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22 December 2019 Women’s Healthcare NPWomensHealtHcare.com

Teen dating violence (TDV) in the United States is a wide- spread, serious public health

problem first reported in studies published in the 1980s. However, it was not until the early 2000s that national estimates of TDV were avail- able.1 These estimates, while alarm- ing, may not reveal the true number of victims because TDV is likely underreported because of shame or fear of retribution.2 The CDC defines teen dating violence as the commis- sion of physical, sexual, psychologi- cal, or emotional aggression within a teen dating relationship, including stalking.3 TDV can occur from a past or present relationship, and in person or through digital forms of communication.

The 2017 Youth Risk Behavior Survey (YRBS) of almost 15,000 teenagers nationwide revealed that, among the 68.3% who reported dat- ing within the past 12 months, 6.9% reported being forced to do sexual things.4 Female students were more likely than male students to experi- ence sexual dating violence (10.7% vs. 2.8%). In terms of breakdown by race/ethnicity among females, sexual dating violence was reported more frequently by Hispanics (11.4%) than by whites (11.1%) or blacks (6.8%). Among males, sexual dating violence was reported slightly more frequently by blacks than by whites or Hispanics (2.7%, 2.6%, and 2.5% respectively). In terms of breakdown by sexual identity, the YRBS showed that sexual dating violence was higher in indi- viduals who reported being lesbian/ gay/bisexual (15.8%) or not sure

By Amber D. Littlefield, DNP, FNP-C, MEd, CNE; Debra A. Hunt, PhD, FNP-BC, GNP-BC, CNE; and Joanne M. Keefe, DNP, MPH, FNP-c, CNE

Teen dating violence (TDV) affects about 20% of females and 10%

of males in the United States. In this article, the authors discuss

risk factors and protective factors, screening, diagnosis, prevention,

treatment, and other considerations with respect to TDV.

Key words: teen dating violence, intimate partner violence, domestic violence, screening

Teen dating violence: Not child’s play

NPWomensHealtHcare.com December 2019 Women’s Healthcare 23

(14.1%) than by heterosexuals (5.5%). Among females in particular, sexual dating violence was reported more frequently by lesbians/bisexuals than by heterosexuals (16.2% vs. 9.3%). Among males in particular, sexual dating violence was reported more frequently by gays/bisexuals than by heterosexuals (13.5% vs. 2.1%).

In addition to sexual dating vio- lence, the 2017 YRBS investigated physical violence in teen dating relationships.4 Among the afore- mentioned 68.3% of students who reported dating within the past 12 months, 8% reported experiencing physical violence by their partner. The prevalence of experiencing physical violence was higher in females than in males (9.1% vs. 6.5%). Among female students, blacks reported a higher prevalence of physical violence by a dating partner (13.1%) than did His- panics (9.2%) or whites (8.0%). Among male students, blacks were more likely to experience physical violence by a dating partner (7.1%) than were His- panics or whites (5.9% for each group). Compared with their heterosexual counterparts, students who identified as lesbian/gay/bisexual or who were unsure of their sexual identity were more likely to report physical dating violence (17.2% vs. 6.4%).

The National Survey of Teen Relationships and Intimate Vio- lence (STRiV) was conducted to better understand the prevalence, characteristics, and risk factors for TDV.5 Survey results suggested that TDV prevalence was much higher than that reported in the YRBS. Methodologic differences may have accounted for some of the discrepancy: The YRBS did not in- clude adolescents who had dropped out of school nor did it include a measure of psychological abuse. In addition, the STRiV reported data on perpetrators of TDV, not just victims. According to STRiV results,

69% of youth who were currently or formerly in a relationship in the past year reported being victims of adolescent relationship abuse (ARA), a broader term than TDV. Psycho- logical abuse was most common (60%), but sexual abuse and physical abuse each affected 18%. Compared with youth aged 15-18 years, those aged 12-14 years reported lower rates of psychological/sexual ARA victimization and ARA perpetration. Although no gender differences for ARA victimization were found, females perpetrated more physical ARA than did males. In particular, females aged 15-18 years reported perpetrating moderate threats/ physical violence at more than twice the rate of younger girls and 3 times the rate of males aged 15-18; furthermore, females aged 15-18 years, compared with their male counterparts, reported perpetrating more than 4 times the rate of serious psychological abuse.

Effects of TDV can be extensive and include acute trauma and, in some cases, post-traumatic stress disorder (PTSD).6 Teenage victims of TDV, versus teens who have not been affected by TDV, are more likely to engage in self-destructive acts such as smoking, heavy alcohol consumption, high-risk sexual be- haviors, and substance abuse.6 TDV victims also are at risk for suicidal ideation, anxiety, depression, unin- tended pregnancy, low self-esteem, decreased academic performance, and eating disorders.7,8

Risk factors and protective factors Teen dating violence can affect any- one, regardless of socioeconomic status, gender, race, sexual or gender identity, or dating experience. How- ever, risk factors that may contribute to unhealthy teen dating relation- ships have been identified, including

perception that violence in a relation- ship is acceptable; being depressed, anxious, or having other symptoms of trauma; displaying aggression toward peers or other antisocial behaviors; using drugs or illegal substances; engaging in early sexual activity and having multiple sexual partners; having a friend involved in TDV; having conflicts with a partner; and witnessing or experiencing violence in the home.3 Researchers also have identified protective factors against TDV: empathy, strong academic per- formance, a sense of attachment to one’s school, a high verbal IQ, having a positive relationship with one’s mother, and having high cognitive dissonance about perpetrating dating violence (i.e., having a realization that TDV is wrong).1

Recent studies suggest that LGBTQ teens are at particularly high risk for TDV.9,10 In one study, whereas 29% of heterosexual teens reported physical abuse by a dating partner, this rate was as high as 42.8% among LGBTQ teens.9 In another study of teen dating relationships, sexual abuse was reported by 12.3% of hetero- sexual teens versus 23.2% of LGBTQ teens.10 Results of yet another study suggested that teens who identified as LGBTQ faced different dating ob- stacles than did heterosexual teens.11 They might not have felt comfortable discussing their gender or sexual identity openly, and they might have feared social stigma and stereotypical judgments from school authorities or law enforcement if they reported their abuse.

Screening Recommendations In 2018, the U.S. Preventive Services Task Force (USPSTF) recommended that healthcare providers (HCPs) screen females of childbearing age for intimate partner violence (IPV).12 The (continued on page 28)

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USPSTF’s recom-

menda- tions are

available hereA. Child-

bearing age is defined as females

aged 14-46 years, which captures the age

group at risk for TDV.13 The USPSTF recommendations are

limited to females because evidence is lacking on the use of IPV screen- ing and preventive interventions in males. Despite recommendations from the USPSTF, the American Med- ical Association, and the American College of Obstetricians and Gynecol- ogists, recent evidence has indicated that only 36% of U.S. females are properly screened for IPV.14

Although the USPSTF recom- mendation does not include specific guidance on how often IPV screening should be conducted, the annual well-visit for teenage females gives HCPs an ideal opportunity to screen for TDV. Screening can be incorpo- rated into routine history-taking. Because considerable evidence demonstrates that many teens skip their annual checkups, some experts recommend that screening occur at every HCP encounter and should not be limited to primary care visits. The U.S. Department of Health and Hu- man Services sponsored an Intimate Partner Violence Screening and Coun- seling Research Symposium in 2013, with findings and recommendations available hereB.15 By including screening at healthcare visits in all set- tings, including in emergency depart- ments and behavioral health centers, screening rates for this population would increase and be better aligned with the recommendations.16

Tools Use of screening tools can help HCPs identify patients at greatest risk for TDV. Several validated IPV screening tools are available.12 Choosing an age-appropriate tool is important because adolescents differ from adults in terms of physical and emotional development. One tool created specifically for TDV is the RED FLAGS Universal Teen Dating Violence ScreenC,17 which was cre- ated for parents, coaches, teachers, and HCPs. The gender-neutral tool includes questions to ask teens, as well as red flags that can be identified through the answers to the ques- tions. The tool includes links to help- ful resources and a teen safety plan.

Diagnosis Victims of TDV may present for healthcare with signs and symp- toms (S/S) similar to those of vic- tims of other types of IPV. Physical signs may include acute injuries (e.g., bruises, welts) to the head, face, abdomen, or genitalia; lacer- ations and abrasions; or fractures of the bones or teeth.18,19 In many cases, though, the presentation is nonspecific, with complaints of chronic pain (e.g., headache, pelvic pain, irritable bowel syndrome, fibromyalgia), insomnia, or vague abdominal symptoms. Recurrent sexually transmitted infections, sexual dysfunction, and repeated requests for pregnancy tests may suggest TDV as well.18

Victims of violence tend to expe- rience higher rates of depression, anxiety, phobias, PTSD, substance abuse, and suicidal ideation/at- tempts.18,19 HCPs should remem- ber that teenage victims of TDV in particular may need more time to feel safe in disclosing information and may need reassurances of confidentiality.7 Displaying posters about TDV in a private location in

the clinic, such as in a restroom or exam room, shows HCP sensitivity to the topic and may increase teens’ comfort.20

Prevention To prevent TDV, teenagers, families, schools, and communities must work together. Most teenagers spend a lot of their day in school, which provides an opportunity to incorporate courses promoting safe dating habits and raising TDV aware- ness. In a study involving 30 public middle schools in New York City, the use of school-based interventions was associated with a 50% reduction in TDV.21 School-based interventions consisted of providing additional faculty and security in areas stu- dents identified as unsafe, issuing temporary school-based restraining orders, encouraging reporting to faculty, and increasing awareness school-wide via posters. Classroom interventions consisted of lessons describing the consequences of IPV for perpetrators, state laws and penalties, gender roles, and healthy relationships. Students exposed to both classroom and school-wide in- terventions reported 32%-47% less sexual violence victimization/perpe- tration 6 months post-intervention.

School-based health centers may provide a safe place for TDV victims to report abuse. HCPs should be trained in facilitating healthy relationships, interventions, and harm-reduction strategies, and in making referrals to a domestic vio- lence or sexual assault advocate.22 A study of 8 school-based health clin- ics showed the possible effective- ness of this type of HCP training23: Students in unhealthy relationships were more likely to report them to their HCP, HCPs felt more com- fortable handling these types of encounters, and the sense of school safety increased.

NPWomensHealtHcare.com December 2019 Women’s Healthcare 29

The CDC offers resources to im- prove school- and community-wide efforts to prevent TDV. For example, the CDC’s Dating Matters: Strategies to Promote Healthy Teen Relationships, a free resource that requires 60 min- utes of online training, is intended for teachers, administrators, counselors, coaches, youth mentors, and other school personnel.24 The CDC’s Dating Matters Capacity Assessment and Planning Tool is a free online resource to help communities take a public health approach to prevent TDV.25 It includes components needed to support development, evaluation, and maintenance of TDV prevention ini- tiatives. Relationships Smarts Plus 4.0 is an evidence-based curriculum that can be purchased and used in schools or community-based programs.26

Treatment The initial approach to any victim of IPV, including a teenager, is to deter- mine immediate safety risk, treat in- juries, and provide support.18,20 Local SANE (sexual assault nurse examiner) and domestic violence agencies may provide needed services. Because both IPV and TDV are associated with increased rates of high-risk sexual be- haviors, suicidal behaviors, unhealthy weight control, adverse mental health diagnoses, substance abuse, and unintended pregnancy, referrals for ongoing support and professional counseling should be considered. Hotlines and online resources are available in the Box.

Reporting acts of violence Healthcare providers should be- come familiar with the reporting laws in their state, which vary ac- cording to the ages of the victim and the perpetrator. To add to the complexity of the reporting process, certain behaviors such as bullying may not be reportable. HCPs must explain the legal reporting require-

ments to their teenage patients to maintain patient–HCP trust.

Other special considerations Teenagers are in a stage of develop- ment that provides challenges and adds complexity to addressing TDV. HCPs providing screening and coun- seling in the clinical setting should be aware of these points:27

• Teens lack relationship experience.

° They may view abuse as an ex- pression of love.

° They may draw from roles seen, but not explored, in the media.

• Teens seek peer acceptance.

° Being in a relationship may in- crease peer-group acceptance.

° They may follow gender roles expected by peers, but not con- forming to who they really are or what they really want from a relationship.

• Teens want to be independent.

° They don’t want to be judged by others.

° They don’t trust adults to re- spect their independence.

HCPs can handle these challenges by being nonjudgmental, asking pa- tients what they need, providing re- spectful education, seeking out peer counselors, offering information and services to patients, and maintaining strict confidentiality.28

Knowledge gaps More research is needed to establish the best strategies for TDV prevention and effective interventions. Communi- ty-based programs should incorporate ongoing evaluation mechanisms to help identify best practices. Research to better understand risk factors and intervention strategies for both ado- lescent females and males as perpe- trators, as well as victims, is needed. Finally, a need exists for a better under- standing of risk factors, protective fac- tors, and interventions to help LGBTQ youth who are victims of TDV.

Conclusion Use of appropriate screening strat- egies, awareness of risk factors, and recognition of possible S/S allow for early TDV identification. Manage- ment includes care for immediate concerns, as well as ongoing support and referrals to prevent long-term effects of TDV. HCPs can advocate for school- and community-based TDV prevention programs and collaborate with multidisciplinary teams in their implementation. =

Amber D. Littlefield is Assistant Pro- fessor, Debra A. Hunt is Associate Professor, and Joanne M. Keefe is As- sistant Professor, all at Frontier Nurs- ing University in Hyden, Kentucky. The authors state that they do not have a financial interest in or other

Box. Hotlines and websites

• The National Domestic Violence Hotline: (800) 799-7233

• National Teen Dating Abuse Helpline: (866) 331-9474

• Love is respect youth.gov

• Victim & Survivor Resources

• teen line hotline: (310) 855-4673 and teen line online Youth Yellow Pages. Dating Violence

• The Trevor Project hotline: (866) 488- 7386 and The Trevor Project website

• CDC. Dating Matters®

• The National Center for Victims of Crime

• Break the Cycle

• The Center for Respect (formerly the Date Safe Project)

• The Fourth R: Healthy Relationships Plus Program

30 December 2019 Women’s Healthcare NPWomensHealtHcare.com

relationship with any commercial product named in this article.

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C. cyfd.org/docs/red_flags.pdf

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