Children and Youth Services Review 32 (2010) 2837

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Children and Youth Services Review

j o u r n a l h o m e p a g e : w w w. e l s ev i e r. c o m / l o c a t e / c h i l d yo u t h

Risk of intimate partner violence: Role of childhood sexual abuse and sexual initiation in women in Japan
Mieko Yoshihama a,, Julie Horrocks b
a b

University of Michigan School of Social Work, United States Department of Mathematics and Statistics, University of Guelph, Guelph, Ontario, Canada

a r t i c l e

i n f o

a b s t r a c t
Objectives: This population-based study examined the prevalence and nature of childhood sexual abuse and intimate partner violence (IPV) and the relationship between the two types of victimization. Methods: As part of a World Health Organization multi-national study, data were collected through face-toface interviews with a stratied, multistage sample of 1371 women aged 1849 in the city of Yokohama. Methods of survival analyses were used to assess relationships among women's experiences in childhood (e.g., sexual abuse or exposure to IPV against the mother), timing and nature of sexual initiation, and IPV. Results: Three percent of the women reported having been sexually abused during childhood by someone they knew, and 7% reported childhood sexual abuse by strangers. Estimated prevalence of physical IPV was 17.70% and 8.49% for sexual IPV. Childhood sexual abuse by known perpetrators, exposure to IPV against the mother, and early sexual initiation, independently contributed to an elevated probability of experiencing IPV in adulthood. Conclusions: The high estimated probability of childhood sexual abuse and IPV, and the signicant association between the two forms of victimization indicate a need for increased prevention efforts beginning in childhood and adolescence and prior to initiating intimate relationships. 2009 Elsevier Ltd. All rights reserved.

Article history: Received 2 May 2009 Accepted 22 June 2009 Available online 28 June 2009 Keywords: Violence against women Childhood sexual abuse Intimate partner violence Domestic violence Family violence Exposure to domestic violence Revictimization Sexual initiation Asian Japanese

1. Introduction Abuse against girls and women is a global problem; its prevalence is alarmingly high and its consequences are devastatingly vast and longlasting. This problem knows no national boundaries, as articulated recently by United Nations Secretary-General Ban Ki-moon (2008): Violence against women is an issue that cannot wait. A brief look at the statistics makes it clear. At least one out of every three women is likely to be beaten, coerced into sex or otherwise abused in her lifetime. Through the practice of prenatal sex selection, countless others are denied the right even to exist. No country, no culture, no woman young or old is immune to this scourge. Far too often, the crimes go unpunished, the perpetrators walk free. Around the globe, abuse of girls and women had been long hidden, often viewed as a personal matter. Abuse that occurs within the
This study was funded in part by grants from the World Health Organization; the Toyota Foundation; the Japan Ministry of Health and Welfare, the University of Michigan Center for the Japanese Studies, Institute for Research on Women and Gender, and School of Social Work; and the Japan National Institute of Population and Social Security Research. Corresponding author. University of Michigan School of Social Work, 1080 S. University, Ann Arbor, MI 48109-1106, United States. Tel.: +1 734 647 6255; fax: +1 734 763 3372. E-mail address: miekoy@umich.edu (M. Yoshihama). 0190-7409/$ see front matter 2009 Elsevier Ltd. All rights reserved. doi:10.1016/j.childyouth.2009.06.013

privacy of home had been particularly shielded from public intervention or research efforts. This lack of public attention and research has contributed to a sense of stigma felt by victims and survivors. The last three decades, however, have seen a varying degree of increase in research efforts around the world to understand this previously neglected social problem. Western countries, such as the United States, have experienced a surge of studies of childhood sexual abuse (CSA) and intimate partner violence (IPV). Unfortunately, such research efforts have been not been evenly shared around the globe; most studies have been conducted in Western countries and/or by Western researchers. The present population-based study of women in Yokohama, the second-largest city in Japan, is the rst of its kind in Japan to examine multiple types of abuse experienced from childhood to adulthood and the relationships between them. 1.1. Research on abuse in childhood and adulthood The prevalence of CSA and IPV has been well documented around the world. Due largely to methodological variations, prevalence estimates of CSA range between 7 and 40% among the general population of women in the United States and other Western countries (Bolen & Scannapieco, 1999; Collins et al., 1999; Finkelhor, 1994; Finkelhor, Hotaling, Lewis, & Smith, 1990; Gilbert et al., 2009; Gorey & Leslie, 1997; Gorey & Leslie, 2001; Kercher & McShane, 1984; Nelson et al., 2002; Paolucci, Genius, & Violato, 2001; Russell, 1983; Schei, 1990; Weaver, Kilpatrick, Resnick,

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Best, & Saunders, 1997; World Health Organization, 2005). With respect to IPV, it is estimated that 2231% of adult women in the United States experience physical and/or sexual violence at the hands of their male intimates at some point in their lives (Collins et al., 1999; Tjaden & Thoennes, 1998); estimates around the globe, however, range widely from 15 to 71% (World Health Organization, 2005). Although initial research efforts tended to examine specic types of abuse, increased attention has been given to multiple types of abuse that girls and women experience over their lifecourse. This line of research, conducted predominantly in Western countries, has consistently documented that a history of childhood abuse is associated with increased probability for experiencing IPV in adulthood in various population groups such as: women seeking health care at a family practice or at primary care clinics (Coid et al., 2001; Coker, Smith, McKeown, & King, 2000; Fergusson, Horwood, & Lynskey, 1997; Schuetze & Eiden, 2005), women on welfare and low-income women (Derr & Taylor, 2004; DiLillo, Giuffre, Tremblay, & Peterson, 2001), college women (Banyard, Arnold, & Smith, 2000; Gidycz, Coble, Lathman, & Layman, 1993; Humphrey & White, 2000; MessmanMoore & Long, 2000; Messman & Long, 1996), and the general population (Caetano, Schafer, Clark, Cunradi, & Raspberry, 2000; Fogarty, Fredman, Heeren, & Liebschutz, 2008; Roberts, O'Connor, Dunn, & Golding, 2004; Schafer, Caetano, & Clark, 1998; West, Williams, & Siegel, 2000). Another line of researchexploring the role of interpersonal victimization in HIV/AIDS riskshas documented a signicant link between CSA and such risk behavior as early sexual initiation, unprotected sex, and forced sex (Arriola, Louden, Doldren, & Fortenberry, 2005; Cohen et al., 2000; Cunningham, Stiffman, Dore, & Earls, 1994; Fergusson et al., 1997; Hillis, Anda, Felitti, & Marchbanks, 2001; Lodico & DiClemente, 1994; Raj, Silverman, & Amaro, 2000; Wilson & Widom, 2008; Wingood & DiClemente, 1997; Zierler et al., 1991; Zierler, Witbeck, & Mayer, 1996). The literature exploring the possible link between witnessing parental violence and experiencing subsequent victimization is comparatively smaller in volume. Some studies have found that exposure to parental IPV was associated with subsequent IPV victimization (O'Keefe, 1998; Sherry, Caetano, Field, & Larkin, 2005), while others have found no signicant relationship (Alexander, Moore, & Alexander, 1991; Jankowski, Leitenberg, Henning, & Coffey, 1999). It is estimated that 10 to 20% of children are exposed to parental IPV, and 33 to 40% of children in homes where IPV takes place witness the violence (Carlson, 2000; Thompson, Satlzman, & Johnson, 2003; Wolak & Finkelhor, 1998). Given these high estimates, further investigation is warranted regarding the potential effect of exposure to IPV against the mother on abuse in later life. Two methodological issues are salient to the investigation of the relationship between CSA and IPV. First, most studies have not distinguished types of CSA by perpetrator, or they have focused on only one type of perpetrator, such as intrafamilial, with some notable exceptions (Bulik, Prescott, & Kendler, 2001; Gagne, Lavoie, & Hebert, 2005). The impact of victimization by known individuals and by strangers is likely to differ. Thus distinguishing among perpetrator types appears critical. Second, most studies use dichotomous grouping of those with a history of CSA as opposed to those without such a history, and they do not take into account the extent of victimization. To address these issues, the present study differentiated perpetrators of CSA (known vs. stranger) and took into account frequency of victimization. Furthermore, in investigating whether the probability of experiencing IPV varies by exposure to CSA, we also examined the possible role of the timing and nature of sexual initiation, as well as exposure to mothers' IPV experiences. Methodologically, this study differs from most previous studies, in that previous studies predominantly employed correlational analyses based on retrospective data, with some notable exceptions (Rich, Gidycz, Warkentin, Loh, & Weiland, 2005; West et al., 2000). The present study, though it used retrospective data, used methods of survival analysis (also known as event history analysis) that allowed for

an examination of probability of experiencing IPV during their adult years, while accounting for other types of life events that occur at various time points over the women's lifecourse. 1.2. Research on child sexual abuse and IPV in Japan Until the early 1990s, IPV in Japan was considered a personal matter rather than a social problem or crime, and the general public tended to tolerate or rationalize a husband's use of violence against his wife (Yoshihama, 2002a,b). Research on IPV in Japan began in early 1990s when the Domestic Violence Action & Research Group conducted a nationwide survey (Domestic Violence Action & Research Group [Domestic Violence Chosakenkyukai], 1998; Yoshihama, 2002a). This study uncovered the serious and widespread nature of IPV (Yoshihama, 2009; Yoshihama & Sorenson, 1994) and helped break the silence and denial surrounding the issue of IPV (Hattori et al., 1994). An increasing number of non-governmental and governmental organizations in Japan have since conducted studies to assess the extent and effect of IPV. Simultaneously, the number of non-governmental shelter programs increased from 5 in 1993 to 17 in 1998 and to more than 100 in 2006. In April 2001, Japan's national legislature passed the country's rst law on IPV, entitled Haigusha Kara No Boryoku No Boshi Oyobi Higaisha No Hogo Ni Kansuru Horitsu (Law for the Prevention of Spousal Violence and the Protection of Victims). This act and its subsequent amendments provide a range of resources for women who have experienced IPV, such as governmentally funded information and counseling services, shelter programs, and stay-away orders. Recent population-based studies found that between 16.1 and 24.9% of adult women experience physical IPV, and 8.1 to 15.8% are subject to sexual IPV (Naikakufu Danjokyodosankakukyoku [Cabinet Ofce-Gender Equality Bureau], 2009; Yoshihama, Horrocks, & Kamano, 2007, 2009). Research on CSA in Japan is far less extensive. In one of the few population-based studies, 55.6% of women aged 2059 reported having experienced some type of sexual abuse (including verbal abuse, indecent exposure, unwanted touch, and forced sex) before age 19 (Ishii, Asukai, Konishi, Inamoto, & Kageyama, 2002). Another study of women aged 1839 found that 15.6% of women had experienced some type of sexual abuse before graduating from elementary school, and 39.4% before age 18 (Kodomo to Kazoku no Kokoro to Kenko Chosaiinkai, 1999). Unfortunately, the low response rate of these studies (19.1% and 25.6%, respectively) limits the generalizability of their ndings. Other studies used a convenience sample of college students (Ishii, Asukai, Konishi, Kojimoto, & Kishimoto, 2002; Ishikawa, 1995; Konishi, 1996; Konishi, 1997) or adult females (Sasagawa et al., 1998). Furthermore, no study in Japan, to our knowledge, has investigated the relationship between CSA and IPV. The current study represents the rst populationbased study in Japan to explore such a relationship. 2. Methods 2.1. Development of research instruments The present study is part of the World Health Organization (WHO) Multi-Country Study of Women's Health and Domestic Violence. We used the WHO Core Questionnaire Version 9.9 (World Health Organization, 2000), which was also used in participating countries such as Bangladesh, Brazil, Ethiopia, Japan, Peru, Namibia, Samoa, Serbia and Montenegro, Thailand, and the United Republic of Tanzania (World Health Organization, 2005). For the present study, the WHO Core Questionnaire was translated into Japanese using the back translation method. Based on two pilot tests, previous research, and professional consultation, questions pertinent to the Japanese socio-cultural and economic context were added to the questionnaire. Prior to the data collection, a pre-test was conducted with a random sample of 150 women in Yokohama. The pilot tests and pre-test prompted modications to the data collection procedures. While the WHO Protocol species that the

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questionnaire is administered through face-to-face interviews at a private location, participants of both the pilot tests and pre-test repeatedly indicated the preference for a nonverbal question format, especially for questions of a sensitive nature (e.g., experience of IPV, reproductive health, and substance use). In addition, interviewers experienced enormous difculties in securing a private space to conduct an interview due to small housing quarters, typical in a large city such as Yokohama. Thus, while using the face-to-face interview as the main data collection method, sensitive questions were administered using a combination of the following methods to avoid vocalization of questions on the part of the interviewer or that of answers on the part of the respondents: (a) a respondent booklet, which listed response categories; (b) in some cases, printing sensitive questions on the respondent booklet so that the interviewer does not have to read them out; and (c) a self-administered paper-and-pencil questionnaire, which the respondent lled out and returned to the interviewer. 2.2. Sampling frame and sampling procedures Using an ofcial resident registry, we drew a stratied cluster sample of 2400 women aged 18 to 49 in the city of Yokohama. Japan maintains an ofcial resident registry (Jumin Kihon Daicho), which lists the names, addresses, birth dates, and sex of all residents. Jumin Kihon Daicho is widely used in Japan to draw random samples for population-based research (Inoue, Inoue, Ono, & Nichigaki, 1997; Sugiyama, 1997; Suzuki & Takahashi, 1991). We stratied Yokohama into 18 districts, which corresponded to the city's 18 administrative wards, and randomly selected 127 blocks (small geographic units equivalent to a census tract) across 18 districts; the number of blocks selected in each district was proportional to the number of women aged 18 to 49 in each district. Systematic random sampling method was used to select every 11th eligible woman from each block, theoretically yielding a self-weighted sample. 2.3. Data collection procedures Approval from the Institutional Review Board was obtained from the rst author's university and the World Health Organization, Geneva, Switzerland. Data were collected between October 2000 and January 2001. An introductory letter was sent to selected women. For safety reasons, the introductory letter described the study as a study of women's health and life experiences. A trained female interviewer contacted the prospective respondents and explained the purpose and procedures of the study prior to obtaining an informed consent. After consent was obtained, face-to-face interviews were conducted at a location of the respondent's choice (predominantly the respondent's place of residence). Of the 2400 women selected, 433 were not eligible or could not be reached. A total of 1371 women completed the interview, resulting in a response rate of 57.1%. Excluding the 433 women who were ineligible or could not be reached, the response rate was 69.7%. This rate is higher than other studies that employed similar methods in Japan; for example, in the 1998 survey of Japanese National Character, the response rate for the six largest cities, including Yokohama, was 49% (Tokei Suri Kenkyujo [The Institute of Statistical Mathematics], 1999). This paper presents analyses of data for 1185 women who had had at least one intimate heterosexual relationship and provided information on CSA, sexual initiation, and IPV. On average, the interview lasted 39.66 min (se = .58). At the conclusion of the interview, respondents received a gift certicate (equivalent of USD 9) and a list of assistance programs. The list was provided to all respondents regardless of whether they reported victimization experiences during the interview. For safety reasons, the list did not explicitly mention IPV and was small in size (business card size) so that it could be easily hidden from an abusive partner. In addition, prior arrangements were made with

local service programs to provide assistance for respondents on an as-needed basis. 2.4. Measures 2.4.1. Experiences of physical and sexual IPV The respondents were asked whether they had experienced each of the six forms of physical violence and three forms of sexual violence at the hands of their husbands or any other intimate partners (see Table 1 for specic items). If the respondent reported having experienced at least one form of physical IPV, she was asked at what age she experienced physical IPV for the rst time. Similarly, the respondent indicated at what age she had experienced sexual IPV for the rst time. From the responses to those questions, we created two dichotomous variables: whether the respondent had experienced physical IPV and sexual IPV, respectively. We also created a variable denoting the respondent's age at her rst experience of physical IPV, and another variable denoting her age at her rst experience of sexual IPV. 2.4.2. Childhood sexual abuse Each respondent was asked whether she had experienced unwanted sexual touching and/or was forced to perform sexual acts against her will before age 15. If so, she provided information about the frequency (once or twice, several, or many times), the relationship of respondent to perpetrator, and the age at which she experienced the abuse for the rst time. 2.4.3. Exposure to IPV against the mother Each respondent was asked whether her mother had experienced physical violence at the hand of her husband or intimate partner. 2.4.4. Sexual initiation Each respondent was asked at what age she rst had intercourse and whether it was wanted or not. 2.4.5. Socio-demographic characteristics We also assessed each respondent's age, relationship status, number of children, educational level, employment status, and personal income at the time of the interview, as well as the age at which the respondent rst married. 2.5. Statistical analysis As stated previously, the sample was designed to be self-weighting. However, because of non-response, some individuals in the nal sample represent more population members than others. To account for this, we constructed post-stratication weights based on a 3-way categorization of age in years, employment status, and marital status using data from the 1997 Employment Status Survey (Somucho Tokeikyoku [Management and Coordination Agency-Statistics Bureau], 1998). All analyses were adjusted using these weights. We used Stata Version 9 and SAS 9.1 and 9.2 to calculate statistics, applying the post-stratication weights and survey procedures that adjust variance estimates to account for the stratication and clustering in the sampling design. To estimate the probability of experiencing IPV by a given age, we used the KaplanMeier estimator. We used a Cox regression model to assess whether the respondents' CSA, exposure to IPV against the mother, and age and nature of sexual initiation were associated with the probability of experiencing IPV in adulthood. 3. Results 3.1. Respondents' characteristics Table 1 presents the distribution of the respondents' characteristics, weighted and adjusted for sampling design. The mean age of the

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respondents was 35.46 years (se = .34). At the time of the interview, the majority (74.67%) were married and/or cohabiting with a male partner, and two thirds (67.64%) had one or more children (mean number of children 1.90, se = .03). On average, the respondents had 13.64 years of schooling (se = .07). The majority of the respondents

Table 1 Respondents' characteristics and experience of childhood sexual abuse, sexual initiation, and physical and sexual intimate partner violence. Weighted % Age 1824 2529 3034 3539 4044 45+ Marital/relationship status Married and/or cohabiting Currently partnered Currently not partnered Divorced/separated Number of children 0 1 2 3+ Educational levels b 12 12 1315 16+ Employment Not employed Employed Personal income None b 120 M 120300 M 300500 M 500+ M Physical IPVany Slapped or object thrown at her that could hurt Pushed or shoved Hit with a st or with something else that could hurt Kicked, dragged, or beat up Choked or burned on purpose Threatened or assaulted with gun, knife, or other weapon Sexual IPVany Physically forced to have sexual intercourse when the respondent did not want to Had sexual intercourse because she was afraid of what the partner might do Forced to engage in a degrading or humiliating sexual act CSAany By known perpetrators By stranger Frequency of CSA experienced Once or twice More than twice Exposure to physical IPV against mother Age of rst intercourse b 17 1719 2022 23+ Unwanted rst intercourse 10.01 19.14 18.86 15.65 15.79 20.55 74.67 12.82 8.47 4.04 32.36 20.34 35.28 12.01 13.64 4.27 32.96 42.12 20.65 42.11 57.89 41.20 27.50 14.22 11.85 5.25 13.57 9.64 9.08 2.22 2.63 .14 .57 6.97 5.51 se 1.00 1.56 1.31 1.01 1.03 1.58 1.85 1.43 1.07 .71 1.63 1.21 1.61 .99 .07 .63 1.92 1.76 1.36 1.71 1.71 1.72 1.34 1.14 1.04 .68 .96 .89 .94 .42 .46 .10 .23 .88 .81 95% CI 8.02, 11.99 16.05, 22.23 16.26, 21.45 13.65, 17.64 13.76, 17.83 17.41, 23.69 71.00, 78.35 9.98, 15.66 6.35, 10.58 2.64, 5.44 29.13, 35.59 17.95, 22.74 32.10, 38.46 10.05, 13.98 13.50, 13.78 3.02, 5.53 29.16, 36.76 38.63, 45.62 17.96, 23.33 38.73, 45.50 54.50, 61.27 37.79, 44.60 24.84, 30.15 11.96, 16.47 9.79, 13.90 3.90, 6.59 11.66, 15.49 7.88, 11.40 7.21, 10.94 1.39, 3.05 1.71, 3.55 .00, .35 .11, 1.03 5.23, 8.71 3.90, 7.12

Fig. 1. Hazard of physical IPV.

(57.89%) were working at the time the interview was conducted. However, only a minority of the women employed outside home (44.62%) were working full-time. With respect to annual incomes from all sources, 41.20% reported no personal income, and 27.50% reported personal income of less than 1,200,000 yen (equivalent of USD 11,000). Based on census and other population-based statistics, the distributions of the respondents' characteristics were comparable to those of female residents aged 1849 in Yokohama with respect to age, educational level, and marital status. (Genshiryoku Anzen System Kenkyujo [Institute of Nuclear Safety System], n.d.; Somucho Tokeikyoku [Management and Coordination Agency-Statistics Bureau], 1998; Tokei Suri Kenkyujo [The Institute of Statistical Mathematics], 1999). 3.2. Self-report and age-adjust estimates of the probability of IPV As shown in Table 1, 13.57% (se = .96%) reported having experienced at least one form of physical IPV sometime prior to the interview. The largest proportion of women (9.64%) reported being slapped or having something thrown at them that could hurt, followed by being pushed or shoved (9.08%). Smaller proportions of women reported that they had been kicked, dragged, or beaten up, had been hit with the st; or had been hit with something else that could hurt them, and choked, burnt on purpose, and threatened with a gun, knife, or other weapon. With respect to sexual IPV, 6.97% (se = .88%) reported having experienced at least one type of sexual violence: 5.51% reported forced sexual intercourse, and an additional 3.62% reported having engaged in unwanted sexual intercourse because they were afraid of what their partners might do if they refused. Because some respondents who had not been victimized at the time of the interview may experience IPV at a later time, survival analysis was used to estimate the age-adjusted probabilities of experiencing physical and sexual IPV during the lifetime. The ageadjusted lifetime probability of experiencing physical IPV at age 50 (maximum age of the respondent1) was 17.70% (se = 1.47%). As seen in Fig. 1, the hazard of experiencing physical IPV begins to increase during the late teen years, reaches a peak in a woman's mid-20s and then falls, but remains positive into her 50s. Fig. 2 shows the cumulative probability of experiencing physical IPV by age. The estimated cumulative probability of experiencing physical IPV at age 30 (the average age at which women in large cities marry for the rst time) was (12.77%, se = 1.06%), suggesting that as many as 13% of women (two thirds of those who would experience physical IPV by age 50) might experience physical IPV before marriage.

3.62

.57

2.49, 4.74

1.48 10.44 3.33 7.29 7.40 2.96 18.57

.37 .96 .57 .78 .82 .49 1.17

.74, 2.22 8.54, 12.34 2.20, 4.47 5.74, 8.84 5.77, 9.03 1.98, 3.93 16.25, 20.89

6.28 35.90 33.56 24.26 21.39

.87 1.36 1.44 1.40 1.31

4.56, 8.00 33.21, 38.60 30.71, 36.42 21.48, 27.04 18.80, 23.98

CSA = childhood sexual abuse; IPV = intimate partner violence.

1 Although one of the inclusion criteria was women aged 1849, some of the respondents who were aged 49 at the time of sampling turned 50 prior to the interview.

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Fig. 2. Cumulative probability of physical IPV. Fig. 4. Cumulative probability of sexual IPV.

The hazard for sexual IPV over women's lifecourse is shown in Fig. 3. It, too, begins to rise in the mid-teens; however, it reaches a peak at age 20, then drops and reaches another smaller peak in a woman's early 40s. The cumulative probability of experiencing sexual IPV is shown in Fig. 4. By age 30, 5.70% (se = .73%) of the respondents were estimated to experience sexual IPV, and by 50, 8.49% (se = 1.19%). 3.3. Childhood experiences: CSA and exposure to IPV against the mother Approximately 1 in 10 respondents (10.44%, se = .96%) indicated that they experienced CSA before age 15 (see Table 1), with 7.29% reporting CSA by a stranger, and 3.33% by a known person. Of those who reported CSA, more than 1 in 4 (28.54%, se= 3.97%) indicated having been victimized more than twice. Known perpetrators included family members, male friends of the family, neighbors, teachers, police, friends, classmates, and coworkers. Only three respondents reported having been abused by both known and stranger perpetrators. Those who experienced CSA by known perpetrators were more likely to have been abused more than twice (41.97%, se = 8.00%) than were those who experienced CSA by strangers (23.66%, se= 4.81%). With respect to exposure to IPV against their own mothers, 18.57% (se = 1.17%) of respondents reported that their mother had experienced physical violence by her husband or intimate partner. 3.4. Sexual initiation On average, respondents reported engaging in intercourse for the rst time when they were 20.59 years old (se = .11, mode = 20 years old). No signicant differences were found in the age of rst intercourse by the experience of CSA (whether by perpetrator type

or victimization frequency) or whether they were exposed to IPV against their mother. The younger the respondent initiated sex, the more likely it was unwanted (RaoScott 2 (3) = 13.02, p = .0046). As high as 27.65% (se = 4.58%) of those who had their rst intercourse before age 17 reported that it was not wanted. The proportion reporting unwanted rst intercourse decreased as age of sexual initiation increased (24.61% for ages 1719, 22.39% for ages 2022, and 13.67% for 23 and above). The proportion of women reporting unwanted rst intercourse did not vary by history of CSA by known or stranger perpetrator or its frequency, or by exposure to IPV against the mother. 3.5. Relationship between childhood experiences, sexual initiation, and IPV 3.5.1. Bivariate analyses Table 2 presents the KaplanMeier estimates of the probability of experiencing physical and sexual IPV at age 50 by the respondents' experiences of CSA; whether they were exposed to IPV against the mother, and the age and nature of the rst intercourse. The probability of experiencing physical IPV by age 50 was signicantly higher for those who had experienced CSA by known perpetrators (39.28%) and those who had experienced CSA by strangers (26.87%), compared to the respondents who had not experienced CSA (log Rank test 2 (1) = 13.74, p = .0002; 2 (1) = 4.68, p = .03, respectively). In addition, those who had experienced CSA more than twice (37.10%) were more likely to have experienced physical IPV than those who had experienced CSA once or twice (28.34%) or those who reported no CSA (16.17%) (log Rank 2 (2) = 15.85, p = .0004). The probability of experiencing physical IPV was higher among women whose mothers had experienced partner physical violence (log Rank test 2 (1) = 14.19, p = .0002). The probability of experiencing physical IPV also varied by age at which the respondents had rst intercourse (log Rank test 2 (3) = 69.88, p b .0001), as well as whether rst intercourse was unwanted (log Rank test 2 (1) = 9.41, p = .002). Only 9.4% of those who did not engage in intercourse until age 23 or later, compared to 47.73% of those who had rst intercourse before 17, would experience physical IPV by age 50. With respect to the probability for experiencing sexual IPV, CSA by known perpetrator, and to a lesser degree, CSA by stranger, was associated with an increased risk. The risk of sexual IPV varied by frequency of child sexual abuse (log Rank test 2 (2) = 13.41, p = .001). Similar to the risk of experiencing physical IPV, hazard of experiencing sexual IPV was associated with exposure to IPV against their mother (log Rank test 2 (1) = 8.66, p = .003), as well as the age of rst intercourse (log Rank test 2 (3) = 20.41, p = .0001) and the experience of unwanted rst intercourse (log Rank test 2 (1) = 20.59, p b .0001).

Fig. 3. Hazard of sexual IPV.

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Table 2 Proportion of women estimate to experience physical and sexual IPV by experiences of childhood sexual abuse, exposure to IPV against mother, and the age and nature of sexual initiation. % estimated to experience physical IPV by age 50 Total CSA, known perpetrator No Yes CSA, stranger No Yes CSA frequency 0 12 3 or more Exposure to physical IPV against mother No Yes Age of rst intercourse b17 1719 2022 23+ First intercourse unwanted No Yes 17.70 16.83 39.28 17.04 26.87 16.17 28.34 37.10 se 1.47 13.74, (1), .0002 1.49 8.67 4.68, (1), .0306 1.52 6.06 1.53 5.83 9.57 15.85, (2), .0004 8.03 12.60 7.50 15.10 18.21 1.23 4.25 1.24 4.58 7.38 13.41, (2), .0012 7.66 26.48 1.19 7.68 3.42, (1), .0643 Log-Rank test 2, (df), p % estimated to experience sexual IPV by age 50 8.49 se 1.19 Log-Rank test, 2, (df), p NA 22.30, (1), b .0001

14.19, (1), .0002 16.29 26.06 47.73 23.70 14.73 9.40 16.12 23.59 1.72 3.49 9.11 3.18 2.27 2.13 1.67 3.21 69.88, (3), b .0001 7.03 12.21 19.73 10.33 7.98 4.76 7.05 14.00 1.19 2.56 7.12 2.41 1.77 1.90 1.39 2.44

8.66, (1), .0033

20.41, (3), .0001

9.41, (1), .0022

20.59, (1), b .0001

CSA = childhood sexual abuse; IPV = intimate partner violence.

3.5.2. Multivariate analyses Because both perpetrator type and frequency of CSA were associated with the probability of experiencing IPV at the bivariate level, we created a grouping variable to classify the respondents into the following four categories based on perpetrator type and frequency: No CSA; CSA by stranger once or twice; CSA by known individual once or twice; and CSA by any perpetrator more than twice; the last category combined known and stranger perpetrators due to small sample size. Three respondents who reported both stranger and known perpetrator abuse were classied to the known perpetrator group. Because risk of IPV can be associated with marital status, a time-varying covariate was included in the model. This variable is
Table 3 Cox regression predicting the probability of experiencing physical and sexual IPV. CSA by stranger once or twice CSA by known perpetrator once or twice CSA any more than twice Exposure to physical IPV against mother Age of rst intercourse b 17 1719 2022 23+ First intercourse unwanted Marital status Age 1824 2529 3034 3539 4044 45+ .36 1.00 1.18 .48 se .37 .38 .42 .19 Hazard ratio 1.43 2.71 3.26 1.61

coded zero for a given respondent until the year of her rst marriage, and a value of 1 is assigned to this respondent thereafter. In addition, all the analyses were conducted controlling for age group (1824, 25 29, 3034, 3539, 4044, 45+) to account for cohort effect. Using Cox regression, we modeled the probability of experiencing physical and sexual IPV. The model included the above-mentioned 4level grouping variable of CSA; exposure to IPV against the mother; age of rst intercourse (categorized into 4-levels: b 17, 1719, 1922, and 23+); whether sexual initiation was unwanted; controlling for marital status (time-varying variable) and age group. As shown in Table 3, the risk of physical IPV varied by CSA grouping based on perpetrator type and frequency. Compared to those who had not

95% CI .69, 2.95 1.28, 5.75 1.42, 7.47 1.12, 2.33

.06 1.10 .06 .51

se .60 .57 1.01 .28

Hazard ratio .94 3.01+ 1.06 1.66+

95% CI .29, 3.03 .99, 9.18 .15, 7.69 .95, 2.91

1.44 .72 .39 Ref .43 .58 1.34 .62 .62 .63 .26 Ref

.35 .27 .28 .19 .24 .42 .35 .30 .29 .30

4.23 2.05 1.48 1.54 1.79 3.82 1.86+ 1.85 1.871 1.293

2.14, 8.34 1.20, 3.50 .86, 2.54 1.07, 2.23 1.13, 2.85 1.68, 8.71 .94, 3.69 1.03, 3.34 1.05, 3.32 .71, 2.35

1.14 .85 .83 Ref .91 .29 1.14 .31 .13 .23 .41 Ref

.60 .45 .44 .26 .38 .53 .47 .42 .42 .44

3.11+ 2.34+ 2.29+ 2.49 1.33 3.14 1.36 .88 .79 .66

.97, 10.00 .97, 5.68 .96, 5.41 1.49, 4.18 .64, 2.78 1.10, 8.95 .54, 3.40 .38, 2.01 .35, 1.81 .28, 1.56

CSA = childhood sexual abuse; IPV = intimate partner violence; Ref = reference group. Analyses were conducted controlling for age and marital status (marital status was entered as a time-varying covariate). + p b .10. p b .05. p b .01. p b .001. p b .0001.

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M. Yoshihama, J. Horrocks / Children and Youth Services Review 32 (2010) 2837

experienced CSA, the hazard or risk of experiencing physical IPV was 2.71 (95% CI = 1.28, 5.75) times higher for those who had experienced CSA by known perpetrators once or twice, and 3.26 times (95% CI = 1.42, 7.47) higher for those who had experienced CSA more than twice (regardless of perpetrator types). However, experiencing CSA by a stranger once or twice was not associated with an elevated risk of physical IPV. The exposure to IPV against the mother also increased the risk of physical IPV by 60% (hazard ratio = 1.61, 95% CI = 1.12, 2.33). Sexual initiation before age 17 quadrupled the risk of experiencing physical IPV, and sexual initiation between ages of 17 and 19 doubled the risk, compared to those whose sexual initiation occurred at age 23 or later. Having unwanted rst intercourse also increased the risk of physical IPV by 50% (hazard ratio = 1.54, 95% CI = 1.07, 2.23). The hazard of experiencing physical IPV was estimated to be 1.79 times higher after marriage (95% CI = 1.13, 2.85). With respect to the risk of sexual IPV, the observed patterns of hazard ratios for most variables were similar to those for the model predicting the risk of physical IPV. Hazard ratios were in the same direction. Their magnitudes tended to be smaller except for unwanted rst sex (2.49, 95% CI = 1.49, 4.18), which increased the risk of sexual IPV even more than physical IPV. In addition, risk of sexual IPV does not change signicantly after marriage. 4. Discussion The proportion of women who reported CSA (10.44%) among this sample of Japanese women is within the 7 to 40% range found in previous studies in other countries. Higher rates found in two population-based studies of Japanese women (Ishii, Asukai, Konishi, Inamoto et al., 2002; Ishii, Asukai, Konishi, Kojimoto et al., 2002; Kodomo to Kazoku no Kokoro to Kenko Chosaiinkai, 1999) are likely due to the fact they included a wider range of abuse, such as verbal and no-contact abuse of a sexual nature. This self-report is probably an underestimation. Sources of underreporting include social desirability responding, memory decay and denitional/cognitive difference (e.g., respondents do not recognize their experience as an act dened as abuse) (Sugarman & Hotaling, 1997; Widom & Morris, 1997; Williams, 1994; Yoshihama & Gillespie, 2002). The WHO Protocol included at the end of the interview an anonymous method of inquiring about the respondents' experience of CSA; Using the same question wording as the one used earlier in the interview, respondents were asked to record their response on a card that had a pictorial representation a sad face for yes and a happy face for no. The respondents then folded it and placed it in a bigger envelope, thus preventing the interviewer or researchers from linking the response to the individual respondent. This anonymous method yielded a slightly higher rate of CSA (13.8%) among this sample, suggesting that CSA was somewhat under-reported due to the use of a non-anonymous method. The extent to which other factors contributed to underreporting remains unknown. The estimated prevalence of IPV at age 50 (17.70% for physical IPV and 8.49% for sexual IPV) can also represent underestimation. Regardless of whether or not they are underestimated, estimates of CSA and IPV prevalence among this sample of women are of grave concern and point to the need for both prevention and intervention for those who have been victimized. Consistent with studies conducted in other countries, this study found a signicant relationship between CSA and sexual initiation and the subsequent risk of IPV among women of Japan. Specic factors associated with an increased risk of experiencing IPV included experiencing CSA, especially by known individuals; having been exposed to IPV against the mother; and early initiation of intercourse, especially if it was unwanted. While these ndings are consistent with previous studies conducted in other countries, notable differences were also observed. Neither CSA nor exposure to IPV against the mother was signicantly associated with earlier sexual initiation or having unwanted rst intercourse in this sample. Studies in other countries, in contrast,

have documented strong associations between CSA and early sexual initiation and other sexual and reproductive behaviors, such as having multiple sex partners, unprotected sex, and engaging in sex while under the inuence of substance (Fergusson et al., 1997; Humphrey & White, 2000). Because these other high-risk behaviors were not assessed in the currently study, it remains unknown whether the lack of association between CSA and age of sexual initiation represents different pathways among Japanese women compared to women in other countries, a question that warrants further investigation. Another notable nding was that regardless of the frequency, experiencing CSA by known perpetrator was associated with a higher probability of experiencing IPV, especially physical IPV. In contrast, experiencing CSA by stranger once or twice was not associated with a higher probability of experiencing physical or sexual IPV. Due to small number of women reporting either type of CSA more than twice, we were not able to estimate IPV risk separately by frequency of experiencing a given type of CSA (e.g., CSA by stranger once or twice vs. more than twice). Further, the small sample size of certain categories resulted in limited statistical power, thus the ndings must be interpreted with caution. However, it appears that CSA perpetrator types have different effects on women's risk of subsequent violence in intimate relationships. 4.1. Study limitations and strengths The use of the ofcial resident roster, Jumin Kihon Daicho, despite its strengths and wide use in Japanese social surveys (Sugiyama, 1997), raises some methodological concerns. All Japanese nationals are required by the Resident Basic Register Law to report any change of residence within 14 days. One limitation of using this registry is that only people who are registered correctly can be sampled; those who are temporarily staying elsewhere without having changed their ofcial addresses are unlikely to be included. However, this is believed to occur infrequently. For example, in the Kokuminsei Chosa [A Study of the Japanese National Character] (Tokei Suri Kenkyujo [The Institute of Statistical Mathematics], 1999), less than 6% of prospective respondents were found to be long-term absent or address unknown/not found. Thus, the registry provides a relatively accurate, convenient, and costeffective way of targeting eligible study participants. Despite the expectation that the response rate for this study would be lower due to the sensitive and personal nature of the questions asked, the overall response rate of 57.1% (69.7% of women contacted) compares favorably to other face-to-face interview studies in Japan that used the resident registry for sampling. The name recognition of the World Health Organization appeared to have helped with response rate. Despite this study's relatively favorable response rate for social research in Japan, it is worth considering the possibility of systematic differences between participants and non-participants that might bias the results. We assessed the extent to which women participating in the study may be considered representative of women aged 1849 in Yokohama, Japan. Because the resident registry provides the age of all sampled women, we assessed the differences between the ages of the women who participated in the study and those women who did not participate. The mean age of the participants was 34.8 years (sd = 8.6), whereas the mean age of the non-participants was 31.9 (sd = 8.8) (t = 8.17, df = 2398, p b .0001) (note: Because we used the age at interview for participants (October 2000 to January 2001), and age at sampling for non-participants (September 2000), there is slight aging among participants). As discussed previously, study participants were compatible to the general female population of Yokohama aged 1849 with respect to marital status and educational levels. However, participants were more likely to be employed, and their incomes tended to be somewhat higher than the general population. The 3-year age difference in average age between the respondents and those who did not participate is unlikely to result in signicant bias in the study's major ndingsprevalence of IPV and the relationship between CSA and IPV.

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35

First, we estimated age-adjusted prevalence of IPV (at age 50), and we controlled for age and marital status in assessing the relationship between CSA and IPV. In addition, we constructed post-stratication weights; the un-weighted and weighted results are virtually identical. With respect to potential measurement errors, the use of one global question to assess CSA is a limitation of the current study. Self-report of abuse tends to be higher when multiple behavior-specic items are used (Bolen & Scannapieco, 1999; Yoshihama, 1999; Yoshihama, 2001). In addition, the present study focused on CSA and exposure to partner violence against the mother and did not address other types of adversities in childhood. The limited number of childhood factors is due largely to the study framework; the focus of the WHO study is adult IPV victimization and, thus, a limited number of variables measured respondents' childhood experiences. Considering that multiple forms of childhood adversities tend to co-occur in a given family (Dong et al., 2004; Fergusson et al., 1997; Finkelhor, 1998), had other childhood adversities been assessed and included in the model, relationships among CSA, exposure to IPV against the mother, and IPV might have been different in magnitudes and/or directions. On the other hand, the current study contained a number of strengthsit distinguished CSA perpetrator types and frequency, assessed the role of sexual initiation, and used methods of survival analyses in assessing the risk of IPV over the women's lifecourse. In particular, the use of Cox regression analysis method allowed for an inclusion of a time-varying covariate that denoted the timing of marriage. There is a distinct advantage of this method over a conventional method, such as dichotomously classifying respondents into married and non-married groups. Such a conventional approach does not take into account that a woman's marital status changes over the course of her lifespan. Because IPV can occur before or after marriage, simply dichotomizing women into married vs. non-married groups would result in erroneous estimation. For example, a woman who married at 22 and experienced IPV for the rst time at 25 while married would, in a conventional approach, be classied into the married group, and her data would contribute to the estimation of the hazard of experiencing IPV for the married group at all ages. The reality, however, is that she is only a member of the married group after age 22. Cox regression with a time-varying covariate allows this woman to contribute to the non-married group until age 22, and thereafter to the married group (Allison, 1995). Including marital status as a time-varying covariate, this study found that marital status was associated with the risk of physical IPV but not sexual IPV. In addition, the use of survival analysis helped examine changing risk of IPV over the women's lifecourse and identify periods with elevated risks as done in Figs. 14. This study found different patterns of risk for physical and sexual IPV. 4.2. Implications for policy and practice There are a number of policy- and practice-related implications to be drawn from the present study. First, given the signicant association between CSA and IPV, professionals working with battered women should assess a history of CSA. Unfortunately, currently available measures are not adequate to comprehensively identify factors related to child exposure (Edleson et al., 2007). Development of a more comprehensive measure in general, such as the Child Exposure to Domestic Violence (CEDV) Scale recently piloted (Edleson, Shin, & Johnson Armendariz, 2008), and an instrument that takes into account socio-cultural context in particular, is urgently needed. In addition, the nding that a substantial proportion of women experience IPV prior to marriage calls for expansion of the current legislation, Law for the Prevention of Spousal Violence and the Protection of Victims, which does not address IPV prior to marriage. Prevention is critical. In addition to primary and secondary prevention of CSA, identifying women who have experienced CSA and/or been exposed to IPV against the mother for purposes of

secondary/selective prevention of IPV appears vital. Because hazard of IPV is associated with early and unwanted rst intercourse, targeting early adolescents for prevention before they initiate sexual activity appears particularly important. The signicant link between CSA and IPV, as well as between exposure to IPV against the mother and women's own experience of IPV, calls for cross-training of child welfare workers and those who work with battered women. Studies in the United States indicate that assessment of IPV by child welfare workers is low (Hazen et al., 2007). In Japan, the need for collaboration between the child welfare system and agencies addressing IPV has not been recognized. For example, the Law for the Prevention of Spousal Violence and the Protection of Victims and its subsequent amendments created or expanded certain types of assistance for battered women. However, the law does not recognize the effect of IPV on children. Nor does the act recognize the possibility that women who have been abused by their intimate partner may have also been victimized during childhood. The closest provision in the act that touches on this issue is Article 23.1, which states that the state and local governments should undertake training and educational activities needed to deepen understanding of the human rights of victims, the distinctive characteristic of spousal violence, etc. among ofcial personnel working in this eld (translation by Research Ofce, Research Committee on Society of Cooperative Way of Life, House of Councillors). Similarly, Jidogyakutai No Boshito Nikansuru Horitsu of 2000 (Child Abuse Prevention Law) does not recognize long-term impact of childhood. Although this law recognizes psychological trauma of children living in a household where IPV occurs (Article 2.4), it contains no specic provision regarding the need for collaboration between agencies addressing child abuse and IPV. To ll this void, coordination between the system of care for victims of child abuse and that for victim of IPV in Japan is urgently needed. Although the Japanese welfare systems have their own strengths and challenges, the ongoing collaboration of the last two decades in the both the United States and in other countries (Hazen et al., 2007; Nixon, Tutty, Weaaver-Dunlop, & Walsh, 2007) can inform the direction and process of enhancing collaboration between currently fragmented systems of response in Japan. Cross-training for example, training of child protection services workers on assessment of and intervention in instances of IPV (Conroy & Magen, 1996; Magen, Conroy, McCartt Hess, Panciera, & Levy Simon, 2001; Mills et al., 2000; Mills & Yoshihama, 2002)may represent a tangible rst step. Enhanced coordination between the domestic violence and child welfare system can improve the welfare of both children and women whose safety and wellbeing are all too often compromised due to multiple types of abuse. Acknowledgments The authors wish to thank the study participants and dedicated interviewers. Special thanks to the Japan project team members: Hiroko Akiyama, Tamie Kaino, Saori Kamano, Fumi Hayashi, and Tomoko Yunomae. References
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