despite these limitations in the research on the effects of CSA on adolescent and young adult health behaviors, the evidence is clear that CSA puts adolescents at greater risk for initiating health-compromising behaviors. It also emphasizes the importance of sexual abuse prevention to reduce health behavior problems. Interventions and educational programs should be implemented to prevent the occurrence of CSA and decrease its negative consequences. For example, school teachers and parents should communicate with children and adolescents to improve their knowledge regarding CSA and self-protection. Teachers and parents should be taught to identify possible victims, and counseling and support should be given to adolescents with sexual abuse experience to alleviate their distress from the traumatic experience and improve their health. Acknowledgments The authors would like to sincerely thank all the researchers at the Johns Hopkins Bloomberg school of Public Health, the Hanoi Institute of Family and Gender Studies, the Health Research Center in Taiwan’s Bureau of Health Promotion, and the Shanghai Institute of Planned Parenthood Research for their contributions to the project.
Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: The authors would like to acknowledge and thank the Bill and Melinda Gates Institute Downloaded from aph.sagepub.com at Bobst Library, New York University on May 19, 2015
9
Zhu et al
for Population and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, who provided financial support for the study.
References 1. Modelli MES, Galvão MF, Pratesi R. Child sexual abuse. Forensic Sci Int. 2012;217:1-4. 2. Stoltenborgh M, van IJzendoorn MH, Euser EM, Bakermans-Kranenburg MJ. A global perspective on child sexual abuse: meta-analysis of prevalence around the world. Child Maltreat. 2011;16:79-101. 3. Pereda N, Guilera G, Forns M, Gómez-Benito J. The prevalence of child sexual abuse in community and student samples: a meta-analysis. Clin Psychol Rev. 2009;29:328-338. 4. World Health Organization Regional Office for Africa. Child sexual abuse: a silent health emergency. http://apps.who.int/iris/handle/10665/1878. Published June 27, 2011. Accessed February 5, 2015. 5. Finkelhor D, Ji K, Mikton C, Dunne M. Explaining lower rates of sexual abuse in China. Child Abuse Negl. 2013;37:852-860. 6. Tang CSK. Childhood experience of sexual abuse among Hong Kong Chinese college students. Child Abuse Negl. 2002;26:23-37. 7. Luo Y, Parish WL, Laumann EO. A population-based study of childhood sexual contact in China: prevalence and long-term consequences. Child Abuse Negl. 2008;32:721-731. 8. Hornor G. Child sexual abuse: consequences and implications. J Pediatr Health Care. 2010;24: 358-364. 9. Chen J, Dunne MP, Han P. Child sexual abuse in China: a study of adolescents in four provinces. Child Abuse Negl. 2004;28:1171-1186. 10. Lin D, Li X, Fan X, Fang X. Child sexual abuse and its relationship with health risk behaviors among rural children and adolescents in Hunan, China. Child Abuse Negl. 2011;35:680-687. 11. Dube SR, Anda RF, Whitfield CL, et al. Long-term consequences of childhood sexual abuse by gender of victim. Am J Prev Med. 2005;28:430-438. 12. Rickert VI, Wiemann CM, Goodrum LA, Berenson AB. Employment and health-risk behaviors among pregnant adolescents. J Pediatr Adolesc Gynecol. 1998;11:79-84. 13. Zabin LS, Emerson MR, Nan L, et al. Levels of change in adolescent sexual behavior in three Asian cities. Stud Fam Plann. 2009;40:1-12. 14. Centers for Disease Control and Prevention. Youth Risk Behavior Survey questionnaires. http://www. cdc.gov/healthyyouth/yrbs/questionnaire_rationale.htm. Accessed February 5, 2015. 15. World Health Organization. The Global School-Based Student Health Survey. http://www.who.int/ chp/gshs/en/. Accessed February 5, 2015. 16. Bonomi AE, Cannon EA, Anderson ML, Rivara FP, Thompson RS. Association between self-reported health and physical and/or sexual abuse experienced before age 18. Child Abuse Negl. 2008;32: 693-701. 17. Chen J, Dunne MP, Han P. Child sexual abuse in Henan province, China: associations with sadness, suicidality, and risk behaviors among adolescent girls. J Adolesc Health. 2006;38:544-549. 18. Pereda N, Guilera G, Forns M, Gómez-Benito J. The international epidemiology of child sexual abuse: a continuation of Finkelhor (1994). Child Abuse Negl. 2009;33:331-342. 19. Chen JQ. A retrospective survey in child sexual abuse among 565 university students. Chin J Epidemiol. 2004;25:873-877. 20. Dunne MP, Chen JQ, Wan Yuen C. The evolving evidence base for child protection in Chinese societies. Asia Pac J Public Health. 2008;20:267-276. 21. Romano E, De Luca RV. Male sexual abuse: a review of effects, abuse characteristics, and links with later psychological functioning. Aggress Violent Behav. 2001;6:55-78. 22. O’Leary PJ, Barber J. Gender differences in silencing following childhood sexual abuse. J Child Sex Abus. 2008;17:133-143. 23. Tsuboi S, Yoshida H, Ae R, Kojo T, Nakamura Y, Kitamura K. Prevalence and demographic distribution of adult survivors of child abuse in Japan [published online May 16, 2013]. Asia Pac J Public Health. doi:10.1177/1010539513488626. 24. Holmes WC. Men’s self-definitions of abusive childhood sexual experiences, and potentially related risky behavioral and psychiatric outcomes. Child Abuse Negl. 2008;32:83-97. 25. Banyard VL, Williams LM, Siegel JA. Childhood sexual abuse: a gender perspective on context and consequences. Child Maltreat. 2004;9:223-238. Downloaded from aph.sagepub.com at Bobst Library, New York University on May 19, 2015
APHXXX10.1177/1010539515573075Asia-Pacific Journal of Public HealthZhu et al
Original Article
Child Sexual Abuse and Its Relationship With Health Risk Behaviors Among Adolescents and Young Adults in Taipei
Asia-Pacific Journal of Public Health 1–9 © 2015 APJPH Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1010539515573075 aph.sagepub.com
Qianqian Zhu, BS1,2, Ersheng Gao, MD2, Yan Cheng, PhD2, Yi-Li Chuang, MA3, Laurie S. Zabin, PhD4, Mark R. Emerson, BS4, and Chaohua Lou, MD2
Abstract This study explores the association of child sexual abuse (CSA) with subsequent health risk behaviors among a cross-section of 4354 adolescents and young adults surveyed in urban and rural Taipei. Descriptive analysis and logistic regressions were employed. The overall proportion of CSA was 5.15%, with more females (6.14%) than males (4.16%) likely to experience CSA. CSA was differently associated with multiple adverse health outcomes, after adjusting other factors, such as age, residence, economic status, education, employment status, and household instability. Both males and females with CSA experience were more likely to report drinking, gambling, and suicidal ideation compared with those who had no history of CSA. However, the significant association between CSA and smoking, fighting, and suicidal attempt was not observed among females. Effective interventions are needed to reduce CSA and its adverse effects on adolescent well-being. Keywords child abuse, sexual, health behaviors, adolescent, Taipei
Child sexual abuse (CSA) is a problem of epidemic proportions, affecting children of all ages, socioeconomic levels, and cultural backgrounds.1 Two recent meta-analyses consistently showed the prevalence of CSA was 18% to 20% for women and 8% for men worldwide.2,3 According to the definition of the World Health Organization,4 CSA is the involvement of a child in sexual activity that he or she does not fully comprehend, is unable to give informed consent to, or for which the child is not developmentally prepared and can not give consent, or that violates the laws or social taboos of society. Sexual abuse involves both contact and non-contact behaviors. These behaviors include, but are not limited to, fondling of breasts, genitals directly or through 1Fudan
University, Shanghai, People’s Republic of China Institute of Planned Parenthood Research, Shanghai, People’s Republic of China 3Bureau of Health Promotion, Department of Health, Taipei, Taiwan 4Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA 2Shanghai
Corresponding Author: Chaohua Lou, Department of Epidemiology and Social Science, Shanghai Institute of Planned Parenthood Research, 779 Lao Hu Min Road, Shanghai 200237, People’s Republic of China. Email: [email protected]
Downloaded from aph.sagepub.com at Bobst Library, New York University on May 19, 2015
2
Asia-Pacific Journal of Public Health
clothing, intercourse, attempted intercourse, oral-genital contact, exhibitionism or exposing children to adult sexual activity or pornography, and the use of children for prostitution or pornography. CSA is a serious infringement of a child’s rights to health and protection. Although a growing number of studies on CSA have appeared over the past decades, little is known about the prevalence of CSA in Taiwan. Taiwan has been dominated by Confucianism for thousands of years, which is an ethical and philosophical system established by the Chinese philosopher Confucius. There are some aspects of traditional Confucian culture that act as protective factors to CSA. First, Confucianism emphasizes the importance of family ties, family responsibility for promoting security and protection,5 and filial piety. In this light, children receive a high level of supervision and monitoring from their parents, and appear to be highly obedient, in comparison to children in Western culture.6 Second, in a Confucian cultural environment interpersonal relations are governed by moral and ethical codes of loyalty, obligation, and reciprocity, which may avoid or minimize inappropriate interpersonal behaviors, including CSA.7 In some aspects, however, Confucian culture could be conductive to CSA. The suppression of sexuality in traditional Confucian culture makes it difficult for children to talk about their sexual abuse experiences.6 In addition, in Confucian culture the needs of a family tend to be considered more important than those of an individual, which results in ignoring the abuse experiences of an individual family member in order to protect the family from the shame associated with its report.2 These may give potential offenders some leeway because they may be confident that neither children nor families will disclose the sexual abuse, thus indirectly encouraging such behavior. On the other hand, Taiwan has been one of the most developed regions in Asia and is undergoing marked sociocultural changes in the wake of modernization, rapid industrialization, and contemporary globalization. With increased Western influence, Confucian values have begun to weaken, and the social norms associated with love and sex have been changing among adolescents and young adults. Whether these changes can affect the prevalence of CSA in Taiwan is a question that needs to be explored. From a child-development perspective, sexual abuse in childhood and adolescence is considered as imposing disruption to the self-development process, which could cause adverse psychological and physical effects. Many studies have suggested that CSA is associated with health risk behaviors (eg, smoking, drinking, drug use, suicide ideation and suicide attempt, and risky sexual behaviors) as well as a number of adverse mental health outcomes, including depression, anxiety, or post-traumatic stress disorder.8-11 However, the majority of existing studies are conducted in Western nations and mainland China; data are limited regarding the association of CSA with health behavior problems in Taiwan. The current study will focus on CSA in Taipei; its aims are to estimate the prevalence of CSA and investigate the relationship between CSA and health risk behaviors. According to the results of previous studies,12 demographic characteristics such as employment status are significantly associated with adolescent health risk behaviors. Therefore, in exploring the association of CSA with health risk behaviors, we will control for several demographic characteristics including age, economic status, education, employment status, and household instability.
Methods Sample and Procedures Data for this article came from the Three-City Collaborative Study of Adolescent Health. This study was conducted in Taipei, Shanghai, and Hanoi among young people aged 15 to 24 in 2006. A 2-part random sampling strategy was adopted in Taipei. The first part was a school approach: 3773 urban and rural students were selected from a 2-stage sample of schools, colleges, and universities. For the students, the primary sampling unit was the school, with careful stratification for sample size and systematic random sampling for the selection of classes within the schools and individuals within the classes. The second part was the sampling of non-students from community Downloaded from aph.sagepub.com at Bobst Library, New York University on May 19, 2015
3
Zhu et al
dwellings: 581 urban and rural youth were identified based on a prior screening enumeration of households. These households included young people who were not attending school, but whose ages qualified them for inclusion. The 4354 youth were thus a representative sample of young people in Taipei. The sampling methodology has been described in detail by Zabin et al.13 Computer-assisted self-interviews were used for sensitive questions. All aspects of this study received approval from the Committee on Human Research at the Johns Hopkins University as well as the collaborating local organizations. Because of the small sample size (n = 27), we eliminated those who were married, and restricted the sample to 4327 individuals who were unmarried in this article. All respondents were asked about their CSA experience. Among them, 226 respondents refused to answer, and 1 had missing data, and after eliminating those, we had 4100 respondents for analyses.
Measures The questions about health risk behaviors in this article were developed based on items used in the Youth Risk Behavior Survey14 and the Global School-based Student Health Survey.15 As the definition of sexual abuse and the criteria for classifying the victim as a child differ from study to study,3 we developed a few questions to screen the experience of sexual abuse before 14 years based on previous literature.7,9,16 The questionnaire was reviewed and validated by adolescent health experts from the Johns Hopkins Bloomberg School of Public Health, the Population and Health Research Center in Taiwan’s Bureau of Health Promotion, and the Shanghai Institute for Planned Parenthood Research. It was pilot-tested in Taipei, and its appropriateness and feasibility were also assessed through focus groups. Demographic Variables. Basic demographic characteristics included respondents’ sex, age, urban/ rural residence, economic status, education, employment status, and household instability. Education was based on the respondents’ highest level of education completed. Economic status was based on the number of listed appliances the family currently owns, coded as 3 categories (low, middle, or high). Household instability was measured by the number of dwellings in which respondents have lived before age 14 years; those having lived in more than 4 different dwellings were coded as having household instability. Child Sexual Abuses. Respondents were asked whether they experienced any of the following sexual abuse before the age of 14. The sexual abuse here included non-contact CSA (eg, someone exposed their bodies to you or watched you while you were unclothed) and contact CSA (eg, made you touch or fondle their genitals/breasts, touched or fondled your genitals/breasts, had their genitals touch you, and had oral sex or had vaginal/anal sexual intercourse with you). Age of the first CSA and the relationship of the victim with the perpetrator were also asked. Health Risk Behaviors. Health risk behaviors included smoking, drinking, gambling, fighting, suicidal ideation, and suicidal attempt. They were defined as follows: (a) smoking on one or more days in the past 30 days; (b) drinking alcohol in the past 30 days; (c) ever having gambled for money; (d) fighting—being in a physical fight with anyone for any reason in the past 12 months; (e) suicidal ideation—thinking about hurting yourself physically or killing yourself during the past 12 months; (f) suicidal attempt—attempting suicide during the past 12 months.
Statistical Analyses Data were analyzed with SAS software 9.2 (SAS Institute, Inc, Cary, NC). All analyses were stratified by sex. Bivariate analyses were used to describe the distributions of demographic characteristics, characteristics of CSA, and the association of CSA with health risk behaviors. Logistic Downloaded from aph.sagepub.com at Bobst Library, New York University on May 19, 2015
4
Asia-Pacific Journal of Public Health
Table 1. Characteristics of the Study Population by Sex, Taipei. Characteristics
Males (n = 2065), n (%)
Age (years) 15-17 18-20 21-24 Residence Urban Rural Economic status Below average Average Above average Education Senior high school or lower College/university or higher Employment status Only in school Both in school and employed Only employed Neither in school nor employed Household instability Yes No Child sexual abuse experience
Females (n = 2035), n (%)
All (N = 4100), n (%)
606 (29.35) 701 (33.95) 758 (36.71)
633 (31.11)* 732 (35.97) 670 (32.92)
1239 (30.22) 1433 (34.95) 1428 (34.83)
1803 (87.31) 262 (12.69)
1819 (89.39)* 216 (10.61)
3622 (88.34) 478 (11.66)
763 (36.95) 855 (41.40) 447 (21.65)
759 (37.30) 812 (39.90) 464 (22.80)
1522 (37.12) 1667 (40.66) 911 (22.22)
941 (45.57)
908 (44.62)
1849 (45.10)
1124 (54.43)
1127 (55.38)
2251 (54.90)
1268 (61.40) 645 (31.23)
1205 (59.21) 692 (34.00)
2473 (60.32) 1337 (32.61)
109 (5.28) 43 (2.08)
101 (4.96) 37 (1.82)
210 (5.12) 80 (1.95)
182 (8.81) 1883 (91.19) 86 (4.16)
178 (8.75) 1857 (91.25) 125 (6.14)**
360 (8.78) 3740 (91.22) 211 (5.15)
*P < .05. **P < .01. ***P < .001.
regression analyses were used to explore the association between CSA experience and health risk behaviors, adjusting for the effects of demographic variables (age, residence, economic status, education, employment status, and household instability).
Results The description of demographic characteristics by sex is presented in Table 1. The overall proportion of CSA was 5.15%, with more females than males likely to report having experienced CSA before 14 years of age (6.14% vs 4.16%, P < .01). Among males and females, significant differences were observed in terms of age and residence (P < .05). More than 80% of the respondents lived in urban areas. About half of the respondents’ education level was college/university or higher. Most respondents were in school and not employed and a majority lived in stable households. These variables were adjusted for in the multivariate analysis.
Experience of CSA As shown in Table 2, although a large proportion of victims could not remember the exact age of their first CSA experience, a total of 7 victims (3.32%) reported their first experience of sexual abuse before age 6. Among those who reported CSA, 55.81% of males and 39.20% of females Downloaded from aph.sagepub.com at Bobst Library, New York University on May 19, 2015
5
Zhu et al Table 2. Characteristics of Child Sexual Abuse (CSA), by Sex, Taipei.
Age of first CSA (years) ≤6 7 8 9 10 11 12 13 Don’t remember Type of CSA Noncontact CSA Contact CSA Sexual intercourse Relationship of first perpetrator Stranger Relative Supervisor/teacher Classmate/friend/neighbor
Males (n = 86), n (%)
Females (n = 125), n (%)
All (N = 211), n (%)
0 2 (2.33) 2 (2.33) 1 (1.16) 3 (3.49) 5 (5.81) 8 (9.30) 18 (20.93) 47 (54.65)
7 (5.60) 7 (5.60) 9 (7.20) 3 (2.40) 13 (10.40) 10 (8.00) 11 (8.80) 12 (9.60) 53 (42.40)
7 (3.32) 9 (4.27) 11 (5.21) 4 (1.90) 16 (7.58) 15 (7.11) 19 (9.00) 30 (14.22) 100 (47.39)
33 (38.37) 48 (55.81) 10 (11.63)
62 (49.60) 49 (39.20) 9 (7.20)
95 (45.02) 97 (45.97) 19 (9.00)
6 (6.98) 40 (46.51) 1 (1.16) 39 (45.35)
56 (44.80) 40 (32.00) 2 (1.60) 27 (21.60)
62 (29.38) 80 (37.91) 3 (1.42) 66 (31.28)
experienced contact CSA, and about 11.63% of males and 7.20% of females reported having oral/vaginal/anal sexual intercourse. Regarding the relationship between the victims and the first perpetrators, a majority of the perpetrators were known to the victims and only 29.38% were strangers. Males were more likely to be abused by relatives, whereas females were much more likely to be abused by strangers.
Relationship Between CSA and Health Risk Behaviors The results of bivariate analyses about the association between CSA and health risk behaviors are shown in Table 3. Higher rates of drinking, gambling, and suicidal ideation were found among respondents who had experienced CSA than those who had not among both males and females. In addition, males with a history of CSA before the age of 14 reported a higher rate of smoking, fighting, and suicidal attempt compared to those who had not experienced. However, these associations were not found in females. Multiple logistic regression analysis was also used to explore the relationship between CSA and health risk behaviors, adjusting for age, residence, economic status, education, employment status, and household instability (Table 4). The relationship between CSA and each of those health risk behaviors is so strong that even adjusting for these demographic factors had no effect on the direction of the relationship or on which were significant. Males with CSA experience were more likely to engage in smoking, drinking, gambling, fighting, suicidal ideation, and suicidal attempt (adjusted odds ratio [AOR] range = 1.87-3.19). Females who had a history of sexual abuse before 14 years of age were more likely to engage in drinking, gambling, and suicidal ideation (AOR range = 1.84-2.17). The significant association between CSA and smoking, fighting, and suicidal attempt was not observed among females. Respondents with a lower education level reported higher rates of smoking, gambling, fighting, suicidal ideation, and suicidal attempt. Females with household instability were more likely to report smoking, drinking, gambling, suicidal ideation, and suicidal attempt compared with those reporting household stability. Downloaded from aph.sagepub.com at Bobst Library, New York University on May 19, 2015
6
Asia-Pacific Journal of Public Health
Table 3. Comparisons of Health Risk Behaviors by Child Sexual Abuse (CSA) Experience and Sex, Taipei. Males Health Risk Behaviors Smoking Drinking Gambling Fighting Suicidal ideation Suicidal attempt
Females
CSA (n = 86), n (%)
No CSA (n = 1979), n (%)
CSA (n = 125), n (%)
32 (37.21) 47 (54.65) 46 (53.49) 29 (33.72) 23 (26.74) 10 (11.63)
434 (21.93)*** 687 (34.71)*** 730 (36.89)** 300 (15.16)*** 252 (12.73)*** 90 (4.55)**
15 (12.00) 53 (42.40) 29 (23.20) 13 (10.40) 38 (30.40) 13 (10.40)
No CSA (n = 1910), n (%) 149 (7.80) 497 (26.02)*** 229 (11.99)*** 153 (8.01) 381 (19.95)** 145 (7.59)
*P < .05. **P < .01. ***P < .001.
Discussion This study estimated the proportion of sexual abuse before 14 years of age and examined its relationship with health risk behaviors among adolescents and young adults in Taipei. Several findings of this study could contribute to our understanding of CSA in Taipei. In this study, 5.15% of respondents experienced sexual abuse prior to 14 years of age—4.16% for males and 6.14% for females. Compared with the prevalence of 18% to 20% for women and 8% for men worldwide,2,3 these proportions are low in Taipei. This difference may be interpreted as related to the traditional Confucian culture—suppression of sexuality, patriarchal familism, the moral and ethical codes of loyalty, and obligation, which govern the interpersonal relations, and emphasize the moral importance of female virginity and chastity. On the one hand, as protective factors, these traditions could reduce the prevalence of CSA to some extent; on the other hand, these traditions could cause the family to conceal the sexual victimization of a family member for fear of losing face or being laughed at by the neighbors. Even as all are influenced by the traditional Confucian culture, results of the current study were different from other studies. The percentage of CSA we report is higher than the study by Luo et al,7 which reported the overall percentage of CSA as 3.3% for women in mainland China. It is lower than some other studies, for example, Chen et al9,17 reported the prevalence of any unwanted sexual experience at 10.5% for males and 16.7% for females among students in 4 secondary schools in 4 provinces of mainland China and 21.9% for female students in a medical secondary school.9,17 The differences in results of these studies may reflect real differences in the prevalence of CSA or just a differential effect of research methodology (eg, child abuse definition, data gathering techniques, populations sampled, the use of broad or more behaviorally specific questions).18 Further studies should be conducted to identify the factors contributing to those differences. In the current study, more females than males reported experiencing CSA (6.7% vs 4.1%), which is consistent with the findings from studies in the West and mainland China.3,9,19,20 The comparatively low prevalence of CSA for males has been discussed by some authors,3,21 who proposed that one of the most important problems is the methodology used in many studies. It is argued that either the experiences of men are not sufficiently captured by the definition of sexual abuse employed or that men fail to identify themselves with the questions asked.3,21 Males’ reluctance to disclose their victimization may also play a role in the lower reported prevalence of CSA. Sexually victimized males may consider it unmanly to seek help, because they believe their victimization occurred because of their own weakness and failure as males.18,21 The traditional social stigma of homosexuality, associated with the finding that most boys are abused by male perpetrators, may also contribute to males’ reluctance to report sexual victimization.21 Moreover, even male victims disclose their CSA experiences, and they tend to do so later than female victims.2,22,23 On average, it would take most male CSA victims more than 10 years before they start to discuss their CSA experiences. For Downloaded from aph.sagepub.com at Bobst Library, New York University on May 19, 2015
7
Downloaded from aph.sagepub.com at Bobst Library, New York University on May 19, 2015
In school and employed Only employed Neither in school nor employed Yes
Yes 18-20 21-24 Rural Average Above average College/university or higher
In school and employed Only employed Neither in school nor employed Yes
Yes 18-20 21-24 Rural Average Above average College/university or higher
Comparative Group
No
Senior high school or lower Only in school
Urban Below average
No 15-17
No
Senior high school or lower Only in school
Urban Below average
No 15-17
Reference Group
2.58 (1.65-4.04)***
3.10 (2.11-4.58) 4.44 (2.25-8.78)* 3.72 (1.45-9.55)
1.38 (0.76-2.48) 2.34 (1.45-3.77)** 1.71 (0.92-3.18) 1.86 (1.28-2.69)** 0.96 (0.62-1.48) 0.96 (0.62-1.49) 0.32 (0.20-0.50)***
1.67 (1.18-2.38)**
1.92 (1.51-2.44) 3.52 (2.19-5.67)** 2.58 (1.33-4.98)
2.15 (1.34-3.44)** 2.22 (1.59-3.09)* 2.98 (1.97-4.50)*** 1.35 (1.02-1.78)* 0.95 (0.71-1.29) 1.29 (0.96-1.72)* 0.39 (0.28-0.54)***
Smoking
Abbreviations: CSA, child sexual abuse; OR, odds ratio; CI, confidence interval. *P < .05. **P < .01. ***P < .001.
Household instability
Employment status
Household instability Females CSA Age (years) Residence Economic status Education
Employment status
Males CSA Age (years) Residence Economic status Education
Variables
1.57 (1.13-2.19)**
1.77 (1.41-2.22) 2.05 (1.29-3.25) 1.55 (0.75-3.20)
1.86 (1.27-2.72)** 1.56 (1.11-2.18) 1.86 (1.24-2.78)** 0.87 (0.67-1.12) 0.81 (0.62-1.07)* 1.08 (0.83-1.40) 0.99 (0.73-1.35)
1.58 (1.15-2.18)**
1.44 (1.17-1.77) 3.03 (1.91-4.80)** 1.85 (0.98-3.51)
2.35 (1.49-3.70)*** 1.39 (1.01-1.92) 1.69 (1.16-2.47)** 1.10 (0.86-1.41) 0.79 (0.61-1.02)** 1.18 (0.92-1.51)** 1.66 (1.22-2.25)**
Drinking
1.56 (1.03-2.36)*
1.01 (0.74-1.36) 0.81 (0.41-1.61) 1.42 (0.60-3.39)
2.17 (1.39-3.37)*** 1.08 (0.71-1.64) 1.33 (0.79-2.23) 1.19 (0.86-1.63) 1.09 (0.76-1.57) 1.23 (0.86-1.76) 0.82 (0.54-1.23)
1.39 (1.01-1.90)*
1.59 (1.30-1.95)*** 0.81 (0.51-1.28) 0.89 (0.46-1.70)
1.87 (1.20-2.90)** 1.26 (0.94-1.68) 1.63 (1.14-2.33)** 0.92 (0.73-1.18) 1.15 (0.90-1.48) 1.19 (0.93-1.52) 0.64 (0.48-0.86)**
Gambling
Table 4. Multivariate Logistic Regression of the Effect of CSA on Health Risk Behaviors (OR, 95% CI), Taipei.
1.61 (0.98-2.64)
1.86 (1.28-2.72) 1.81 (0.74-4.47) 2.67 (0.96-7.46)
1.37 (0.74-2.54) 0.69 (0.44-1.09) 0.41 (0.21-0.80)* 1.14 (0.77-1.68) 0.81 (0.52-1.26) 0.89 (0.58-1.37) 0.40 (0.24-0.67)***
1.02 (0.62-1.66)
1.47 (1.10-1.96)* 0.79 (0.39-1.61) 0.92 (0.34-2.55)
3.19 (1.93-5.28)*** 0.60 (0.43-0.84) 0.35 (0.21-0.59)*** 0.96 (0.69-1.34) 1.25 (0.85-1.83) 1.39 (0.95-2.03) 0.32 (0.21-0.49)***
Fighting
2.34 (1.65-3.30)***
1.17 (0.90-1.53) 0.89 (0.49-1.63) 1.14 (0.50-2.59)
1.84 (1.21-2.80)** 1.29 (0.94-1.76) 1.07 (0.69-1.65) 0.81 (0.60-1.08) 1.21 (0.89-1.63) 0.96 (0.70-1.30) 0.28 (0.20-0.39)***
1.46 (0.95-2.24)
0.85 (0.63-1.15) 0.72 (0.36-1.44) 1.27 (0.54-3.00)
2.49 (1.51-4.12)*** 1.13 (0.78-1.63) 0.82 (0.50-1.34) 1.00 (0.71-1.41) 0.93 (0.65-1.33) 0.94 (0.66-1.34) 0.58 (0.39-0.86)**
Suicidal Ideation
2.27 (1.44-3.57)***
1.85 (1.26-2.72) 1.49 (0.67-3.32) 1.58 (0.52-4.81)
1.32 (0.71-2.45) 1.31 (0.84-2.07) 1.44 (0.77-2.69) 0.91 (0.59-1.40) 0.87 (0.56-1.35) 0.82 (0.53-1.28) 0.25 (0.15-0.40)***
1.23 (0.60-2.53)
0.74 (0.45-1.24) 0.79 (0.27-2.24) 1.43 (0.41-4.99)
2.82 (1.40-5.70)** 1.09 (0.63-1.90) 0.76 (0.35-1.67) 1.37 (0.83-2.25) 0.98 (0.54-1.77) 1.14 (0.64-2.03) 0.51 (0.27-0.95)*
Suicidal Attempt
8
Asia-Pacific Journal of Public Health
women, the average period between the CSA experiences and disclosure was found to be much shorter.2 Even the report of about 4% of males experiencing CSA in the current study indicates that it is not rare; attention to sexual victimization should not neglect young males. Child sexual abuse can have both immediate and long-term adverse effects. In line with previous studies,17,24 we also found a significant positive association of CSA with drinking, gambling, and suicidal ideation among male and female adolescents and young adults. Experiencing sexual abuse may leave children with little sense of control over what happens to them, and leave feelings of helplessness, powerlessness, stigmatization, guilt, and negative self-image.25 Victims may adopt substance abuse and behavior patterns to escape or dissociate from the negative feelings that CSA engenders. In addition, males experiencing CSA also are more likely to engage in smoking, fighting, and suicidal attempt, an association not significant among females. Further study should explore the moderators and mechanisms by which CSA could result in negative health outcomes. In the current study, we also found females with household instability had a higher incidence of health risk behaviors. A possible explanation is that adolescents and young adults who lived in unstable households may get inadequate supervision or inadequate education about these risks from their parents. They may engage in these behaviors just out of curiosity, or to draw the attention of parents. In addition, adolescents with household instability were more likely to come from economically disadvantaged homes; thus, socioeconomic characteristics may also affect their behaviors. Several potential limitations of the study should be noted. First, the current study relied on selfreports of CSA and health risk behaviors, raising questions about the accuracy of retrospective recall, and the validity of self-reporting on sensitive and socially undesirable behaviors. However, computer-assisted interviews were used for the sensitive parts of the interview to minimize biased reports. Second, this study was cross-sectional, which limited our ability to establish causality between CSA and health risk behaviors. However, as defined here CSA was before age 14, the health risk behaviors were largely in the last 12 months and thus had to have occurred after CSA. Third, because respondents experiencing sexual intercourse prior to 14 years were relatively few, we could not analyze deeply the effects of different severity levels of CSA on health behaviors. Despite these limitations in the research on the effects of CSA on adolescent and young adult health behaviors, the evidence is clear that CSA puts adolescents at greater risk for initiating health-compromising behaviors. It also emphasizes the importance of sexual abuse prevention to reduce health behavior problems. Interventions and educational programs should be implemented to prevent the occurrence of CSA and decrease its negative consequences. For example, school teachers and parents should communicate with children and adolescents to improve their knowledge regarding CSA and self-protection. Teachers and parents should be taught to identify possible victims, and counseling and support should be given to adolescents with sexual abuse experience to alleviate their distress from the traumatic experience and improve their health. Acknowledgments The authors would like to sincerely thank all the researchers at the Johns Hopkins Bloomberg school of Public Health, the Hanoi Institute of Family and Gender Studies, the Health Research Center in Taiwan’s Bureau of Health Promotion, and the Shanghai Institute of Planned Parenthood Research for their contributions to the project.
Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: The authors would like to acknowledge and thank the Bill and Melinda Gates Institute Downloaded from aph.sagepub.com at Bobst Library, New York University on May 19, 2015
9
Zhu et al
for Population and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, who provided financial support for the study.
References 1. Modelli MES, Galvão MF, Pratesi R. Child sexual abuse. Forensic Sci Int. 2012;217:1-4. 2. Stoltenborgh M, van IJzendoorn MH, Euser EM, Bakermans-Kranenburg MJ. A global perspective on child sexual abuse: meta-analysis of prevalence around the world. Child Maltreat. 2011;16:79-101. 3. Pereda N, Guilera G, Forns M, Gómez-Benito J. The prevalence of child sexual abuse in community and student samples: a meta-analysis. Clin Psychol Rev. 2009;29:328-338. 4. World Health Organization Regional Office for Africa. Child sexual abuse: a silent health emergency. http://apps.who.int/iris/handle/10665/1878. Published June 27, 2011. Accessed February 5, 2015. 5. Finkelhor D, Ji K, Mikton C, Dunne M. Explaining lower rates of sexual abuse in China. Child Abuse Negl. 2013;37:852-860. 6. Tang CSK. Childhood experience of sexual abuse among Hong Kong Chinese college students. Child Abuse Negl. 2002;26:23-37. 7. Luo Y, Parish WL, Laumann EO. A population-based study of childhood sexual contact in China: prevalence and long-term consequences. Child Abuse Negl. 2008;32:721-731. 8. Hornor G. Child sexual abuse: consequences and implications. J Pediatr Health Care. 2010;24: 358-364. 9. Chen J, Dunne MP, Han P. Child sexual abuse in China: a study of adolescents in four provinces. Child Abuse Negl. 2004;28:1171-1186. 10. Lin D, Li X, Fan X, Fang X. Child sexual abuse and its relationship with health risk behaviors among rural children and adolescents in Hunan, China. Child Abuse Negl. 2011;35:680-687. 11. Dube SR, Anda RF, Whitfield CL, et al. Long-term consequences of childhood sexual abuse by gender of victim. Am J Prev Med. 2005;28:430-438. 12. Rickert VI, Wiemann CM, Goodrum LA, Berenson AB. Employment and health-risk behaviors among pregnant adolescents. J Pediatr Adolesc Gynecol. 1998;11:79-84. 13. Zabin LS, Emerson MR, Nan L, et al. Levels of change in adolescent sexual behavior in three Asian cities. Stud Fam Plann. 2009;40:1-12. 14. Centers for Disease Control and Prevention. Youth Risk Behavior Survey questionnaires. http://www. cdc.gov/healthyyouth/yrbs/questionnaire_rationale.htm. Accessed February 5, 2015. 15. World Health Organization. The Global School-Based Student Health Survey. http://www.who.int/ chp/gshs/en/. Accessed February 5, 2015. 16. Bonomi AE, Cannon EA, Anderson ML, Rivara FP, Thompson RS. Association between self-reported health and physical and/or sexual abuse experienced before age 18. Child Abuse Negl. 2008;32: 693-701. 17. Chen J, Dunne MP, Han P. Child sexual abuse in Henan province, China: associations with sadness, suicidality, and risk behaviors among adolescent girls. J Adolesc Health. 2006;38:544-549. 18. Pereda N, Guilera G, Forns M, Gómez-Benito J. The international epidemiology of child sexual abuse: a continuation of Finkelhor (1994). Child Abuse Negl. 2009;33:331-342. 19. Chen JQ. A retrospective survey in child sexual abuse among 565 university students. Chin J Epidemiol. 2004;25:873-877. 20. Dunne MP, Chen JQ, Wan Yuen C. The evolving evidence base for child protection in Chinese societies. Asia Pac J Public Health. 2008;20:267-276. 21. Romano E, De Luca RV. Male sexual abuse: a review of effects, abuse characteristics, and links with later psychological functioning. Aggress Violent Behav. 2001;6:55-78. 22. O’Leary PJ, Barber J. Gender differences in silencing following childhood sexual abuse. J Child Sex Abus. 2008;17:133-143. 23. Tsuboi S, Yoshida H, Ae R, Kojo T, Nakamura Y, Kitamura K. Prevalence and demographic distribution of adult survivors of child abuse in Japan [published online May 16, 2013]. Asia Pac J Public Health. doi:10.1177/1010539513488626. 24. Holmes WC. Men’s self-definitions of abusive childhood sexual experiences, and potentially related risky behavioral and psychiatric outcomes. Child Abuse Negl. 2008;32:83-97. 25. Banyard VL, Williams LM, Siegel JA. Childhood sexual abuse: a gender perspective on context and consequences. Child Maltreat. 2004;9:223-238. Downloaded from aph.sagepub.com at Bobst Library, New York University on May 19, 2015
