The European Journal of Contraception & Reproductive Health Care

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Multiple violence victimisation associated with sexual ill health and sexual risk behaviours in Swedish youth Helena Blom, Ulf Högberg, Niclas Olofsson & Ingela Danielsson To cite this article: Helena Blom, Ulf Högberg, Niclas Olofsson & Ingela Danielsson (2016) Multiple violence victimisation associated with sexual ill health and sexual risk behaviours in Swedish youth, The European Journal of Contraception & Reproductive Health Care, 21:1, 49-56, DOI: 10.3109/13625187.2015.1089227 To link to this article: http://dx.doi.org/10.3109/13625187.2015.1089227

Published online: 29 Sep 2015.

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Date: 15 March 2016, At: 16:10

THE EUROPEAN JOURNAL OF CONTRACEPTION AND REPRODUCTIVE HEALTH CARE, 2016 VOL. 21, NO. 1, 49–56 http://dx.doi.org/10.3109/13625187.2015.1089227

Multiple violence victimisation associated with sexual ill health and sexual risk behaviours in Swedish youth Helena Bloma,b, Ulf Ho¨gbergc, Niclas Olofssond and Ingela Danielssona,d

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a Department of Clinical Sciences, Obstetrics and Gynaecology, Umea˚ University, Umea˚, Sweden; bDepartment of Obstetrics and Gynaecology, Sundsvall, Umea˚ University, Sweden; cDepartment of Women’s and Children’s Health, Uppsala University, Uppsala, Sweden; d Department of Public Health and Research, Sundsvall, Umea˚ University, Sweden

ABSTRACT

ARTICLE HISTORY

Objectives To address the associations between emotional, physical and sexual violence, specifically multiple violence victimisation, and sexual ill health and sexual risk behaviours in youth, as well as possible gender differences. Methods A cross-sectional population-based survey among sexually experienced youth using a questionnaire with validated questions on emotional, physical, and sexual violence victimisation, sociodemographics, health risk behaviours, and sexual ill health and sexual risk behaviours. Proportions, unadjusted/adjusted odds ratios (ORs) with 95% confidence intervals (CIs) were calculated. Results The participants comprised 1192 female and 1021 male students aged 15 to 22 years. The females had experienced multiple violence (victimisation with two or three types of violence) more often than the males (21% vs. 16%). The associations between multiple violence victimisation and sexual ill health and sexual risk behaviours were consistent for both genders. Experience of/ involvement in pregnancy yielded adjusted ORs of 2.4 (95% CI 1.5–3.7) for females and 2.1 (95% CI 1.3–3.4) for males, and early age at first intercourse 2.2 (95% CI 1.6–3.1) for females and 1.9 (95% CI 1.2–3.0) for males. No significantly raised adjusted ORs were found for non-use of contraceptives in young men or young women, or for chlamydia infection in young men. Conclusions Several types of sexual ill health and sexual risk behaviours are strongly associated with multiple violence victimisation in both genders. This should be taken into consideration when counselling young people and addressing their sexual and reproductive health.

Received 26 March 2015 Revised 18 August 2015 Accepted 27 August 2015 Published online 24 September 2015

Introduction The World Health Organization definition of sexual health includes not merely an absence of disease: it also recognises sexual and reproductive rights including pleasurable and safe sexual experiences free from coercion, discrimination and violence.[1] Unplanned pregnancy and sexually transmitted infection (STI) have been included in defining sexual ill health,[1] and sexual violence has also recently received attention.[2]. Many STIs, especially chlamydia, mostly affect young women and men.[3] Overall, adolescent sexual development and sexual health are linked to a variety of factors including economic and social justice, poverty, educational opportunity, human rights and gender equity, and experiences during adolescence set the stage for sexual health in later life.[1] Both adolescence and young adulthood are important, crucial and distinct periods of development, including sexual development and health,[4] and events or behaviours during these periods may affect health later in life.[5] Sexual risk behaviours increase the risk of contracting an STI and having an unplanned pregnancy; they are commonly defined to include early age at first intercourse, having multiple sexual partners, having sex under the influence of alcohol or drugs, and non-use of condoms or birth control.[6– 8] A review article covering guidelines and studies on CONTACT Helena Blom

[email protected]

KEYWORDS

Adolescents; sexual behaviours; sexual health; violence; youth

increased risk of sexually transmitted diseases (STDs) in high income countries revealed a strong to moderate level of empirical support for increased STD risk for the following predictors: multiple lifetime sexual partners, younger age, race/ethnicity, concurrent STI diagnosis, and sex with a symptomatic/infected partner. Socioeconomic status and drug/alcohol use showed weak evidence as predictors,[9] although low socioeconomic status is known to influence sexual ill health.[10] A cross-sectional study showed that early age at sexual debut was associated with high-risk behaviours, sexual risk behaviours, and exposure to physical and sexual violence.[8] Adolescents and young adults are highly exposed to violence: [11,12] strong correlations between violence, health risk behaviours, and physical and psychological ill health are well documented in adolescents and young adults.[6,13] Violence victimisation, particularly sexual violence, is recognised as a risk factor for sexual ill health.[2,13,14] Youth and childhood sexual violence victimisation has been shown to be associated with poor health outcomes and long-term health consequences in both genders; child abuse may be considered a life-course social determinant of adult health.[15–18] Studies on children and young adolescents raise the possibility that sexual violence victimisation in children and adolescents may serve as a ‘gateway’ to violence victimisation in general, and that sexual violence

Department of Women’s Health, Sundsvall Hospital, SE-851 86 Sundsvall, Sweden.

ß 2015 The European Society of Contraception and Reproductive Health

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victimisation often co-occurs with poly-victimisation.[19,20] Poly-victimisation is defined by Finkelhor and co-workers as four or more different types of 34 specified victimisation events in the current year19; for lifetime violence victimisation the definition is the top 10% of the victimised study sample.[20] In a Swedish youth survey the top 10% of the study sample included 10 events, corresponding to 12.5% of the female participants and 8.1% of the male participants.[21] Higher levels of trauma symptoms have been found in poly-victimised children and young adolescents.[19,20] In a previous study we identified a considerable overlap between emotional, physical and sexual violence victimisation in young men and women, and distinctive gender differences.[12] Earlier studies of sexual ill health or sexual risk behaviours and violence victimisation in youth have often been restricted in that they have used just one [2,6,7,22] or possibly two types of violence.[6,8] Often only young women are included.[14,23] However, by using just one type of violence in the analyses, exposure to multiple violence victimisation may be overlooked. The association between multiple violence victimisation and sexual ill health and sexual risk behaviours among adolescents and young adults still needs to be addressed, and possible gender differences must also be investigated. The objective of this study was to assess the associations between emotional, physical and/or sexual violence, especially multiple violence victimisation, and sexual ill health and sexual risk behaviours in youth by gender, and also by sociodemographics and health risk behaviours.

Methods Material In spring 2007, students aged 15 to 22 years at all upper secondary schools in a medium-sized town in Sweden were invited to answer a validated questionnaire about violence exposure and health. Exclusion criteria were mental retardation and not understanding written Swedish. Students completed the questionnaires in silence in their classroom, and then returned them in sealed envelopes. Those who did not want to participate were asked to return an empty questionnaire. Of 4083 students, 3259 (1658 females and 1589 males) submitted responses. Twelve questionnaires were excluded, either because no sex was indicated (n ¼ 8) or because the questionnaires were empty (n ¼ 4). The response rate was 83% for female students and 77% for male students, including those who were not in school on the day of the study. Only sexually experienced students were included in the study. The questions on violence victimisation had internal dropout rates of 0.4–3.4% among female students and 0.9– 4.8% among male students, while the questions on sexual experience, sexual ill health and sexual risk behaviours had internal dropout rates of 0.9–5.8% and 1.4–9.3%, respectively.

Measures Violence The questions on violence were taken from the NorVold Abuse Questionnaire (NorAQ).[12,24,25] In this study, the

Table 1. Questions about moderate and severe emotional, physical and sexual violence victimisation from the NorAQ, with minor changes of the wording. Type and level of violence Emotional Moderate Severe Physical Moderate

Severe Sexual Moderate Severe

Question Have you experienced anybody repeatedly, by threat or force, trying to limit your contacts with others or controlling what you may and may not do? Have you experienced living in fear because someone repeatedly and for a long period has threatened you or somebody close to you? Have you experienced anybody hitting you with his/her fist(s) or with a hard object, kicking you, pushing you violently, giving you a beating or doing anything similar to you? Have you experienced anybody threatening your life by, for instance, trying to strangle you, showing a weapon or a knife, or by any other similar act? Has anybody against your will touched your genitals, used your body to satisfy him/herself sexually or forced you to touch anybody else’s genitals? Has anybody against your will put or tried to put his penis, or something else, into your (vagina), mouth or rectum?

violence variables included lifetime emotional, physical and sexual violence (moderate and severe; Table 1). The NorAQ includes validated, detailed questions on violence, ranging from mild to severe, which are answered with ‘yes’ or ‘no’. Mild violence was not included in this study (questions not shown).[12,24,25] Multiple violence was defined as a respondent reporting two or three of the different types of violence. Variables for single-type violence, i.e., solely emotional, solely physical and solely sexual violence, were constructed to measure violence of just one type, excluding all respondents with any overlapping violence (Figure 1). Respondents with singletype violence might have been victimised with that specific type of violence more than once. For emotional violence, repetitiveness was inherent in the questions (Table 1). In this article, ‘violence’ and ‘violence victimisation’ will be used synonymously.

Health variables The variables for sexual ill health and sexual risk behaviours included: (i) having ever experienced or been involved in pregnancy; (ii) non-use of contraceptives by either the respondent or the partner at the latest intercourse; (iii) ever having received treatment for genital chlamydia; (iv) first intercourse 14 years of age; and (v) three or more sexual partners during the past 12 months (equal to the 75th quartile).

Covariates Covariates included age, sociodemographics, health risk behaviours and poor general health. Age was a continuous variable. Family structure was divided into: (i) living with both parents; (ii) living with one parent; and (iii) living alone/with someone else (girlfriend/boyfriend). Immigrant status was divided into: (i) Swedish-born youth with one or two Swedish-born parents; and (ii) foreign- or Swedish-born youth with two foreign-born parents (immigrants). Upper secondary school programmes were either academic

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Females (N=1192) Emotional violence (n=415)*

Physical violence (n=278)

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Males (N=1021)

Sexual violence (n=210)*

Emotional violence (n=238)

Sexual violence (n=35)

Physical violence (n=407)* Figure 1. Overlap of lifetime moderate and severe emotional, physical and sexual violence in sexually experienced upper secondary school students (2007). *p50.001 for the difference between females and males.

or vocational. Health risk behaviours included hazardous alcohol consumption, daily smoking, and drug use (e.g., ecstasy, hash, marijuana, GHB and anabolic steroids). Alcohol Use Disorders Identification Test Consumption (AUDIT-C) was used to identify hazardous alcohol consumption, with cut-off values suitable for the youth population: 5 for young women and 6 for young men.[26,27] The questions on daily smoking and drug use were dichotomised into ‘yes’ or ‘no’ and were drawn from the Swedish National Public Health Survey.[28] Self-reported health status was also drawn from the Swedish National Public Health Survey using the question ‘How do you rate your general health status?’ Answers were dichotomised as: (i) ‘good’ (including ‘very good’, ‘good’ or ‘neither good nor bad’); and (ii) poor (including ‘poor’ or ‘very poor’).[28]

Statistical methods Descriptive statistics for the study population were stratified by sex/gender. Student’s t-test was used to analyse differences in continuous numerical values. Pearson’s 2 test was used for differences in frequencies of categorical variables, and Fisher’s exact test was used in small samples. Univariate logistic regression was used to examine associations between the outcomes for different sexual ill health/sexual risk behaviours: (i) experience of/ involvement in pregnancy; (ii) ever having had treatment for chlamydia; (iii) non-use of contraceptives at latest

intercourse; (iv) early age at first intercourse; and (v) three or more sexual partners during the past 12 months; and the explanatory variables for violence: lifetime solely emotional, physical or sexual violence and multiple violence victimisation. Univariate logistic regression was also used to examine associations between the health outcomes for sexual ill health/sexual risk behaviours and sociodemographics (family structure, age, vocational programme and immigrant status), health risk behaviours (hazardous alcohol consumption, daily smoking, and drug use) and poor general health. In the multivariate logistic regression model, the associations between the explanatory variables, including lifetime solely physical, solely sexual and multiple violence victimisation, and the outcomes for sexual ill health/sexual risk behaviours were adjusted for possible confounders. All covariates were used as confounders, including age, vocational programme, family structure, immigrant status, hazardous alcohol consumption, daily smoking, and drug use. The covariates were chosen according to univariate logistic regression and empirical evidence in the literature. Only violence victimisation variables significantly associated with any of the health outcomes in the univariate analyses were included. Age was a continuous variable in the logistic regression models. Crude and adjusted odds ratios (ORs) were estimated; p50.05 was considered statistically significant. Version 20 of the SPSS software package was used for the statistical analyses.

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Ethics The study was approved by the regional ethics review board at Umea˚ University (Registration number 06-118M). Before participating in the study, the students were informed verbally and in writing. Oral informed consent was considered sufficient. All students were informed about the possibility of receiving prompt counselling related to the study if required.

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Results In all, 1192 young women and 1021 young men were included in the study. Sociodemographics, sexual ill health, sexual risk behaviours and violence victimisation are presented in Table 2. Female students reported higher levels of treatment for chlamydia compared with male students (11% vs. 5%) and a higher percentage of early age at first intercourse (37% vs. 25%). There were no significant differences between females and males in non-use of contraceptives at the latest intercourse or having had three or more sexual partners during the past 12 months. Experience of or involvement in a pregnancy was reported by 13% of the females and 7% of the males. Experience of multiple violence was more frequent in the females (21%) than in the males (16%). Multiple violence was more frequent in young women, while in young men solely physical violence was more frequent (24%) than multiple violence (16%). The frequencies and co-occurrence of lifetime emotional, physical and/or sexual violence are presented in Figure 1. In both males and females, sexual violence often co-occurred with both emotional and physical violence. While the majority of the physically victimised young men were solely physically victimised, a majority of the physically victimised young women were also emotionally and/or sexually victimised. Health risk behaviour, sociodemographics and violence victimisation in relation to sexual ill health and sexual risk behaviours are presented in Table 3. Overall, high proportions of multiple violence victimisation were seen in females reporting sexual ill health and sexual risk behaviours, while in males high proportions of both multiple violence victimisation and solely physical violence victimisation were seen in relation to these factors. Associations between violence victimisation, health risk behaviours and sociodemographics on the one hand, and sexual ill health and sexual risk behaviours on the other, are presented in Table 4. Young people reporting multiple violence victimisation had significantly raised ORs for all sexual risk behaviours and sexual ill health variables, except non-use of contraception in males. Solely physical and solely sexual violence produced occasional raised ORs among the young women. Health risk behaviours yielded significantly raised ORs for all variables for sexual ill health and sexual risk behaviours in both females and males. Attending a vocational programme in upper secondary school and not living with both parents were associated with sexual ill health and sexual risk behaviours in females, while the association in males varied (Table 4). Immigrant status was associated with three sexual ill health and sexual risk behaviour variables in males, and with non-use of contraceptives in females. After adjusting for age, family structure, present school programme, immigrant status and health risk behaviours, the

adjusted ORs for multiple violence victimisation and sexual ill health and sexual risk behaviours were overall consistent for both female and male respondents (Table 5). The adjusted ORs for experience of/involvement in pregnancy were 2.4 (95% confidence interval [CI] 1.5–3.7) for females and 2.1 (95% CI 1.3–3.4) for males, and the adjusted ORs for early age at first intercourse were 2.2 (95% CI 1.6–3.1) for females and 1.9 (95% CI 1.2–3.0) for males. Similar adjusted ORs were found for three or more sexual partners in the past year: 2.1 (95% CI 1.4–3.1) for females and 1.7 (95% CI 1.0–2.9) for males. No significantly raised adjusted OR was found for nonuse of contraceptives in young men or women or for selfreported chlamydia infection in young men. Sexual violence victimisation in young women was the only single violence victimisation with a raised adjusted OR (2.1; 95% CI 1.1–4.1). When separately analysing the associations between different combinations of multiple violence and sexual ill health/sexual risk behaviour, the combinations not including sexual violence also had significantly raised risks for different sexual risk behaviours (data not shown).

Discussion Findings and interpretation In this study there were consistent associations in young women between multiple violence victimisation and sexual ill health and sexual risk behaviours; adjusted ORs were raised for all variables except for non-use of contraception. Similar associations were found in young men, except for chlamydia infection. The only single violence victimisation that yielded a raised adjusted OR was sexual violence and early age at first intercourse in women. In men, no single violence victimisation gave a significantly raised adjusted OR. Although the patterns of violence, as well as some sexual ill health and demographic factors, differed between the young men and women, no substantial gender differences were found in the adjusted ORs for sexual ill health and sexual risk behaviours. One question to be asked is whether the raised risks are predominately related to multiple violence victimisation or whether they are primarily due to sexual violence victimisation, which is often included in multiple violence victimisation. In this study, sexual violence often overlapped with emotional and/or physical violence in both genders; and, as in other studies, young women were more often exposed to sexual violence compared with young men.[12,13] Still, the associations between multiple violence victimisation and sexual ill health and sexual risk behaviours were also consistent in young men. In addition, when analysing the associations between different combinations of multiple violence and sexual ill health, it was clear that combinations not including sexual violence were also associated with sexual risk behaviours, indicating that multiple violence victimisation is an important factor.

Strengths and weaknesses of the study The major strengths of this study are the validated questions on violence victimisation, the population-based material, the very high participation rate in combination with the low internal dropout rate, and the fact that both young men and women were included. A further strength is that the

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Table 2. Sociodemographics, sexual ill health, sexual risk behaviours and violence victimisation in sexually experienced females and males.

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Variable Mean age, years (lowest–highest) Age at first intercourse, mean years (lowest–highest)* Upper secondary school, vocational programme, n (%) Family structure Living with both parents, n (%) Living with one parent, n (%) Living alone/with someone else, n (%) Immigrant, n (%) Age 14 years at first intercourse*, n (%) Sexual partners 3 in past 12 months, n (%) Ever been pregnant, n (%) Ever made someone pregnant, n (%) Non-use of contraceptives at latest intercourse, n (%) Treatment of genital chlamydia infection, n (%) Hazardous alcohol consumption, n (%) Daily smoking, n (%) Drug use, n (%) Self-reported poor health status, n (%) Lifetime solely emotional violence (moderate/severe), n (%) Lifetime solely physical violence (moderate/severe), n (%) Lifetime solely sexual violence (moderate/severe), n (%) 2–3 types of lifetime violence (moderate/severe), n (%)

Females (N ¼ 1192)

Males (N ¼ 1021)

17.3 (15–21) 14.9 (12–19) 600 (50)

17.4 (15–22) 15.2 (12–20)** 575 (57)y

546 415 219 75 436 218 156

(46) (35) (19)** (6) (37)** (18) (13)

542 347 116 72 256 164

(53) (34) (12) (7) (25) (16)

315 129 578 162 129 68 178 64 49 253

(27) (11)** (49) (14)y (11) (6)** (15)** (5) (4)** (21)y

68 275 49 518 108 153 25 82 249 8 164

(7) (28) (5) (51) (11) (15)y (2) (8) (24)** (1) (16)

*Excluded 10 females and 20 males reporting age at first intercourse 511 years. **p50.001 females vs. males. yp50.01 females vs. males.

complexity of overlapping of violence victimisation was taken into account. The study also has some weaknesses. Since it is a crosssectional survey, no conclusions about causality can be made. The order of events of sexual risk behaviours and sexual ill health and violence victimisation may not be established. Also, as in other surveys, our data are entirely retrospective and self-reported, with the possibility of recall bias. The setting is a medium-sized city in Sweden which has a lower percentage of youth of foreign background (6–7%) compared with the general population in Sweden (15%), and also a somewhat lower educational level. Therefore, this setting may not be representative of the whole of Sweden; and the results may differ on some counts, such as frequencies in violence victimisations and sexual ill health, compared with Sweden as a whole.[10] Even so, the strong associations between multiple violence victimisation and sexual ill health and sexual risk behaviour would most probably be the same.

Differences in results and conclusions Only a small number of studies have examined the associations between multiple violence and sexual ill health and sexual risk behaviours. A longitudinal study found no associations between multiple teen dating violence and sexual ill health and sexual risk behaviours.[6] In that study, the variables for sexual ill health and sexual risk behaviours were summed into a single score, which was not the case in our study. A Swedish cross-sectional study found, in line with our results, a relationship between multiple violence during childhood and early age at first intercourse in 15- and 17-year-olds.[29] A newly published meta-analysis concluded that both sexual and physical violence were associated with an increased risk of adolescent pregnancy in women, but the strongest association was found when the two types of violence co-occurred.[30]

Finkelhor et al. [19,31] reported that the associations between the individual types of violence and trauma symptoms were reduced, or even eliminated, when polyvictimisation was taken into account. Since the polyvictimised child or youth is exposed to different forms of violence in different areas of life, this might reflect adversities across multiple contexts in life. Another possible interpretation might be that the combined types of violence victimisation reflect a more severe violent environment. Widespread cross-context violence victimisation may damage the potential for resiliency and may also affect deficits in social and personal recourses that could help moderate the negative effects of violence victimisation.[20] These theories may also be used to understand the associations between multiple violence victimisation and sexual ill health and sexual risk behaviours in youth found in the present study. Earlier cross-sectional studies have, without including multiple violence, demonstrated a relationship between dating violence in young women and non-use of condoms/ contraception.[7,23] We found no association between single or multiple violence victimisation and non-use of contraceptives, after adjusting for sociodemographic factors and health risk behaviours. Several factors other than violence may be associated with the non-use of contraceptives, such as dissatisfaction with contraceptive methods.[32] Solely sexual violence was associated with early age at first intercourse among the young women in our study; the absence of significant similar associations in the young men may be due to the small numbers of solely sexually victimised young men. Solely physical violence victimisation did not produce any significantly raised adjusted ORs for sexual ill health or sexual risk behaviours in our study. This contrasts with the results of Steiner et al. [22], who found physical violence victimisation in youth to be a possible risk factor for STIs later in life. Steiner et al. did not separate multiple violence victimisations among the physically victimised youth, but it is likely that

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Table 3. Numbers and proportions of health risk behaviours, sociodemographics and violence victimisations according to the variables for sexual ill health and sexual risk behaviours in sexually experienced females (N ¼ 1192) and males (N ¼ 1021) in upper secondary school (2007).

No contraceptives

First intercourse 14 years

Sexual partners 3

Variable

Pregnancy*

Chlamydia infection

Females/males, N Females, n (%) Hazardous alcohol consumption Daily smoking Drug use Poor self-assessed general health Upper secondary school, vocational programme Immigrant status Living with single parent Living with someone else/alone Lifetime solely emotional violence (moderate/severe) Lifetime solely physical violence (moderate(severe) Lifetime solely sexual violence (moderate/severe) 2 or 3 types of lifetime violence (moderate/severe) Males, n (%) Hazardous alcohol consumption Daily smoking Drug use Poor self-assessed general health Upper secondary school, vocational programme Immigrant status Living with single parent Living with someone else/alone Lifetime solely emotional violence (moderate/severe) Lifetime solely physical violence (moderate(severe) Lifetime solely sexual violence (moderate/severe) 2 or 3 types of lifetime violence (moderate/severe)

156/68

129/49

315/275

436/256

218/164

107 63 35 15 121 12 60 55 22 9 6 73

(69) (40) (22) (9.6) (78) (7.2) (38) (35) (14) (5.8) (3.8) (47)

91 48 30 10 81 12 44 46 16 11 10 46

(71) (37) (23) (7.8) (63) (9.4) (34) (36) (12) (8.5) (7.8) (36)

176 60 51 26 171 33 125 64 50 24 13 75

(56) (19) (16) (8.3) (54) (10) (40) (20) (16) (7.6) (4.1) (24)

260 99 65 31 267 24 166 92 63 30 27 133

(60) (23) (15) (7.1) (61) (5.5) (38) (21) (14) (6.9) (6.2) (31)

167 54 53 14 126 15 85 47 27 12 12 78

(77) (25) (24) (6.4) (58) (6.9) (39) (22) (12) (5.5) (5.5) (36)

44 15 18 4 41 8 22 10 5 22 1 18

(65) (22) (26) (5.9) (60) (12) (32) (15) (7.4) (32) (1) (26)

32 14 19 6 34 7 14 9 4 12 1 14

(65) (29) (39) (12) (69) (14) (29) (18) (8) (24) (2) (29)

176 59 65 11 167 32 89 32 22 77 3 46

(64) (21) (24) (4) (61) (12) (32) (12) (8) (28) (1.1) (17)

152 42 47 4 153 19 90 34 20 72 1 54

(59) (16) (18) (1.6) (60) (7.4) (35) (13) (7.8) (28) (0.4) (21)

109 40 47 6 96 34 52 25 12 45 1 41

(66) (24) (29) (3.7) (59) (21) (32) (15) (7) (27) (0.6) (25)

*Ever experienced/been involved in a pregnancy.

Table 4. ORs and 95% CIs for associations between violence victimisation, health risk behaviours and sociodemographics in sexually experienced youth according to sexual ill health and sexual risk behaviours in females (N ¼ 1192) and males (N ¼ 1021) in upper secondary school. Variable

Pregnancy* OR (95% CI)

Chlamydia infection OR (95% CI)

No contraception OR (95% CI)

First intercourse 14 years OR (95% CI)

Sexual partners 3 OR (95% CI)

Females** Lifetime solely emotional violence (moderate/severe) Lifetime solely physical violence (moderate(severe) Lifetime solely sexual violence (moderate/severe) 2–3 types of lifetime violence (moderate/severe) Hazardous alcohol consumption Daily smoking Drug use Poor self-assessed general health Age Upper secondary school, vocational programme Immigrant status Living with single parent Living with someone else/alone Males** Lifetime solely emotional violence (moderate/severe) Lifetime solely physical violence (moderate(severe) Lifetime solely sexual violence (moderate/severe) 2–3 types of lifetime violence (moderate/severe) Hazardous alcohol consumption Daily smoking Drug use Poor self-assessed general health Age Upper secondary school, vocational programme Immigrant status Living with single parent Living with someone else/alone

1 0.9 1.0 0.8 4.3 2.1 6.0 2.7 2.2 1.2 3.1 1.2 1.8 3.6 1 1.0 1.2 3.1 3.1 2.1 5.1 3.3 4.6 1.0 1.4 1.9 0.9 1.8

1 0.8 1.7 2.2 2.9 2.8 4.9 2.9 1.5 1.5 1.8 1.6 1.7 3.7 1 1.0 0.9 7.8 3.0 1.9 3.9 3.9 6.7 1.3 1.9 2.6 0.9 1.9

1 1.1 1.7 1.0 1.3 1.5 1.7 2.1 1.9 1.1 1.3 2.4 1.5 1.4 1 1.0 1.3 4.3 1.3 2.1 3.9 2.3 2.0 0.9 1.4 2.4 0.9 1.0

1 0.9 1.5 2.3 3.3 2.2 4.0 2.3 1.6 0.8 2.1 0.9 1.5 1.7 1 0.9 1.3 1.4 2.2 1.6 2.7 1.9 1.2 0.8 1.3 1.4 1.0 1.7

1 0.8 1.0 1.4 2.7 4.6 2.6 3.9 1.2 1.2 1.5 1.1 1.4 1.4 1 0.9 1.2 1.6 2.5 2.2 4.2 3.0 1.7 1.2 1.2 3.1 1.0 1.6

(0.6–1.5) (0.5–2.1) (0.3–2.0) (2.9–6.3)y (1.5–3.0)y (4.1–8.8)y (1.8–4.2)y (1.2–4.1)y (1.0–1.4)y (2.1–4.5)y (0.6–2.4) (1.2–2.7)y (2.3–5.5)y (0.6–1.8) (0.8–1.7) (0.7–14) (2.0–4.6)y (1.5–3.0)y (3.3–7.8)y (2.3–4.9)y (2.1–10)y (0.9–1.2) (1.0–2.0)y (1.1–3.3)y (0.6–1.3) (1.1–2.9)y

(0.5–1.4) (0.9–3.4) (1.0–4.4)y (1.9–4.5)y (1.9–4.2)y (3.2–7.3)y (1.8–4.6)y (0.7–3.0) (1.2–1.8)y (1.2–2.6)y (0.8–3.1) (1.1–2.7)y (2.3–5.9)y (0.4–2.9) (0.4–1.8) (1.5–41)y (1.4–6.1)y (1.0–3.4)y (2.0–7.5)y (2.1–7.1)y (2.6–18)y (1.0–1.8)y (1.0–3.6)y (1.1–6.0)y (0.5–1.8) (0.9–4.3)

(0.8–1.6) (1.0–2.9)y (0.5–1.8) (1.0–1.8)y (1.2–2.0)y (1.2–2.5)y (1.4–3.1)y (1.1–3.1)y (0.9–1.2) (1.0–1.6)y (1.5–3.8)y (1.1–2.0)y (1.0–2.0)y (0.6–1.9) (0.9–1.7) (1.1–18)y (0.9–1.9) (1.5–2.8)y (2.6–5.9)y (1.6–3.3)y (0.9–4.5) (0.8–1.1) (1.0–1.8)y (1.5–4.0)y (0.7–1.2) (0.7–1.6)

(0.7–1.3) (0.9–2.5) (1.3–4.1)y (2.4–4.5)y (1.7–2.8)y (2.8–5.7)y (1.6–3.3)y (1.0–2.7)y (0.7–0.9) (1.6–2.6)y (0.5–1.4) (1.1–2.0)y (1.2–1.4)y (0.5–1.5) (0.9–1.8) (0.3–6.1) (1.5–3.3)y (1.2–2.1)y (1.8–4.1)y (1.3–2.7)y (0.5–3.0) (0.7–0.9) (1.0–1.8)y (0.9–2.4) (0.8–1.4) (1.1–2.6)y

(0.5–1.2) (0.5–1.9) (0.7–2.8) (1.9–3.9)y (3.2–6.5)y (1.8–3.8)y (2.6–5.8)y (0.6–2.2) (1.0–1.4)y (1.1–2.0)y (0.6–2.0) (1.0–1.9)y (1.0–2.1)y (0.5–1.8) (0.8–1.8) (0.3–7.8) (1.6–3.9)y (1.5–3.1)y (2.7–6.6)y (2.0–4.5)y (0.6–4.3) (1.0–1.4)y (0.9–1.7) (1.8–5.6)y (0.7–1.4) (1.0–2.7)y

*Ever experienced/been involved in a pregnancy. **Reference groups are: not exposed to violence, no health risk behaviour, good self-assessed general health, younger age, academic programme, non-immigrant status, and living with two parents. Age is a continuous variable. ySignificantly raised OR.

several of their participants were exposed to several different types of violence. If multiple violence victimisation is not taken into account, the importance of a specific type of violence may be overestimated.[19].

The strong associations between drug use, hazardous alcohol consumption, attending vocational programmes, and sexual ill health and sexual risk behaviours in both men and women found in this study are consistent with those of

THE EUROPEAN JOURNAL OF CONTRACEPTION AND REPRODUCTIVE HEALTH CARE

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Table 5. Adjusted ORs with 95% CIs for associations between lifetime violence victimisation and sexual ill health and sexual risk behaviours in sexually experienced upper secondary school students, adjusted for age, living with one parent/someone else/alone, immigrant status, vocational programme, hazardous alcohol consumption, daily smoking, and drug use. Variable

Females Lifetime solely physical violence (moderate/severe)y Lifetime solely sexual violence (moderate/severe)y 2–3 types of lifetime violence (moderate/severe)z Males Lifetime solely physical violence (moderate/severe)y Lifetime solely sexual violence (moderate/severe)y 2–3 types of lifetime violence (moderate/severe)z

Chlamydia infection Adjusted OR (95% CI)

No contraception Adjusted OR (95% CI)

First intercourse 14 years Adjusted OR (95% CI)

Sexual partners 3 Adjusted OR (95% CI)

0.5 (0.2–1.4) 0.6 (0.2–1.1) 2.4 (1.5–3.7)**

1.3 (0.6–3.0) 2.0 (0.9–4.3) 1.8 (1.1–2.9)**

1.4 (0.8–2.5) 0.9 (0.5–1.8) 1.0 (0.7–1.4)

1.2 (0.7–2.1) 2.1 (1.1–4.1)** 2.2 (1.6–3.1)**

1.0 (0.5–2.0) 1.2 (0.6–2.4) 2.1 (1.4–3.1)**

1.2 (0.8–1.8) 3.0 (0.7–14) 2.1 (1.3–3.4)**

1.0 (0.5–2.1) 4.9 (0.5–45) 1.9 (0.8–4.5)

1.1 (0.8–1.6) 2.8 (0.6–13) 0.9 (0.6–1.5)

1.2 (0.8–1.7) 1.5 (0.3–6.8) 1.9 (1.2–3.0)**

1.1 (0.7–1.7) 0.8 (0.1–6.4) 1.7 (1.0–2.9)**

Pregnancy* Adjusted OR (95% CI)

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*Ever experienced/been involved in a pregnancy. **Significantly raised adjusted OR. yNot exposed to single-type or multiple violence victimisation as the referent. zNot multiple violence victimised as the referent.

other studies.[10,33,34] The association between smoking and sexual ill health and sexual risk behaviours was, however, surprisingly high. A large population-based Nordic study found that women who started smoking at an early age engaged in more risky sexual behaviours than women who started smoking later or who never smoked.[35] Smoking could be regarded as a proxy for low socioeconomic status,[36,37] which is known to influence sexual ill health.[10]

Relevance of the findings: implications for clinicians and policy-makers Knowledge about the strong associations between multiple violence victimisations and sexual ill health and sexual risk behaviours in youth is important in the clinical setting. Sexual and reproductive health care providers should be encouraged to include a question about violence victimisation as part of the medical history. By asking about violence, professionals may also help young people to receive further counselling from social workers, psychologists or physicians when needed. When identifying one type of violence, it is important to ask about other forms of violence in both females and males. Violence is a global public health problem, and violence among youth is a matter of high priority. Since youth violence victimisation may have serious health consequences, possible interventions and early preventions against violence should be prioritised. Violence is not inevitable and needs to be addressed.

Unanswered questions and future research In this study, sexual-minority young people were not specifically approached. Studies have found a higher prevalence of violence among sexual-minority adolescents than among their heterosexual counterparts;[38,39] more studies on violence victimisation and sexual health are important for these vulnerable youth.

Conclusion Multiple violence victimisation in youth is strongly associated with sexual ill health and various sexual risk behaviours in both females and males, even when sexual violence is not

included. Sexual and reproductive health care providers should be encouraged to help identify young people who are victims of violence, and specifically youth who are multiply victimised. Multiple violence has strong implications for health, and should be taken into consideration when counselling young people and addressing their sexual and reproductive health.

Declaration of interest The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.

Funding Funding for this project was provided by the Crime Victim Compensation and Support Authority, Sweden, and from the Department of Research and Development, Va¨sternorrland County Council, Sweden.

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