Cover Story/Symposium: Violence and young women: implications for clinicians

Cover Story Violence against young women: implications for clinicians By Vaughn I. Rickert, PsyD, Roger D. Vaughan, Dr PH, and Constance M. Wiemann, PhD Many adolescents and young adult women experience physical or sexual violence perpetrated by someone close. Knowledge of risk factors and sequelae associated with interpersonal violence and of screening methods to detect it can help the ob/gyn identify potential victims of assault. Careful management and referral of victims is critical and anticipatory guidance also is advised. Although once hidden, violence against women has been identified as a significant public health problem.1 This review outlines the prevalence of violence experienced by females during adolescence and young adulthood and associated risk factors and sequelae. Clinically useful screening mechanisms and anticipatory guidance issues also are addressed. Physical violence Adolescent and young adult women report the highest rates of violence perpetrated by an intimate partner. In fact, women aged 16 to 24 years experienced the highest per capita rates of intimate partner violence (IPV), with 19.6 victims per 1,000 women.2 The prevalence of IPV across racial and ethnic populations varies. For example, Tjaden and Thoennes found that Hispanic women were less likely to report that they were the victims of rape than non-Hispanic women.3 In contrast, the redesigned National Crime Victimization Survey found no racial/ethnic differences in prevalence rates of IPV.4 These disparities may be attributable to differences in reporting tendencies across populations as well as different rates of victimization and confounding effects of demographic (income, education, and age) and reproductive characteristics.4,5 Dating relationships. Symons and colleagues found that 60% of adolescents reported experiencing one or more violent acts during their dating relationships, with 24% reporting extreme violence, including episodes of rape or use of weapons.6 Recent surveys suggest that as many as 50% of young adult couples had engaged in some form of physical violence during the preceding year.7 In fact, violence appears to be more common among dating adolescents than among married couples.8 An often-controversial topic is whether females and males are equally abused in dating relationships. A recent study among college-aged women and men found no difference in frequency of physical victimization or aggression between women and men.9 However, while equal rates of violence have been reported, females are more likely to report severe violence and injury.10 Unfortunately, dating violence among minority and high-risk subgroups of adolescents such as high school dropouts has been less frequently examined. Wingood and colleagues found that among African-American females, dating violence was reported by 18.4% of respondents.11 In another study among adolescents attending a high school dropout prevention program, two out of three females reported perpetrating violence against a dating partner.12 IPV has been associated with women's reproductive health behaviors, but research examining these relationships is limited. Women who have experienced IPV have also reported younger age at sexual initiation, multiple sexual partners, and infrequent condom use.5,13 It has also been suggested that IPV is related to a failure to use contraception because the threat of abuse makes birth control negotiation difficult.14 Pregnancy and postpartum. Physical violence during pregnancy is now recognized as a significant public health concern, with between 0.9% and 20.1% of pregnant women reporting assault at the hands of their intimate partners.15-18 Gelles found that pregnant women had a greater risk of both minor and severe violence than non-pregnant women.19 Moreover, pregnant adolescents may experience IPV during the prenatal period at higher rates than do adult women.20 In fact, adolescents who report IPV during pregnancy, as compared with those who do not, are significantly more likely to also report verbal abuse, prior family assault, sexual assault, having witnessed an attack on others, having carried a weapon for protection, and being fearful of being hurt by other teens.21 Assault during pregnancy has consequences for both mother and fetus. Assault may result in maternal injuries and has been associated with fetal injuries and a lower infant birthweight.22 Parker and colleagues studied adult and adolescent women receiving prenatal care and reported that one in four abused adolescents and one in five abused adult women did not begin prenatal care until the final 3 months of pregnancy.23 Violence can begin, escalate, or terminate during the postpartum period.24-26 Gielen and colleagues found that physical violence was more common at 6 months postpartum than during the prenatal period, with younger mothers at greatest risk.24 In another study, the proportion of adolescent mothers reporting IPV decreased from 21% to 13% between 3 and 24 months postpartum.26 In contrast, across this same time period, the percentage of assaulted young mothers reporting severe IPV increased from 41% to 62%. Young mothers who were assaulted during pregnancy were 3.4 times more likely to report IPV 3 months after delivery than those who had not experienced a prior assault. Yet three fourths of those reporting IPV 3 months after delivery had not experienced IPV during the 12 months prior to childbirth.26 Date rape Adolescents aged 16 to 19 and young adults aged 20 to 24 are four times more likely to be sexually assaulted than women in all other age groups.27 Moreover, adolescents who have experienced a rape or attempted rape are twice as likely to experience a subsequent assault during their college years.28 In most sexual assaults, young women were victimized by someone they knew.27 Unfortunately, forced sexual contact between dating partners is not universally viewed as rape.29 Many adolescents and young adults believe that forced intercourse is considered rape only if a stranger commits the act in a violent and brutal manner, often with the use of a weapon. In addition, to be considered a victim of rape, the female must have a good reputation and her prior actions and behaviors must be beyond reproach.29 Therefore, any situation in which any of these components is missing is less likely to be considered rape by a young woman. The role that race and ethnicity play in prevalence of sexual assault among adolescent and young adult women remains unclear. For example, in a study comparing sexual victimization among adult women, African-Americans reported the highest rates, followed by Caucasians and Latinas, respectively.30 In contrast, two recent studies comparing female adolescents and adult rape victims who presented for evaluation of sexual assault found no differences in prevalence associated with race or ethnicity.31 Risk factors for physical and sexual violence Prior research has found an association between physical and/or sexual violence among adolescents and demographic and reproductive characteristics, attitudes and beliefs condoning dating violence, date-specific behaviors, and substance use (Table 1).32,33 Although much of the research on risk factors has been conducted among Caucasians, data recently published suggest that African-American females who had a history of dating violence were almost three times more likely to have an STD, to have nonmonogamous male partners, and half as likely to use condoms consistently than those African-American females without such a history.11 These adolescents were also significantly more likely to be afraid of the perceived consequences of negotiating condom use and fearful of talking to their partner about pregnancy prevention.11 Thus, helping adolescents to prevent or cope with dating violence could be an essential element in reducing their risk of pregnancy, STDs, and HIV. TABLE 1 Factors that increase vulnerability to violence Foshee and colleagues identified predictors of dating violence that occurred between young adolescents' baseline assessment and a follow-up report 18 months later.34 Females were more likely to commit dating violence if they had friends who were victims of dating violence, used alcohol, and were of a race other than white. In contrast, males were more likely to commit dating violence if they held attitudes that were accepting of such activity. Among adults, 27% to 34% of women who perpetrated physical violence against their male partners reported drinking at the time of the event.35 Interestingly, Foshee and colleagues found that alcohol use was a predictor of dating violence by females but not by males, even after controlling for potential confounders such as other problem behaviors.34 Girls who are drinking alcohol at early ages (8th and 9th grades) appear to be at particularly high risk for becoming perpetrators of dating violence.34 Alcohol consumption is one of the strongest predictors of sexual violence in the context of a date, with estimates indicating that approximately half of such assault cases involve alcohol consumption by the perpetrator, victim, or both.36,37 While alcohol consumption and sexual assault frequently occur together, this phenomenon does not prove that alcohol use causes sexual assault. Rather, alcohol contributes to sexual assault through multiple pathways, often exacerbating existing risk factors.37 For example, many males report using alcohol as a strategy to facilitate sexual advances, either by using alcohol to justify their own behavior or to decrease a dating partner's inhibitions.36,37 Drugs used to facilitate sexual assault cause sedation and amnesia to the extent that a potential victim cannot resist or may not be aware of the assault.38 About 25% of the women who contacted the Canadian Sexual Assault Center reported that drugs were a factor in a rape.38 Besides alcohol, the drugs most commonly used to facilitate sexual assault are flunitrazepam and gamma hydroxybutyrate acid (GHB), which is considered a new recreational "club drug."39 Another important risk factor for date rape is a past history of child sexual abuse or past sexual victimization as an adolescent.27,40 Adolescents with a history of sexual abuse are five times more likely to report coercive sex with a friend or date than their nonabused peers.41 Sequelae of violence The sequelae associated with intimate partner violence include both mental health concerns and sexual health behaviors. Magdol and colleagues found that young adult female victims of severe partner violence report more anxiety and depression than do nonvictims.42 In another study, male and female high school victims were much more likely to report decreased quality-of-life indices, suicidal ideation and attempts, and decreased life satisfaction.7 Finally, Wingood and colleagues reported that adolescent females who have experienced dating violence are more likely than nonvictims to have poorer sexual health (past history of pregnancy or sexually transmitted disease, or both), engage in risky sexual behaviors (nonmonogamous male partner and inconsistent condom use), and have poorer sexual attitudes and beliefs (fear of talking to partner about condom use or pregnancy prevention, worry about STD acquisition).11 Clinicians should be aware of the signs and symptoms of sexual victimization in their young patients because many may not label this unwanted experience as violence (Table 2). Sleep disturbance and decreased appetite as well as somatic reactions (chronic pelvic pain or recurrent abdominal pain) can be symptoms of sexual violence.15 Other heightened sequelae unique to date rape include self-blame, decreased self-esteem, and difficulty maintaining relationships.36 Mental health concerns commonly associated with sexual violence include depressive symptoms, particularly in the first 2 months postassault, and anxiety that remains at high levels throughout the first year and may include posttraumatic stress disorder.27 TABLE 2 Signs and symptoms of sexual victimization Clinical care and management Disclosure. Obstetricians and gynecologists should not assume that their patients will spontaneously and accurately report all victimization events. Disclosure of victimization is affected by the patient's belief in rape myths, attribution of blame, and cultural beliefs and stereotypes.27,43 The concurrent use of alcohol or other drugs may also affect disclosure, especially among adolescents.27 In contrast to the disclosure of stranger rape, most disclosures of child abuse or adolescent and young adult sexual abuse do not occur in the emergency room where an established protocol is available. Instead, disclosure of childhood maltreatment, date rape, or intimate partner violence may occur weeks, months, or even years after the victimization. Alerting patients about the prevalence of violence can help promote disclosure in the office setting. This can be accomplished through the use of educational materials such as pamphlets or educational videos. Providing information and self-assessment about sexual and physical assault in dating relationships also may help the victimized patient to realize that she is not the only person who has experienced this type of violence (Table 1). Screening. Screening for intimate partner violence is an important component of providing comprehensive care and an activity advocated by several prominent medical and public health organizations. Unfortunately, screening for IPV often is not documented in the patient's medical record whether or not screening has occurred.44,45 Coker and colleagues found that IPV screening rates increased and more materials on IPV were taken from examination rooms in a practice that placed a sticker on patients' medical records listing IPV screening questions, identifying who conducted the screening, and documenting referral and follow-up information given to patients than at a control site that provided the usual care. It is critical that all female patients be screened for past and present physical and sexual violence. You can initiate a useful dialogue by emphasizing how common violence is in many adolescents' lives and acknowledging how difficult it can be to discuss these topics. Ask if any person (friend, boyfriend, girlfriend, teacher, relative, or stranger) has ever touched a patient's body without her consent. If the patient responds positively to part of this question, allow her time to give you details. It is also critical to offer empathy to your patients whenever they disclose a history of maltreatment during childhood. Alternatively, you may want to use an "icebreaker" before screening for violence. For example, you could say, "Unfortunately, many of my patients have been hurt physically or sexually, either as children or during more recent relationships. Because I want to help my patients, I ask every single patient who I see about these topics. I also know that it may be hard for some patients to talk about being hurt in their lives." This framework sets the stage for an adolescent or young adult to believe that sensitive questions are a routine component of the history. You should ask direct questions about prior as well as ongoing violence. It is helpful to ask how problems or conflicts are handled at home or in dating situations and to allow a patient time to provide detailed responses. Specific questions about whether or not an adolescent or young adult has ever been pushed, kicked, slapped, punched, or beaten should be included, as well as queries designed to elicit detailed information about the identity of the perpetrator, the frequency of this violence, and the date of the last episode. It is not unusual for a young patient to minimize the full extent of the violence she has experienced. Do not be surprised if a patient who has been assaulted takes responsibility for the aggressive acts and laces her descriptions with self-blame. Whenever you suspect injuries or a patient reports them to you, it is imperative that you perform a thorough history and physical examination and document all information in the medical chart. Body diagrams are very helpful in documenting physical findings. Many centers also use colposcopy and medical photography to document clinical findings. Depending on the age of your patient and the nature of the history and physical findings, her case may need to be reported to appropriate authorities such as child protective services or police. Many health-care institutions have rape crisis counselors and advocates available on a 24-hour basis who can provide tremendous assistance in the care and management of these victimized young women. Anticipatory guidance. Despite their hectic clinic schedules, clinicians should not overlook anticipatory guidance as an extremely effective mechanism to foster awareness and understanding of sexual and physical violence. Present facts and listen to the concerns and reactions of your young patients. Take all of their concerns seriously, answer questions honestly, and confront distortions and myths. You can indicate, for example, that while it's okay for a dating partner to be jealous, jealousy is not the same as love. Young patients need to be encouraged to trust their instincts about a given dating situation or partner. Anticipatory guidance for patients should also include a discussion of risk factors and warning signs for victimization (Tables 3 and 4). In reviewing risk factors and warning signs of potentially violent partners, it is important that you not make these associations appear causal. For example, do not leave a patient with the impression that if she allows her partner to pay dating expenses she will, in fact, be sexually assaulted or that just because her current boyfriend loses his temper, he will hit her. TABLE 3 Are you involved with an abuser? Is jealous or possessive, checks up on me, refuses to let me go out with my other friends? Is bossy, gives orders, makes all the decisions in the relationship? Puts me down and embarrasses me in front of others? Pressures me to have sex? Has a history of failed relationships but blames the other person for all of the problems? Abuses alcohol or drugs and pressures me to use them? Has a history of violence, losing his or her temper? Makes friends and family worry about me? TABLE 4 Warning signs of a potentially violent partner Witnessed or experienced abuse as a child Loses temper more often than is appropriate Expresses anger in violent ways Has already revealed violent attitudes or actions toward others Overly jealous and possessive Doesn't listen to you Ignores your personal space boundaries Tries to make you feel guilty Heavy drinker Manipulative or deceitful; exploitative Management following assault. Although research suggests that adolescent and young adult women delay seeking medical care after sexual assault, some may present for care within 72 hours.27,29 When that is the case, forensic evidence (rape kit) can be collected, medical treatment given for STDs, and emergency contraception provided as well as counseling for HIV prophylaxis.27,29 Data suggest adolescent victims are less likely to sustain physical injuries during an assault than are adult victims of sexual violence.27,29 Nevertheless, you should conduct a careful and thorough physical examination, be aware of the signs and symptoms of interpersonal violence (Table 2), and understand that many adolescent and young adult victims will not press charges against a perpetrator.27 However, you may be required to disclose the assault to child protective services, depending on the victim's age and the reporting requirements in your state. A clinician's initial response to disclosure should be one of empathy and support.27 This is critical to keeping the lines of communication open and also demonstrates respect. Your job is not to determine if a rape occurred, but rather, to recognize and appreciate the subjective experience from the patient's perspective. Encourage your patient to feel that she is a normal, healthy individual by acknowledging her feelings, concerns, and fears. Help her regain a sense of control and acknowledge her ability to make choices. This may include helping a patient identify and access her social network in order to elicit support from those closest to her, but always ask permission before involving family members. Issues of personal safety should be addressed by asking your patient if she is still in a relationship with the perpetrator and determining whether he or she has access to her car, apartment, or any other area of her life through which her personal safety could be compromised. If the answer is yes, you may need to schedule a patient for frequent office visits and be available to her by phone during the first few months after disclosure. Finally, evaluate your patient's need for referral for psychologic or psychiatric treatment based on presenting or ongoing mental health symptoms. Support groups or group therapy can help a young victim regain a sense of normalcy and also provide the most appropriate therapeutic environment that will facilitate recovery. It is important that you identify community resources that address violence against women, including locally available child protective service agencies, hotlines for domestic/intimate partner violence, and battered women shelters. Having a working relationship with these groups and with mental health professionals will assist you in making the most appropriate referral for a particular patient. Conclusions High rates of violence occur in the lives of adolescent and young adult women. The obstetrician/gynecologist is in an ideal position to help prevent violence and to promote disclosure about episodes of violence. By providing office-based educational materials, such as pamphlets and videotapes, you can demonstrate your sensitivity to violence and your willingness to discuss aggression by family members, dating partners, spouses, or strangers. Through sensitive anticipatory guidance, you can address myths, alert young women to the potential risk factors for violence, and strengthen your ability to communicate with patients about their beliefs and desires. Such interactive discussion can easily be incorporated into the well-woman exam and can greatly contribute to the prevention of unwanted physical and sexual experiences in your patients' relationships. Victims of violence often present with a number of psychological sequelae rather than by disclosing an assault itself. In fact, many young women may not initially label the experience of forced intercourse by a dating partner as rape. Your response to the discovery of a violent episode must be empathic, supportive, and respectful. Your job is to recognize and appreciate the subjective experience from the patient's perspective. Encourage your patient to feel that she is a normal, healthy individual and help her regain feelings of control and personal safety. Remember that ongoing mental health symptoms may signal the need for psychologic or psychiatric referral. REFERENCES 1. Gelles RJ. Public policy for violence against women: 30 years of successful and remaining challenges. Am J Prev Med. 2000;19:298-301. 2. Rennison CM, Welchans S. Intimate Partner Violence. U.S. Department of Justice, Office of Justice Programs. NCJ-178247, 2000. 3. Tjaden P, Thoennes N. Prevalence, Incidence, and Consequences of Violence Against Women: Findings From the National Violence Against Women Survey. 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McNutt LA, Carlson BE, Rose IM, et al. Partner violence intervention in the busy primary care environment. Am J Prev Med. 2002;22:84-91. 45. Lapidus G, Cooke MB, Gelven E, et al. A statewide survey of domestic violence screening behaviors among pediatricians and family physicians. Arch Pediatr Adolesc Med. 2002;156:332-336. Dr. Rickert is the Director for Research and Evaluation at the Center for Community Health and Education and Professor of Population and Family Health, Heilbrunn Department of Population and Family Health, Mailman School of Public Health at Columbia University, New York, N.Y. Dr. Vaughan is an Associate Professor, Heilbrunn Department of Population and Family Health and Biostatistics, Mailman School of Public Health at Columbia University, New York, N.Y. Dr. Wiemann is an Associate Professor, Department of Pediatrics, Section of Adolescent and Sports Medicine, Baylor College of Medicine, Houston, Tex. Key points Violence is more common among dating adolescents than among married couples. As many as half of young adult couples may engage in some type of physical violence. Pregnant women are at higher risk of minor and severe violence than non-pregnant women. Women aged 16 to 24 are more likely to be sexually assaulted than all other age groups. Do not assume that if a patient has been victimized, she will automatically tell you about it. Incorporate discussions about violence into your well-woman exam and offer educational materials. If you uncover a violent episode in a patient's past, be empathetic, supportive, and respectful and help her to regain a sense of control and personal safety and to seek psychologic or psychiatric referral, if necessary. Vaughn Rickert, Roger Vaughan, Cosntance Wiemann. Cover Story/Symposium: Violence and young women: implications for clinicians. Contemporary Ob/Gyn 2003;2:30-45.