Mary P. Koss

Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults. The Adverse Childhood Experiences (ACE) Study.

BACKGROUND The relationship of health risk behavior and disease in adulthood to the breadth of exposure to childhood emotional, physical, or sexual abuse, and household dysfunction during childhood has not previously been described. METHODS A questionnaire about adverse childhood experiences was mailed to 13,494 adults who had completed a standardized medical evaluation at a large HMO; 9,508 (70.5%) responded. Seven categories of adverse childhood experiences were studied: psychological, physical, or sexual abuse; violence against mother; or living with household members who were substance abusers, mentally ill or suicidal, or ever imprisoned. The number of categories of these adverse childhood experiences was then compared to measures of adult risk behavior, health status, and disease. Logistic regression was used to adjust for effects of demographic factors on the association between the cumulative number of categories of childhood exposures (range: 0-7) and risk factors for the leading causes of death in adult life. RESULTS More than half of respondents reported at least one, and one-fourth reported > or = 2 categories of childhood exposures. We found a graded relationship between the number of categories of childhood exposure and each of the adult health risk behaviors and diseases that were studied (P < .001). Persons who had experienced four or more categories of childhood exposure, compared to those who had experienced none, had 4- to 12-fold increased health risks for alcoholism, drug abuse, depression, and suicide attempt; a 2- to 4-fold increase in smoking, poor self-rated health, > or = 50 sexual intercourse partners, and sexually transmitted disease; and 1.4- to 1.6-fold increase in physical inactivity and severe obesity. The number of categories of adverse childhood exposures showed a graded relationship to the presence of adult diseases including ischemic heart disease, cancer, chronic lung disease, skeletal fractures, and liver disease. The seven categories of adverse childhood experiences were strongly interrelated and persons with multiple categories of childhood exposure were likely to have multiple health risk factors later in life. CONCLUSIONS We found a strong graded relationship between the breadth of exposure to abuse or household dysfunction during childhood and multiple risk factors for several of the leading causes of death in adults.

Original ArticlesRelationship of Childhood Abuse and Household Dysfunction to Many of the Leading Causes of Death in Adults: The Adverse Childhood Experiences (ACE) Study

BACKGROUND The relationship of health risk behavior and disease in adulthood to the breadth of exposure to childhood emotional, physical, or sexual abuse, and household dysfunction during childhood has not previously been described. METHODS A questionnaire about adverse childhood experiences was mailed to 13,494 adults who had completed a standardized medical evaluation at a large HMO; 9,508 (70.5%) responded. Seven categories of adverse childhood experiences were studied: psychological, physical, or sexual abuse; violence against mother; or living with household members who were substance abusers, mentally ill or suicidal, or ever imprisoned. The number of categories of these adverse childhood experiences was then compared to measures of adult risk behavior, health status, and disease. Logistic regression was used to adjust for effects of demographic factors on the association between the cumulative number of categories of childhood exposures (range: 0-7) and risk factors for the leading causes of death in adult life. RESULTS More than half of respondents reported at least one, and one-fourth reported > or = 2 categories of childhood exposures. We found a graded relationship between the number of categories of childhood exposure and each of the adult health risk behaviors and diseases that were studied (P < .001). Persons who had experienced four or more categories of childhood exposure, compared to those who had experienced none, had 4- to 12-fold increased health risks for alcoholism, drug abuse, depression, and suicide attempt; a 2- to 4-fold increase in smoking, poor self-rated health, > or = 50 sexual intercourse partners, and sexually transmitted disease; and 1.4- to 1.6-fold increase in physical inactivity and severe obesity. The number of categories of adverse childhood exposures showed a graded relationship to the presence of adult diseases including ischemic heart disease, cancer, chronic lung disease, skeletal fractures, and liver disease. The seven categories of adverse childhood experiences were strongly interrelated and persons with multiple categories of childhood exposure were likely to have multiple health risk factors later in life. CONCLUSIONS We found a strong graded relationship between the breadth of exposure to abuse or household dysfunction during childhood and multiple risk factors for several of the leading causes of death in adults.

Characteristics of Aggressors Against Women: Testing a Model Using a National Sample of College Students

Structural equation modeling was used to study the characteristics of college men (N = 2,652) who aggressed against women either sexually, nonsexually, or both. According to the model, hostile childhood experiences affect involvement in delinquency, leading to aggression through two paths: (a) hostile attitudes and personality, which result in coerciveness both in sexual and nonsexual interactions, and (b) sexual promiscuity, which, especially in interaction with hostility, produces sexual aggression. In addition, sexual and nonsexual coercion were hypothesized to share a common underlying factor. Although its development was guided by integrating previous theory and research, the initial model was refined in half of the sample and later replicated in the second half. Overall, it fitted the data very well in both halves and in a separate replication with a sample for whom data were available about sexual but not about nonsexual aggression.

Revising the SES: A collaborative process to improve assessment of sexual aggression and victimization

The Sexual Experiences Survey (SES) assesses victimization and perpetration of unwanted sexual experiences (e.g., Koss, Gidycz, & Wisniewski, 1987). Revised versions of the SES that resulted from the work of the SES Collaboration are now available. This article reviews weaknesses of the SES that were identified, strengths that were preserved, and methodological considerations in the measurement of unwanted sexual experiences that informed the revisions. The primary changes include: more behavioral specificity; conversion to gender neutrality; full crossing of unwanted acts and coercive tactics; and revised and updated wording for assessing consent, alcohol-related incidents, unwanted acts, and coercive tactics. For illustration, the full text of the revised victimization version and its scoring rules are provided. The article concludes with suggestions for future research. These suggestions aim to involve researchers in a coordinated agenda to develop data that clarify methodological questions and contribute to continued improvement in assessing sexual victimization and perpetration.

Discriminant Analysis of Risk Factors for Sexual Victimization among a National Sample of College Women.

Examined the accuracy with which rape and lesser sexual assaults were predicted among a representative national sample of 2,723 college women. A total of 14 risk variables operationalized three vulnerability hypotheses: (a) vulnerability-creating traumatic experiences, (b) social-psychological vulnerability, and (c) vulnerability-enhancing situations. Each hypothesis was tested individually, and a composite model was developed via discriminant analysis. Only the traumatic experiences variables clearly improved over the base rates in identifying rape victims, but risk variables from each vulnerability hypothesis met criteria for inclusion in the composite model. A risk profile emerged that characterized only 10% of the women, but among them the risk of rape was twice the rate of women without the profile. The concept of traumatic sexualization was used to explain this finding. However, the vast majority of sexually victimized women (75-91%) could not be differentiated from nonvictims.

Stranger and Acquaintance Rape: Are There Differences In the Victim's Experience?:

Most published research on the victim–offender relationship has been based on small samples that consisted mainly of women who were raped by nonintimate and nonromantic acquaintances, who viewed their experience as rape, and/or who were seeking treatment. In the present study, 489 rape victims were located among a national sample of 3, 187 female college students by a self-report survey that avoided reliance on helpseekers. Two sets of comparisons were performed. First, the experiences reported by victims of stranger rape (n = 52) were compared with those of victims of acquaintance rape (n = 416). Then, the experiences of women assaulted by different types of acquaintances were compared including nonromantic acquaintances (n = 122), casual dates (n = 103), steady dates (n = 147), and spouses or other family members (n = 44). Rapes by acquaintances, compared with strangers, were more likely to involve a single offender and multiple episodes, were less likely to be seen as rape or to be revealed to anyone, and were similar in terms of the victims resistance. In general, acquaintance rapes were rated as less violent than stranger rapes. The exception was rapes by husbands or other family members which were rated equally violent to stranger rapes but were much less likely to occur in a context of drinking or other drug use. In spite of these different crime characteristics, virtually no differences were found among any of the groups in their levels of psychological symptoms. A significant feature of these data is that they have tapped the experiences of unreported and unacknowledged rape victims, a group that is potentially much larger than the group of identified victims.

Adult health status of women with histories of childhood abuse and neglect

PURPOSE Several recent studies have found associations between childhood maltreatment and adverse adult health outcomes. However, methodologic problems with accurate case determination, appropriate sample selection, and predominant focus on sexual abuse have limited the generalizability of these findings. SUBJECTS AND METHODS We administered a survey to 1,225 women who were randomly selected from the membership of a large, staff model health maintenance organization in Seattle, Washington. We compared women with and without histories of childhood maltreatment experiences with respect to differences in physical health status, functional disability, numbers and types of self-reported health risk behaviors, common physical symptoms, and physician-coded ICD-9 diagnoses. RESULTS A history of childhood maltreatment was significantly associated with several adverse physical health outcomes. Maltreatment status was associated with perceived poorer overall health (ES = 0.31), greater physical (ES = 0.23) and emotional (ES = 0.37) functional disability, increased numbers of distressing physical symptoms (ES = 0.52), and a greater number of health risk behaviors (ES = 0.34). Women with multiple types of maltreatment showed the greatest health decrements for both self-reported symptoms (r = 0.31) and physician coded diagnoses (r = 0.12). CONCLUSIONS Women with childhood maltreatment have a wide range of adverse physical health outcomes.

THE HIDDEN RAPE VICTIM: PERSONALITY, ATTITUDINAL, AND SITUATIONAL CHARACTERISTICS

A hidden rape victim is one who has never reported her experience to a rape crisis center or to police. It has been estimated that only 10–50% of the rapes that actually occur are ever reported to authorities. Since most previous rape studies have selected samples from official sources, hidden victims have been overlooked. The goals of the present study were to describe the victimization experienced by hidden victims and to determine whether any psychological variables were related to victimization status. The psychological variables examined included personality, attitudinal, and situational characteristics relevant to the three major models of rape victimization: social control, victim precipitation, and situational blame. Subjects were 82 not sexually victimized, 37 low sexually victimized, 50 moderately victimized, and 62 highly sexually victimized women. Subjects completed questionnaires and participated in a one-to-one standardized interview. Data were analyzed via multivariate analysis of variance. Personality variables and attitudes did not differentiate the groups of women, while numerous situational variables did. The theoretical implications of these findings are discussed.

Detecting the Scope of Rape A Review of Prevalence Research Methods

This article focuses on rape prevalence research and examines the relationship between measurement methods and level of rape detection. After a brief overview of empirical data, the relative threat to the validity of prevalence estimates posed by fabrication versus nondisclosure is weighed. Then various methodological choices and their relationship to the magnitude of prevalence estimates are examined. Addressed are the definitions underlying the studies, the questions used to elicit reports of rape, the context in which rape questioning occurred, the confidentiality of the responses, the method of data collection, and the sample integrity. The conclusions include 10 recommendations for the design of future studies of rape prevalence.

Perpetration of partner violence and HIV risk behaviour among young men in the rural Eastern Cape, South Africa

Objectives:To examine associations between the perpetration of intimate partner violence and HIV risk behaviour among young men in rural South Africa. Design:An analysis of baseline data from men enrolling in a randomized controlled trial of the behavioural intervention, Stepping Stones. Methods:Structured interviews with 1275 sexually experienced men aged 15–26 years from 70 villages in the rural Eastern Cape. Participants were asked about the type, frequency, and timing of violence against female partners, as well as a range of questions about HIV risk behaviours. Results:A total of 31.8% of men reported the perpetration of physical or sexual violence against female main partners. Perpetration was correlated with higher numbers of past year and lifetime sexual partners, more recent intercourse, and a greater likelihood of reporting casual sex partners, problematic substance use, sexual assault of non-partners, and transactional sex. Men who reported both physical and sexual violence against a partner, perpetration both before and within the past 12 months, or more than one episode of perpetration reported significantly higher levels of HIV risk behaviour than men who reported less severe or less frequent perpetration of violence. Conclusion:Young men who perpetrate partner violence engage in significantly higher levels of HIV risk behaviour than non-perpetrators, and more severe violence is associated with higher levels of risky behaviour. HIV prevention interventions must explicitly address the links between the perpetration of intimate partner violence and HIV risk behaviour among men, as well as the underlying gender and power dynamics that contribute to both.