1. Adolescent and Young Adult Relationship Abuse and Health: An Integrated Approach California Adolescent Health Conference Elizabeth Miller, MD, PhD Robin Kirkpatrick, LCSW, MPH

2. Objectives At the end of this session, participants will be better able to: Identify three ways adolescent development may impact how teens experience relationship abuse Talk to teens about the limits of confidentiality Promote healthy relationships through universal and targeted education

3. From “Teen Dating Violence” to “Adolescent Relationship Abuse” Adolescence spans a LONG time (ages 10 – 24) – i.e., not just teenagers Interventions need to be developmentally appropriate Inclusive of range of abusive behaviors (not only violence) Opportunity for youth and young adults to define diverse “relationships”

4. Adolescent Developmental Framework Developmental trajectories and transitions –Biological –Psychological –Social –Cognitive How might this impact their experiences of adolescent relationship abuse?

5. Adolescent Developmental Framework for Adolescent Relationship Abuse Sexual drive, bodies maturing faster than brains Intensity of need for social acceptance Constant connections through social media = greater vulnerability to abuse New independence, more reticent to disclose to adults Expectation for violence as norm in the context of trying out new relationships

6. Additional considerations with Adolescent Relationship Abuse Electronic media and social networking Minor consent laws – balancing safety, mandated reporting, and confidentiality Clustering of vulnerabilities

7. Adolescent Relationship Abuse is Prevalent Approximately one in three adolescent girls in the United States is a victim of physical, emotional or verbal abuse from a dating partner Nationwide, nearly one in ten high-school students has been hit, slapped or physically hurt on purpose by a boyfriend or girlfriend.

8. Adolescent Relationship Abuse is Prevalent One in four teens in a relationship report being called names, harassed, or put down by their partner via cell phone/texting One in five teen girls have electronically sent or posted nude/semi-nude photos or videos of themselves (12% of these girls say they felt ‘pressured’ to do so)

9. Adolescent Relationship Abuse is a Public Health Problem Sexual and reproductive health Mental health and substance use Overall health status?

10. Intimate Partner Violence (IPV) and Pregnancy Pregnant adolescents 2-3 times more likely to have experienced violence during and after pregnancy than older pregnant women

11. ARA and Sexual Risk for Adolescents Partner violence among adolescent males and females as with adults is linked with poor reproductive and sexual health outcomes including unplanned pregnancies, STI/HIV, rapid repeat pregnancies. Girls reporting physical/sexual violence more likely to report early age of sexual activity, greater condom nonuse, more sexual partners. Girls may not recognize coercive sexual behaviors as sexual assault

12. Adolescent Health Programs are KEY sites for ARA education, assessment and intervention 5 confidential teen clinics in low-income neighborhoods Greater Boston area ACASI Anonymous cross-sectional survey Female teen clinic users ages 14-20 (N=448) 76% response rate

13. Adolescent Health Programs are KEY sites for ARA education, assessment and intervention Adolescent Females Utilizing Teen Clinics N=448 Sexual violence in intimate relationship (insisted, threatened, physical force to have sex) 21.2% Physical violence in intimate relationship (includes hit, choked, used knife or gun against) 31.9% Physical and/or sexual violence ever in relationship 40.0%

14. Lack of Control Around Sex with Abusive Male Partner “I'm not gonna say he raped me... he didn't use force, but I would be like, "No," and then, next thing, he pushes me to the bedroom, and I'm like, "I don't want to do anything, " and then, we ended up doin' it, and I was cryin' like a baby, and he still did it. And then, after that... he got up, took his shower, and I just stayed there like shock...”

15. Perpetrator Condom Refusal Leading to STD “I told him to put a condom on, he didn't...I went to a clinic, and they were like, "Oh, he gave you Chlamydia." [H]e said it was me messin' around with some other guy, and that's not true, 'cause I was like, "You were the only guy I was with." And he's like, "Oh, that's you, you're messin' around," he's like, “fuck you, I thought you loved me."

16. Survey Findings on Lifetime STD History Lifetime STD History and IPV OR Adj = 1.64 (95% CI 0.94, 2.85)

17. Perpetrator Condom Refusal Leading to Pregnancy “He [used condoms] when we first started, and then he would fight with me over it, and he would just stop [using condoms] completely, and didn't care. He got me pregnant on purpose, and then he wanted me to get an abortion….”

18. Survey Findings on Forced Condom Nonuse Forced Condom non-use and IPV OR Adj = 4.67 (95% CI 2.55, 8.57)

19. Survey Findings on Pregnancy Experience Lifetime Pregnancy History and IPV OR Adj = 1.88 (95% CI 1.12, 3.16)

20. Birth Control Sabotage Leading to Pregnancy “I was on the birth control, and I was still taking it, and he ended up getting mad and flushing it down the toilet, so I ended up getting pregnant. I found out that [before this] he talked to my friends and he told them that we were starting a family. I didn't know that. I didn't want to start a family. I wanted to finish school.” Miller E, Decker MR, Reed E, Raj A, Hathaway J, Silverman JG. Male Partner Pregnancy Promoting Behaviors and Adolescent Partner Violence: Findings From a Qualitative Study With Adolescent Females. Ambulatory Pediatrics 2007;7:360-66.

21. Survey Findings on Pressure to Become Pregnant Lifetime Pregnancy Pressure and IPV OR Adj = 7.79 (95% CI 2.60, 23.73)

22. Adolescent Relationship Abuse and Mental Health Depression and anxiety Disordered eating Suicidality Substance abuse

23. Exploring Chronologies of ARA and Mental Health Suicide attempt in context of ARA: “It got so bad, I tried to kill myself. I tried jumping off the bridge, and stuff like that; cause I just couldn't deal with it anymore. I couldn't deal with it. I stopped talking to all my friends. I had a ton of friends from [my hometown], and I wasn't allowed to talk to any of them.”

24. Exploring Chronologies IPV and Mental Health Suicide attempt in context of family violence; persistent suicidal ideation: “ And like my mom use to hit me a lot. Me and my brother. Like me and my brother have the same father, and then she has 2 other kids like from my stepfather, and like I would get so mad because she only hits me and him, and it was just, so I decided to like run away with my boyfriend and stuff, so I went to live with him.” (cont.)

25. Exploring Chronologies of IPV and Mental Health Suicide attempt in context of family violence; persistent suicidal ideation in context of ARA: “I mean like we were always fighting and stuff. Like the first time he hit me, oh my God, I went like, I wanted to kill myself so badly, I just, I mean it was the same thing. Like I didn’t even know what to think, because it was the same thing from moving to one hell to another. So it didn’t change anything. I don’t know, it didn’t change anything, and like so many times I’d like, like when I was pregnant, I wanted to kill myself so bad. Like I always thought about it.”

26. Felt Depressed (past year) Depression and IPV: OR Adj = 2.35 (95% CI 1.56-3.53)

27. Attempted Suicide (past year) Suicide Attempt and IPV: OR Adj = 3.51 (95% CI 1.57-7.83)

28. Intergenerational Transmission Retrospective studies suggest that patterns of battering in adolescent relationships may be reproduced in partner abuse in adulthood Victims of child maltreatment more likely to perpetrate youth violence and young adult IPV (Fang et al. 2007) Inter-parental violence as predictor (mixed results)

29. Sexual and Gender Norms Condom non-use in context of forced sex Pregnancy –Boys’ abusive responses to pregnancy and STDs –Belief re: Girls intend pregnancy to preserve relationship Silverman JG, Decker MR, Reed E, Rothman EF, Hathaway JE, Raj A, Miller E. Social Norms and Beliefs regarding Sexual Risk and Pregnancy Involvement among Adolescent Males Treated for Dating Violence Perpetration. Journal of Urban Health 2006; 83(4) 723-35.

30. Condom Non-use During Forced Sex “…if she's saying no, she could leave… while you're putting the condom on. So…you don't have time…” “…if she doesn't want to [have sex], then she'll leave if you're trying to put a condom on and, you know, she doesn't want to do it so you don't want her to get away.” “…When you're raping somebody, like, it's an impersonal thing. I mean because you're raping them, you're not going to really be responsible for the consequences.” Raj A, Reed E, Miller E, Decker MR, Silverman J. Condom Use and Nonuse Among Young Abusive Males. AIDS Care 2007; 19(8): 970-3.

31. ‘Running Trains’ Emerged in interviews and focus groups One female, multiple males, sequential oral and vaginal intercourse Inconsistent condom use Boys talking about turning girls ‘out’ to their friends Rothman E, Decker M, Reed E, Raj A, Silverman J, Miller E. “Running a Train”: Adolescent Boys’ Accounts of Sexual Intercourse Involving Multiple Males and One Female. Journal of Adolescent Research 2008;23(1): 97-113.

32. Boys’ Clinic Survey Data N = 299 males (mean age 16.8) 68% response rate 46% Hispanic; 43% Black 17% non-US born

33. Boys’ Clinic Survey Data 56.9% ever had sex Of those sexually active: 17.1% ever had STD 27.9% ever involved in pregnancy 13% forced girl to have sex w/out condom 29.3% participated in a train

34. Boys’ Clinic Survey Data Physical IPV perpetration: 9.6% –Hit, slam, choke, threaten or use weapon Sexual IPV perpetration: 17.0% –Threaten or force vag sex or other sexual activity Any physical or sexual IPV perpetration: 23.3%

35. Summary of Research on Adolescent Partner Violence Adolescent IPV: is COMMON is associated with multiple risk behaviors and poor health indicators has SIGNIFICANT CONSEQUENCES for health is highly prevalent in clinical and school-based settings

36. Implications for Prevention and Intervention What is the role for parents? –Parent engagement tools as part of adolescent health programming Other mentors, such as coaches? –Coaching Boys into Men and related programs Use of social networking sites? –That’s Not Cool campaign and website

37. Primary Prevention Efforts Coaching Boys into Men Training Program -shifting gender norms -redefining masculinity and athletics -stopping disrespectful and harmful behaviors towards women and girls Funding: Family Violence Prevention Fund; Waitt Institute for Violence Prevention; Nike Foundation

38. Primary Prevention Efforts

39. That’sNotCool.com

40. Adolescent Health Programs: Opportunity for Prevention AND Intervention Points of contact?

41. Adolescent Health Programs: Opportunity for Prevention AND Intervention Points of contact: Teen clinics, school health centers, primary care, health education, other prevention programs (after-school programs), sports teams, juvenile hall, group homes, pregnant/parenting teen programs, etc. etc.

42. Adolescent Health Programs: Opportunity for Prevention AND Intervention The Healthcare Education, Assessment & Response Tool for Teen Relationships (H.E.A.R.T.) Primer and Training Project: 1)Linking education about relationship abuse and adolescent health concerns (universal anticipatory guidance and assessment) 2)Discuss harm reduction behaviors 3)Raise awareness of victim advocacy services relevant for youth Funding: Office of Juvenile Justice and Delinquency Prevention Programs

43. Minor Consent and Confidentiality Confidentiality statutes and minor consent laws vary state by state Limits of confidentiality (or conditional confidentiality) should be stated up front (part of education about seeking care) Integrate discussions about minor consent and confidentiality with adult caregivers (when present)

44. Assessment or Education? Few adolescents report experiences of violence to adults, and adolescents make up a small proportion of clients utilizing domestic violence services. (Foshee et. al, 2000) Goal may be education about ARA and that the adolescent health program is a safe place to discuss these issues

45. Universal Anticipatory Guidance “One of the things that I talk to all my patients about is how you deserve to be treated by the people you go out with. You have the right to: Be treated with kindness Be with your friends when you want to be Wear what you want to wear Feel safe and have your boundaries be respected. Go only as far as you want to go as far as touching, kissing, or anything sexual Speak up about any controlling behavior, including textual harassment such as receiving too many texts, phone calls or embarrassing posts about you on Facebook or other sites.”

46. Implications for Practice 1)Targeted prevention and intervention efforts for vulnerable youth (consider LIFETIME exposure to violence) –Identify relevant outreach to marginalized populations including runaway/homeless youth, youth in foster care, incarcerated youth –School health centers have opportunity to connect with youth at risk for drop-out

47. Implications for Practice 2) Integrate adolescent relationship abuse prevention and intervention efforts with other adolescent health programs – HIV, substance use, sexual and reproductive health, suicide prevention

48. Implications for Practice 3) Every adolescent clinical encounter is an opportunity to: convey prevention education messages about healthy relationships share with youth that your clinical space is safe and confidential identify and support youth who may be experiencing controlling and abusive behaviors in their relationships

49. Summary: Implications for Prevention and Intervention Adolescent relationship abuse is a public health problem Youth experiencing ARA can be identified in adolescent settings Violence in adolescent relationships clusters with other adolescent risk behaviors -- join forces with other prevention programs

50. THANK YOU!