Unique characteristics of adolescent relationship abuse

Depending on the adolescent’s stage of social/emotional development, the young person may not recognize the warning signs of abuse, confusing the controlling behaviors and possessiveness as signs of “true love.” Similarly, a young person may defer seeking care due to multiple barriers, including fear of breaches of confidentiality, lack of trust in adult providers, a desire to protect the abusive partner, self-blame, and inability to access care. The health care provider should always consider the adolescent’s developmental stage, and discuss concrete and specific behaviors (“does she or he get mad at you if you don’t respond to his or her calls right away?”) rather than vague questions, such as “Are you in an abusive relationship?” In addition, in some communities, adolescents use different terms to describe ARA. Knowledge of and/or clarifying the use of local terms for relationships can create a shared understanding of what behaviors constitute ARA and may help initiate the discussion of ARA.

Reproductive coercion

ARA is associated with increased sexual risk behavior and sexually transmitted infections (STIs). ARA also has been associated with teen pregnancy, with up to two-thirds of such pregnancies occurring in the context of an abusive relationship. Unintended pregnancies, which make up more than 80% of adolescent pregnancies, are also 2 to 3 times more likely to be associated with abuse than intended pregnancies at any time during the 12 months before conception or during pregnancy. Condom nonuse, inconsistent condom use, and fear of condom negotiation are common among abused adolescents. Lack of control over contraception, coupled with coercive or forced unprotected sex, is a recognized mechanism in elevating risk for unintended pregnancy, as well as human immunodeficiency virus (HIV) and other STIs for both boys and girls.

Evidence in the past decade has identified reproductive coercion (ie, partner pressure to get pregnant, condom manipulation, and birth control sabotage) as an additional mechanism for increasing a young woman’s risk for unintended pregnancy. In a study among young women using family planning clinics, 25% had ever experienced reproductive coercion, which was associated with unintended pregnancy. Reproductive coercion is more likely to occur in the context of ARA, yet adolescent girls may not recognize these behaviors as abusive or detrimental to their health. Adolescents and young adult women who are seeking care for STI testing, pregnancy testing, and requesting emergency contraception are also more likely to be experiencing ARA and reproductive coercion. Health care providers may need to inquire directly about reproductive coercion. Discussion with adolescent patients about ARA and reproductive coercion may facilitate adolescent recognition of ARA and encourage use of harm-reduction behaviors to increase safety and reduce risk for STI and pregnancy.

Cyber dating abuse

Texting, social networking sites, and cell phones are ubiquitous. This electronic networking, although building positive social connections, can become an arena for exploitation and abuse, including excessive texting, “sexting” (transmitting nude images of oneself or one’s partner), spying, or constant cell phone monitoring. Emerging research among adolescents has highlighted the prevalence of cyber dating abuse (use of technology to control or harass a partner), which is also associated with poor reproductive and sexual health outcomes. In a study with students seeking care in School-Based Health Centers (SBHCs) in northern California, lifetime prevalence of physical or sexual ARA victimization was 25%, with 13% reporting such abuse in the past 3 months. Recent cyber dating abuse was reported by 41% of this clinic sample. Among female participants, even low levels of cyber dating abuse exposure was associated with lower rates of contraceptive use (adjusted odds ratio [AOR] 1.8, 95% confidence interval [CI] 1.2–2.7) and more reproductive coercion (AOR 3.0, 95% CI 1.4–6.2), underscoring the association of relationship abuse (including cyber abuse) with pregnancy risk. Health care providers should include discussion of the benefits, as well as risks, associated with social media with young patients and their parents, including how to set limits and maintain privacy (see www.thatsnotcool.com for teens to learn about setting their own “digital line”).

Primary prevention

Talk with all adolescent patients about the importance of healthy relationships (including sexual communication) and provide information on supports and resources related to ARA and SV that they can share with friends.

Early intervention

Connect youth experiencing ARA and SV to appropriate trauma-focused counseling and advocacy services, as in the following example.

Universal education around healthy relationships normalizes and contextualizes inquiry about ARA:

I talk to all of my patients about the importance of healthy relationships, how everyone deserves to be treated with trust and respect. Some of my patients tell me about how the people they’re seeing are constantly checking up on them or putting them down, has anything like that happened to you?

And when the young person says, “No” to the question, follow-up with sharing an educational resource (see for example, a palm-sized educational brochure described later in this article and available at https://www.futureswithoutviolence.org/hanging-out-or-hooking-up-teen-safety-card/ ):

I’m glad to hear that’s not happening to you. You might have a friend who can use this information. If you’re interested, please take this along with you. You can take 2 or 3 to share.

It is not unusual for adolescents to disclose that they are victims of ARA to their friends rather than to their parents or other adults. This enables providers to raise the topic of ARA as it pertains to the patient’s peer group, not just to the individual. This approach of offering information “to help a friend” also reduces the stigma for a young person, so she or he does not feel as if the provider is focusing only on her/him.

We make sure to talk about unhealthy relationships with all of our patients, because you may know someone for whom this information might be useful. Please know that this is a safe place to bring friends you are concerned about.

Experiences of abuse and violence cluster with other common adolescent health and social problems. Adolescents experiencing violence in their homes from adult caregivers are more likely to experience abusive relationships with a partner. In an attempt to leave the abusive family living situation, they may seek out a less-monitored peer setting, and thus become more vulnerable to unhealthy, abusive, or exploitative relationships. Adolescents experiencing ARA are also more likely to be depressed, use substances, and engage in unprotected intercourse (increasing risk for pregnancy and infections). This means that when addressing any other adolescent behavior relevant to a young person’s health and well-being (whether it is smoking, school performance, unprotected sex, substance use, or nonsuicidal self-injury), the provider should consider the possibility of an abusive relationship as part of the differential diagnosis .

With a young person who has had several STIs, a provider might say, “When I see a pattern of infections like this, I worry about someone making you do things sexual that you did not want to do. Could that be part of your story?”

And regardless of whether the young person discloses an abusive relationship or not, the provider should always offer ARA-related information. “We’re giving this information to all our patients, as we really care that our patients are in healthy relationships . ”

Clinical red flags

In addition to universal discussions about ARA with patients, providers should be alert to particular signs and symptoms that may signal the possibility that a patient is using abuse in a relationship, being abused, or both. Adolescents may present with nonspecific complaints, such as recurrent headaches, poor sleep, abdominal pain, or fatigue. Depression, anxiety, disordered eating, suicidal ideation, and substance misuse all co-occur with ARA and SV exposure. Frequent requests for pregnancy testing, STI testing, and use of emergency contraception are also associated with ARA.

In the presence of such “clinical red flags,” providers should conduct a more thorough assessment, providing education on what constitutes abusive behavior (regardless of whether the young person discloses an abusive relationship or not), offering harm-reduction strategies that may help a young person reduce their risk for abuse and violence, as well as ensuring that the young person is aware of specific resources and supports in the community to support victims of violence.

For example, for an adolescent who has been diagnosed with an STI, such as Chlamydia, notifying her sexual partner about the need to be treated for an infection can be challenging, and even more so in the context of an abusive relationship. Providers can assess for safety by inquiring, “How is the person you are having sex with going to react when they hear that they need to be treated, too?” To help adolescent patients stay safer (harm reduction), providers can offer to speak with the partner and offer treatment, assist the patient in using an anonymous Web site to notify sex partners (such as www.sotheycanknow.org ), or contact the partner anonymously by phone.

Universal education, brief counseling, and warm referrals

There are several reasons why best practice is to provide universal education and brief counseling to all patients about ARA , rather than relying on a survey or checklist and simply screening youth for violence exposure and responding only to disclosures.

First, a primary prevention approach may be more feasible and more effective in the context of primary care. Raising the topic of ARA and SV with patients with the explicit goal of having them disseminate the information to peers, or becoming “positive upstanders” (rather than passive and silent bystanders) in peer ARA situations, can reduce ARA in the population. Perceived peer approval of ARA and associated SV contributes to attitudes sanctioning such behavior. Engaging youth as active bystanders in preventing ARA and SV is one strategy for promoting change within social contexts. Additionally, conveying ARA education by encouraging youth to be prepared to help a friend facilitates both provision and receipt of this sensitive information that reduces stigma and promotes more positive bystander behavior.

Second, universal education is important because not all youth recognize abusive behaviors as problematic. Providing information about healthy and unhealthy relationship behaviors may help youth remain vigilant when they meet new partners. The lack of recognition of abusive behaviors in relationships has been associated with lower help-seeking for abuse, highlighting need for education. Qualitative studies have indicated that survivors want health providers to be sensitive to how difficult it can be to disclose interpersonal violence to a health provider, and want information, resources, and support regardless of disclosure . In one intervention trial, the practice of informing all female family planning patients about partner violence and reproductive coercion benefited all women; women who received the intervention, both those who were and were not experiencing abuse, were 63% more likely than those in the control group to end a relationship because they perceived the relationship to be unhealthy or unsafe. A patient who checks “no” on a screening question or does not disclose exposure to violence during a clinical encounter may have a myriad reasons for nondisclosure, including not recognizing their experiences as abuse, feeling shame, and fearing the consequences of disclosure. Provision of ARA-relevant information to all patients reduces the stigma around violence exposure, educates youth about what they deserve in a relationship, and communicates that the clinic is a safe space for talking about relationship concerns.

Third, providing brief counseling about steps a young person might take to protect herself from specific harms that occur in the context of ARA can make an important difference. Harm reduction is effective in managing a range of health risk behaviors, including sexual health and partner violence. A goal of the universal education approach is to provide examples of harm-reduction strategies that adolescents can use for themselves or their peers; examples include how to reduce their risk for ARA victimization and sexual risk via contraceptive options that do not require partner knowledge, safer strategies for STI partner notification (example offered previously), safer condom negotiation, reducing isolation, connecting with safe adults, and breaking up safely. A recent trial in family planning clinics found that all clients who received the universal education and brief counseling about harm-reduction strategies had significant increases in knowledge of available resources and in self-efficacy to enact harm-reduction behaviors.

Finally, the universal education approach creates an opportunity to share with adolescent patients that there are adults in health care who are able to provide support and guidance to young people exposed to ARA or SV. The trust and rapport that the health care provider has with an adolescent patient can serve as a “bridge” to advocacy services and counseling as appropriate. A warm referral is the process of connecting a patient directly with an advocate (in person, or by phone or telemedicine) rather than simply providing a number to call. Making warm referrals to victim service advocates can assist clients in overcoming barriers to accessing services, including self-blame, lack of recognition of abuse, lack of knowledge of services, and perception that services are limited in scope (eg, solely crisis oriented). Describing the scope of services available and normalizing use of such services may facilitate awareness and use of ARA services, improve mental health symptoms, and reduce re-victimization. Providers can benefit from establishing formal agreements and connections with local violence-related services relevant for adolescents to communicate the availability of these teen-friendly ARA resources and to support adolescents in making the connection to these resources when appropriate. This may include allowing a young person to use the phone in clinic to call and speak with an advocate (rather than using her own cell phone) or setting up a time that an advocate can come meet with the young person in clinic.

Creating a safe environment for possible disclosure

A supportive and safe environment includes having posters, brochures, and messages in the clinical space about relationships and love that are geared toward adolescents. Brochures that provide education about ARA lay the groundwork for a conversation with the provider. The materials used should be multicultural, depict same-sex and opposite-sex relationships, and avoid “victim-blaming” language (see www.loveisrespect.org and www.futureswithoutviolence.org for teen relevant materials).

Framing the conversation

Every encounter with an adolescent in the health care setting is an opportunity to educate youth about what healthy relationships are, the ways in which unhealthy relationships affect their health, and how health care providers are prepared to support youth experiencing abuse and violence in their relationships. Although it may seem counterintuitive, the goal is not to extract a disclosure from the young person, because it is not essential that the provider knows whether or not the patient has experienced abuse to provide helpful information and motivate the patient to take action on his or her own to improve safety. The goal is to ensure that patients leave clinic with information about ARA-relevant resources, that they know the clinic is a safe place to discuss such concerns, and that they know the provider is comfortable with discussing sensitive topics and can be an important ally for them.

Collaborative model for care

Given the complexities of caring for adolescents, providers should identify the resources in their community where there are specialists in partner and SV. These individuals and/or agencies are helpful for consultation and referral.

• •

  Identify a local domestic violence agency and/or rape crisis center and invite staff from those agencies to attend meetings with clinic staff. Have materials from the agency readily available in examination rooms and know how to reach an advocate (if geographically close, some advocates may even come to the clinic to meet with a patient).

• •

  Connect with allies in mental health, social work, behavioral pediatrics, and adolescent medicine, as well as other local community resources, such as domestic violence and rape crisis centers, child protection services, and legal advocates familiar with youth law.

• •

  Create an adolescent-friendly environment in the clinical setting, and enlist other clinic staff in helping to create a “safe” space for teens that conveys respect for youth strengths, privacy, and self-determination.

• •

  Ensure that all youth in the practice receive information on relationship abuse, SV, and healthy relationships. These materials should resonate with them regardless of gender and sexual identity. Adolescents should leave the clinic knowing that the clinic team cares about them, their relationships, and their well-being.

The Healthcare Education Assessment and Response for Teen Relationships intervention (HEART) is a provider-delivered universal education and brief counseling intervention for boys and girls seeking routine care that has been tested in SBHCs (comprehensive health centers located in high schools). In a cluster randomized controlled trial, youth seeking services at intervention SBHCs were more likely to report increased knowledge of ARA resources, increased self-efficacy to use harm-reduction strategies, increased disclosure of ARA during their clinic visit, and less ARA victimization 3 months later.

The HEART intervention is universal, inclusive of all gender and sexual identities and clinic visit types, addressing a range of abusive behaviors, including cyber dating abuse and reproductive coercion. The core intervention components are as follows:

• 1.

  SBHC provider–delivered ARA information and resources regardless of disclosure (universal education)

• 2.

  ARA assessment including for reproductive and sexual coercion and discussion of harm-reduction strategies to reduce risk for ARA and sexual risk

• 3.

  Supported referrals to victim service advocates (referrals made via phone or in person during the clinic visit)

• 4.

  Peer-to-peer sharing of information to raise awareness about ARA and availability of the SBHC for support; all SBHC users receive a card with ARA information.

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Related

Related posts:

1. Interviewing Adolescents About Sexual Matters
2. Talking to Parents About Adolescent Sexuality
3. Adolescent Pregnancy
4. Adolescent Sexuality

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