Updates on Adolescent Dating and Sexual Violence Prevention and Intervention

Abstract

Purpose of Review:

Dating and sexual violence victimization are not uncommon in early adolescence and increase in prevalence throughout adolescence into young adulthood with profound health and social consequences. Greater attention to what works in prevention is needed to inform current policies and practices.

Recent Findings:

Adolescent dating violence (ADV) and sexual violence (SV) victimization, including cyber dating abuse, are highly prevalent among adolescents. Studies have found sex category differences, with adolescent females reporting more victimization compared to males, particularly sexual violence. Sexual and gender minority youth also experience a higher prevalence of violence victimization compared to their heterosexual counterparts. Studies on risk factors include examinations of childhood adversities, exposure to sexually explicit material, and substance use as well as the role of gender inequitable attitudes on violence perpetration. Recent prevention research includes examining the impact of bystander interventions and transforming gender norms.

Summary:

Recent ADV/SV research highlights both prevalence as well as modifiable risk and protective factors that may help reduce such violence. Practitioners caring for youth should consider ADV/SV when seeing patients (including those struggling with substance use and other behaviors that contribute to poor health) and not simply rely on screening tools to identify those suffering from ADV/SV.

Introduction

Adolescent dating violence (ADV) and sexual violence (SV; sexual coercion, non-consensual sexual contact, and rape) are common among adolescents. ADV, also called adolescent relationship abuse, refers to emotional, physical, or sexual abuse of a dating or sexual partner where at least one person is an adolescent. Abusive and controlling behaviors can involve a range of behaviors from monitoring a partner’s cell phone use, telling partners what to wear, controlling where and with whom they hang out, manipulating contraceptive use, and other possessive behaviors including cyber dating abuse (1–3). The focus on ‘adolescent’ rather than ‘teen’ dating and sexual violence draws attention to the fact that abusive and controlling behaviors can occur in early adolescence (prior to teen years) and extend into young adulthood (the highest prevalence of partner and sexual violence is among young adults ages 18–22) (4), spanning all of adolescence. SV is also prevalent among adolescents and overlaps with ADV, with more than half of experiences of SV occurring in the context of a dating or intimate relationship (5). SV outside of dating relationships is also common, with 28% to 56% of women in college samples reporting at least one such experience (6, 7). Over three quarters of women who have been sexually assaulted report that the first of such experiences occurred before the age of 25, underscoring that partner and sexual violence are adolescent and young adult concerns (4).

Here we review the most up to date prevalence estimates of ADV and SV and the latest research on contextual factors that increase the likelihood of ADV and SV exposure (both victimization and perpetration). While studies on prevention interventions for ADV and SV are limited, we draw attention to several promising programs and the clinical, public health, and policy implications of this emerging body of work.

Prevalence

Since 1999, the Centers for Disease Control and Prevention has provided estimates of physical ADV victimization through conducting the national Youth Risk Behavior Survey. In 2013, with input from experts and practitioners, the CDC revised the physical ADV survey item to add frequency of experiencing such victimization. Additionally, a sexual violence ADV item was added, with the same response choices that allowed students to report how many times they had experienced such victimization (8). These changes in the measurement of ADV revealed a substantial sex category difference in prevalence estimates with female students reporting significantly higher ADV victimization (either physical or sexual) compared to male students (20.9% to 10.4%). The 2015 YRBS data (21.4% vs. 9.6%) appear similar to 2013 (9).

This disparity by sex category has also been noted in a representative survey conducted in Quebec, Canada with high school adolescents. This study was the first to include threatening behaviors (such as ‘threatened to hit you or throw something at you’) as well as questions related to impacts and chronicity. The survey included measures of psychological violence and highlighted that psychological and emotional abuse are by far the most frequent form of ADV. They also found that girls were more likely to report all forms of ADV victimization compared to boys (62.7% vs. 40.5%), similar to the CDC survey in the U.S, with a three-fold higher prevalence of sexual ADV compared to boys (20.2% vs. 5.7%). Additionally, in assessing the impact of victimization on other health indicators, feelings of fear, distress, and post-traumatic stress symptoms were significantly more common among adolescent girls (10).

In contrast, this sex category difference, especially with sexual ADV, was not seen in a U.S. nationally representative household survey of over 1800 adolescents -- the National Survey on Teen Relationships and Intimate Violence (11). This study found no gender differences for ADV victimization (e.g., for SV victimization 17.8% for girls compared to 18.2% for boys). This survey also assessed ADV perpetration and found girls reported perpetrating more physical and serious psychological ADV compared to boys. The substantial variation in prevalence estimates for ADV and SV victimization (and perpetration) across studies is likely related to differences in measures and sampling. Overall, however, despite methodologic differences, all these recent studies demonstrate that ADV and SV are highly prevalent among adolescents, regardless of gender.

Two important studies underscored the particularly elevated levels of violence victimization experienced by sexual and gender minority youth (i.e., youth who are same-sex attracted, having same sex sexual contacts, identify as gay, lesbian, bisexual, as well as who are transgender and genderqueer). From the 2015 national Youth Risk Behavior Survey (the first time a question was included to assess sexual identity), the authors found that 30% of female lesbian or bisexual students and about a quarter (26%) of male gay or bisexual students had experienced ADV (sexual and physical violence victimization), compared to 20% of heterosexual female students and 8% of heterosexual male students (12). Importantly, this study did not assess whether sexual minority youth experienced ADV with same- or opposite-gender partners. Using the National College Health Assessment (NCHA), a survey of 16,000 students from 28 campuses, Coulter et al. examined past year prevalence of campus sexual assault and found that among cisgender men, sexual minority students had 3.5 times greater odds of sexual assault than heterosexuals. While cisgender women had higher odds of sexual assault than cisgender men, this study did not find differences in the odds of sexual assault victimization between heterosexual and lesbian or bisexual women. Overall, transgender people had 4-fold higher odds of past-year sexual assault compared to cisgender men. Further, among transgender students, Black students had an 8.3 fold greater odds of sexual assault than White students. Predicted probabilities for sexual assault varied widely by race and sexual and gender minority status, ranging from 2.6% (for Asian/Pacific Islander cisgender men) to 57.7% (Black transgender individuals), reflecting critical intersections in violence vulnerability by gender, sexual identity, gender identity, and race/ethnicity (13).

A growing focus within ADV/SV research is on cyber dating abuse – the use of digital technologies to target victims online. Cyber dating abuse is associated with other bullying behaviors, and the detrimental effects of cyber abuse victimization appear to be more pronounced for girls (14). Where most digital abuse studies in the past five years have focused on victimization, one recent study focused on factors associated with cyber dating abuse perpetration, which include substance use, engaging in sexual activity, and use of drugs or alcohol before sex (15). As cyber dating abuse has been associated with poor health outcomes including suicidality(15) and heavy episodic drinking, efforts to help youth recognize and intervene with such abusive behaviors among their peers is critically needed (16). Practitioners should also be alert to the risk for cyber dating abuse among youth who are involved in behaviors such as substance use which may increase risk for such violence victimization.

Another recently described form of cyber abuse is ‘sextortion’ which involves threats to expose sexual images to coerce victims into providing additional images, sexual favors, or other things of value. A recent study using recruitment via Facebook identified a convenience sample of victims of sextortion (90% identified as female). When comparing experiences of minors (17 and younger) to young adults (18–25 years), in addition to overlap with ADV, minors were more likely to have been pressured into providing sexual images, threatened for more than half a year, and urged to harm themselves by their dating or sexual partner (14). Ongoing efforts to educate adolescents and their parents/adult care givers about cyber abuse and about the many manifestations of controlling and coercive behaviors in dating relationships using digital technology are needed to increase safety for youth.

Social Influences on ADV and SV

Studies over the past year have addressed broader contextual factors that may increase risk for ADV/SV, in an effort to elucidate novel targets for prevention efforts. A review of neighborhood influences suggests that while studies on environmental contexts and direct associations with ADV/SV appear promising, the evidence base remains quite limited (17). In contrast, a review of exposure to sexually explicit and violent media drew on over 40 studies to highlight that exposure to such material is associated not only with attitudes condoning ADV/SV (especially men’s attitudes regarding ADV/SV), but also with exposure to such violence. (18) Ybarra et al.’s longitudinal study (19), in addition to demonstrating how prior exposure to parent’s domestic violence and SV victimization increase risk for subsequent SV perpetration, also found associations of violent pornography consumption with SV perpetration. Teaching youth critical analytic skills in media literacy and discussing the dangers associated with some sexually explicit material may be promising practices in ADV/SV prevention.

A number of epidemiologic studies in the past year underscore known risk factors in ADV/SV victimization including childhood sexual abuse (20), early onset of puberty (21), early onset of sexual activity (22), and substance abuse (23, 24). Particularly relevant in the context of the opioid epidemic, one study using the nationally representative Youth Risk Behavior Survey showed that experiencing both physical and sexual ADV victimization is associated with non-medical use of prescription drugs (NMUPD) for both high school age adolescent males and females. When analyzing by sex category, some subtle but important differences emerged (25). Among males, an association of lifetime NMUPD with SV victimization was found, while among females, lifetime NMUPD was associated with physical ADV victimization, suggesting different pathways linking substance use with ADV/SV exposure for different genders. NMUPD may increase vulnerability to violence victimization and such victimization may increase the likelihood of maladaptive coping strategies including substance abuse. It is also possible that both ADV victimization and NMUPD share common causes. Regardless of direction, practitioners should be alert to the intersections of violence exposure with substance use, including offering universal education about healthy relationships and assessing for ADV with youth engaging in substance use.

Finally, these studies on risk and protective factors emphasize the critical importance of violence prevention in school age and early adolescent years – i.e., the need for primary prevention. Several studies (mostly qualitative) have focused on the emergence of gender inequitable attitudes in early adolescence as another potentially modifiable risk factor (26, 27), which requires intentional focus on gender norms in addition to violence prevention in the middle school years. As an example, from a gender violence prevention program in Uganda, Pulerwitz et al. found high prevalence of gender inequitable attitudes among youth ages 10–14 (74%) which was associated with both early sexual debut and ADV involvement (28). That is, not only are inequitable gender attitudes associated with ADV/SV, these norms can be measured and likely changed through implementation of gender transformative programming – a prevention approach that involves challenging and shifting harmful gender and sexuality norms that contribute to ADV/SV (29–33).

Prevention and Early Intervention

The past year has also seen an increase in studies of what works in ADV/SV prevention, including in lower and middle income countries (34), some with relevance for pediatric and adolescent health practitioners (35). A randomized trial of the Green Dot bystander behavior program (trained educators working with youth leaders on increasing positive bystander behaviors to interrupt peers’ disrespectful and harmful behaviors) demonstrated sustained reductions in SV perpetration as well as in SV victimization, sexual harassment, stalking, and dating violence perpetration and victimization (36). Three other recent studies focused on a critical risk factor for ADV/SV exposure - prior exposure to violence. In a controlled evaluation, Expect Respect Support Group, an ADV/SV prevention program for youth with prior exposure to violence, demonstrated declines in aggression for both boys and girls as well as reductions in ADV perpetration and victimization among boys (but not girls) (37). A ten-year follow up study of an early childhood support intervention for parents of preschoolers showed that the girls (now adolescents with mean age of 16 years) whose parents received the intervention were less likely to experience ADV exposure in their peer group and to hold perceptions of ADV as normative (38). A small scale trial of Project Date SMART, which uses cognitive behavioral therapy-based skills with girls already exposed to physical DV victimization, showed promising reductions in ADV victimization as well as depression (39). Prevention efforts among youth who are already exposed to violence in their lifetime (and thus are at elevated risk for subsequent violence exposure) incorporate trauma-focused cognitive behavioral therapy and related modalities to increase the youth’s skills and to interrupt the transmission of intergenerational violence.

Prevention efforts also continue to identify key messengers. An evaluation of a healthy relationships brief counseling intervention delivered by school nurses found that students were enthusiastic about discussing healthy and unhealthy relationships with their school nurse. Of the almost one in five (19%) who had ever been in an unhealthy relationship, one quarter reported talking to the school nurse about those experiences, suggesting that school nurses may be a highly promising messenger for dissemination of research-informed best practices in ADV prevention (40). Studies on athletic coaches as messengers for ADV/SV prevention are also promising – one with college athletes (41) and another with middle school age male athletes (42).

Conclusions

A review of the ADV/SV related literature over the past year reveals several critical challenges for promoting the health of children, youth, and young adults. First, ADV/SV is highly prevalent, even among younger adolescents, pointing to the need for greater focus on primary prevention in the elementary and middle school years. Second, closer attention to the many manifestations of cyber dating abuse is needed to strengthen research in this area as well as to increase discussions among parents, practitioners, and adolescents about the influences of social media (including pornography) on adolescents’ health and well-being. Third, trauma-informed universal education approaches may help increase the distribution of relevant resources without requiring youth to disclose what has happened to them. The prevention efforts described above suggest a paradigmatic shift in the theory of change towards neighborhood and contextual factors and greater attention to trauma-focused interventions. A practitioner caring for youth and young adults should consider the possibility of ADV/SV when seeing patients and not simply rely on screening tools to identify those suffering from experiences of ADV/SV.

Key Points.

• Despite methodologic differences, recent studies demonstrate that ADV and SV are highly prevalent among adolescents, regardless of gender, occuring in early adolescence and increasing throughout the adolescent years.

• Sexual and gender minority youth are at elevated risk for ADV and SV victimization.

• Cyber dating abuse has many manifestations and more research is needed in this area to understand risk and protective factors for engaging in cyber dating abuse.

• Recent prevention efforts are focusing on neighborhood and contextual factors and the role of trauma-focused interventions and transforming gender norms.