PEDIATRICS Vol. 107 No. 5 May 2001, p. e72

ELECTRONIC ARTICLE:
Dating Violence and the Sexual Health of Black Adolescent Females

Gina M. Wingood, ScD, MPH^*, , Ralph J. DiClemente, PhD^{*, , §}, Donna Hubbard McCree, PhD, MPH^*, , Kathy Harrington, MPH, MEd, and Susan L. Davies, PhD, MEd

From the ^* Department of Behavioral Sciences and Health Education, Rollins School of Public Health, Atlanta, Georgia;  Emory/Atlanta Center for AIDS Research, Atlanta, Georgia; ^§ Department of Pediatrics, Division of Infectious Diseases, Epidemiology and Immunology, Emory University School of Medicine, Atlanta, Georgia; and  Department of Health Behavior, School of Public Health, University of Alabama, Birmingham, Alabama.

	ABSTRACT

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Objective.  This study examines the association between having a history of dating violence and the sexual health of adolescent females.

Methods.  Black adolescent females (n = 522) completed a survey that assessed dating violence, defined as ever having a physically abusive boyfriend, and an interview that assessed sexual behaviors.

Results.  Dating violence was reported by 18.4% of adolescents (n = 96). Adolescents with a history of dating violence were, in the past 6 months, 2.8 times more likely to have a sexually transmitted disease, 2.8 times more likely to have nonmonogamous male partners, and half as likely to use condoms consistently. Furthermore, adolescents with a history of dating violence were significantly more likely to fear the perceived consequences of negotiating condom use (odds ratio [OR] = 2.8); fear talking with their partner about pregnancy prevention (OR = 2.6); have a higher perceived risk of acquiring a sexually transmitted disease (OR = 2.1); perceive less control over their sexuality (OR = 2.4); have peer norms nonsupportive of using condoms (OR = 3.1); and have norms nonsupportive of having a healthy relationship (OR = 2.1).

Conclusions.  Adolescents who have experienced dating violence are more likely to exhibit a spectrum of unhealthy sexual behaviors, attitudes, beliefs, and norms.  Key words:  dating violence, sexual behaviors, pregnancy.

Although society is becoming more aware of domestic violence involving adults, the issue of dating violence among adolescents has not received sufficient attention.¹ The majority of adolescents have begun dating by 16 years old, and many have experienced an episode of dating violence by age 15 years.² The prevalence of dating violence among adolescents ranges from 9% to 39%,^1,3-5 with previous research indicating a higher prevalence of dating violence among black female adolescents compared with female adolescents of other ethnic groups.^1,3

A number of studies have examined factors that may contribute to violence in dating relationships.^1-8 Much of the research on dating violence has been conducted with school-based, predominantly white populations. Although informative, findings from these studies may not be relevant for black female adolescents, a population that has a higher prevalence of dating violence and has higher rates of unintended pregnancy and sexually transmitted diseases (STDs), including human immunodeficiency virus (HIV). Although several studies have reported that between 15% and 25% of pregnant teens experience physical assault,^9,10 there has been limited research examining the relationship between dating violence and adolescent females sexual health. The paucity of research examining dating violence among black female adolescents and its relationship to pregnancy and STD/HIV risk-taking has created a gap in our knowledge of adolescent females' sexual health.

The aim of this study is to examine the association between dating violence and the sexual health, behaviors, norms, and attitudes of black female adolescents.

	METHODS

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From December 1996 through April 1999, project recruiters screened teens in an adolescent medicine clinic, a health department, and school health classes to determine their eligibility for participating in an HIV/STD prevention study. Adolescents were eligible to participate in the study if they were black females, between the ages of 14 and 18 years at the time of enrollment, sexually active in the previous 6 months, and provided written informed consent. Six hundred nine teens were eligible. Of the eligible adolescents, 522 (85.7%) agreed to participate in the study. The majority of eligible teens who did not participate in the study were unavailable because of conflicts with their employment schedules. The study protocol was approved by the committee on human research of the university before implementation.

Data Collection

Data collection was conducted at the Family Medicine Clinic and consisted of a self-administered survey that assessed dating violence and adolescents' sexuality-related attitudes, beliefs, and perceived norms, and a structured personal interview that assessed sexual risk behaviors.

The self-administered survey was conducted in a group setting with monitors providing assistance to adolescents with limited literacy and helping to ensure confidentiality of responses. Subsequently, adolescents completed a face-to-face interview that assessed sexual risk behaviors. The interview was administered by trained black female interviewers in private examination rooms. Adolescents were reimbursed $20 for their participation.

Measures

Sociodemographic Variables Sociodemographic variables assessed adolescents' age, education, work history, family residence, whether their family are recipients of public assistance (Temporary Assistance For Needy Families), and parental monitoring.

Dating Violence The primary predictor variable, dating violence, was assessed by asking adolescents, "Has a boyfriend ever physically abused you (ie, punched, hit, or pushed you)?" Adolescents who responded affirmatively then were asked whether dating violence occurred within the past 6 months.

History of STDs and Pregnancy Adolescents were asked 4 items to determine whether in the past 6 months they had been treated for chlamydia, trichomoniasis, gonorrhea, or syphilis. Adolescents who reported being treated for any of the STDs were defined as having a history of STDs in the previous 6 months. Additionally, adolescents were also asked whether they had ever been pregnant.

Sexual Behaviors The interview assessed a number of sexual behaviors within the previous 6 months. These variables included the frequency of condom use, having multiple sexual partners, and having a male partner who had other female sexual partners (ie, a nonmonogamous partner).

Alcohol Consumption The interview assessed the number of days that alcohol was consumed during the past 60 days, whether adolescents engaged in binge drinking (drinking 5 or more drinks at once), and the typical number of drinks that adolescents consumed at 1 time.

Psychosocial Scales Several psychosocial scales were included as part of the survey and their psychometric properties are displayed in Table 1. The survey assessed adolescents' perceived control over their sexuality, their perceived risk of acquiring an STD, their fears about the potential consequences of negotiating condom use, their fears about talking with their partner about pregnancy prevention, and their norms about healthy relationships. Because of the highly skewed distribution of the scale scores, all of the scales were dichotomized based on a median split of the distribution.

Peer Norms About Condom Use One item assessed peer norms regarding condom use. This item asked adolescents, "How many of your girlfriends use a condom most of the time when they have sex?" Responses to this item ranged from none (1) to all (5), with lower values indicative of having perceived norms nonsupportive of using condoms.

Data Analysis

The data analysis was comprised of several sequential steps. First, descriptive statistics were used to describe the prevalence of dating violence. Subsequently, adolescents who reported a history of dating violence within the past 6 months (n = 29) were excluded from the analyses because of our inability to determine a temporal sequence between exposure to dating violence and the outcomes of interest. In subsequent univariate analyses, adolescents reporting a history of dating violence were compared with adolescents without a history of dating violence with respect to specified outcomes (eg, sexual health, behaviors, attitudes, beliefs, and norms). Next, to identify potential covariates, adolescents reporting a history of dating violence were compared with adolescents without a history of dating violence with respect to sociodemographic characteristics and alcohol use. Finally, outcomes and observed covariates significantly associated with dating violence in univariate analyses (P < .05) were included in logistic regression analyses. Model statistics computed include adjusted odds ratios, 95% confidence intervals, and their corresponding P values.¹¹

	RESULTS

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Between December 1996 and April 1999, 522 single black females, 14 to 18 years old, participated in the study. A history of dating violence was reported by 18.4% of adolescents (n = 96). Among adolescents experiencing dating violence, 30.2% (n = 29) had been abused in the past 6 months. We excluded these 29 adolescents from subsequent analyses.

In univariate analyses, a history of dating violence was associated with poorer sexual health indices (Table 2). Additionally, older age was identified as associated with having a history of dating violence and with having a history of STDs. Thus, this variable was considered as a covariate in subsequent logistic regression analyses. No other associations were observed between dating violence, other sociodemographic variables, or alcohol use.

In logistic analyses (Table 2), a history of dating violence was associated with being 2.8 times more likely to have had an STD, 2.8 times more likely to have a nonmonogamous partner, half as likely to use condoms consistently during the past 6 months, and 2.1 times more likely to have ever been pregnant. Additionally, dating violence was associated with a number of risky attitudes, beliefs, and norms, including being more than twice as likely to have a greater perceived risk of acquiring an STD, being more than twice as likely to have norms nonsupportive of a healthy relationship, and being nearly 21/2 times as likely to perceive themselves as having limited control over their sexuality. Furthermore, compared with adolescents having no history of dating violence, adolescents who reported a history of dating violence were 2.6 times more likely to fear talking with their partner about pregnancy prevention, 2.8 times more likely to fear the consequences of negotiating condom use, and 3.1 times more likely to have peer norms nonsupportive of condom use.

	DISCUSSION

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In this sample of black female adolescents, 18.4% reported a history of physical dating violence. These results corroborate findings from other studies identifying the prevalence of physical dating violence.^12-14 This study also observed an association between a history of dating violence and adolescents' sexual health, their sexual behaviors, attitudes, beliefs, and perceived norms. The findings corroborate previous studies observing an association between having a physically abusive partner and adverse sexual health behaviors among adult women.¹⁵ Although the findings indicate that the magnitude of the associations observed is substantial, it is the consistent pattern of associations observed across these different outcomes that is particularly concerning.

Research in the field of domestic violence may provide a useful framework for understanding the association between dating violence and the observed findings. A history of dating violence by one's boyfriend may produce passivity and helplessness.¹⁶ Consequently, those who have experienced dating violence may fear the consequences of negotiating condom use, perceive themselves as having less control over their sexuality, and, thus, may fear talking about pregnancy prevention. Additionally, this fear and perceived limited control may reduce the likelihood of practicing safer sex, resulting in these adolescents being more concerned about acquiring STDs and having an increased risk of STDs and pregnancy.

In addition to their own experiences with dating violence, between 50% and 80% of teens say that they know of other teens who have been involved in violent relationships.¹⁷ Adolescents' perception of the prevalence of dating violence and their own experience of abuse may shape their beliefs regarding dating violence as normative and adversely influence their perceptions about safer sex and healthy relationships.

The prevalence of dating violence and its association with unhealthy behaviors that could lead to unintended pregnancy, STDs, and HIV infection have implications for clinical and public health practice. Dating violence is not only an immediate threat to the health of the adolescent, but exposure to dating violence also may thwart the use of appropriate sexual health behaviors that prevent disease acquisition. Health care providers serving adolescents could provide a comprehensive risk assessment that includes screening for dating violence. Identification of a history of dating violence would be an important opportunity to provide referral to appropriate counseling and education, including resources on pregnancy, STDs, and HIV prevention. Additionally, STD/HIV and pregnancy interventions may be more efficacious if they validate adolescents' victimization; discuss the relationship between dating violence, pregnancy, and sexual risk-taking; and provide referral to counseling.

Limitations

The present study is not without limitations. Foremost, the primary limitation is the use of a retrospective research design to examine the association between dating violence and adolescents' sexual health, although adolescents experiencing dating violence in the 6-month assessment period were excluded from analyses. Additionally, these data examine the association between dating violence and risk behaviors that occurred in the past 6 months, as opposed to examining risk behaviors that had ever occurred. Thus, the analysis does not allow us to examine the presence of risk behaviors that may have been present before the date violence occurred. These risk behaviors could have increased adolescents' vulnerability to dating violence. Furthermore, the present study may have limited generalizability. The study results may be only applicable to black adolescents residing in high-risk social environments. The findings may not be applicable to adolescents of other ethnic/racial backgrounds or same-sex couples. Finally, the lack of data about sexual and emotional abuse, the perpetrator, and misclassification that may result from underreporting this experience may have weakened the association between dating violence and the outcomes.

	CONCLUSION

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These findings highlight the public health importance of understanding the relationship between dating violence and its implications for pregnancy and HIV/STD prevention. Helping adolescents to deal with dating violence could be an essential element in reducing their risk of pregnancy, STDs, and HIV. The prevalence of dating violence and its association with adolescents' sexual health remains an understudied area of research. Additional studies are warranted to characterize, more precisely, the mechanisms through which dating violence affects adolescents sexual health, so that appropriate interventions can be designed.

	ACKNOWLEDGMENTS

This study was supported by Grant 1R01 MH54412 from the Center for Mental Health Research on AIDS, National Institute of Mental Health.

	FOOTNOTES

Received for publication May 17, 2000; accepted Dec 11, 2000.

Reprint requests to (G.M.W.) Department of Behavioral Sciences and Health Education, Rollins School of Public Health, 1518 Clifton Rd NE, Room 548, Atlanta, GA 30322. E-mail: gwingoo{at}sph.emory.edu

	ABBREVIATIONS

STD, sexually transmitted disease; HIV, human immunodeficiency virus; OR, odds ratio.

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