Risk profiles of adolescent girls who were victims of dating violence.

Howard, Donna E. ; Wang, Min Qi

The designation of violent and abusive behavior as a U.S. public health priority is evidenced by its inclusion in the Healthy People 2000 and 2010 objectives (U.S. Department of Health and Human Services, 2000a, 2000b). Intimate partner violence is an important subdomain of such behavior. Overall, studies indicate that the prevalence of non-sexual courtship violence ranges from 9% to 65%, depending on the definitions and research methods used (Centers for Disease Control, 2000). Moreover, it is now apparent that the reach of relationship violence extends well into the world of adolescence. In acknowledgment of this, a series of Healthy People health status objectives specifically targets physical partner abuse and assault leading to injury among females as young as 12 years of age.

Two probability samples (Silverman, Raj, Mucci, & Hathaway, 2001; Halpern, Oslak, Young, Martin, & Kupper, 2001) and several nonprobability samples (Foshee, Linder, Bauman, Langwick, Arriaga, Health, McMahon, & Bangdiwala, 1996; Jackson & Foshee, 1998; Gray & Foshee, 1997; Foshee, 1996) have provided the basis for what is currently known about the prevalence of adolescent dating violence and some of its psychosocial correlates. The Centers for Disease Control (2000), in summarizing the extent of dating violence in young adults, reported that the average prevalence for high school and college students is 22% and 32% respectively. Recently, Silverman et al. (2001), utilizing Massachusetts Youth Risk Behavior Survey (YRBS) data from 1997 and 1999, reported that about one in five adolescent high school girls has experienced dating violence. Examining data from the National Longitudinal Study of Adolescent Health, collected during the 1994-95 school year, Halpern et al. (2001) calculated the prevalence of psycholo gical and minor physical violence victimization among 7ththrough 12th-grade adolescents in romantic heterosexual relationships, and found that 32% reported experiencing some kind of violence in dating relationships in the 18 months prior to the interview. While the majority of these reports involved psychological violence, such as swearing, 12% reported physical victimization experiences (e.g., being shoved, having something thrown at them).

In an attempt to establish a theoretical framework for understanding and preventing adolescent dating violence, research has moved forward on several fronts, including a focus on individual and interpersonal influences, as well as ecological contexts such as the home, school, and community (Foshee et al., 1996). A lifespan perspective has led to the examination of developmental histories of youth who report such experiences (Jackson & Foshee, 1998). Behavioral correlates associated with dating violence victimization, among girls at least, include use of a variety of illicit substances, unhealthy weight control practices, sexual risk behaviors, and suicidality (Silverman et al., 2001). Conceptually, a problem behavior model as articulated by Jessor (Jessor, 1982, 1991), Dryfoos (1990), and others (DiClemente, Hansen, & Ponton, 1996; Resnick, Bearman, Blum, Bauman, Harris, Jones, Tabor, Beuhring, Sieving, Shew, Ireland, Bearinger, & Udry, 1997), to account for the apparent clustering of risk behaviors among cer tain adolescents, may be relevant for dating violence as well. While there is debate over whether health risk behavior among adolescents represents a single behavioral syndrome or multidimensional structure, evidence suggests that the co-occurrence of multiple problem behaviors such as substance use, delinquency, and sexual behavior among certain youth (Basen-Engquist, Edmundson, & Parcel, 1996; Farrell, Danish, & Howard, 1992) may have underlying personality and cognitive problem-solving referents (Siegel, Cousins, & Rubovits, 1993). The risk profile of adolescent girls who are victims of dating violence fits this framework; however, the evidence is far from definitive.

The present study examines the prevalence of adolescent dating violence and its relationship to demographic, psychological, and behavioral risk factors among a large, nationally representative sample of U.S. youth. While there are strong indications that violence in adolescent dating relationships involves the reciprocal use of violence by both partners (Gray & Foshee, 1997; Foshee, 1996; Gaertner & Foshee, 1999; O'Keefe, Brockopp, & Chew, 1986), the focus here is on adolescent females. Many have argued that girls are more likely than boys to suffer injury from partner violence (Gelles, 1981; Lane & Gwartney-Gibbs, 1985). In addition, this orientation is consistent with national health objectives which target women as victims of assaultive dating violence.

This study advances our present knowledge in two important ways. First, it provides current and comprehensive information on dating violence among adolescent girls in the U.S. Consequently, findings from this study have national significance. Prevalence data on adolescent dating violence should provide the kind of empirical evidence necessary to evaluate whether Healthy People 2010 objectives are on target to be achieved. Specifically it provides baseline data, enabling comparisons with subsequent prevalence rates. Second, it aims to broaden the profile of at-risk female adolescents. To this end we will examine the relationship of physical dating violence with other forms of violence, emotional health, sexual behavior, and substance use, and attempt to establish a more complete cluster of risk factors.

METHOD

Sample

The 1999 national school-based Youth Risk Behavior Survey (YRBS) data were used for this study. The YRBS is one component of the Youth Risk Behavior Surveillance System (YRBSS) that was established by the Centers for Disease Control and Prevention (CDC) to monitor the prevalence of youth behaviors that most influence health. Comprehensive design and sampling procedures are available from the CDC's Morbidity and Mortality Weekly Report series, and are presented here in condensed form (CDO, 2000). The YRBS used a three-stage cluster sample design to produce a nationally representative sample of high school students in grades 9-12. The first stage contained 1,270 primary sampling units (PSUs), which consisted of large counties or groups of smaller, adjacent counties. From these, 52 were selected from 16 strata, formed on the basis of the degree of urbanization and the relative percentage of African-American and Hispanic students in the PSU. Each PSU was selected with probability proportional to the size of the s chool enrollment. The second sampling stage selected 187 schools, also with probability proportional to school enrollment size. The third stage randomly selected one or two intact classes of a required subject (e.g., English or social studies) from the 9th-l2th grades at the chosen school. All students in the selected classes were eligible to participate. A total of 15,349 students in 144 schools completed survey questionnaires. The school response rate was 77% and the student response rate was 86%, resulting in an overall response rate of 66%. For the purpose of this study, only female participants (N = 7,824) were selected for the analysis.

A weighting factor was applied to each participant to adjust for non-response and for the varying probabilities of selection, including those resulting from the oversampling of African-American and Hispanic students. The weights were scaled so that (a) the weighted count of students was equal to the total sample size and (b) the weighted proportions of students in each grade matched national population proportions. The data were representative of students in grades 9-12 in public and private schools in the 50 states and the District of Columbia.

Survey Procedures and Measures

Surveys were administered anonymously in order to protect the participants' privacy. Participation was voluntary, and students completed the self-administered questionnaire in their classrooms during a regular class period. They recorded their responses on a scannable answer sheet. Parental permission was obtained before survey administration.

The survey focused on health risk behaviors established during adolescence that result in the most significant mortality, morbidity, disability, and social problems for youths and, later, adults. Monitoring progress in these areas was relevant in assessing the degree to which national health objectives for the year 2000 were achieved. Results were also to be used to help focus programs and policies for comprehensive school health education on those behaviors that contribute most to the leading causes of mortality and morbidity.

One dependent variable was included in the present study, physical dating violence. Physical dating violence was measured by the question: "During the past 12 months, did your boyfriend or girlfriend ever bit, slap, or physically hurt you on purpose?" The response categories for this variable were yes or no.

The independent variables included four dimensions: violence, suicide, substance use, and sexual risk behavior. Violence-related behavior encompassed three questions: (1) "During the past 30 days, on how many days did you carry a gun?" The response categories were coded as 0 days or 1 or more days. (2) "During the past 12 months, how many times were you in a physical fight?" The response categories were coded as 0 times, 1 time, or 2 or more times. (3) "During the past 12 months, how many times were you in a physical fight in which you were injured and had to be treated by a doctor or nurse?" The response categories were coded as 0 times or 1 or more times.

Suicide-related behavior consisted of two questions: (1) "During the past 12 months, did you ever seriously consider attempting suicide?" The response categories were yes or no. (2) "During the past 12 months, how many times did you actually attempt suicide?" The response categories for attempting suicide were coded as yes or no. One additional question examined sad or hopeless feelings: "During the past 12 months, did you ever feel so sad or hopeless almost every day for two weeks or more in a row that you stopped doing some usual activities?" The response categories were yes or no.

Substance use behavior consisted of three questions: (1) "During the past 30 days, on the days you smoked, how many cigarettes did you smoke per day?" The response categories were coded as 0, 1, or 2 or more cigarettes per day. (2) "During the past 30 days, on how many days did you have five or more drinks of alcohol in a row, that is, within a couple of hours?" The response categories were coded as 0 days, 1--5 days, or 6 or more days. (3) "During the past 30 days, how many times did you use any form of cocaine, including powder, crack, or freebase, or sniff glue, or breathe the contents of aerosol spray cans, or inhale any paints or sprays to get high?" The response categories were coded as 0 times or 1 or more times.

Sexual risk behavior consisted of three questions: (1) "During the past three months, with how many people did you have sexual intercourse?" The response categories were coded as never had sexual intercourse, none during past three months, 1 person, or 2 or more people. (2) "Did you drink alcohol or use drugs before you had sexual intercourse the last time?" The response categories were coded as never had sexual intercourse, yes, or no. (3) 'The last time you had sexual intercourse, did you or your partner use a condom?" The response categories were coded as never had sexual intercourse, yes, or no.

In addition, two demographic variables, grade and ethnicity, were included. Some of the above-mentioned variables were coded, as necessary, based on the frequencies in the response categories and the appropriateness for statistical analysis.

Data Analysis

All statistical analyses were performed using Survey Data Analysis (SUDAAN; Shad, Barnwell, & Bieler, 1997) statistical software. SUDAAN can account for multistage sampling by including the design factors (i.e., the stratum and PSU levels) in the analytical model. The data were first analyzed using univariate logistic models to examine relationships between the dependent variable (physical dating violence) and each independent variable (substance use, suicide, physical violence, and sexual risk behaviors). Unadjusted odds ratios (OR) and 95% confidence intervals (CI), as well as results of [chisquare] tests, were examined. To identify the most significant risk factors associated with physical dating violence, multivariate logistic regression analysis, including all significant independent variables in the bivariate analysis, was conducted. Adjusted OR and 95% CI were examined.

RESULTS

In terms of prevalence (see Table 1), 9.23% of the adolescent girls reported experiencing dating violence. While the prevalence of dating violence was highest for 12th-grade girls (10.88%), differences in prevalence across the four grades were not statistically significant. Regarding ethnicity, Black girls reported the highest prevalence of dating violence (14.15%).

Bivariate Relationships

Table 1 shows the unadjusted odds ratios for relationships between risk factors (including grade and ethnicity) and physical dating violence. In all analytic models, no dating violence served as the reference category for the dependent variable.

Adolescent girls who reported a higher prevalence of emotional distress and suicidal thoughts and behaviors were more likely to report dating violence. Girls who reported at least one episode in which they felt sad or hopeless almost every day for two or more consecutive weeks were 3.62 times as likely to have been victims of dating violence. The odds of experiencing dating violence were increased by a factor of 2.46 for girls who had considered suicide over the past year, and 2.19 if they had actually attempted suicide during that same time period.

Involvement in other violent behaviors increased the odds of being a victim of dating violence. Girls who reported physical fights during the past 12 months, and physical fights that had to be treated by doctors or nurses, were also more likely to report dating violence. Girls who carried guns during the past 30 days were 5.29 times as likely to experience dating violence.

Having used a variety of drugs over the past month was associated with increased dating violence among adolescent girls. That is, girls who reported more cigarette smoking, more days when they consumed five or more drinks at one occasion, and, in particular, use of cocaine or inhalants were more likely to report dating violence.

Adolescent girls who reported engaging in risky sexual behaviors were more likely to experience dating violence. The odds of being a victim of dating violence increased by a factor of nearly seven for girls who had sexual intercourse with two or more people during the previous three-month period, as well as for girls who reported using alcohol or drugs before their last sexual encounter. Girls who reported that they did not use condoms the last time they had sexual intercourse were more than five times as likely to report dating violence.

Multivariate Relationships

In order to detect the most significant risk factors associated with dating violence, a multivariate logistic regression analysis, including all significant variables in the bivariate analysis, was performed. The results showed that physical dating violence was significantly associated with six variables (see Table 2). The odds of being a victim of dating violence were greater for those adolescent girls who experienced a recent, prolonged episode where they felt sad or hopeless, reported regular binge drinking, used cocaine or inhalants, had multiple sex partners, and did not use condoms during their last sexual encounter. Being Black or Hispanic also increased the odds of being a victim of dating violence.

DISCUSSION

Several important findings emerged from the analysis of the data. First, dating violence against adolescent girls was widespread. Almost one in ten of the 9th- through 12th-grade females who participated in the 1999 Youth Risk Behavior Survey reported being a victim of physical dating violence (i.e., had been hit, slapped, or physically hurt on purpose) within the past year.

Second, no systematic pattern emerged by grade level for physical dating violence. Twelfth-grade girls had the highest prevalence, but differences across the four grades were not significant. Indeed, such findings make clear that prevention and intervention efforts should be initiated before 9th grade.

Third, the prevalence of physical dating violence was lowest for White girls. Black girls were approximately twice as likely to report physical dating violence. More needs to be learned about the relationship between ethnicity and dating violence. Nevertheless, these findings suggest the need for culturally sensitive prevention efforts, as has been emphasized in the risk prevention and intervention literature (Freudenberg, 1995).

Fourth, from the bivariate analyses, a profile emerged of adolescent girls at higher risk for physical dating violence. Emotionally, they were more likely to report feeling sad or hopeless and to have both considered and attempted suicide. Girls who reported fighting and weapon carrying, the use of a variety of substances (such as tobacco, cocaine, and inhalants), and engaging in risky sexual behaviors (e.g., not using condoms) were at greater risk for being a victim of dating violence. The co-occurrence of these factors supports the notion of an at-risk profile for adolescent girls, and reinforces the concept of problem behavior, in that adolescents who engage in one risky behavior are likely to be involved in other risky behaviors as well.

Finally, multivariate analyses, adjusting for the effects of all significant risk factors, clarified the risk profile of adolescent girls who reported physical dating violence. Emotional state, use of illicit substances, and sexual risk behaviors were salient. A recent experience of having felt sad or hopeless was associated with over a twofold increase in the likelihood of being a victim of dating violence. Girls who reported binge drinking and cocaine use over the previous month were also more likely to be victims, as were those who did not use condoms the last time they had sexual intercourse. Further, girls' risk of physical dating violence increased significantly if they had two or more sexual partners. in the previous three-month period. Thus, multiple sexual partners and lack of condom use are not only important risk factors for sexually transmitted diseases and teen pregnancy, but also for experiencing physical dating victimization.

While the profile of girls who were victims of dating violence suggests a pattern of risky practices, this particular clustering may be suggestive of something more than simply risk behavior. One wonders if these behaviors represent a deliberate or inadvertent effort by girls who, feeling sad or hopeless, may be searching for something or escaping from some turmoil. Regarding the associations with emotional wellbeing, an alternative explanation may be that adolescent girls who, for whatever reasons, experience strong feelings of sadness or hopelessness seek out or passively find themselves in dating situations where they may be disrespected and/or abused (Blum, Gallagher, Resnick, & Tolman, 1999).

Overall, the findings suggest that adolescent girls who use illicit substances, or use them excessively, may place themselves at greater risk for violence in their dating relationships. The severity of courtship violence has been found elsewhere to increase with consumption of alcohol by either the victim or perpetrator (Muehlenhard & Linton, 1987; Makepeace, 1988). The findings also underscore the need for programs that focus on sexual behavior among adolescent girls, as well as boys, with the aim of discouraging risky sexual practices, including intercourse with multiple partners and nonuse of condoms. Development of tailored interventions may impact on several important adolescent health outcomes concurrently. That is, such interventions may be instrumental in the achievement of disease (e.g., HIV) and pregnancy risk-reduction objectives as presented in Healthy People 2000 and 2010 national goals (U.S. Department of Health and Human Services, 2000a, 2000b).

In order to utilize these findings to monitor progress toward achievement of decennial national health priorities for violent and abusive behavior, however, some refinements appear to be needed in the operationalization of Healthy People objectives. As currently written, the category of maltreatment may be overly broad and may reflect child abuse by older youths or adults (U.S. Department of Health and Human Services, 2000a, 2000b), not the specific physical violence that occurs in adolescent dating relationships. The objective to reduce physical abuse of women by male partners is nonspecific for age and, thus, does not adequately frame the issue in regard to adolescent girls. Assaultive injuries among females aged 12 and older is, likewise, too inclusive to have great utility. It would seem that age-specific objectives targeting reduction of physical victimization need to be developed, with adolescents comprising one such stratum.

Limitations

A cross-sectional design, while allowing for a determination of prevalence, is limited in its ability to clarify temporal relationships. In addition, measurement of dating violence by single-item self-report questions has drawbacks. First, reports of dating behavior constituting intent to harm are subjective. Second, use of unitary variables to capture dynamic social phenomena may be less valid than using multiple items. Furthermore, the data did not afford the opportunity to examine the profile of perpetrators of dating violence. Nor did the data provide insight into whether the risk factors are equally salient in same-gender adolescent dating relationships.

Directions for Future Research and Intervention

The findings not only have important implications for adolescent dating violence prevention, but also offer directions for future research. At present, it is unclear whether physical dating violence precipitated the sad and/or hopeless emotions. In addition, it could be argued that, in an attempt to cope with the emotional, social, and physical experience of victimization, girls may have resorted to drug or alcohol use. It is also possible that another factor accounts for both substance use and sad/hopeless feelings. Further, having multiple sex partners might be at the fulcrum of antecedent factors that put adolescent girls at risk for courtship violence. It is left for future research to establish the temporality of the factors associated with dating violence against girls, not only in regard to sexual behaviors but emotional health as well. Longitudinal studies, initiated well before adolescence, would shed light on these important relationships.

At the same time, intervention efforts should be targeted at the perpetrators of dating violence, so as not to further the impression of blaming the victim. Given the prevalence of violent behavior by boys in romantic relationships (Halpern, Oslak, Young, Martin, & Kupper, 2001; Centers for Disease Control, 2000; Foshee, 1996; Gray & Foshee, 1997; Gwartney-Gibbs, Stockard, & Brobmer, 1987), their role and responsibility must be clearly addressed. Likewise, improving the ability of interventions to reduce sexually transmitted diseases and teen pregnancy necessitates a concentration on both partners in dating relationships.

Conclusion

Physical dating violence against adolescent girls is an important public health problem. This study provides not only generalizable findings on such violence, but also highlights implications for intervention and prevention research. As part of a comprehensive dating violence prevention program, intervention efforts should be targeted at girls who have risk profiles for victimization. Such programs may concurrently impact other forms of violence and sexual behavior outcomes.

In sum, the findings provide further evidence that there is a clustering of problem behaviors and other risk factors among certain adolescents, specifically girls who experience dating violence. This risk profile can help in the identification of appropriate content for intervention and prevention programs.

Table 1

Prevalence Rates and Unadjusted Odds Ratios for Relationships Between
Dating Violence and Demographic, Psychological, and Behavioral Risk
Factors Among Adolescent Girls Participating in the 1999 YRBS

Risk Factor Prevalence (%) Odds Ratio 95% CI

Grade
 12th grade 10.88 1.40 0.66-2.98
 11th grade 8.77 1.10 0.65-1.86
 10th grade 9.58 1.21 0.68-2.16
 9th grade 8.02 1.00
Ethnicity
 Black 14.15 2.05 ** 1.40-3.01
 Hispanic 11.31 1.59 0.92-2.76
 Other 10.08 1.40 0.79-2.48
 White 7.43 1.00
Felt Sad/Hopeless
 Yes 16.52 3.62 ** 2.51-5.22
 No 5.19 1.00
Considered Suicide
 Yes 15.77 2.46 ** 1.63-3.70
 No 7.08 1.00
Attempted Suicide
 Yes 16.78 2.19 ** 1.48-3.26
 No 8.42 1.00
Physical Fight
 2+ times 18.14 3.13 ** 2.10-4.67
 1 time 14.39 2.38 ** 1.53-3.70
 0 times 6.61 1.00
Physical Fight and Treated
 1+ times 28.82 4.26 ** 2.29-7.94
 0 times 8.68 1.00
Gun Carrying
 1+ days 34.24 5.29 ** 2.47-11.36
 0 days 8.95 1.00
Daily Cigarette Smoking
 2+ cigarettes 16.47 3.02 ** 2.09-4.35
 1 cigarette 11.27 1.94 ** 1.24-3.06
 0 cigarettes 6.13 1.00
Had 5+ Alcoholic Drinks
 6+ days 21.81 4.27 ** 2.52-7.23
 1-5 days 15.49 2.81 ** 2.01-3.91
 0 days 6.13 1.00
Used Cocaine or Glue
 1+ times 50.21 10.25 ** 4.51-23.30
 0 times 8.96 1.00
Multiple Sex Partners
 2+ people 26.48 6.88 ** 4.20-11.25
 1 person 14.79 3.32 ** 2.26-4.87
 None 4.98 1.00
Alcohol/Drugs Before Sex
 Yes 21.45 6.91 ** 4.22-11.34
 No 13.78 4.04 ** 2.74-5.98
 Never had intercourse 3.80 1.00
You/Partner Used Condoms
 No 17.58 5.41 ** 3.39-8.64
 Yes 13.26 3.88 ** 2.63-5.71
 Never had intercourse 3.79 1.00

Note. The last category was used as the reference.

* p < .05

** p < .01

Table 2

Adjusted Odds Ratios for Relationships Between Dating Violence and
Demographic, Psychological, and Behavioral Risk Factors Among Adolescent
Girls Participating in the 1999 YRBS

Risk Factor Odds Ratio 95% CI

Ethnicity
 Black 2.32 ** 1.43-3.76
 Hispanic 1.82 * 1.04-3.19
 Other 1.20 0.62-2.29
 White 1.00
Felt Sad/Hopeless
 Yes 2.13 ** 1.49-3.06
 No 1.00
Considered Suicide
 Yes 1.67 0.87-3.20
 No 1.00
Attempted Suicide
 Yes 0.77 0.36-1.66
 No 1.00
Physical Fight
 2+ times 1.36 0.75-2.49
 1 time 1.46 0.84-2.53
 0 times 1.00
Physical Fight and Treated
 1 + times 1.63 0.77-3.46
 0 times 1.00
Gun Carrying
 1+ days 2.26 0.54-9.51
 0 days 1.00
Daily Cigarette Smoking
 2+ cigarettes 1.12 0.69-1.80
 1 cigarette 1.42 0.88-2.28
 0 cigarettes 1.00
Had 5+ Alcoholic Drinks
 6+ days 1.96 * 1.17-3.28
 1-5 days 1.56 ** 1.17-2.08
 0 days 1.00
Used Cocaine or Glue
 1+ times 2.90 * 1.05-8.00
 0 times 1.00
Multiple Sex Partners
 2+ people 2.38 * 1.24-4.56
 1 person 1.61 0.82-3.13
 None 1.00
Alcohol/Drugs Before Sex
 Yes 1.57 0.77-3.19
 No 1.45 0.82-2.58
 Never had intercourse 1.00
You/Partner Used Condoms
 No 1.53 * 1.01-2.32
 Yes 1.48 0.82-2.64
 Never had intercourse 1.00

Note. The last category was used as the reference.

* p < .05

** p < .01

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Min Qi Wang, Department of Public and Community Health, College of Health and Human Performance, University of Maryland.

Reprint requests to Donna E. Howard, Department of Public and Community Health, College of Health and Human Performance, University of Maryland, Suite 2387 Valley Drive, College Park, Maryland 20742. E-mail: dh192@umail.umd.edu