Adolescent relationship abuse (ARA), often referred to as teen dating violence, dating abuse, and sexual violence (SV) are prevalent throughout adolescence. ARA includes emotional, physical, or sexual abuse by a dating or sexual partner that can occur in person or via social media including texting.1 The term “adolescent relationship abuse” (in contrast to “teen dating violence”) underscores that such behaviors occur throughout adolescence, prior to the teen years and into young adulthood. Adolescents may not describe their sexual and intimate relationships as “dating.” Thus, the term ARA reminds health professionals that youth experience relationships in diverse ways and prevention education should recognize the fluidity of adolescent relationships.
Although ARA and SV contribute to elevated risk for physical injuries, many abusive behaviors are not physical. Monitoring the whereabouts of a partner or checking his or her cell phone, controlling with whom he or she associates with, manipulating contraceptives or refusing to use condoms, engaging in unwanted sexual behaviors (including insisting on receiving nude or semi-nude photos from a partner), and other controlling behaviors are all examples of ARA.
The best estimates of the prevalence of ARA nationally are from the Centers for Disease Control and Prevention's (CDC) Youth Risk Behavior Surveillance Survey (YRBSS). One in ten high school students state they have been physically hurt on purpose by a boyfriend or girlfriend in the past year, which has remained unchanged for the last decade.2 Sexual violence is also common, and often overlaps with ARA. Beginning in 2013, the YRBSS included a question about SV victimization in a dating relationship. Female respondents report higher victimization (either physical or sexual dating violence) compared to male respondents (21.4% vs 9.6%).2 SV, which includes nonconsensual sexual contact as well as rape, is prevalent; one-quarter to more than one-half of college women report at least one such experience.3 According to the CDC's National Intimate Partner and Sexual Violence Survey, 22% of women and 15% of men first experienced violence at the hands of a partner in adolescence (age 11 to 17 years).4 And for more than three-quarters of women who have histories of SV, they report their first experiences of SV occurred before age 25 years.5 Given this high prevalence of ARA and SV, it is important for health professionals who are caring for adolescents and young adults to understand how to support young people who may have been exposed to such violence.
Discrimination and Exposure to Violence and Other Childhood Adversities
Health professionals should recognize added vulnerabilities for ARA and SV among populations who experience marginalization and social disadvantage. For example, sexual and gender minority youth (ie, youth who identify as gay, lesbian, bisexual, are same-sex attracted, have same-sex sexual contacts as well as youth who are transgender and genderqueer) experience high levels of violence victimization overall— bullying, bias-based discrimination, as well as interpersonal violence. The 2015 YRBSS found that approximately one-third of female lesbian or bisexual students (30%) and approximately one-quarter of male gay or bisexual students (26%) had experienced sexual and physical violence victimization in a relationship in the past year, compared to 20% and 8% of heterosexual female and male students, respectively.6 These data on violence victimization do not include information about perpetrators or whether the violence is inflicted by same- or opposite-gender partners. In a study involving 28 colleges (16,000 students) that examined past-year prevalence of campus sexual assault, cisgender women had higher odds of sexual assault than cisgender men; people who identified as transgender had 4-fold higher odds of past-year sexual assault compared to cisgender men. Underscoring the effect of multiple forms of marginalization by race, gender, and socioeconomic status, the same survey found that among transgender students, black students had 8.3-fold greater odds of experiencing sexual assault than cisgender white students.7
ARA and SV also often emerge in the context of other forms of violence victimization; histories of childhood maltreatment and violence exposure are well-established risk factors for both interpersonal violence perpetration and victimization.8–11 The pathways from childhood adversities to increased exposure to ARA and SV victimization are complex, and include mechanisms such as the role of childhood sexual abuse on early onset puberty, pressures to engage in early onset sexual activity, and increased exposure to substance use, all of which increase vulnerability for interpersonal violence.11–15 Although beyond the scope of this article, these factors also contribute to increased likelihood of sexual exploitation.
Health Effects of ARA and SV
Exposure to ARA and SV is associated with multiple poor physical and mental health problems. These include concerns related to reproductive and sexual health (unintended pregnancy, sexually transmitted infections [STIs], HIV), mental health (depression, suicidality, substance abuse, disordered eating), chronic pain, poor sleep, and injuries sustained in an abusive situation.16–19 Given the multiple physical and mental health consequences of ARA and SV, health care providers are likely to encounter youth who are survivors of such violence. This means providers are well-positioned to connect youth to resources and support. Compared to the general adolescent population, ARA is also noted in clinical studies to be more prevalent among adolescents seeking confidential care such as in family planning clinics17,20 and school-based health centers.21
Providers should be alert to signs and symptoms that may signal a patient is being abused in a relationship.1 Adolescents may present with trauma symptoms or injuries associated with abuse but may also present with nonspecific complaints such as headaches, poor sleep, abdominal pain, or fatigue. Depression, anxiety, suicidal ideation, and substance misuse all co-occur with exposure to ARA and SV. Frequent requests for pregnancy testing, STI testing, and use of emergency contraception are also associated with such violence exposure.16
Although victims of abuse may present with specific symptoms as the focus of the clinical encounter, and health care providers should be attuned to certain “red flags” associated with ARA and SV as noted above, case identification is not the goal. Adolescents may be seeking care for problems associated with abuse but may not recognize that they are in an abusive relationship; and even if aware, they are unlikely to disclose this to a provider. Health professionals have a critical role in providing universal education and anticipatory guidance related1 to healthy relationships and supports available for youth experiencing violence for all adolescent patients.
Trauma-informed care is a universal practice whereby health care settings and providers treat all patients in a compassionate and supportive way that assumes patients have experienced trauma.22 Survivors of abuse want health professionals to be sensitive to how difficult it can be to disclose interpersonal violence to anyone, much less a provider, and want information, resources, and support regardless of disclosure.1,23 A patient who checks “no” on a screener or does not disclose exposure to violence during a clinical encounter may have a myriad of reasons for not disclosing, including not recognizing their experiences as abusive, shame, fearing consequences of disclosure, or wanting to protect their partner.23 Provision of trauma-sensitive care and relevant education to all patients reduces the stigma around violence, teaches youth about healthy relationships, and communicates that the clinic is a safe space for talking about concerns and connecting youth to relevant services and supports.
Preparing a clinical practice to educate, support, and care for survivors of ARA and SV requires that not only providers, but front-desk staff, medical assistants, nurses, health educators, and anyone else who may interact with a patient are trained about the effect of trauma, are sensitive to avoiding revictimization, and demonstrate empathy in all interactions. Policies and protocols related to ARA and SV should be implemented for the clinic, and all staff should receive training on how to implement these protocols. Care should emphasize a young person's privacy and confidentiality (including the limits of that confidentiality), safety, culturally and linguistically inclusive education, informed consent, shared decision-making, and autonomy.
Establishing the Clinic as a Safe Space
In addition to staff training, a trauma-informed clinic environment (Table 1) includes having educational materials such as posters and brochures in the clinical space about ARA and SV, including hotline numbers. Visual images that are geared toward adolescents and address ARA and SV in concrete ways also communicate that staff are comfortable talking about these issues. All materials should be multicultural, reflect a diversity of relationships and gender expression, and avoid “victim-blaming” language (see www.loveisrespect.org and www.ipvhealth.org).
Elements of Trauma-Informed Care
“CUES” Mnemonic Approach
The emerging research on universal education and brief counseling interventions for ARA and SV in adolescent and young adult clinical settings is promising. Youth and young adults in clinics where providers are trained in this universal education approach show improvement in knowledge about ARA/SV, use of resources as well as reductions in ARA victimization and reproductive coercion.21,24,25 Notably, although disclosure is not the goal, when the focus is on provision of education for all patients, adolescents in clinics with providers trained in this approach report disclosing their experiences of ARA and SV 3 times more often than in clinics providing standard of care.24 One such approach uses the CUES mnemonic—Confidentiality, Universal Education, Empowerment, and Support.
Health care settings should have a policy that patients are seen alone at some point during the clinical encounter (ie, with health provider and chaperone when necessary, but no accompanying persons). Although some patients may state they want their “partner” or family member to stay, it is critical to have time alone with a patient, who may be scared to ask the accompanying person to leave.
Given fear as well as stigma associated with being in an abusive relationship, confidentiality and privacy are especially important to survivors. Health care providers must balance the safety of minors while creating spaces that are confidential for adolescents to share experiences with their provider.1 Before discussing healthy relationships, health care providers should disclose the limits of confidentiality to their adolescent patients.1
Here's an example of what that may look like: “I am so glad you are here today. Before we get started, I wanted to remind you that your privacy is important to me. And, I also want to make sure you know there are various laws in this state to help keep young people safe. If I have a young person here who is going to hurt himself or herself or someone is hurting them, I sometimes must get other adults involved to help keep them safe. What questions do you have about that.”
It is essential for providers to be aware of their state's statutes related to confidential care as well as child abuse reporting requirements. Developing connections with colleagues (eg, social workers, domestic violence agencies, rape crisis centers) to discuss options and reporting requirements is essential. Reporting a case to an outside agency without considering safety could place the young person at significantly greater risk for harm. The ARA/SV protocols for a clinic should have a clear pathway for supporting a patient for whom a report to child protective services is needed. When at all possible, the young person should be present when making a report so that he or she can provide input related to their safety.
Universal Education and Empowerment
Every encounter with an adolescent in a health care setting can be a chance to educate youth about healthy relationships, and how unhealthy relationships can affect health.1 It is considered best practice to provide universal education and brief counseling to all adolescent patients rather than relying on a survey or checklist and responding only to disclosures (see ipvhealth.org).
Universal education involves discussing healthy relationships (including sexual communication) with all adolescent patients and providing information on supports and resources related to abuse and violence that they can share with friends. As adolescents may share their abuse experiences with friends, it is helpful to encourage patients to take information so they “can help a friend.” Focusing on skills to be “positive upstanders” (rather than passive bystanders) in peer situations can also reduce the stigma of discussing a sensitive topic such as ARA and SV. Offering information to patients so they can help others can be highly empowering and an opportunity to enhance resiliency for young people.
Not all youth recognize abusive behaviors as problematic, and this lack of recognition of abusive behaviors has been associated with lower help-seeking for abuse.23 Youth who grew up in neglectful or violent households, or who experienced chronic sexual abuse, may believe such behavior is acceptable or even normal. Universal education, then, encourages youth who have been victimized to understand that what has happened to them is not acceptable and they are not to blame.
In summary, universal education around healthy relationships normalizes and contextualizes inquiry about abuse and violence and reduces stigma for youth who have survived ARA or SV. In the simple act of offering information, the topic is introduced as one that is safe to discuss with a health care provider, and highlights for youth that they are not alone. Regardless of whether a young person discloses a history of ARA or SV, providers should offer an educational resource (for example, a palm-sized educational brochure is available at https://www.futureswithoutviolence.org/hanging-out-or-hooking-up-teen-safety-card/). This ensures that every young person leaves with information, regardless of how they may have responded to a screening question or whether they chose to disclose.
The universal education regarding healthy relationships education can also be followed by asking whether the young person has experienced any of this. Providers should remember that disclosure is not the goal; here is an example of what a provider can say: (1) We make sure to talk about relationships with all of our patients, because you may know someone who might find this useful (offer educational card). Please know this is a good place to bring friends you are worried about; and (2) I talk to everyone about the importance of healthy relationships, how everyone deserves to be treated with respect. Some patients tell me that people they're seeing are constantly checking up on them or putting them down.1
This approach can provide an opportunity to share resources or engage in hypothetical safety-planning about who youth might reach out to in a dangerous situation. This trauma-informed approach can also serve to build trust with patients who over time may become more open to sharing their stories and discussing how any abuse they are experiencing may be affecting their health.26 As patients become accustomed to their provider asking them about their experiences, they may become more comfortable with sharing and asking for help they may need.
Support: Counseling Regarding Harm Reduction Strategies
Particularly in the presence of any “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 care for their health and increase safety, as well as ensuring that the young person is aware of specific resources and supports in the community for survivors of violence.1
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 in an abusive relationship. To assess for safety, for example, providers might ask, “How is the person you are having sex with going to react when they hear that they need to be treated, too?” To help adolescents stay safer, providers might offer to speak with the partner and offer treatment, introduce the patient to an anonymous website to notify sex partners, or contact the partner anonymously by phone about need for treatment. When a provider takes the time to ask questions like, “How hard will it be for you to reach people you've had sex with to let them know about the need for treatment?” they are also signaling to the young person that they understand that some sex partners may not be known to the patient.
Some youth may have had several STIs or exhibit other symptoms that raise concerns for abuse or exploitation. Although disclosure is not the goal, a provider might set the stage by saying, “When I see a pattern like this, I worry about someone making you do things sexually that you did not want to do. Could that be part of your story?” And regardless of whether the young person discloses abuse or not, the provider should always offer ARA/SV information: “I want you to have this information. We give this to everyone, as we really care that our patients are in healthy relationships.”
If a provider is particularly concerned that a youth is experiencing abuse or exploitation, it may be helpful to normalize how difficult it can be to disclose information about such experiences: “I'm worried that something has happened to you, but I also understand that it doesn't always feel safe to share that with someone you just met. In case there is something going on, I want to share some resources with you that I have learned could be helpful for young people. Would that be all right with you?”
Support: Patient-Centered Examinations
Shared decision-making (arriving at plans for care together) should occur throughout the clinical encounter. Clear communication with patients regarding what will happen during the examination before it happens is critical to keep the patient informed and empower them. The clinical encounter should be as predictable as possible. Providers should review the physical examination prior to having the patient undress into a gown, and explain each step of the examination, always giving the patient the option to refuse at any point. Providers should reiterate the voluntary nature of the clinical history and examination as well as receipt of services; provide information both verbally and in writing; and offer multiple opportunities for patients to ask questions. The right to refuse should be reiterated at regular intervals during complicated, lengthy, or stressful procedures.
A pelvic examination may trigger flashbacks for some patients, which can look like the patient “zoning out” such that they appear to be in a different place and stop responding to questions. Inviting patients to provide guidance on how they would like the examination to proceed or what would make the examination more comfortable (eg, provider explains every step, or patient listens to music during examination or talks to the medical assistant who is helping with the examination) can be helpful.
Support: When Disclosures Happen
Although disclosures are not the goal, disclosures do happen. Providers can first express appreciation for a young person's courage in sharing their story. Providers not only serve as a critical source of information and connection to services, they can also foster a sense of security and caring by the way they approach and interact with a youth who is disclosing.
Caring for adolescents experiencing abuse is complex. Providers should identify and connect with allies in mental health, social work, advocates, and adolescent medicine who can be helpful for consultation and referral to more intensive services. Resources for youth include hotlines, domestic violence agencies, rape crisis centers, child protection services, legal advocacy, mental health counseling, child advocacy centers as well as services for meeting basic needs such as youth shelters, food, education, and job skills. Having materials from these agencies readily available in examination rooms also provide signals to patients about the ability of providers to help. Providers should also know how to connect to an advocate by reaching out to victim service agencies in their local area.
Whenever possible, providers should offer patients a “warm” referral by connecting them directly with an advocate (in person, or by phone or videoconference) rather than simply providing a number to call. A warm referral means that the provider is using the trust that they have engendered with their patient and transferring this trust to another helper, in this case, a victim service advocate. Offering to a young person to use the phone in clinic to speak with an advocate (rather than using their own phone) or setting up a time that an advocate can come meet with the young person in clinic helps ensure safety and confidentiality. Making warm referrals to victim service advocates can assist young people in overcoming barriers to accessing services, including self-blame, lack of recognition of abuse, limited knowledge of the types of services available, and perception that services are limited in scope (eg, solely crisis-oriented).27 Describing services available and normalizing use of such services may facilitate use of services, improve mental health symptoms, and reduce re-victimization.1,28 Additionally, formal agreements with local violence-related services can facilitate connections to relevant resources.
The provision of trauma-informed, patient-centered care can become routine. From strategic placement of posters and brochures, to assurance of privacy during the visit, to the use of universal education and connections, to community supports, there are many meaningful steps that providers can take to help their young patients feel safe and to ensure that care is provided in a trauma-sensitive way.
- Miller E. Prevention of and interventions for dating and sexual violence in adolescence. Pediatr Clin N Am. 2017;64(2):423–434. doi:. doi:10.1016/j.pcl.2016.11.010 [CrossRef]
- Rasberry C, Tiu G, Kann L, et al. Health-related behaviors and academic achievement among high school students—United States, 2015. MMWR Morb Mortal Wkly Rep. 2017;66(35):921–927. doi:. doi:10.15585/mmwr.mm6635a1 [CrossRef]
- Mouilso ER, Fischer S, Calhoun KS. A prospective study of sexual assault and alcohol use among first-year college women. Violence Vict. 2012;27(1):78–94. doi:10.1891/0886-6708.27.1.78 [CrossRef]
- Breiding MJ, Chen J, Black MC. Intimate partner violence in the United States—2010. https://www.cdc.gov/violenceprevention/pdf/cdc_nisvs_ipv_report_2013_v17_single_a.pdf. Accessed June 17, 2019.
- Black M, Basile K, Breiding M, et al. National Intimate Partner and Sexual Violence Survey (NISVS). 2010 summary report. https://www.cdc.gov/violenceprevention/pdf/nisvs_report2010-a.pdf. Accessed June 17, 2019.
- Olsen EOM, Vivolo-Kantor AM, Kann L. Physical and sexual teen dating violence victimization and sexual identity among U.S. high school students, 2015 [published online ahead of print May 1, 2017]. J Interpers Violence. doi:10.1177/0886260517708757 [CrossRef].
- Coulter R, Mair C, Miller E, Blosnich J, Matthews D, McCauley HL. Prevalence of past-year sexual assault victimization among undergraduate students: exploring differences by and intersections of gender identity, sexual identity, and race/ethnicity. Prev Sci. 2017;18(6):726–736. doi:. doi:10.1007/s11121-017-0762-8 [CrossRef]
- Fang X, Corso PS. Child maltreatment, youth violence, and intimate partner violence: developmental relationships. Am J Prevent Med. 2007;33(4):281–290. doi:. doi:10.1016/j.amepre.2007.06.003 [CrossRef]
- Hamby S, Finkelhor D, Turner H, Ormrod R. The overlap of witnessing partner violence with child maltreatment and other victimizations in a nationally representative survey of youth. Child Abuse Negl. 2010;34(10):734–741. doi:. doi:10.1016/j.chiabu.2010.03.001 [CrossRef]
- Miller E, Breslau J, Chung W-JJ, Green JG, McLaughlin KA, Kessler RC. Adverse childhood experiences and risk of physical violence in adolescent dating relationships. J Epidemiol Community Health. 2011;65(11):1006–1013. doi:10.1136/jech.2009.105429 [CrossRef]
- Hebert M, Moreau C, Blais M, Lavoie FMG. Child sexual abuse as a risk factor for teen dating violence: findings from a representative sample of Quebec youth. J Child Adolesc Trauma. 2017;10(1):51–61. doi:. doi:10.1007/s40653-016-0119-7 [CrossRef]
- Chen F, Rothman EF, Jaffee S. Early puberty, friendship group characteristics, and dating abuse in US girls. Pediatrics. 2017;139(6):e20162847. doi:. doi:10.1542/peds.2016-2847 [CrossRef]
- Ihongbe T, Cha S, Masho SW. Age of sexual debut and physical dating violence victimization: sex differences among US high school students. J Sch Health. 2017;87(3):200–208. doi:. doi:10.1111/josh.12485 [CrossRef]
- Reyes H, Foshee VA, Tharp A, Ennett S, Bauer D. Substance use and physical dating violence: the role of contextual moderators. Am J Prev Med. 2015;49(3):467–475. doi:. doi:10.1016/j.amepre.2015.05.018 [CrossRef]
- Johnson R, LaValley M, Schneider K, Musci R, Pettoruto K, Rothman EF. Marijuana use and physical dating violence among adolescents and emerging adults: a systematic review and meta-analysis. Drug Alcohol Depend. 2017;174:47–57. doi:. doi:10.1016/j.drugalcdep.2017.01.012 [CrossRef]
- Decker MR, Silverman JG, Raj A. Dating violence and sexually transmitted disease/HIV testing and diagnosis among adolescent females. Pediatrics. 2005;116(2):e272–276. doi:. doi:10.1542/peds.2005-0194 [CrossRef]
- Miller E, Decker MR, McCauley HL, et al. Pregnancy coercion, intimate partner violence, and uinintended pregnancy. Contraception. 2010;81(4):316–322. doi:. doi:10.1016/j.contraception.2009.12.004 [CrossRef]
- Exner-Cortens D, Eckenrode J, Rothman E. Longitudinal associations between teen dating violence victimization and adverse health outcomes. Pediatrics. 2013;131(1):71–78. doi:. doi:10.1542/peds.2012-1029 [CrossRef]
- Foshee V, Reyes H, Gottfredson N, Chang L, Ennett S. A longitudinal examination of psychological, behavioral, academic, and relationship consequences of dating abuse victimization among a primarily rural sample of adolescents. J Adolesc Health. 2013;53(6):723–729. doi:. doi:10.1016/j.jadohealth.2013.06.016 [CrossRef]
- Miller E, McCauley HL, Tancredi DJ, Decker MR, Anderson H, Silverman JG. Recent reproductive coercion and unintended pregnancy among female family planning clients. Contraception. 2014;89(2):122–128. doi:. doi:10.1016/j.contraception.2013.10.011 [CrossRef]
- Miller E, Goldstein S, McCauley HL, et al. A school health center intervention for abusive adolescent relationships: a cluster RCT. Pediatrics. 2015;135(1):76–85. doi:. doi:10.1542/peds.2014-2471 [CrossRef]
- Felitti VJ, Anda RF, Nordenberg DC, et al. Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults: The Adverse Childhood Experiences (ACE) Study. Am J Prev Med. 1998;14(4):245–258. doi:. doi:10.1016/S0749-3797(98)00017-8 [CrossRef]
- Markoff LS, Reed BG, Fallot RD, Elliott DE, Bjelajac P. Implementing trauma-informed alcohol and other drug and mental health services for women: lessons learned in a multisite demonstration project. Am J Orthopsychiatry. 2005;75(4):525–539. doi:. doi:10.1037/0002-9422.214.171.1245 [CrossRef]
- Miller E, Decker MR, McCauley HL, et al. A family planning clinic partner violence intervention to reduce risk associated with reproductive coercion. Contraception. 2011;83(3):274–280. doi:. doi:10.1016/j.contraception.2010.07.013 [CrossRef]
- Miller E, Tancredi DJ, Decker MR, et al. A family planning clinic-based intervention to address reproductive coercion: a cluster randomized control trial. Contraception. 2016;94(1):58–67. doi:. doi:10.1016/j.contraception.2016.02.009 [CrossRef]
- Chang JC, Decker MR, Moracco KE, Martin SL, Petersen R, Frasier PY. Asking about intimate partner violence: advice from female survivors to health care providers. Patient Educ Couns. 2005;59(2):141–147. doi:. doi:10.1016/j.pec.2004.10.008 [CrossRef]
- Logan TK, Evans L, Stevenson E, Jordan CE. Barriers to services for rural and urban survivors of rape. J Interpers Violence. 2005;20(5):591–616. doi:. doi:10.1177/0886260504272899 [CrossRef]
- Bennett L, Riger S, Schewe P, Howard A, Wasco S. Effectiveness of hotline, advocacy, counseling, and shelter services for victims of domestic violence: a statewide evaluation. J Interpers Violence. 2004;19(7):815–829. doi:. doi:10.1177/0886260504265687 [CrossRef]
Elements of Trauma-Informed Care
Adapted to a young person's needs, and tailored to be inclusive and culturally and linguistically relevant
Celebrate a young person's strengths, be supportive, and avoid judgmental statements or actions
Integrative and holistic—not just focused on clinical symptoms
Empower—ensuring that a young person's rights to information, privacy, bodily integrity, and participation in decision-making are respected and promoted
Promote healing and recovery through a shared and mutually derived treatment plan that honors a young person's autonomy