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Review| Volume 33, ISSUE 4, P332-338, August 2020

Dating Violence in Adolescence: Implications for Girls’ Sexual Health

Published:February 19, 2020DOI:https://doi.org/10.1016/j.jpag.2020.02.007
Dating Violence in Adolescence: Implications for Girls’ Sexual Health
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      ABSTRACT

      Adolescents in the United States are too often involved in relationships characterized by coercion and violence. An emerging body of research suggests that dating violence is linked with other health risks in adolescent relationships, particularly sexual risk behavior. The confluence of risks conferred by dating violence and sexual risk behavior are particularly acute for adolescent girls. Adolescent gynecology providers need to understand the nature of dating violence in adolescence and the ways in which dating violence and sexual risk behavior are mutually influential. This article reviews the literature on the links between dating violence and sexual risk in adolescent girls’ relationships. The prevalence, risk factors, and consequences of dating violence in adolescence are discussed, followed by a review of the research linking dating violence and sexual risk, with a focus on common mechanisms underlying these relationship risk behaviors. The review concludes with implications for screening, prevention, intervention, and future directions for research.

      Key Words

      Dating Violence: Definitions

      The term dating violence (DV) typically refers to intimate partner violence (IPV) in the context of young people's relationships.
      • Basile K.C.
      Sexual violence surveillance: Uniform definitions and recommended data elements.
      https://calio.dspacedirect.org/handle/11212/2310
      Date: 2014
      Date accessed: March 23, 2017
      According to the uniform definitions of the Centers for Disease Control and Prevention (CDC), an intimate partner could be a current or former boyfriend, girlfriend, dating partner, or sexual partner.
      • Breiding M.J.
      • Basile K.C.
      • Smith S.G.
      • et al.
      Intimate partner violence surveillance: uniform definitions and recommended data elements.
      National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, Atlanta, GA2015
      Both IPV and DV include physical and sexual violence, stalking, and psychological aggression.
      • Breiding M.J.
      • Basile K.C.
      • Smith S.G.
      • et al.
      Intimate partner violence surveillance: uniform definitions and recommended data elements.
      National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, Atlanta, GA2015
      DV is alternatively referred to as relationship abuse, relationship violence, and dating abuse.
      • Mumford E.A.
      • Liu W.
      • Taylor B.G.
      Parenting profiles and adolescent dating relationship abuse: attitudes and experiences.
      J Youth Adolesc. 2016; 45: 959
      ,
      • Chen F.R.
      • Rothman E.F.
      • Jaffee S.R.
      Early puberty, friendship group characteristics, and dating abuse in US girls.
      Pediatrics. 2017; 139: 1
      According to the CDC, physical DV is “the intentional use of physical force with the potential for causing death, disability, injury, or harm” and can include coercing a partner to commit physical violence.
      • Breiding M.J.
      • Basile K.C.
      • Smith S.G.
      • et al.
      Intimate partner violence surveillance: uniform definitions and recommended data elements.
      National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, Atlanta, GA2015
      Sexual violence is defined as a sexual act that is committed or attempted by another person without freely given consent of the victim or against someone who is unable to consent or refuse.”
      • Breiding M.J.
      • Basile K.C.
      • Smith S.G.
      • et al.
      Intimate partner violence surveillance: uniform definitions and recommended data elements.
      National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, Atlanta, GA2015
      Sexual violence includes sexual coercion, which involves using nonphysical pressure to obtain sex,
      • Basile K.C.
      Sexual violence surveillance: Uniform definitions and recommended data elements.
      https://calio.dspacedirect.org/handle/11212/2310
      Date: 2014
      Date accessed: March 23, 2017
      ,
      • Breiding M.J.
      • Basile K.C.
      • Smith S.G.
      • et al.
      Intimate partner violence surveillance: uniform definitions and recommended data elements.
      National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, Atlanta, GA2015
      ,
      • Smith S.G.
      • Basile K.C.
      • Gilbert L.K.
      • et al.
      The National Intimate Partner and Sexual Violence Survey (NISVS): 2010-2012 State Report.
      National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, Atlanta, GA2017
      pressuring someone to engage in sexual acts with a third party, and noncontact sexual abuse, such as forcing a victim to watch pornography.
      • Basile K.C.
      Sexual violence surveillance: Uniform definitions and recommended data elements.
      https://calio.dspacedirect.org/handle/11212/2310
      Date: 2014
      Date accessed: March 23, 2017
      Notably, all forms of sexual violence involve a lack of freely given consent by the victim.
      • Basile K.C.
      Sexual violence surveillance: Uniform definitions and recommended data elements.
      https://calio.dspacedirect.org/handle/11212/2310
      Date: 2014
      Date accessed: March 23, 2017
      It is important to note that sexual violence is not the same as sexual risk behaviors (SRB). SRB are behaviors that put adolescents at risk for sexually transmitted infections (STIs), including human immunodeficiency virus (HIV), as well as unintended pregnancy. The connection between DV and SRB in adolescent girls' relationships is the focus of this review. The links among DV, SRB, and health are likely multidirectional, and are best conceptualized within a socioecological framework, acknowledging the role of systems in which adolescent girls are embedded, intersecting identities, and power imbalances that perpetuate violence and health risks, particularly for members of underrepresented minority groups.
      Stalking includes “a pattern of repeated, unwanted, attention and contact that causes fear or concern for one's own safety or the safety of someone else,” such as a family member or friend.
      • Breiding M.J.
      • Basile K.C.
      • Smith S.G.
      • et al.
      Intimate partner violence surveillance: uniform definitions and recommended data elements.
      National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, Atlanta, GA2015
      By definition, victims of stalking either feel fear or believe that they or someone else will be harmed by the perpetrator.
      • Breiding M.J.
      • Basile K.C.
      • Smith S.G.
      • et al.
      Intimate partner violence surveillance: uniform definitions and recommended data elements.
      National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, Atlanta, GA2015
      Finally, psychological aggression is defined by the CDC as the “use of verbal and nonverbal communication with the intent to: a) harm another person mentally or emotionally, and/or b) exert control over another person.”
      • Breiding M.J.
      • Basile K.C.
      • Smith S.G.
      • et al.
      Intimate partner violence surveillance: uniform definitions and recommended data elements.
      National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, Atlanta, GA2015
      Psychological aggression is inherently manipulative and covert, may not be recognized as DV by the victim or others, and includes attempts to coerce or control a partner.
      • Breiding M.J.
      • Basile K.C.
      • Smith S.G.
      • et al.
      Intimate partner violence surveillance: uniform definitions and recommended data elements.
      National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, Atlanta, GA2015
      Reproductive coercion, or the control of a partner's reproductive or sexual health, is recognized as a form of psychological aggression by the CDC.
      • Breiding M.J.
      • Basile K.C.
      • Smith S.G.
      • et al.
      Intimate partner violence surveillance: uniform definitions and recommended data elements.
      National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, Atlanta, GA2015
      Adolescents can be victims or perpetrators of DV, and often engage in both types of behaviors.
      • Taylor B.G.
      • Mumford E.A.
      A national descriptive portrait of adolescent relationship abuse: results from the National Survey on Teen Relationships and Intimate Violence.
      J Interpers Violence. 2016; 31: 963
      Perpetration refers to inflicting DV, and victimization refers to being a target of DV.
      • Breiding M.J.
      • Basile K.C.
      • Smith S.G.
      • et al.
      Intimate partner violence surveillance: uniform definitions and recommended data elements.
      National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, Atlanta, GA2015

      Adolescence Dating Violence in the United States

      The CDC
      Centers for Disease Control and Prevention
      Prevalence and characteristics of sexual violence, stalking, and intimate partner violence victimization—National Intimate Partner and Sexual Violence Survey, United States, 2011.
      https://www.cdc.gov/mmwr/preview/mmwrhtml/ss6308a1.htm?s_cid=ss6308a1_e
      Date: 2011
      Date accessed: February 11, 2017
      ,
      • Breiding M.J.
      • Chen J.
      • Black M.C.
      Intimate partner violence in the United States.
      National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, Atlanta, GA2014
      and the World Health Organization (WHO)
      World Health Organization
      Responding to Intimate Partner Violence and Sexual Violence Against Women: WHO Clinical and Policy Guidelines.
      World Health Organization, Geneva2013
      both have identified DV as a serious public health concern. Several studies, including both nationally representative and smaller or more targeted samples, have attempted to estimate the prevalence of adolescent DV in the US. Due to definitional, methodological, analytic, and timing differences in these studies, there is a lack of consensus in the data on adolescent DV prevalence.
      • Shorey R.C.
      • Cornelius T.L.
      • Bell K.M.
      A critical review of theoretical frameworks for dating violence: comparing the dating and marital fields.
      Aggress Violent Behav. 2008; 13: 185
      Thus, I report several estimates of DV prevalence in the US, particularly as they highlight different data elements and ways of measuring DV. For example, in 2014, 68.7% of girls aged 12-18 in the National Survey on Teen Relationships and Intimate Violence (STRiV) who had dated in the past year reported some type of DV victimization, and 63.4% reported perpetration.
      • Taylor B.G.
      • Mumford E.A.
      A national descriptive portrait of adolescent relationship abuse: results from the National Survey on Teen Relationships and Intimate Violence.
      J Interpers Violence. 2016; 31: 963
      STRiV is the first nationally representative household survey to assess adolescent DV, although the study authors prefer the term adolescent relationship abuse (ARA). According to STRiV, psychological violence is the most common type of DV reported by adolescent girls: 65.5% reported victimization and 62.2% reported perpetration.
      • Taylor B.G.
      • Mumford E.A.
      A national descriptive portrait of adolescent relationship abuse: results from the National Survey on Teen Relationships and Intimate Violence.
      J Interpers Violence. 2016; 31: 963
      Physical DV victimization was reported by 15.3% of adolescent girls, and 14.7% reported physical DV perpetration.
      • Taylor B.G.
      • Mumford E.A.
      A national descriptive portrait of adolescent relationship abuse: results from the National Survey on Teen Relationships and Intimate Violence.
      J Interpers Violence. 2016; 31: 963
      Sexual violence is also prevalent in adolescent relationships. In the 2014 National Survey of Children's Exposure to Violence (NatSCEV III), 16.4% of girls aged 14-17 reported being the victim of a sexual offense by an adult or peer, including attempted or completed rape (4.4%), sexual harassment (11.5%), and unwanted sexual solicitation online (8.5%).
      • Finkelhor D.
      • Turner H.A.
      • Shattuck A.
      • et al.
      Violence, crime, and abuse exposure in a national sample of children and youth: an update.
      JAMA Pediatr. 2013; 167: 614
      In the STRiV study, 17.8% of girls aged 12-18 reported sexual DV victimization, and 10.6% reported sexual DV perpetration.
      • Taylor B.G.
      • Mumford E.A.
      A national descriptive portrait of adolescent relationship abuse: results from the National Survey on Teen Relationships and Intimate Violence.
      J Interpers Violence. 2016; 31: 963
      Results from more geographically focused studies suggest similar prevalence rates: for example, in a study including 1042 high school students in Texas, up to 20% of adolescents were involved in DV as either perpetrator or victim, and between 10% and 20% were involved in sexual violence.
      • Choi H.J.
      • Temple J.R.
      Do gender and exposure to interparental violence moderate the stability of teen dating violence? Latent transition analysis.
      Prev Sci. 2016; 17: 367
      Rates of DV among adolescents are consistent across genders,
      • Collibee C.
      • Furman W.
      Chronic and acute relational risk factors for dating aggression in adolescence and young adulthood.
      J Youth Adolesc. 2016; 45: 763
      ,
      • Capaldi D.M.
      • Knoble N.B.
      • Shortt J.W.
      • et al.
      A systematic review of risk factors for intimate partner violence.
      Partn Abuse. 2012; 3: 231
      with mutual violence occurring in many relationships.
      • Taylor B.G.
      • Mumford E.A.
      A national descriptive portrait of adolescent relationship abuse: results from the National Survey on Teen Relationships and Intimate Violence.
      J Interpers Violence. 2016; 31: 963
      ,
      • Foshee V.A.
      • Fletcher G.
      • Bauman K.E.
      • et al.
      The Safe Dates Project: theoretical basis, evaluation design, and selected baseline findings.
      Am J Prev Med. 1996; 12: 39
      , 
      • O’Keefe M.
      Teen Dating Violence: A Review of Risk Factors and Prevention Efforts.
      National Online Resource Center on Violence Against Women, 2005
      https://vawnet.org/sites/default/files/materials/files/2016-09/AR_TeenDatingViolence.pdf
      Date accessed: February 23, 2020
      , 
      • O’Leary K.D.
      • Slep A.M.S.
      • Avery-Leaf S.
      • et al.
      Gender differences in dating aggression among multiethnic high school students.
      J Adolesc Health. 2008; 42: 473
      , 
      • Mulford C.
      • Giordano P.C.
      Teen dating violence: a closer look at adolescent romantic relationships. Natl Inst Justice J.
      https://nij.ojp.gov/topics/articles/teen-dating-violence-closer-look-adolescent-romantic-relationships
      Date: 2008
      Date accessed: February 29, 2020
      For example, 65% of girls in violent relationships report that both partners perpetrate physical DV.
      • O’Leary K.D.
      • Slep A.M.S.
      • Avery-Leaf S.
      • et al.
      Gender differences in dating aggression among multiethnic high school students.
      J Adolesc Health. 2008; 42: 473
      In the STRiV study, 59.8% of girls aged 12-18 years reported that they were both the victim and perpetrator of DV.
      • Taylor B.G.
      • Mumford E.A.
      A national descriptive portrait of adolescent relationship abuse: results from the National Survey on Teen Relationships and Intimate Violence.
      J Interpers Violence. 2016; 31: 963
      For psychological DV, 57.5% of girls were both victim and perpetrator; for physical DV, this figure was 11.3%, and for sexual DV, it was 7.9%.
      • Taylor B.G.
      • Mumford E.A.
      A national descriptive portrait of adolescent relationship abuse: results from the National Survey on Teen Relationships and Intimate Violence.
      J Interpers Violence. 2016; 31: 963
      However, sexual violence is primarily perpetrated by males, disproportionately affecting females.
      • Foshee V.A.
      • Fletcher G.
      • Bauman K.E.
      • et al.
      The Safe Dates Project: theoretical basis, evaluation design, and selected baseline findings.
      Am J Prev Med. 1996; 12: 39
      ,
      • O’Keefe M.
      Predictors of dating violence among high school students.
      J Interpers Violence. 1997; 12: 546
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      • O’Keefe M.
      • Treister L.
      Victims of dating violence among high school students: are the predictors different for males and females?.
      Violence Women. 1998; 4: 195
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      • Reidy D.E.
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      • et al.
      Dating Violence and injury among youth exposed to violence.
      Pediatrics. 2016; 137: e20152627
      Among female adolescents in 2017, 9.1% reported physical DV victimization, and 10.7% reported sexual DV.
      • Kann L.
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      Most women first experience sexual, physical, or stalking abuse before age 25 years (71%), with 26% reporting a first experience before age 18.
      • Kann L.
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      • Harris W.A.
      • et al.
      Youth risk behavior surveillance—United States, 2017.
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      • Smith S.G.
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      • et al.
      The National Intimate Partner and Sexual Violence Survey: 2015 Data Brief–Updated Release.
      National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, Atlanta, GA2018
      https://www.cdc.gov/violenceprevention/pdf/2015data-brief508.pdf
      Date accessed: February 24, 2019
      Young women are affected disproportionately by severe consequences of DV.
      • O’Keefe M.
      Teen Dating Violence: A Review of Risk Factors and Prevention Efforts.
      National Online Resource Center on Violence Against Women, 2005
      https://vawnet.org/sites/default/files/materials/files/2016-09/AR_TeenDatingViolence.pdf
      Date accessed: February 23, 2020
      Between 2003 and 2016, 90% of adolescent victims of intimate partner homicides were female.
      • Adhia A.
      • Kernic M.A.
      • Hemenway D.
      • et al.
      Intimate partner homicide of adolescents.
      JAMA Pediatr. 2019; 173: 571
      The literature on gender differences in adolescent DV victimization and perpetration is divided, depending on how DV is measured. Most studies show gender parity in adolescent DV involvement,
      • O’Keefe M.
      • Treister L.
      Victims of dating violence among high school students: are the predictors different for males and females?.
      Violence Women. 1998; 4: 195
      ,
      • Reidy D.E.
      • Kearns M.C.
      • Houry D.
      • et al.
      Dating Violence and injury among youth exposed to violence.
      Pediatrics. 2016; 137: e20152627
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      • Hamby S.
      A scientific answer to a scientific question: the gender debate on intimate partner violence.
      Trauma Violence Abuse. 2017; 18: 145
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      • Hamby S.
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      Measuring teen dating violence in males and females: insights from the National Survey of Children’s Exposure to Violence.
      Psychol Violence. 2013; 3: 323
      , 
      • Molidor C.
      • Tolman R.M.
      Gender and contextual factors in adolescent dating violence.
      Violence Women. 1984; : 180
      with numerous studies suggesting that girls perpetrate more physical DV than boys.
      • Foshee V.A.
      • Fletcher G.
      • Bauman K.E.
      • et al.
      The Safe Dates Project: theoretical basis, evaluation design, and selected baseline findings.
      Am J Prev Med. 1996; 12: 39
      ,
      • O’Leary K.D.
      • Slep A.M.S.
      • Avery-Leaf S.
      • et al.
      Gender differences in dating aggression among multiethnic high school students.
      J Adolesc Health. 2008; 42: 473
      ,
      • O’Leary K.D.
      • Smith Slep A.M.
      A dyadic longitudinal model of adolescent dating aggression.
      J Clin Child Adolesc Psychol. 2003; 32: 314
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      • Feiring C.
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      Romantic relationship aggression and attitudes in high school students: the role of gender, grade, and attachment and emotional styles.
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      Aggression in adolescent dating relationships: prevalence, justification, and health consequences.
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      However, findings from a large longitudinal study suggest that boys aged 13-19 perpetrate more severe physical and sexual DV.
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      The development of four types of adolescent dating abuse and selected demographic correlates.
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      The STRiV survey found no gender differences in any type of DV victimization,
      • Taylor B.G.
      • Mumford E.A.
      A national descriptive portrait of adolescent relationship abuse: results from the National Survey on Teen Relationships and Intimate Violence.
      J Interpers Violence. 2016; 31: 963
      whereas in the NatSCEV II study, girls were twice as likely than boys to be victimized by physical DV.
      • Finkelhor D.
      • Turner H.A.
      • Shattuck A.
      • et al.
      Violence, crime, and abuse exposure in a national sample of children and youth: an update.
      JAMA Pediatr. 2013; 167: 614
      Consistent with the adult IPV literature, girls appear to be more likely than boys to experience fear or injury from DV victimization.
      • Hamby S.
      • Turner H.
      Measuring teen dating violence in males and females: insights from the National Survey of Children’s Exposure to Violence.
      Psychol Violence. 2013; 3: 323
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      • Sege R.
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      Girls are more likely to experience severe violence and mental health consequences associated with DV.2
      • Reidy D.E.
      • Kearns M.C.
      • Houry D.
      • et al.
      Dating Violence and injury among youth exposed to violence.
      Pediatrics. 2016; 137: e20152627
      ,
      • Molidor C.
      • Tolman R.M.
      Gender and contextual factors in adolescent dating violence.
      Violence Women. 1984; : 180
      Overall, studies on sexual and severe physical DV show that girls are disproportionately the victims of these types of relationship abuse.
      • Molidor C.
      • Tolman R.M.
      Gender and contextual factors in adolescent dating violence.
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      ,
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      • et al.
      Gender differences in the longitudinal predictors of adolescent dating violence.
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      Gender and power dynamics in relationships can intensify hostility and coercion toward young women, particularly young women with intersectional identities who are at greatest risk for power-based violence.
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      The sexual and reproductive consequences for DV-involved girls confer unique risks.
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      • Shortt J.W.
      • et al.
      A systematic review of risk factors for intimate partner violence.
      Partn Abuse. 2012; 3: 231
      Adolescent girls with a history of sexual coercion are more likely to engage in health risk behaviors, including SRB.
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      This suggests that experiencing DV in an adolescent dating relationship may set in motion a cycle of risk, with coercive and violent experiences with partners increasing adolescent girls' subsequent SRB and risk for hostile and violent interactions. This is consistent with the adult literature on IPV and sexual health, which suggests that women involved in violent relationships face myriad risks related to sexual and reproductive coercion, including inconsistent use of contraceptives, STIs, and unintended pregnancy.
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      It is important to distinguish between behaviors that may seem similar but that reflect significant power and consent differences: for example, one person may choose not to use a condom because it feels better, but another person may not use a condom because they fear how their partner will react. The first is an example of SRB, whereas the second is an example of sexual or reproductive coercion. Reproductive coercion is a form of psychological aggression, but is also a tactic used to perpetrate sexual DV, according to the CDC's uniform definitions for intimate partner and sexual violence surveillance.
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      • et al.
      Centers for Disease Control and Prevention
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      Research over the past twenty years has increasingly focused on DV as a public health crisis with implications for physical and mental health.
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      Severe dating violence and quality of life among South Carolina high school students.
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      DV is associated with unhealthy eating behaviors,
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      depressive symptoms, and suicide attempts,
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      • Howard D.
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      as well as subsequent intimate partner violence in adulthood.
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      Longitudinal research suggests that experiencing sexual DV, specifically sexual coercion, is linked with subsequent increases in substance use, externalizing symptoms, and SRB, including number of sexual partners, and frequency of intercourse.
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      Changes in adolescents’ risk factors following peer sexual coercion: evidence for a feedback loop.
      Dev Psychopathol. 2012; 24: 559
      Multiple studies have found bidirectional associations between DV and SRB in adolescence, specifically among girls.
      • Coker A.L.
      • McKeown R.E.
      • Sanderson M.
      • et al.
      Severe dating violence and quality of life among South Carolina high school students.
      Am J Prev Med. 2000; 19: 220
      ,
      • Silverman J.G.
      • Raj A.
      • Clements K.
      Dating violence and associated sexual risk and pregnancy among adolescent girls in the United States.
      Pediatrics. 2004; 114: e220
      ,
      • Howard D.
      • Qiu Y.
      • Boekeloo B.
      Personal and social contextual correlates of adolescent dating violence.
      J Adolesc Health. 2003; 33: 9
      ,
      • Raiford J.L.
      • Diclemente R.J.
      • Wingood G.M.
      Effects of fear of abuse and possible STI acquisition on the sexual behavior of young African American women.
      Am J Public Health. 2009; 99: 1067
      , 
      • Wingood G.M.
      • DiClemente R.J.
      • McCree D.H.
      • et al.
      Dating violence and the sexual health of black adolescent females.
      Pediatrics. 2001; 107: E72
      , 
      • Roberts T.A.
      • Auinger P.
      • Klein J.D.
      Intimate partner abuse and the reproductive health of sexually active female adolescents.
      J Adolesc Health. 2005; 36: 380
      , 
      • Alleyne B.
      • Coleman-Cowger V.H.
      • Crown L.
      • et al.
      The effects of dating violence, substance use and risky sexual behavior among a diverse sample of Illinois youth.
      J Adolesc. 2011; 34: 11
      In a study with 1,124 adolescent girls from diverse backgrounds, DV victimization and sexual violence were both linked to multiple sexual partners and less condom use.
      • Alleyne B.
      • Coleman-Cowger V.H.
      • Crown L.
      • et al.
      The effects of dating violence, substance use and risky sexual behavior among a diverse sample of Illinois youth.
      J Adolesc. 2011; 34: 11
      Among a representative sample of sexually experienced US high school girls, adolescents who had been victimized in the past year were twice as likely to have multiple sexual partners, and 1.8 times more likely to become pregnant.
      • Silverman J.G.
      • Raj A.
      • Clements K.
      Dating violence and associated sexual risk and pregnancy among adolescent girls in the United States.
      Pediatrics. 2004; 114: e220
      Another study using data from the 1997 and 1999 Massachusetts Youth Risk Behavior Survey (YRBS) found that adolescent girls with a history of DV victimization were 4-6 times more likely to have been pregnant.
      • Silverman J.G.
      • Raj A.
      • Clements K.
      Dating violence and associated sexual risk and pregnancy among adolescent girls in the United States.
      Pediatrics. 2004; 114: e220
      Girls who had experienced both sexual and physical DV reported having sex at earlier ages and were more likely to have multiple sexual partners.
      • Silverman J.G.
      • Raj A.
      • Clements K.
      Dating violence and associated sexual risk and pregnancy among adolescent girls in the United States.
      Pediatrics. 2004; 114: e220
      SRB like condom nonuse and multiple sexual partners also may be risk factors for DV. For example, unprotected sex and multiple sexual partners are associated with greater odds of physical DV victimization for adolescent girls,
      • Howard D.E.
      • Wang M.Q.
      • Yan F.
      Psychological factors associated with reports of physical dating violence among US adolescent females.
      Adolescence. 2007; 42: 311-324
      and risk factors for severe adolescent DV include being sexually active, pregnancy involvement, and more lifetime and more recent sexual partners.
      • Coker A.L.
      • McKeown R.E.
      • Sanderson M.
      • et al.
      Severe dating violence and quality of life among South Carolina high school students.
      Am J Prev Med. 2000; 19: 220

      Demographic Differences and Health Disparities in Dating Violence and Sexual Risk Behaviors

      The ADDRESSING framework
      • Hays P.A.
      Addressing Cultural Complexities in Practice: Assessment, Diagnosis, and Therapy.
      2nd ed. American Psychological Association, Washington, DC2008
      provides a useful model for conceptualizing the intersection of multiple identities of adolescent girls according to age, developmental or acquired disability, religion, ethnicity, socioeconomic status, sexual orientation, indigenous heritage, national origin, and gender. Intersecting identities create unique risk and protective factors for adolescent girls in terms of risk for DV and SRB.
      • Collins P.H.
      The social construction of black feminist thought.
      Signs. 1989; 14: 745
      ,
      • Crenshaw K.
      Demarginalizing the intersection of race and sex: a black feminist critique of antidiscrimination doctrine, feminist theory and antiracist politics. 1989. Univ Chicago Legal Forum, Chicago, IL1989: 139
      Although data are not available in relation to every aspect of ADDRESSING diversity in terms of DV and SRB for adolescent girls, research does suggest that identity and personal characteristics, such as mental and physical disabilities, serve as markers of important systemic and power differentials that exacerbate the risk for, interaction of, and effects of DV and SRB on health. For example, age differences in perpetration and victimization are also characteristic of adolescent DV.
      • Reidy D.E.
      • Kearns M.C.
      • Houry D.
      • et al.
      Dating Violence and injury among youth exposed to violence.
      Pediatrics. 2016; 137: e20152627
      ,
      • Orpinas P.
      • Hsieh H.-L.
      • Song X.
      • et al.
      Trajectories of physical dating violence from middle to high school: association with relationship quality and acceptability of aggression.
      J Youth Adolesc. 2013; 42: 551
      DV involvement increases from ages 13-17, then decreases by age 18-19.
      • Reidy D.E.
      • Kearns M.C.
      • Houry D.
      • et al.
      Dating Violence and injury among youth exposed to violence.
      Pediatrics. 2016; 137: e20152627
      ,
      • Orpinas P.
      • Hsieh H.-L.
      • Song X.
      • et al.
      Trajectories of physical dating violence from middle to high school: association with relationship quality and acceptability of aggression.
      J Youth Adolesc. 2013; 42: 551
      Among adolescents with suspected violence exposure, younger adolescent boys reported more fear/intimidation, injury, and sexual victimization than younger girls. However, older (age 17) girls reported more physical injury perpetration than older boys.
      • Reidy D.E.
      • Kearns M.C.
      • Houry D.
      • et al.
      Dating Violence and injury among youth exposed to violence.
      Pediatrics. 2016; 137: e20152627
      ,
      • Orpinas P.
      • Hsieh H.-L.
      • Song X.
      • et al.
      Trajectories of physical dating violence from middle to high school: association with relationship quality and acceptability of aggression.
      J Youth Adolesc. 2013; 42: 551
      Serious physical and sexual DV victimization is stable over the course of adolescence,
      • Foshee V.
      Longitudinal predictors of serious physical and sexual dating violence victimization during adolescence.
      Prev Med. 2004; 39: 1007
      underscoring the importance of early screening and prevention.
      Adolescent girls who identify as members of underrepresented racial and/or ethnic minority groups face increased risks for both DV and SRB.
      • Kann L.
      • McManus T.
      • Harris W.A.
      • et al.
      Youth risk behavior surveillance—United States, 2017.
      MMWR Surveill Summ. 2018; 67: 1
      Although some studies have found similar lifetime prevalence of DV among adolescents from diverse racial and ethnic backgrounds,
      • O’Keefe M.
      • Treister L.
      Victims of dating violence among high school students: are the predictors different for males and females?.
      Violence Women. 1998; 4: 195
      others suggest that black/African American adolescents report higher rates of DV perpetration than their white/European American peers,
      • Foshee V.A.
      • Benefield T.
      • Suchindran C.
      • et al.
      The development of four types of adolescent dating abuse and selected demographic correlates.
      J Res Adolesc. 2009; 19: 380
      ,
      • Foshee V.A.
      • Linder F.
      • MacDougall J.E.
      • et al.
      Gender differences in the longitudinal predictors of adolescent dating violence.
      Prev Med. 2001; 32: 128
      ,
      • Foshee V.A.
      • Ennett S.T.
      • Bauman K.E.
      • et al.
      The association between family violence and adolescent dating violence onset does it vary by race, socioeconomic status, and family structure?.
      J Early Adolesc. 2005; 25: 317
      ,
      • Foshee V.A.
      • McNaughton Reyes H.L.
      • Ennett S.T.
      Examination of sex and race differences in longitudinal predictors of the initiation of adolescent dating violence perpetration.
      J Aggress Maltreat Trauma. 2010; 19: 492
      and that the prevalence of DV among Latinx/Hispanic adolescents is comparable to that of black/African American teens.
      • Schnurr M.P.
      • Lohman B.J.
      How much does school matter? An examination of adolescent dating violence perpetration.
      J Youth Adolesc. 2008; 37: 266
      In a study with 1666 adolescents, non-Hispanic black girls reported the highest rates of DV perpetration versus teens of either gender from other racial/ethnic backgrounds. Multiple studies indicate that black/African American and Hispanic teens are more likely to experience DV victimization than white/European American adolescents.
      • O’Leary K.D.
      • Slep A.M.S.
      • Avery-Leaf S.
      • et al.
      Gender differences in dating aggression among multiethnic high school students.
      J Adolesc Health. 2008; 42: 473
      ,
      • Howard D.E.
      • Wang M.Q.
      • Yan F.
      Psychological factors associated with reports of physical dating violence among US adolescent females.
      Adolescence. 2007; 42: 311-324
      ,
      • Coker A.L.
      • McKeown R.E.
      • Sanderson M.
      • et al.
      Severe dating violence and quality of life among South Carolina high school students.
      Am J Prev Med. 2000; 19: 220
      ,
      • Silverman J.G.
      • Raj A.
      • Clements K.
      Dating violence and associated sexual risk and pregnancy among adolescent girls in the United States.
      Pediatrics. 2004; 114: e220
      ,
      • Raiford J.L.
      • Diclemente R.J.
      • Wingood G.M.
      Effects of fear of abuse and possible STI acquisition on the sexual behavior of young African American women.
      Am J Public Health. 2009; 99: 1067
      , 
      • Wingood G.M.
      • DiClemente R.J.
      • McCree D.H.
      • et al.
      Dating violence and the sexual health of black adolescent females.
      Pediatrics. 2001; 107: E72
      , 
      • Roberts T.A.
      • Auinger P.
      • Klein J.D.
      Intimate partner abuse and the reproductive health of sexually active female adolescents.
      J Adolesc Health. 2005; 36: 380
      ,
      • Halpern C.T.
      • Spriggs A.L.
      • Martin S.L.
      • et al.
      Patterns of intimate partner violence victimization from adolescence to young adulthood in a nationally representative sample.
      J Adolesc Health. 2009; 45: 508
      ,
      • Watson J.M.
      • Cascardi M.
      • Avery-Leaf S.
      • et al.
      High school students’ responses to dating aggression.
      Violence Victim. 2001; 16: 339
      Black adolescent girls who have experienced DV are 2.8 times more likely to have an STI, 2.8 times more likely to have nonmongamous partners, and 50% less likely to use condoms consistently.
      • Wingood G.M.
      • DiClemente R.J.
      • McCree D.H.
      • et al.
      Dating violence and the sexual health of black adolescent females.
      Pediatrics. 2001; 107: E72
      Adolescents who identify as lesbian, gay, bisexual, transgender, or queer/questioning (LGBTQ+) are also at greater risk for DV, STIs (including HIV), and unintended pregnancy.
      Institute of Medicine (US)
      Committee on Lesbian, Gay, Bisexual, and Transgender Health Issues and Research Gaps and Opportunities.
      in: The Health of Lesbian, Gay, Bisexual, and Transgender People: Building a Foundation for Better Understanding. National Academies Press, Washington, DC2011
      ,
      • Coker T.R.
      • Austin S.B.
      • Schuster M.A.
      The health and health care of lesbian, gay, and bisexual adolescents.
      Annu Rev Public Health. 2010; 31: 457
      For example, lesbian and bisexual female high school students have higher rates of physical and sexual DV than their heterosexual female peers.
      • Kann L.
      • McManus T.
      • Harris W.A.
      • et al.
      Youth risk behavior surveillance—United States, 2017.
      MMWR Surveill Summ. 2018; 67: 1
      Finally, adolescents with disabilities are likely another underrepresented group at greater risk for DV. Adult women with disabilities are at high risk for IPV,
      • Smith D.L.
      Disability, gender and intimate partner violence: relationships from the behavioral risk factor surveillance system.
      Sex Disabil. 2008; 26: 15
      including young women: for example, a qualitative study with young adult women with mental health and other disabilities suggests that DV is common with both casual and long-term partners.
      • Bonomi A.
      • Nichols E.
      • Kammes R.
      • et al.
      Sexual violence and intimate partner violence in college women with a mental health and/or behavior disability.
      J Womens Health. 2018; 27: 359
      However, there is very limited information on DV or SRB for adolescents with disabilities.
      • Crooks C.V.
      • Jaffe P.
      • Dunlop C.
      • et al.
      Preventing gender-based violence among adolescents and young adults: lessons from 25 years of program development and evaluation.
      Violence Women. 2019; 25: 29
      Young mothers are also at risk for DV and SRB, and are more likely to have intersecting identities that make them more vulnerable to health disparities. Hispanic and non-Hispanic black teens give birth twice as often as non-Hispanic whites,
      • Hamilton B.E.
      • Martin J.A.
      • Osterman M.J.K.
      • et al.
      Births: final data for 2014.
      Natl Vital Stat Rep. 2015; 64: 1
      with educational and income disparity deficits likely contributing to this difference.
      • Sedgh G.
      • Finer L.B.
      • Bankole A.
      • et al.
      Adolescent pregnancy, birth, and abortion rates across countries: levels and recent trends.
      J Adolesc Health. 2015; 56: 223
      Teen mothers have more violent relationships than either other adolescents
      • Moffitt T.E.
      • E-Risk Study Team
      Teen-aged mothers in contemporary Britain.
      J Child Psychol Psychiatry. 2002; 43: 727
      ,
      • Florsheim P.
      • Sumida E.
      • McCann C.
      • et al.
      The transition to parenthood among young African American and Latino couples: relational predictors of risk for parental dysfunction.
      J Fam Psychol. 2003; 17: 65-79
      or older mothers.
      • Moffitt T.E.
      • E-Risk Study Team
      Teen-aged mothers in contemporary Britain.
      J Child Psychol Psychiatry. 2002; 43: 727
      ,
      • Lipsky S.
      • Holt V.L.
      • Easterling T.R.
      • et al.
      Impact of police-reported intimate partner violence during pregnancy on birth outcomes.
      Obstet Gynecol. 2003; 102: 557
      A recent study with pregnant adolescent couples found that 35% had some type of physical DV in their relationship, with most reporting mutual violence.
      • Lewis J.B.
      • Sullivan T.P.
      • Angley M.
      • et al.
      Psychological and relational correlates of intimate partner violence profiles among pregnant adolescent couples.
      Aggress Behav. 2017; 43: 26
      Adolescent mothers are also at greater risk than nonparenting peers for STIs, including HIV.
      • Kershaw T.
      • Niccolai L.
      • Ickovics J.
      • et al.
      Short and long-term impact of adolescent pregnancy on postpartum contraceptive use: implications for prevention of repeat pregnancy.
      J Adolesc Health. 2003; 33: 359
      , 
      • Koniak-Griffin D.
      • Lesser J.
      • Uman G.
      • et al.
      Teen pregnancy, motherhood, and unprotected sexual activity.
      Res Nurs Health. 2003; 26: 4
      , 
      • Meade C.S.
      • Ickovics J.R.
      Systematic review of sexual risk among pregnant and mothering teens in the USA: pregnancy as an opportunity for integrated prevention of STD and repeat pregnancy.
      Soc Sci Med. 2005; 60: 661
      In a sample of 572 minority adolescent mothers, 82% reported condom nonuse at last sex.
      • Koniak-Griffin D.
      • Lesser J.
      • Uman G.
      • et al.
      Teen pregnancy, motherhood, and unprotected sexual activity.
      Res Nurs Health. 2003; 26: 4
      Between 32% and 63% of young mothers report never or infrequently using condoms.
      • Meade C.S.
      • Ickovics J.R.
      Systematic review of sexual risk among pregnant and mothering teens in the USA: pregnancy as an opportunity for integrated prevention of STD and repeat pregnancy.
      Soc Sci Med. 2005; 60: 661
      DV during pregnancy has serious health implications for both mothers and developing fetuses,
      • Espinosa L.
      • Osborne K.
      Domestic violence during pregnancy: implications for practice.
      J Midwifery Womens Health. 2002; 47: 305
      and DV in young parents’ relationships is associated with a host of negative health outcomes for children.
      • Moore D.R.
      • Florsheim P.
      Interpartner conflict and child abuse risk among African American and Latino adolescent parenting couples.
      Child Abuse Negl. 2008; 32: 463
      , 
      • Sarkar N.N.
      The impact of intimate partner violence on women’s reproductive health and pregnancy outcome.
      J Obstet Gynaecol J Inst Obstet Gynaecol. 2008; 28: 266
      , 
      • Bailey B.A.
      • Daugherty R.A.
      Intimate partner violence during pregnancy: incidence and associated health behaviors in a rural population.
      Matern Child Health J. 2007; 11: 495
      Adolescent parents in violent relationships are less likely to break up,
      • Milan S.
      • Lewis J.
      • Ethier K.
      • et al.
      Relationship violence among adolescent mothers: frequency, dyadic nature, and implications for relationship dissolution and mental health.
      Psychol Women Q. 2005; 29: 302
      which may compound the risk for SRB sequelae. In a case-control study of 100 adolescent mothers, physical and sexual DV victimization were associated with approximately 4 times greater risk of rapid repeat pregnancy within 18 months and 22 times greater risk for spontaneous abortion.
      • Jacoby M.
      • Gorenflo D.
      • Black E.
      • et al.
      Rapid repeat pregnancy and experiences of interpersonal violence among low-income adolescents.
      Am J Prev Med. 1999; 16: 318

      Emotional and Behavioral Health Implications

      Both DV and SRB are part of a complex cycle of mental and physical health challenges, personal and interpersonal experiences, which are most likely to affect members of underrepresented minority groups who face significant health disparities. In particular, traumatic events and life stressors clearly increase risk for adolescent involvement in DV and SRB.
      • Wolitzky-Taylor K.B.
      • Ruggiero K.J.
      • Danielson C.K.
      • et al.
      Prevalence and correlates of dating violence in a national sample of adolescents.
      J Am Acad Child Adolesc Psychiatry. 2008; 47: 755
      ,
      • Riggs D.S.
      • O’Leary K.D.
      A theoretical model of courtship aggression.
      in: Violence in Dating Relationships: Emerging Social Issues. Praeger, New York, NY1989: 53
      In a nationally representative survey, adverse childhood experiences (ACEs) accounted for 53.4% of the population-attributable risk proportion of adolescent DV, with childhood sexual abuse, interparental violence, and parental mental illness conferring the greatest risk.
      • Miller E.
      • Breslau J.
      • Chung W.-J.J.
      • et al.
      Adverse childhood experiences and risk of physical violence in adolescent dating relationships.
      J Epidemiol Community Health. 2011; 65: 1006
      There are longitudinal associations between emotion dysregulation and sexual risk-taking in adolescence,
      • Raffaelli M.
      • Crockett L.J.
      Sexual risk taking in adolescence: the role of self-regulation and attraction to risk.
      Dev Psychol. 2003; 39: 1036
      ,
      • Hessler D.
      • Katz L.F.
      Brief report: associations between emotional competence and adolescent risky behavior.
      J Adolesc. 2010; 33: 241
      and teens with internalizing and externalizing mental health symptoms report SRB such as early sexual debut and inconsistent condom use.
      • Tubman J.G.
      • Windle M.
      • Windle R.C.
      The onset and cross-temporal patterning of sexual intercourse in middle adolescence: prospective relations with behavioral and emotional problems.
      Child Dev. 1996; 67: 327
      , 
      • Schofield H.-L.T.
      • Bierman K.L.
      • Heinrichs B.
      • et al.
      Predicting early sexual activity with behavior problems exhibited at school entry and in early adolescence.
      J Abnorm Child Psychol. 2008; 36: 1175
      , 
      • Brown L.K.
      • Hadley W.
      • Stewart A.
      • et al.
      Psychiatric disorders and sexual risk among adolescents in mental health treatment.
      J Consult Clin Psychol. 2010; 78: 590
      , 
      • Brown L.K.
      • Tolou-Shams M.
      • Lescano C.
      • et al.
      Depressive symptoms as a predictor of sexual risk among african american adolescents and young adults.
      J Adolesc Health. 2006; 39: 444
      Adolescents with ACE histories often struggle with emotion regulation and social functioning.
      • Cameron L.D.
      • Carroll P.
      • Hamilton W.K.
      Evaluation of an intervention promoting emotion regulation skills for adults with persisting distress due to adverse childhood experiences.
      Child Abuse Negl. 2018; 79: 423
      ,
      • Boyes M.E.
      • Hasking P.A.
      • Martin G.
      adverse life experience and psychological distress in adolescence: moderating and mediating effects of emotion regulation and rumination.
      Stress Health J. 2016; 32: 402
      When adolescents experience negative emotions such as anxiety, anger, and sadness, they may engage in unhealthy coping behaviors like unprotected sex or DV perpetration.
      • O’Keefe M.
      Predictors of dating violence among high school students.
      J Interpers Violence. 1997; 12: 546
      ,
      • Tice D.M.
      • Bratslavsky E.
      • Baumeister R.F.
      Emotional distress regulation takes precedence over impulse control: if you feel bad, do it!.
      J Pers Soc Psychol. 2001; 80: 53
      Children of adolescent mothers who are in coercive and violent intimate relationships face increased health and mental health risks, including child abuse,
      • Moore D.R.
      • Florsheim P.
      Interpartner conflict and child abuse risk among African American and Latino adolescent parenting couples.
      Child Abuse Negl. 2008; 32: 463
      , 
      • Sarkar N.N.
      The impact of intimate partner violence on women’s reproductive health and pregnancy outcome.
      J Obstet Gynaecol J Inst Obstet Gynaecol. 2008; 28: 266
      , 
      • Bailey B.A.
      • Daugherty R.A.
      Intimate partner violence during pregnancy: incidence and associated health behaviors in a rural population.
      Matern Child Health J. 2007; 11: 495
      and adolescent mothers who are experiencing both DV and SRB may be at particularly high risk for rapid repeat pregnancies and STI infection.
      • Meade C.S.
      • Kershaw T.S.
      • Ickovics J.R.
      The intergenerational cycle of teenage motherhood: an ecological approach.
      Health Psychol. 2008; 27: 419
      ,
      • Ruedinger E.
      • Cox J.E.
      Adolescent childbearing: consequences and interventions.
      Curr Opin Pediatr. 2012; 24: 446
      ACE history is also associated with interpersonal skills difficulties for young women,
      • Elliott D.E.
      • Bjelajac P.
      • Fallot R.D.
      • et al.
      Trauma-informed or trauma-denied: principles and implementation of trauma-informed services for women.
      J Community Psychol. 2005; 33: 461
      which decrease rates of condom use
      • Herrman J.W.
      How teen mothers describe dating violence.
      J Obstet Gynecol Neonatal Nurs. 2013; 42: 462
      ,
      • Kershaw T.S.
      • Milan S.
      • Westdahl C.
      • et al.
      Avoidance, anxiety, and sex: the influence of romantic attachment on HIV-risk among pregnant women.
      AIDS Behav. 2007; 11: 299
      and increase the risk of DV.
      • Grych J.
      • Kinsfogel K.
      Exploring the role of attachment style in the relation between family aggression and abuse in adolescent dating relationships.
      J Aggress Maltreat Trauma. 2010; (Available at:)
      http://epublications.marquette.edu/psych_fac/7
      Adolescent girls are more likely to be violent when they perceive dating relationships to be more serious, and both male and female teens report that jealousy is often the cause of DV.
      • O’Keefe M.
      • Treister L.
      Victims of dating violence among high school students: are the predictors different for males and females?.
      Violence Women. 1998; 4: 195
      Navigating the challenges of dating relationships requires teens to quickly learn skills to help them resolve conflicts, manage difficult emotions, and negotiate safe sexual practices. For example, successful condom negotiation requires assertive communication skills.
      • Schmid A.
      • Leonard N.R.
      • Ritchie A.S.
      • et al.
      Assertive communication in condom negotiation: insights from late adolescent couples’ subjective ratings of self and partner.
      J Adolesc Health. 2015; 57: 94
      ,
      • Javier S.J.
      • Abrams J.A.
      • Moore M.P.
      • et al.
      Condom use efficacy and sexual communication skills among African American college women.
      Health Promot Pract. 2018; 19: 287
      Although there is a lack of research on condom negotiation and DV among adolescent girls, research with college students suggests that condom negotiation mediates the association between DV victimization and condom use.
      • Peasant C.
      • Sullivan T.P.
      • Ritchwood T.D.
      • et al.
      Words can hurt: the effects of physical and psychological partner violence on condom negotiation and condom use among young women.
      Women Health. 2018; 58: 483
      Given the links between emotion regulation, interpersonal skills, and mental health, it is not surprising that depressive symptoms are both risk factors and outcomes of girls’ unhealthy relationships.
      • Ackard D.M.
      • Eisenberg M.E.
      • Neumark-Sztainer D.
      Long-term impact of adolescent dating violence on the behavioral and psychological health of male and female youth.
      J Pediatr. 2007; 151: 476
      ,
      • Brown A.
      • Cosgrave E.
      • Killackey E.
      • et al.
      The longitudinal association of adolescent dating violence with psychiatric disorders and functioning.
      J Interpers Violence. 2009; 24: 1964
      , 
      • East P.L.
      • Felice M.E.
      Adolescent Pregnancy and Parenting: Findings from a Racially Diverse Sample.
      Lawrence Erlbaum Associates, Mahwah, NJ1996
      , 
      • Cutrona C.E.
      • Hessling R.M.
      • Bacon P.L.
      • et al.
      Predictors and correlates of continuing involvement with the baby’s father among adolescent mothers.
      J Fam Psychol. 1998; 12: 369
      , 
      • Gee C.B.
      • Rhodes J.E.
      Postpartum transitions in adolescent mothers’ romantic and maternal relationships.
      Merrill-Palmer Q. 1999; 45: 512
      Longitudinal studies have demonstrated an association between depressive symptoms in adolescence and DV victimization
      • Howard D.E.
      • Wang M.Q.
      • Yan F.
      Psychological factors associated with reports of physical dating violence among US adolescent females.
      Adolescence. 2007; 42: 311-324
      ,
      • Rao U.
      • Hammen C.
      • Daley S.E.
      Continuity of depression during the transition to adulthood: a 5-year longitudinal study of young women.
      J Am Acad Child Adolesc Psychiatry. 1999; 38: 908
      ,
      • Lehrer J.A.
      • Shrier L.A.
      • Gortmaker S.
      • et al.
      Depressive symptoms as a longitudinal predictor of sexual risk behaviors among US middle and high school students.
      Pediatrics. 2006; 118: 189
      and perpetration.
      • Foshee V.A.
      • McNaughton Reyes H.L.
      • Ennett S.T.
      Examination of sex and race differences in longitudinal predictors of the initiation of adolescent dating violence perpetration.
      J Aggress Maltreat Trauma. 2010; 19: 492
      ,
      • Capaldi D.M.
      • Crosby L.
      Observed and reported psychological and physical aggression in young, at-risk couples.
      Soc Dev. 1997; 6: 184
      These associations may be bidirectional: for example, DV is predictive of subsequent increases in internalizing symptoms for rural adolescent girls.
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      • et al.
      A longitudinal examination of psychological, behavioral, academic, and relationship consequences of dating abuse victimization among a primarily rural sample of adolescents.
      J Adolesc Health. 2013; 053: 723
      Multiple studies suggest links between depressive symptoms, psychological distress, and SRB.
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      • et al.
      Negative affect and hiv risk in alcohol and other drug (AOD) abusing adolescent offenders.
      J Child Adolesc Subst Abuse. 2003; 13: 1
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      Motherhood during the teen years: a developmental perspective on risk factors for childbearing.
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      , 
      • Murphy D.A.
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      No change in health risk behaviors over time among HIV infected adolescents in care: role of psychological distress.
      J Adolesc Health. 2001; 29: 57
      , 
      • Brooks T.L.
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      • et al.
      Association of adolescent risk behaviors with mental health symptoms in high school students.
      J Adolesc Health. 2002; 31: 240
      , 
      • Brown L.K.
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      • et al.
      Self-cutting and sexual risk among adolescents in intensive psychiatric treatment.
      Psychiatr Serv. 2005; 56: 216
      , 
      • Joppa M.C.
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      • Brown L.K.
      • et al.
      Internalizing symptoms and safe sex intentions among adolescents in mental health treatment: personal factors as mediators.
      Child Youth Serv Rev. 2014; 46: 177
      One study with black adolescent girls found that depressive symptoms were associated with pregnancy, unprotected sex, nonmonogamous sexual partners, contraceptive nonuse, greater perceived barriers to condom use, and condom negotiation fears 6 months later.
      • DiClemente R.J.
      • Wingood G.M.
      • Crosby R.A.
      • et al.
      A prospective study of psychological distress and sexual risk behavior among black adolescent females.
      Pediatrics. 2001; 108: e85
      These authors also found that depressive symptoms were associated with decreased feelings of control in dating relationships and increased risk of DV.
      • DiClemente R.J.
      • Wingood G.M.
      • Crosby R.A.
      • et al.
      A prospective study of psychological distress and sexual risk behavior among black adolescent females.
      Pediatrics. 2001; 108: e85
      Using illegal drugs, tobacco, alcohol, and steroids also increases risk for severe teen DV.
      • Coker A.L.
      • McKeown R.E.
      • Sanderson M.
      • et al.
      Severe dating violence and quality of life among South Carolina high school students.
      Am J Prev Med. 2000; 19: 220
      Associations between DV and substance use may depend on both the type of substance and the type of DV. Heavy smoking, binge drinking, and cocaine use are more common among adolescent girls who have experienced physical, sexual, or both types of DV.
      • Silverman J.G.
      • Raj A.
      • Clements K.
      Dating violence and associated sexual risk and pregnancy among adolescent girls in the United States.
      Pediatrics. 2004; 114: e220
      Marijuana use is associated with increased DV perpetration for girls.
      • Foshee V.A.
      • McNaughton Reyes H.L.
      • Ennett S.T.
      Examination of sex and race differences in longitudinal predictors of the initiation of adolescent dating violence perpetration.
      J Aggress Maltreat Trauma. 2010; 19: 492
      Longitudinal data from a sample of rural adolescents suggests that psychological DV is a predictor of alcohol use, whereas physical DV predicts tobacco and marijuana use for girls.
      • Foshee V.A.
      • Reyes H.L.M.
      • Gottfredson N.C.
      • et al.
      A longitudinal examination of psychological, behavioral, academic, and relationship consequences of dating abuse victimization among a primarily rural sample of adolescents.
      J Adolesc Health. 2013; 053: 723
      Because DV involvement is associated with using substances before sexual intercourse,
      • Alleyne B.
      • Coleman-Cowger V.H.
      • Crown L.
      • et al.
      The effects of dating violence, substance use and risky sexual behavior among a diverse sample of Illinois youth.
      J Adolesc. 2011; 34: 11
      and substance use is associated with SRB such as condom nonuse
      • Seth P.
      • Sales J.M.
      • DiClemente R.J.
      • et al.
      Longitudinal examination of alcohol use: a predictor of risky sexual behavior and Trichomonas vaginalis among African-American female adolescents.
      Sex Transm Dis. 2011; 38: 96-101
      ,
      • Swartzendruber A.
      • Sales J.M.
      • Rose E.S.
      • et al.
      Alcohol use problems and sexual risk among young adult African American mothers.
      AIDS Behav. 2016; 20: 74
      and multiple sexual partners,
      • Swartzendruber A.
      • Brown J.L.
      • Sales J.M.
      • et al.
      Developmental changes in sexual risk and substance use among african american females: an integrated data analysis approach using time-varying effect models.
      Prev Sci. 2019; 21: 182
      substance use in the context of sexual and dating relationships may be one mechanism by which DV increases the risk for SRB, and vice versa. However, there is very little research on the additive or interaction effects of DV and SRB for adolescent girls in terms of mental or physical health.

      Prevention, Screening, and Intervention for DV and Sexual Risk

      Adolescent girls and their partners need skills that they can realistically use to prevent DV and SRB. Adolescent DV prevention programs are promising, but research to date generally finds small effect sizes.
      • De Koker P.
      • Mathews C.
      • Zuch M.
      • et al.
      A systematic review of interventions for preventing adolescent intimate partner violence.
      J Adolesc Health. 2014; 54: 3
      Programs often focus primarily on either DV or SRB, not both, and cover other aspects of relationship health to varying degrees (for a review, see De Koker et al., 2014, and Ellsberg et al., 2018).
      • De Koker P.
      • Mathews C.
      • Zuch M.
      • et al.
      A systematic review of interventions for preventing adolescent intimate partner violence.
      J Adolesc Health. 2014; 54: 3
      ,
      • Ellsberg M.
      • Ullman C.
      • Blackwell A.
      • et al.
      What works to prevent adolescent intimate partner and sexual violence? A global review of best practices.
      in: Wolfe D.A. Temple J.R. Adolescent Dating Violence. Academic Press, San Diego, CA2018: 381
      Evidence-based adolescent DV prevention programs, such as Safe Dates, The Fourth R, and Shifting Boundaries, focus on relationships skills (e.g., communication, decision-making, personal safety), understanding gender and power inequities, and are typically delivered in school or community settings.
      • De Koker P.
      • Mathews C.
      • Zuch M.
      • et al.
      A systematic review of interventions for preventing adolescent intimate partner violence.
      J Adolesc Health. 2014; 54: 3
      More recently, the CDC has developed Dating Matters®, a universal prevention program for 11- to 14-year-olds in high-risk urban environments.
      • Tharp A.T.
      Dating MattersTM: the next generation of teen dating violence prevention.
      Prev Sci. 2012; 13: 398
      Dating Matters addresses both individual (SRB, emotion regulation, substance use, gender norms) and relationship-level risk factors for DV.
      • Tharp A.T.
      Dating MattersTM: the next generation of teen dating violence prevention.
      Prev Sci. 2012; 13: 398
      For adolescent girls with previous DV exposure, the Date SMART prevention program uses cognitive−behavioral therapy skills to target depressive symptoms, emotion regulation, and interpersonal skills to reduce risk for both DV and SRB.
      • Rizzo C.J.
      • Joppa M.
      • Barker D.
      • et al.
      Project date smart: a dating violence (DV) and sexual risk prevention program for adolescent girls with prior DV exposure.
      Prev Sci. 2018; 19: 416
      ,
      • Collibee C.
      • Rizzo C.J.
      • Kemp K.
      • et al.
      Depressive symptoms moderate dating violence prevention outcomes among adolescent girls.
      J Interpers Violence. 2018; 19
      Finally, limited programs exist to reduce DV perpetration by male identified-adolescents. Coaching Boys into Men is one such program for male high school student-athletes.
      • Miller E.
      • Tancredi D.J.
      • McCauley H.L.
      • et al.
      “Coaching boys into men”: a cluster-randomized controlled trial of a dating violence prevention program.
      J Adolesc Health. 2012; 51: 431
      A promising recent addition to the prevention literature is WiseGuyz, a gender-transformative healthy relationships program for Canadian high school students who identify as male that is based on feminist and social norms prevention approaches.
      • Exner-Cortens D.
      • Wright A.
      • Hurlock D.
      • et al.
      Preventing adolescent dating violence: an outcomes protocol for evaluating a gender-transformative healthy relationships promotion program.
      Contemp Clin Trials Commun. 2019; 16: 100484
      Taken together, the literature suggests that in order to increase the effectiveness of DV and SRB prevention, interventions need to do the following: (1) target skills that research shows can help reduce the prevalence of both DV and SRB in adolescent of all genders; (2) reduce barriers to engagement in prevention programming, such as time, travel, insurance, and stigma associated with these topics; and (3) be tailored to the needs of adolescents who are most at risk, such as girls with older partners, members of underrepresented minority groups, and young mothers.
      The American College of Obstetrics and Gynecology (ACOG) encourages providers to screen all women regularly for DV, including adolescents, and new mothers at postpartum visits.
      ACOG
      Intimate partner violence.
      http://www.acog.org/Resources-And-Publications/Committee-Opinions/Committee-on-Health-Care-for-Underserved-Women/Intimate-Partner-Violence
      Date accessed: February 23, 2017
      ,
      ACOG: ACOG Committee opinion no
      758: promoting healthy relationships in adolescents.
      Obstet Gynecol. 2018; 132: e213
      DV is increasingly recognized by pediatric providers as a serious public health problem. The AAP emphasizes the role of pediatric providers in screening, reporting, education, and care coordination for adolescents at risk for DV; however, they do not explicitly connect DV and SRB. Neither ACOG nor AAP provides comprehensive guidance to providers on assessment, prevention, or intervention strategies to address adolescent DV. However, ACOG does recommend beginning anticipatory guidance about healthy relationships in middle school; advises providers to be aware of mandatory reporting and confidentiality laws to facilitate these conversations; and advises providers to pay special attention to the unique needs of underrepresented adolescents, including young mothers and patients who identify as having disabilities or as LGBTQ+.
      ACOG: ACOG Committee opinion no
      758: promoting healthy relationships in adolescents.
      Obstet Gynecol. 2018; 132: e213
      Adolescent gynecology providers could efficiently address both DV and SRB together in office visits by asking about patients' recent relationships with intimate partners, which can build rapport and trust as well as facilitating screening for signs of DV and SRB. Assessing DV with adolescents who present for preventive care, or even prenatal and obstetric care, is difficult given time constraints. Providers should consider providing psychoeducational information about DV, its impact on young women's health, and local developmentally-appropriate DV resources. Another promising avenue is to have trained behavioral health interventionists deliver brief, skills-based interventions to promote healthy relationship skills such as condom negotiation, assertive communication, and conflict resolution in concert with routine preventive gynecological care for adolescents.

      Conclusions and Future Directions

      Although research on adolescent DV is a growing area,
      • Wolfe D.A.
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      • Temple J.R.
      Adolescent dating violence: theory, research, and prevention.
      http://search.ebscohost.com/login.aspx?direct=true&scope=site&db=nlebk&db=nlabk&AN=1724660
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      ,
      • Chen M.S.
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      Dating abuse: prevalence, consequences, and predictors.
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      we know relatively little about the links between DV and SRB. Much of the literature focuses on identifying risk factors for DV and SRB, but not their co-occurrence or the mechanisms that might explain their connection. Person-centered, qualitative, and mixed-methods approaches to studying the context and confluence of DV and SRB are needed to inform prevention and intervention programming. Longitudinal research can clarify the temporal sequence and intersections of risk in adolescent girls’ relationships: although most studies have focused on DV as a preceding or concurrent risk factor for SRB, the relationship is likely more bidirectional, and several studies suggest that SRB increases risk for DV as well.
      • Howard D.E.
      • Wang M.Q.
      • Yan F.
      Psychological factors associated with reports of physical dating violence among US adolescent females.
      Adolescence. 2007; 42: 311-324
      ,
      • Foshee V.A.
      • Reyes H.L.M.
      • Gottfredson N.C.
      • et al.
      A longitudinal examination of psychological, behavioral, academic, and relationship consequences of dating abuse victimization among a primarily rural sample of adolescents.
      J Adolesc Health. 2013; 053: 723
      For example, conflict over condom nonuse, reproductive coercion, or extradyadic sexual partners might precipitate DV.
      The social determinants of women's health, particularly of young women from racial, ethnic, and sexual minority groups, are best approached from an intersectional, social ecological, and minority stress-informed perspective.
      • Crenshaw K.
      Mapping the margins: intersectionality, identity politics, and violence against women of color.
      Stanford Law Rev. 1991; 43: 1241
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      • Bauer G.R.
      Incorporating intersectionality theory into population health research methodology: challenges and the potential to advance health equity.
      Soc Sci Med. 2014; 110: 10
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      • Crenshaw K.
      Demarginalizing the intersection of race and sex: a black feminist critique of antidiscrimination doctrine, feminist theory and antiracist politics. 1989. Univ Chicago Legal Forum, Chicago, IL1989: 139
      ,
      Institute of Medicine (US)
      Committee on Lesbian, Gay, Bisexual, and Transgender Health Issues and Research Gaps and Opportunities.
      in: The Health of Lesbian, Gay, Bisexual, and Transgender People: Building a Foundation for Better Understanding. National Academies Press, Washington, DC2011
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      • Hatzenbuehler M.L.
      • Pachankis J.E.
      Stigma and minority stress as social determinants of health among lesbian, gay, bisexual, and transgender youth: research evidence and clinical implications.
      Pediatr Clin North Am. 2016; 63: 985
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      • Meyer I.H.
      Prejudice, social stress, and mental health in lesbian, gay, and bisexual populations: conceptual issues and research evidence.
      Psychol Bull. 2003; 129: 674
      Research addressing the links between DV and SRB, particularly the development of strategies for screening, prevention, and intervention, should be grounded in these theoretical frameworks. For example, a recent study on the mental health sequelae of IPV among women who identify as non-heterosexual and disabled could be replicated with adolescents.
      • Coston B.M.
      Disability, sexual orientation, and the mental health outcomes of intimate partner violence: a comparative study of women in the U.S.
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      Underrepresented young women are most vulnerable to DV and SRB, and also less likely to be engaged in regular medical care. For example, ACOG has identified unintended pregnancy and access to birth control as areas of health disparity for racial and ethnic minority women.
      ACOG
      Racial and ethnic disparities in obstetrics and gynecology.
      https://www.acog.org/Clinical-Guidance-and-Publications/Committee-Opinions/Committee-on-Health-Care-for-Underserved-Women/Racial-and-Ethnic-Disparities-in-Obstetrics-and-Gynecology
      Date accessed: February 22, 2019
      Given the health disparities in adolescent DV, pregnancy, and STI prevalence in the US,
      • Kann L.
      • McManus T.
      • Harris W.A.
      • et al.
      Youth risk behavior surveillance—United States, 2017.
      MMWR Surveill Summ. 2018; 67: 1
      ,
      • Hamilton B.E.
      • Martin J.A.
      • Osterman M.J.K.
      • et al.
      Births: final data for 2014.
      Natl Vital Stat Rep. 2015; 64: 1
      targeted and community-informed screening, prevention, and intervention initiatives are needed. Lesbian and bisexual women are also less likely than heterosexual women to engage with preventive healthcare.
      Institute of Medicine (US)
      Committee on Lesbian, Gay, Bisexual, and Transgender Health Issues and Research Gaps and Opportunities.
      in: The Health of Lesbian, Gay, Bisexual, and Transgender People: Building a Foundation for Better Understanding. National Academies Press, Washington, DC2011
      The effects of stigma related to DV involvement, sexual or gender identity disclosure, documentation status, partner age, parenting status, English language proficiency, and other aspects of diversity often intersect with structural and systemic barriers (eg, racism, sexism, transportation, health insurance) that may impede access to healthcare.
      • Kann L.
      • McManus T.
      • Harris W.A.
      • et al.
      Youth risk behavior surveillance—United States, 2017.
      MMWR Surveill Summ. 2018; 67: 1
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      • Mayer K.H.
      • Bradford J.B.
      • Makadon H.J.
      • et al.
      Sexual and gender minority health: what we know and what needs to be done.
      Am J Public Health. 2008; 98: 989
      Identifying and reducing risk for DV and SRB is essential for pediatric and adolescent gynecology providers interested in providing culturally sensitive, developmentally appropriate care for underrepresented young women.

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      Article info

      Publication history

      Published online: February 19, 2020

      Footnotes

      M.C.J. has nothing to disclose.

      Identification

      DOI: https://doi.org/10.1016/j.jpag.2020.02.007

      Copyright

      © 2020 North American Society for Pediatric and Adolescent Gynecology. Published by Elsevier Inc.

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