Exposure to family violence from childhood to adulthood RESEARCH ARTICLE Open Access Exposure to family violence from childhood to adulthood Margot Shields1, Lil Tonmyr1* , Wendy E. Hovdestad1, Andrea Gonzalez2 and Harriet MacMillan2,3 Abstract Background: Both childhood maltreatment (CM) and intimate partner violence (IPV) are public health problems that have been related to a wide range of adverse health consequences. However, studies examining associations between specific types of CM and experiencing IPV in adulthood have yielded conflicting results. Methods: Using data from 10,608 men and 11,458 women aged 18 or older from Canada’s 2014 General Social Survey, we examined associations between three types of CM—childhood physical abuse (CPA), childhood sexual abuse (CSA), and childhood exposure to IPV —and subsequent intimate partner violence (IPV) in adulthood (physical, sexual or emotional). Results: When potential confounders were controlled, CPA, CSA and childhood exposure to IPV were associated with IPV in adulthood for both sexes (odds ratios, 1.7, 1.8 and 2.0 for men, and 2.2, 2.0 and 2.1 for women). When severity and frequency of CM were examined, a dose-response relationship between all three types of CM and IPV in adulthood was observed among women (meaning that as the severity/frequency of CM increased, the likelihood of reporting IPV also increased); among men, a dose-response relationship was observed only for CPA. Conclusions: The association between CM and IPV in adulthood is particularly concerning because experiencing multiple forms of trauma has cumulative effects. Lifespan studies have shown that individuals who experience multiple incidents of abuse exhibit the highest levels of impairment. This underscores the importance of programs to eradicate both CM and IPV. This underscores the importance of programs to eradicate both CM and IPV. Future research should focus on assessing interventions designed to promote healthy relationships and the provision of emotional support and coping mechanisms to children and families in abusive situations. Keywords: Intimate partner violence, Physical abuse, Sexual abuse, Childhood exposure to intimate partner violence, Domestic violence Background The World Health Organization defines intimate partner violence (IPV) as any “behaviour by an intimate partner that causes physical, sexual or psychological harm, includ- ing acts of physical aggression, sexual coercion, psycho- logical abuse and controlling behaviours. This definition covers violence by both current and former spouses and other intimate partners” [1]. IPV victimization is associated with short- and long-term health consequences including injury and other physical health conditions, mental health symptoms and disorders, and death [2]. Those experiencing IPV use proportionately more health care services (primary care, emergency, and hospital), even when confounding factors such as socioeconomic status are taken into account [2]. The causes of IPV are complex. The ecological model contends the multiple risk factors are involved including individual, relationship, community, and societal factors [2–4]. An extensive body of literature has examined childhood maltreatment (CM) as a risk factor for being © The Author(s). 2020 Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. * Correspondence: Lil.Tonmyr@canada.ca 1Public Health Agency of Canada, 785 Carling Ave. 7th floor, Ottawa, ON K1A 0K9, Canada Full list of author information is available at the end of the article Shields et al. BMC Public Health (2020) 20:1673 https://doi.org/10.1186/s12889-020-09709-y http://crossmark.crossref.org/dialog/?doi=10.1186/s12889-020-09709-y&domain=pdf http://orcid.org/0000-0002-8722-7616 http://creativecommons.org/licenses/by/4.0/ http://creativecommons.org/publicdomain/zero/1.0/ mailto:Lil.Tonmyr@canada.ca victimized by IPV in adulthood, with the majority of studies focusing on associations with childhood sexual abuse (CSA) [5–18] and childhood physical abuse (CPA) [5–7, 9, 10, 12–22]. Studies of associations with other types of CM, such as childhood exposure to IPV, emo- tional abuse, and neglect, are less common [5, 6, 13–20, 22–25]. Many of these studies have samples comprised exclusively of women [5, 9, 10, 13, 14, 17, 19, 20]. However, findings tend to be inconsistent. Some studies have found that CM increases the likelihood of IPV in adulthood; others have reported null associ- ations between specific types of CM and IPV [5–7, 12–14, 19, 20, 22, 24, 26–29]. Two meta-analyses [30, 31] of associations between specific types of CM (CPA, CSA, childhood exposure to IPV, neglect, and emotional abuse) and IPV in adulthood concluded that associations were weak, but statistically signifi- cant. One of these studies [30] focused on associa- tions between CM and IPV among men and noted a need for research on different kinds of CM and the co-occurrence of CM in relation to IPV victimization and perpetration among men. Evidence is also mixed about whether greater severity of CM heightens the risk of IPV in adulthood [5, 9, 12, 15, 18–20, 28, 32]. It has been argued that simply being ex- posed to CM, regardless of severity, increases the risk for future abuse [33]. Some studies have suggested that the number of types of maltreatment that a child experiences is more important in predicting IPV in adulthood than is the severity of a specific form of maltreatment [15, 34]. A Canadian study using data from the population- based 1999 General Social Survey (GSS) found an associ- ation between CSA and IPV in adulthood for both sexes, although the relationship was weaker for men [11]. The 1999 GSS identified CSA and CPA with questions about life-time history of sexual and physical assault and age of onset; respondents reporting assault before age 18 were classified as having experienced CSA/CPA [35]. For the 2014 GSS, the questions were broadened to include items to measure CSA, CPA, and childhood exposure to IPV [36]. An analysis of 2014 GSS data observed an as- sociation between CSA/CPA and severe IPV in adult- hood (being beaten, choked, threatened with a gun or a knife, or forced or manipulated into unwanted sexual ac- tivity) [37]. However, this study did not examine if in- creases in severity of CM augmented the likelihood of adult IPV victimization. Childhood exposure to IPV was not considered nor were sex differences in associations between CM and IPV victimization in adulthood. This article uses data from the 2014 GSS to meet three objectives: 1. to examine associations between three types of CM (CPA, CSA, and childhood exposure to IPV) and being victimized by three types of IPV in adulthood (physical, sexual and emotional); 2. to investigate whether greater severity and frequency of specific forms of CM and the co- occurrence of different types of CM increase the risk of IPV in adulthood; and 3. to determine if associations between CM and IPV in adulthood differ by sex. Examining these questions will address important gaps in the literature; associations between CM and IPV have rarely been examined among men and more studies are needed to clarify if the co-occurrence and severity of particular types of CM increases the likeli- hood of IPV. In this article we use the terms “experienced” IPV or “reported IPV” to refer to “being victimized” by IPV. The article does not address IPV perpetration (see Limitations). Methods Data source Data are from Statistics Canada’s 2014 General Social Survey: Victimization. The GSS target population was household residents aged 15 or older living in the 10 provinces and 3 territories. Two samples were se- lected (one for the provinces; one for the territories) using complex multistage sampling designs that uti- lized a sampling frame derived from the census and various administrative sources, which combined land- line and cellular telephone numbers. More informa- tion about the sample design is available in the GSS Microdata User Guide [38]. The response rate was 52.9% for the provinces (33,127 respondents) and 58.7% for the territories (2040 respondents). The two samples were pooled to produce estimates for all Canadians. The study population for the present analysis was re- spondents aged 18 or older currently living with a spouse/partner or who had contact with an ex-spouse/ ex-partner in the past 5 years (10,608 men and 11,458 women). Respondents aged 15 to 17 years were excluded since our objective was to examine CM in relation to IPV in adulthood. Measures Child maltreatment CPA, CSA, and childhood exposure to IPV were assessed retrospectively by asking respondents about “events that may have happened before you were 15” using the items in Fig. 1 (adapted from Shields et al., [39]). The items for CPA and childhood exposure to IPV are from the Childhood Experiences of Violence Question- naire (CEVQ) [40]. For each type of abuse, binary Shields et al. BMC Public Health (2020) 20:1673 Page 2 of 15 variables (yes/no) were created following CEVQ guide- lines. As well, variables were derived to indicate the se- verity and frequency of abuse (Fig. 1). We also examined the co-occurrence of the three types of CM maltreat- ment as well as each type of CM occurring in isolation. We created a variable to indicate: � no CM, � CPA only (no CSA/childhood exposure to IPV), � CSA only (no CPA/childhood exposure to IPV), � childhood exposure to IPV only (no CPA/CSA), � 2 or more types of CM. We attempted to consider two co-occurrence categor- ies separately (i.e., 2 types and 3 types) but there was in- sufficient sample size to consider 3 types. For CPA and CSA, all incidents of abuse were in- cluded regardless of the relationship of the perpetrator to the child (e.g., parent, stepparent, other family mem- ber, teacher, stranger etc.). Fig. 1 Childhood maltreatment items and definitions. CPA = Childhood physical abuse. CSA = Childhood sexual abuse. CEIPV=Childhood exposure to intimate partner violence. Note: Fig. 1 is adapted from Shields et al., [39] Shields et al. BMC Public Health (2020) 20:1673 Page 3 of 15 Intimate partner violence in adulthood To identify physical, sexual and emotional IPV in adult- hood, questions were asked about the respondent’s current spouse/partner, and then, about the respondent’s ex-spouse/ex-partner (if applicable and if they had con- tact in the past 5 years). Respondents in same-sex rela- tionships are included in the study. IPV that occurred in dating relationships was excluded. The IPV items are based on the Conflict Tactics Scales [41, 42]. Questions about physical and sexual IPV pertained to experiences that occurred over the past 5 years; no time frame was specified for emotional IPV. Table 1 displays the items used to measure IPV. Covariates Selection of potential confounders to use in the multi- variate regression models was based on a review of the literature examining socio-demographic risk factors for CM and IPV [23, 43–47] as well as socio-demographic controls used in other studies investigating CM in rela- tion to IPV in adulthood [5–10, 13–15]. The control var- iables used in this study include: current age (18–24, 25–39, 40–54, 55–69, 70 or older), born in Canada (yes/ no), Indigenous status (First Nations, Métis or Inuk (Inuit)/non-Indigenous), marital status (married, living common-law, widowed, divorced, separated, single/never married), household income (less than $20,000, $20, 000–$39,000, $40,000–$59,000, $60,000–$79,000, $80, 000–$99,000, $100,000 or more), highest level of educa- tion attained by respondent (less than high school graduation, high school diploma, postsecondary certifi- cate/diploma, university degree), and highest level of education attained by respondent’s mother and father (less than high school graduation, high school diploma, some postsecondary, postsecondary certificate/diploma, university degree). Analysis Frequency estimates were produced to describe the prevalence of CM and IPV among the study population. Associations between CM and IPV in adulthood were examined using cross-tabulations and logistic regression models that controlled for potential confounders. Two sets of analyses were conducted to address objectives 1 and 2; one based on binary (yes/no) CM variables, and the other to examine severity. The small proportion of respondents with missing data for the CM and/or IPV variables (Table 2) were excluded from the analyses. All analyses were based on weighted data. Weights created by Statistics Canada ensured that the data were representative of the Canadian population in 2014. To account for the survey design effect of the GSS, standard errors, coefficients of variation, and 95% confidence in- tervals were estimated using the bootstrap technique [38]. Differences between estimates were tested for stat- istical significance, which was established at the p < 0.05 level. All analyses were conducted using SAS 9.4 (SAS Institute Inc.; Cary, North Carolina, USA). Preliminary analyses considered CM in relation to the three types of IPV in adulthood: physical, sexual, and emotional. Sample size was not sufficient to examine asso- ciations with sexual IPV separately; therefore, sexual and physical IPV were combined. Owing to the overlap be- tween physical/sexual and emotional IPV, we examined associations between CM and three outcomes: emotional IPV alone (no physical/sexual IPV); physical/sexual IPV alone (no emotional IPV); and both emotional IPV and physical/sexual IPV. Sample size was insufficient to deter- mine associations between CM and physical/sexual IPV with no emotional IPV. When the outcomes were emo- tional IPV with no physical/sexual IPV or physical/sexual Table 1 Intimate partner violence (IPV) items and definitions Physical IPV: reporting at least one of the following 9 experiences During the past 5 years, has your spouse/partner or ex-spouse/ex- partner: 1 threatened to hit you with his/her fist or anything else that could have hurt you? 2 thrown anything at you that could have hurt you? 3 pushed, grabbed or shoved you in a way that could have hurt you? 4 slapped you? 5 kicked you, bit you, or hit you with his/her fist? 6 hit you with something that could have hurt you? 7 beaten you? 8 choked you? 9 used or threatened to use a gun or knife on you? Sexual IPV: reporting at least one of the following 2 experiences During the past 5 years, has your spouse/partner or ex-spouse/ex- partner: 1 forced you into any unwanted sexual activity, by threatening you, holding you down, or hurting you in some way? 2 subjected you to a sexual activity to which you were not able to consent. By this I mean were you drugged, intoxicated, manipulated or forced in other ways than physically? Emotional IPV: reporting at least one of the following 7 experiences Your spouse/partner or ex-spouse/ex-partner: 1 tries to limit your contact with family or friends; 2 puts you down or calls you names to make you feel bad; 3 is jealous and doesn’t want you to talk to other men or women; 4 harms, or threatens to harm, someone close to you; 5 harms or threatens to harm your pet(s); 6 demands to know who you are with and where you are at all times; 7 damages or destroys your possessions or property. Shields et al. BMC Public Health (2020) 20:1673 Page 4 of 15 Table 2 Percentage experiencing intimate partner violence (IPV) in adulthood and childhood maltreatment (CM), by sex, household population aged 18 or older, currently living with a spouse/partner or who had contact with an ex-spouse/partner during last 5 years, Canada, 2014 Men Women Sample size Weighted percent 95% CI Sample size Weighted percent 95% CI IPV in adulthood Any IPV Yes 1684 16.1 (15.1, 17.1) 1911 14.0* (13.2, 14.8) No 8743 83.9 (82.9, 84.9) 9389 86.0 (85.2, 86.8) Missing 181 158 Emotional IPV Yes 1563 14.9 (13.9, 15.8) 1808 13.1* (12.3, 13.9) No 8896 85.1 (84.2, 86.1) 9521 86.9 (86.1, 87.7) Missing 149 129 Physical IPV Yes 435 4.3 (3.7, 4.9) 572 3.5* (3.1, 3.9) No 10,030 95.7 (95.1, 96.3) 10,755 96.5 (96.1, 96.9) Missing 143 131 Sexual IPV Yes 14 F 81 0.5* (0.3, 0.6) No 10,456 99.9 (99.8, 100) 11,250 99.5 (99.4, 99.7) Missing 138 127 Physical or sexual IPV Yes 437 4.3 (3.7, 4.9) 582 3.6* (3.2, 4.0) No 10,020 95.7 (95.1, 96.3) 10,741 96.4 (96.0, 96.8) Missing 151 135 Emotional IPV and/or physical/sexual IPV Both emotional IPV and physical/sexual IPV 316 3.2 (2.6, 3.7) 479 2.8 (2.4, 3.2) Emotional IPV, no physical/sexual IPV 1229 11.6 (10.8, 12.5) 1321 10.3* (9.5, 11.0) Physical/sexual IPV, no emotional IPV 120 1.2 (0.9, 1.5) 102 0.8 (0.6, 1.0) No emotional IPV and no physical/sexual IPV 8743 84.0 (83.0, 85.0) 9389 86.1 (85.3, 86.9) Missing 200 167 Childhood maltreatment Any CMa Yes 2889 26.9 (25.8, 28.0) 3047 25.1* (24.0, 26.2) No 7218 73.1 (72.0, 74.2) 8120 74.9 (73.8, 76.0) Missing 501 291 CPA Yes 2513 23.4 (22.3, 24.5) 1771 14.6* (13.7, 15.4) No 7612 76.6 (75.5, 77.7) 9431 85.4 (84.6, 86.3) Missing 483 256 CPA severity and frequency Severe and frequent CPA 313 2.7 (2.3, 3.1) 260 2.0* (1.6, 2.3) Severe CPA (≤10 times) 783 7.4 (6.8, 8.1) 508 4.1* (3.6, 4.6) CPA (excluding severe CPA) 1392 13.1 (12.3, 14.0) 991 8.4* (7.7, 9.1) No CPA 7612 76.7 (75.7, 77.8) 9431 85.5 (84.7, 86.4) Missing 508 268 Shields et al. BMC Public Health (2020) 20:1673 Page 5 of 15 IPV and emotional IPV, associations with CM were simi- lar. Therefore, only the results for any IPV (physical, sex- ual, or emotional) are presented. To examine sex differences in associations between CM and IPV, logistic regression was used to test for in- teractions with sex and CM. A significant interaction in- dicates that the strength of the association between CM and IPV differs by sex (for example, if a statistically sig- nificant interaction greater than 1.0 is found between CM and IPV for being female, the association with IPV is stronger for women than for men). When significant interactions terms were found, we reported on relative risks based on rates since it is not appropriate to com- pare odds ratios across models. Results Estimates of IPV Among people aged 18 years or older currently living with a spouse/partner or who had contact with an ex- spouse/partner in the last 5 years, a slightly higher per- centage of men than women reported any IPV victimization (physical, sexual or emotional): 16.1% ver- sus 14.0% (Table 2). Men were more likely than women to report physical and emotional IPV, while women were more likely to re- port sexual IPV. Based on Statistics Canada guidelines, the sample size for men who reported sexual IPV was too small for the estimate to be published; therefore, the combined percentage reporting physical/sexual IPV is presented. Table 2 Percentage experiencing intimate partner violence (IPV) in adulthood and childhood maltreatment (CM), by sex, household population aged 18 or older, currently living with a spouse/partner or who had contact with an ex-spouse/partner during last 5 years, Canada, 2014 (Continued) Men Women Sample size Weighted percent 95% CI Sample size Weighted percent 95% CI CSA Yes 557 4.7 (4.2, 5.2) 1705 13.5* (12.7, 14.3) No 9823 95.3 (94.8, 95.8) 9550 86.5 (85.7, 87.3) Missing 228 203 CSA severity and frequency Severe and frequent (≥ 3 times) CSA 93 0.7 (0.5, 0.9) 406 3.2* (2.7, 3.6) Severe CSA (≤2 times) 180 1.6 (1.3, 1.9) 507 4.1* (3.6, 4.5) Sexual touching (excluding severe CSA) 282 2.5 (2.1, 2.9) 786 6.2* (5.7, 6.8) No CSA 9823 95.3 (94.8, 95.8) 9550 86.5 (85.7, 87.3) Missing 230 209 Childhood exposure to IPV Yes 624 5.4 (4.9, 6.0) 888 7.0* (6.3, 7.7) No 9729 94.6 (94.0, 95.1) 10,377 93.0 (92.3, 93.7) Missing 255 193 Frequency of childhood exposure to IPV More than 10 times 276 2.2 (1.9, 2.6) 478 3.5* (3.0, 4.0) Three to 10 times 348 3.2 (2.8, 3.6) 410 3.5 (3.0, 4.0) Never, once or twice 9729 94.6 (94.0, 95.1) 10,377 93.0 (92.3, 93.7) Missing 255 193 Co-occurrence of CM No CM 7218 73.6 (72.4, 74.7) 8120 75.4 (74.3, 76.4) CPA only (no CSA/Childhood exposure to IPV) 1780 17.0 (16.1, 18.0) 791 6.9* (6.3, 7.6) CSA only (no CPA/Childhood exposure to IPV) 209 2.0 (1.6, 2.3) 889 7.3* (6.6, 7.9) Childhood exposure to IPV only (no CPA/CSA) 137 1.3 (1.0, 1.6) 259 2.4* (1.9, 2.8) Two or 3 types of CM 700 6.1 (5.6, 6.7) 1032 8.1* (7.4, 8.7) Missing 564 367 Source: Statistics Canada: 2014 General Social Survey: Victimization CPA: childhood physical abuse; CSA: childhood sexual abuse a CPA, CSA or childhood exposure to IPV * Significantly different from men (p < 0.05) F too unreliable to be published Shields et al. BMC Public Health (2020) 20:1673 Page 6 of 15 The percentages of men and women reporting both emotional IPV and physical/sexual IPV were similar (3.2 and 2.8%, respectively). Reporting physical/sexual IPV with no emotional IPV was rare for both sexes (1.2 and 0.8%, respectively). Among the population who reported physical/sexual IPV, it was very common to also report emotional IPV; 72.7% among men and 77.4% among women (data not shown). Estimates of CM Men were slightly more likely than women to report any CM: 26.9% versus 25.1%. A higher percentage of men than women reported CPA (23.4% versus 14.6%), but women were more likely to report CSA (13.5% versus 4.7%) and childhood exposure to IPV (7.0% versus 5.4%). Similarly, men were more likely than women to report severe/frequent CPA, while women were more likely to report severe/frequent CSA and frequent childhood ex- posure to IPV. A higher percentage of women than men reported co-occurrence of two or more forms of CM (8.1% versus 6.1%). Associations between CM and IPV For both sexes, those who had experienced any CM were more likely to report being victimized by IPV in adult- hood (Table 3). Among men reporting any CM, 23.4% reported IPV in adulthood, compared with 13.2% of those who did not experience CM; among women, the corresponding figures were 23.0 and 10.9%. Men and women who had experienced each type of CM (CPA, CSA and childhood exposure to IPV) had higher rates of IPV than did those who had not. The associations between the three individual types of CM and IPV in adulthood persisted when potential socio-demographic confounders were taken into ac- count. For both sexes, the adjusted odds ratios for reporting IPV were significant for each type of CM. When we simultaneously controlled for the co- occurrence of CM, all three types remained statistically significant for both sexes, demonstrating that each type is independently associated with IPV in adulthood. Associations between severity of CM and IPV When severity/frequency of CM was considered, a dose- response relationship between CPA and IPV in adult- hood emerged for both sexes—as the frequency/severity of CPA increased, so did the likelihood of reporting IPV (Table 4). The highest IPV rates were among those who had experienced severe/frequent CPA (31.3% for men and 31.8% for women), substantially exceeding the rates among those who had not experienced any CPA (13.8% for men and 11.8% for women). Among women, a dose-response relationship emerged between severity/frequency of CSA and IPV. By contrast, among men, there were no statistically significant differ- ences by severity/frequency of CSA. Also, for women, a dose-response relationship was ob- served between the frequency of childhood exposure to IPV and IPV in adulthood; this was not the case for men. Women who had experienced two or more types of CM had a higher likelihood of reporting IPV in adult- hood than did those who had experienced only one of the three types. However, among men, having experi- enced multiple types of CM was not associated with a higher rate of IPV; rates were similar among those who had experienced two or more types of CM and those who had experienced one type. The bivariate associations between the severity/fre- quency CM variables and being victimized by IPV in adulthood persisted when controlling for potential socio-demographic confounders. Sex differences in associations between CM and IPV To examine sex differences, we combined the sexes, and using logistic regression, we tested for interactions be- tween sex and CM in relation to reporting IPV in adult- hood, while controlling for potential socio-demographic confounders. A significant sex interaction was observed for CPA—the association between CPA and IPV in adulthood was stronger for women than for men. Women who reported CPA were 2.2 times more likely to experience IPV in adulthood than were those who did not report CPA (25.9/11.8) (Table 3). For men, the dis- parity was smaller, with those reporting CPA being 1.7 times more likely to experience IPV in adulthood than were those who did not report CPA (23.3/13.8). Significant sex interactions were also observed for CPA severity. Compared with men who reported no CPA, experiencing IPV in adulthood was 2.3 times higher (31.3/13.8) for those reporting severe and fre- quent CPA, 1.8 times higher (25.2/13.8) for severe CPA, and 1.5 times higher (20.2/13.8) for CPA, excluding se- vere CPA (Table 4). Associations were stronger for women—compared with those reporting no CPA, ex- periencing IPV in adulthood was 2.7 higher for severe and frequent CPA, 2.6 for severe CPA, and 1.9 for CPA, excluding severe CPA. Similarly, men who reported at least two types of CM were 2.0 times more likely to experience IPV in adult- hood than those who reported no CM. For women, the gradient was steeper, with those reporting at least two types of CM being 2.9 times more likely to experience IPV in adulthood. Discussion This study, based on a large, representative sample of the Canadian population in 2014, found that CM is Shields et al. BMC Public Health (2020) 20:1673 Page 7 of 15 associated with IPV in adulthood. For both sexes, CPA, CSA and childhood exposure to IPV were independently associated with subsequent IPV. Associations between CPA and IPV were stronger for women than for men. Among women, a dose-response relationship emerged between each of the three types of CM and IPV in Table 3 Prevalence of and adjusted odds ratios for experiencing any intimate partner violence (IPV) in adulthood, by sex and childhood maltreatment (CM), household population aged 18 or older, currently living with a spouse/partner or who had contact with an ex-spouse/partner during last 5 years, Canada, 2014 Any IPV in adulthood % 95% CI Odds 95% CI Men Any CMa Yes 23.4* (21.2, 25.6) 1.8 * (1.5, 2.1) No (reference) 13.2 (12.1, 14.3) 1.0 … CPA Yes 23.3 * (21.0, 25.6) 1.7 * (1.4, 2.0) No (reference) 13.8 (12.7, 14.9) 1.0 … CSA Yes 25.1 * (20.3, 29.9) 1.8 * (1.4, 2.5) No (reference) 15.5 (14.5, 16.6) 1.0 … Childhood exposure to IPV Yes 27.7 * (23.0, 32.4) 2.0 * (1.5, 2.6) No (reference) 15.3 (14.3, 16.3) 1.0 … Simultaneously controlling for other CM types CPA (reference no CPA) 1.5 * (1.3, 1.8) CSA (reference no CSA) 1.5 * (1.1, 2.1) Childhood exposure to IPV (reference no childhood exposure to IPV) 1.7 * (1.3, 2.2) Women Any CMa Yes 23.0 * (21.1, 25.0) 2.1 * (1.8, 2.5) No (reference) 10.9 (10.0, 11.8) 1.0 … CPA Yes 25.9 * (23.0, 28.7) 2.2 * (1.8, 2.7) No (reference) 11.8 (11.0, 12.7) 1.0 … CSA Yes 24.8 * (22.1, 27.4) 2.0 * (1.7, 2.5) No (reference) 12.2 (11.3, 13.1) 1.0 … Childhood exposure to IPV Yes 26.6 * (22.6, 30.7) 2.1 * (1.6, 2.8) No (reference) 13.0 (12.2, 13.8) 1.0 … Simultaneously controlling for other CM types CPA (reference no CPA) 1.8 * (1.4, 2.2) CSA (reference no CSA) 1.6 * (1.3, 1.9) Childhood exposure to IPV (reference no childhood exposure to IPV) 1.5 * (1.2, 2.0) Source: Statistics Canada: 2014 General Social Survey: Victimization CPA: childhood physical abuse; CSA: childhood sexual abuse a CPA, CSA or childhood exposure to IPV * Significantly different from reference (p < 0.05) Note: Odds are adjusted by age group, Canadian-born, Indigenous status, marital status, household income, highest level of education of respondent, and highest level of education of respondent’s father and mother … not applicable Shields et al. BMC Public Health (2020) 20:1673 Page 8 of 15 T a b le 4 Pr ev al en ce o f an d ad ju st ed o d d s ra ti o s fo r ex p er ie n ci n g an y in ti m at e p ar tn er vi o le n ce (IP V) in ad u lt h o o d ,b y se x an d co -o cc u rr en ce o f ch ild h o o d m al tr ea tm en t (C M ) an d C M se ve rit y, h o u se h o ld p o p u la ti o n ag ed 18 o r o ld er ,c u rr en tl y liv in g w it h a sp o u se /p ar tn er o r w h o h ad co n ta ct w it h an ex -s p o u se /p ar tn er d u rin g la st 5 ye ar s, C an ad a, 20 14 A n y IP V in ad u lt h o o d % 9 5 % C I O d d s 9 5 % C I M en C P A se ve ri ty an d fr eq u en cy Se ve re an d fr eq u en t C PA (> 10 ti m es ) 31 .3 *a (2 4. 1, 38 .4 ) 2. 3 * (1 .6 ,3 .3 ) Se ve re C PA (≤ 10 ti m es ) (r ef er en ce 3) 25 .2 * (2 1. 0, 29 .5 ) 1. 7 * (1 .4 ,2 .2 ) C PA (e xc lu d in g se ve re C PA ) (r ef er en ce 2) 20 .2 * (1 7. 2, 23 .2 ) 1. 6 * (1 .2 ,1 .9 ) N o C PA (r ef er en ce 1) 13 .8 (1 2. 7, 14 .9 ) 1. 0 … C SA se ve ri ty an d fr eq u en cy Se ve re an d fr eq u en t (≥ 3 ti m es ) C SA 28 .8 * (1 6. 8, 40 .8 ) 1. 9 (0 .9 ,3 .9 ) Se ve re C SA (≤ 2 ti m es ) (r ef er en ce 3) 23 .8 * (1 5. 0, 32 .6 ) 1. 6 (0 .9 ,2 .8 ) Se xu al to u ch in g (e xc lu d in g se ve re C SA ) (r ef er en ce 2) 24 .7 * (1 8. 1, 31 .2 ) 1. 9 * (1 .3 ,2 .8 ) N o C SA (r ef er en ce 1) 15 .5 (1 4. 5, 16 .6 ) 1. 0 … Fr eq u en cy o f ch ild h o o d ex p o su re to IP V M o re th an 10 ti m es 24 .7 * (1 7. 8, 31 .6 ) 1. 6 * (1 .0 ,2 .5 ) Th re e to 10 ti m es (r ef er en ce 2) 29 .8 * (2 3. 2, 36 .4 ) 2. 3 * (1 .7 ,3 .2 ) N ev er ,o n ce o r tw ic e (r ef er en ce 1) 15 .3 (1 4. 3, 16 .3 ) 1. 0 … C o -o cc u rr en ce o f C M N o C M (r ef er en ce 1) 13 .2 (1 2. 1, 14 .3 ) 1. 0 … C PA o n ly (n o C SA /C h ild h o o d ex p o su re to IP V - re fe re n ce 2) 22 .3 * (1 9. 5, 25 .1 ) 1. 7 * (1 .4 ,2 .1 ) C SA o n ly (n o C PA /C h ild h o o d ex p o su re to IP V - re fe re n ce 3) 23 .1 * (1 5. 2, 30 .9 ) 2. 0 * (1 .2 ,3 .3 ) C h ild h o o d ex p o su re to IP V (n o C PA /C SA - re fe re n ce 4) 29 .3 * (1 8. 5, 40 .0 ) 2. 4 * (1 .4 ,4 .1 ) Tw o o r 3 ty p es o f ch ild h o o d m al tr ea tm en t 25 .8 * (2 1. 5, 30 .1 ) 2. 2 * (1 .7 ,2 .9 ) W o m en C P A se ve ri ty an d fr eq u en cy Se ve re an d fr eq u en t C PA (> 10 ti m es ) 31 .8 *a (2 3. 8, 39 .7 ) 2. 7 * (1 .7 ,4 .2 ) Se ve re C PA (≤ 10 ti m es ) (r ef er en ce 3) 30 .4 *a (2 4. 7, 36 .0 ) 2. 6 * (1 .9 ,3 .7 ) C PA (e xc lu d in g se ve re C PA ) (r ef er en ce 2) 22 .3 * (1 8. 8, 25 .7 ) 2. 0 * (1 .6 ,2 .5 ) N o C PA (r ef er en ce 1) 11 .8 (1 1. 0, 12 .7 ) 1. 0 … Shields et al. BMC Public Health (2020) 20:1673 Page 9 of 15 T a b le 4 Pr ev al en ce o f an d ad ju st ed o d d s ra ti o s fo r ex p er ie n ci n g an y in ti m at e p ar tn er vi o le n ce (IP V) in ad u lt h o o d ,b y se x an d co -o cc u rr en ce o f ch ild h o o d m al tr ea tm en t (C M ) an d C M se ve rit y, h o u se h o ld p o p u la ti o n ag ed 18 o r o ld er ,c u rr en tl y liv in g w it h a sp o u se /p ar tn er o r w h o h ad co n ta ct w it h an ex -s p o u se /p ar tn er d u rin g la st 5 ye ar s, C an ad a, 20 14 (C o n tin u ed ) A n y IP V in ad u lt h o o d % 9 5 % C I O d d s 9 5 % C I C SA se ve ri ty an d fr eq u en cy Se ve re an d fr eq u en t (≥ 3 ti m es ) C SA 28 .3 *a (2 2. 4, 34 .1 ) 2. 3 * (1 .7 ,3 .3 ) Se ve re C SA (≤ 2 ti m es ) (r ef er en ce 3) 29 .3 *a (2 3. 9, 34 .6 ) 2. 5 * (1 .8 ,3 .5 ) Se xu al to u ch in g (e xc lu d in g se ve re C SA ) (r ef er en ce 2) 20 .0 * (1 6. 7, 23 .3 ) 1. 6 * (1 .2 ,2 .1 ) N o C SA (r ef er en ce 1) 12 .2 (1 1. 3, 13 .1 ) 1. 0 … Fr eq u en cy o f ch ild h o o d ex p o su re to IP V M o re th an 10 ti m es 30 .7 *a (2 4. 9, 36 .5 ) 2. 5 * (1 .8 ,3 .5 ) Th re e to 10 ti m es (r ef er en ce 2) 22 .7 * (1 7. 2, 28 .1 ) 1. 8 * (1 .3 ,2 .6 ) N ev er ,o n ce o r tw ic e (r ef er en ce 1) 13 .0 (1 2. 2, 13 .8 ) 1. 0 … C o -o cc u rr en ce o f C M N o C M (r ef er en ce 1) 10 .9 (1 0. 0, 11 .8 ) 1. 0 … C PA o n ly (n o C SA /C h ild h o o d ex p o su re to IP V - re fe re n ce 2) 19 .8 * (1 6. 1, 23 .5 ) 1. 8 * (1 .3 ,2 .3 ) C SA o n ly (n o C PA /C h ild h o o d ex p o su re to IP V - re fe re n ce 3) 17 .5 * (1 4. 5, 20 .5 ) 1. 5 * (1 .1 ,2 .0 ) C h ild h o o d ex p o su re to IP V (n o C PA /C SA - re fe re n ce 4) 21 .2 * (1 4. 9, 27 .6 ) 2. 1 * (1 .4 ,3 .3 ) Tw o o r 3 ty p es o f ch ild h o o d m al tr ea tm en t 31 .1 *a b c (2 7. 0, 35 .2 ) 3. 1 * (2 .4 ,4 .0 ) So u rc e: St at is ti cs C an ad a: 2 0 1 4 G en er al So ci al Su rv ey :V ic ti m iz at io n C P A :c h ild h o o d p h ys ic al ab u se ;C SA :c h ild h o o d se xu al ab u se * Si g n if ic an tl y d if fe re n t fr o m re fe re n ce 1 (p < 0 .0 5 ) a Si g n if ic an tl y d if fe re n t fr o m re fe re n ce 2 (p < 0 .0 5 ) b Si g n if ic an tl y d if fe re n t fr o m re fe re n ce 3 (p < 0 .0 5 ) c Si g n if ic an tl y d if fe re n t fr o m re fe re n ce 4 (p < 0 .0 5 ) N o te : O d d s ar e ad ju st ed b y ag e g ro u p ,C an ad ia n -b o rn , In d ig en o u s st at u s, m ar it al st at u s, h o u se h o ld in co m e, h ig h es t le ve l o f ed u ca ti o n o f re sp o n d en t, an d h ig h es t le ve l o f ed u ca ti o n o f re sp o n d en t’ s fa th er an d m o th er … n o t ap p lic ab le Shields et al. BMC Public Health (2020) 20:1673 Page 10 of 15 adulthood—increases in the severity and frequency of the CM were associated with increases in the likelihood of reporting IPV; among men, a dose-response relation- ship was observed only for CPA. For women, but not men, having experienced two or more types of CM was more strongly associated with IPV than was experien- cing one type. Consistent with results of a study based on data from a 2012 Canadian survey [43], the present analysis found that women were more likely than men to report CSA and childhood exposure to IPV, while men were more likely than women to report CPA. The present study found that men were slightly more likely than women to report IPV in adulthood. Other studies have also found that women are equally, or somewhat less likely, than men to report IPV, particu- larly when IPV is broadly defined to include any type of hitting and/or emotional IPV [48, 49]. However, it is im- portant to note that women are at increased likelihood of experiencing severe/frequent IPV, as well as serious consequences, such as psychological harm, physical in- juries and mortality [50–52]. Many other studies have found that IPV in adulthood is more common among people who have experienced CSA [5–18] and CPA [5–7, 9, 10, 12–22]. Fewer studies have examined IPV in relation to other types of CM, but associations have been found for childhood exposure to IPV [5, 13, 16–20, 23–25], neglect [5, 6, 14, 15, 20, 22], and childhood emotional abuse [5, 6, 14, 15, 20]. None- theless, results have been inconsistent, with some studies finding a null association between specific types of CM and IPV [5–7, 12–14, 19, 20, 22, 24, 26–29]. This likely reflects differences in the definitions of CM and IPV, the reference periods for CM and IPV, the control variables in the analyses (including simultaneously controlling for multiple types of CM), the study population, and the sample size. CM severity in relation to IPV in adulthood has been studied less frequently. It has been suggested that expos- ure to CM, regardless of severity, increases the risk of subsequent abuse [33]. Two meta-analyses of associa- tions between CM and IPV published in 2019 (one based solely on men and one on both sexes) [30, 31] reported weak but statistically significant associations. Failure to account for severity of the CM may have masked the full nature of the association. According to our analysis, se- verity was an important factor, especially for women. Much of the research examining associations be- tween CM and IPV has been based solely on samples of women; sex differences have rarely been examined. It has been suggested that the lack of studies on male IPV victimization reflects the more serious conse- quences experienced by females victimized by IPV [30]. Similar to our results for women, other studies revealed a dose-response relationship between the number of types of CM and IPV in adulthood [5, 9, 12, 15, 18–20, 28, 32]. We found that associations be- tween CPA and IPV were stronger among women, but the association was also significant among men. Additional work is needed using mixed gender sam- ples in which multiple types of CM and IPV are con- sidered. Most studies based on men have focused solely on IPV perpetration [30]. However, studies in- cluding males victimized by IPV are important to in- form both the general population and health care professionals of the importance of recognizing that men also experience victimization and for the devel- opment of interventions aimed at reducing male IPV victimization [30]. The most common framework for interpreting IPV risk factors is the ecological model [3, 4]. This model ex- tends beyond individual characteristics to encompass family, community, and societal factors. It recognizes that individuals evolve within a set of nested environ- mental structures and attempts to identify mechanisms that contribute to vulnerability to repeated abuse. Exo- system and macro-system variables, such as a scarcity of resources, lack of social support, and cultural tendencies to blame the victim, may increase the likelihood that people who experienced CM will be exposed to IPV in adulthood, independent of their individual characteris- tics. For example, lack of access to affordable housing and well-paying jobs may increase the likelihood that in- dividuals with histories of CM will enter and maintain intimate relationships with people who are violent to- ward them. CM is associated with numerous negative long-term economic outcomes including unemployment, low income, homelessness, and lack of job skills [44]. This is further exacerbated by experiences of adult IPV victimization which have been shown to inhibit job sta- bility [53]. Another ecological consideration is that the abusive and violent behaviours towards children and partners may not be condemned universally. If people grow up and continue to live in a social milieu where violence is sometimes regarded as acceptable, exposure to frequent and severe violence in childhood may be a marker for exposure to violence in adulthood. This is consistent with the social learning theory model which contends that CM may serve as a model for future interpersonal relationships [54]. Children who experience abuse or have a caregiver who is abused may perceive violence as a normal part of a relationship. Initiatives such as the #MeToo movement (https://metoomvmt.org/about/) may have a role in decreasing IPV. The movement may reduce the likelihood of accepting abuse of any kind in intimate relationships, regardless of past experiences of violence. Research based on Canadian administrative Shields et al. BMC Public Health (2020) 20:1673 Page 11 of 15 https://metoomvmt.org/about/ data found an increase in reporting sexual assaults to the police after the emergence of #MeToo, particularly cases involving a known perpetrator [55]. The ecological model also incorporates the idea that the family environment in which the CM initially oc- curred may be associated with future abuse. A system- atic review of risk and protective factors for revictimization after CSA found that the perception of parental care acted as a buffer, reducing the risk of revic- timization [56]. A 2019 study [57] found that positive childhood expe- riences reduced the risk of poor mental health in adult- hood, independent of childhood abuse and neglect and household dysfunction (such as parental substance abuse). The measures of positive childhood experiences included items such as participation in community tradi- tions, a sense of belonging in high school, and social support from friends. These findings demonstrate the utility of the ecological model when investigating associ- ations between CM and other negative outcomes in adulthood such as IPV. Strengths and limitations This study has notable strengths: it is based on a large, representative sample of the Canadian population; mul- tiple behaviour-specific items were used to measure CM and IPV; and these measures have been shown to have greater validity and reliability than broad, subjectively defined items [41, 42, 58–60]. As a result, it was possible to examine CM severity in relation to IPV in adulthood and to test for sex differences in associations. However, the analysis has limitations that should be considered when interpreting the findings: � All information was based on retrospective self- reports. Recall bias may have influenced the ob- served associations between CM and IPV. People who experienced violence in adulthood may more readily recall CM, which could have inflated associa- tions. On the other hand, those who experienced CM may be less likely to report IPV in adulthood because of habituation to violence in general; this would weaken associations. � Individuals who experienced CM and/or IPV may have been reluctant to disclose these experiences in a survey. � The items used to measure IPV in adulthood were asked only of respondents with a current spouse or common-law partner and/or those who had contact with an ex-spouse/common-law partner in the past 5 years. IPV that occurred in dating relationships was excluded. Evidence suggests that the association between CM and IPV is stronger for dating couples than for married ones [31]. � The GSS questionnaire did not include measures of childhood emotional abuse and neglect, which have been shown to be associated with IPV [5, 6, 14, 15, 20, 22]. � In the regression models, it was not possible to control for some potentially important confounders (such as overall family dysfunction) due to unavailability in the GSS. It has been hypothesized that family dysfunction may be more strongly related to negative outcomes than is CM, but some research indicates that each is independently related to dysfunction in adulthood [61]. Socioeconomic status during childhood was partially controlled by inclusion of highest level of education of the father and mother in the regression analyses; family income data would have offered a more complete control for childhood socioeconomic status. � The coverage of the GSS excludes people who are homeless and those living in institutions—populations for which experiences of CM and IPV are more prevalent. � The extent to which the low GSS response rate (52.9% for the provinces; 58.7% for the territories) affects associations between CM and IPV is unknown. An analysis of data from Statistics Canada’s Canadian Community Health Survey (an ongoing annual health survey) reported steady declines in response rates over time. The characteristics of respondents and non-respondents differed in ways that cannot be fully corrected via weighting [62]. Furthermore, vulnerable populations (for instance, lower socioeconomic status and poor health) [62, 63] are the least likely to respond to surveys. � Previous studies have found that CM is associated with IPV perpetration, particularly among men [8, 30, 32, 64, 65], and reciprocal IPV [8, 32, 65]. However, the GSS did not include questions on IPV perpetration so it was not possible to examine CM in relation to IPV perpetration. � It is possible that there are subpopulations for which the associations between CM and IPV in adulthood are stronger such as Indigenous peoples [23]. The child’s relationship to the perpetrator may also be an important factor [5]; children who experience abuse from a parent or caregiver may be at a heighted risk of experiencing IPV compared with those whose relationship to the abuser was more distant. We did not have adequate sample to examine interactions with these variables. Future research should examine other types of CM such as neglect and emotional maltreatment in relation to IPV in adulthood. A survey with a larger sample size Shields et al. BMC Public Health (2020) 20:1673 Page 12 of 15 would be instrumental in identifying subpopulations with elevated associations between CM and IPV who are particularly in need of early interventions. More research on the effectiveness of community-based interventions such as fostering a sense of belonging to school and community traditions is warranted [57]. Conclusion Numerous studies have found that both CM and IPV are associated with an increased risk of a wide range of physical and mental health conditions [66–68]. The negative outcomes of physical IPV are immediate and apparent, including injury, physical disability, and in se- vere cases, mortality [66]. However, emotional IPV also has serious ramifications; emotional IPV is strongly re- lated to numerous adverse conditions, including chronic disease and poor mental health [69]. The association be- tween CM and IPV in adulthood merits attention be- cause of cumulative effects—lifespan studies have shown that individuals who experience numerous incidents of abuse exhibit the highest levels of impairment [70, 71]. Costs to the health care system and the burden to indi- viduals experiencing multiple incidents of abuse under- score the importance of intervention programs to eradicate CM and IPV. Interventions aimed at promot- ing healthy relationships and providing emotional sup- port and coping mechanisms to children and families in abusive situations are key components to ending the cycle of violence and preventing IPV in adulthood [72]. Abbreviations CI: confidence interval; CPA: childhood physical abuse; CSA: childhood sexual abuse; GSS: General Social Survey; IPV: intimate partner violence Acknowledgements Not applicable. Authors’ contributions MS, LT, WH, AG and HM conceived and designed the study. MS analyzed the data. MS and LT drafted the manuscript. WH, AG, and HM commented on and critically revised the manuscript. All authors read and approved the final manuscript. Funding No funding was received to conduct this research. HM is supported by the Chedoke Health Chair in Child Psychiatry. Availability of data and materials The data are available for analysis from Statistics Canada. MS conducted the analyses as an employee of Statistics Canada, under a contact between the Public Health Agency of Canada and Statistics Canada. Ethics approval and consent to participate Data for the GSS were collected by Statistics Canada under the provisions of the Statistics Act. Before starting the survey, GSS respondents were informed that the information they provided would be used for statistical purposes, that their answers would be kept strictly confidential, and their participation in the survey was voluntary. This article is based on data from an existing file and thus the project did not undergo ethics review. Consent for publication Not applicable. Competing interests The authors declare they have no competing interests. Author details 1Public Health Agency of Canada, 785 Carling Ave. 7th floor, Ottawa, ON K1A 0K9, Canada. 2Department of Psychiatry & Behavioural Neurosciences, McMaster University, 1280 Main Street West - MIP 201A, Hamilton, ON L8S 4K1, Canada. 3Department of Psychiatry & Behavioural Neurosciences, and of Pediatrics, McMaster University, 1280 Main Street West - MIP 201A, Hamilton, ON L8S 4K1, Canada. Received: 30 May 2020 Accepted: 15 October 2020 References 1. World Health Organization. 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Kimerling R, Alvarez J, Pavao J, Kaminski A, Baumrind N. Epidemiology and consequences of women's revictimization. Womens Health Issues. 2007; 17(2):101–6. Publisher’s Note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. Shields et al. BMC Public Health (2020) 20:1673 Page 15 of 15 Abstract Background Methods Results Conclusions Background Methods Data source Measures Child maltreatment Intimate partner violence in adulthood Covariates Analysis Results Estimates of IPV Estimates of CM Associations between CM and IPV Associations between severity of CM and IPV Sex differences in associations between CM and IPV Discussion Strengths and limitations Conclusion Abbreviations Acknowledgements Authors’ contributions Funding Availability of data and materials Ethics approval and consent to participate Consent for publication Competing interests Author details References Publisher’s Note