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Adolescent relationship abuse including physical and sexual teen dating violence

Adolescent relationship abuse including physical and sexual teen dating violence
Literature review current through: Sep 2023.
This topic last updated: Aug 23, 2023.

INTRODUCTION — Adolescent relationship abuse (ARA) is a major public health problem, associated with unintended pregnancy, sexually transmitted infections, physical injury, and mental health and educational consequences.

The epidemiology, health and social consequences, trauma-sensitive approach to, and prevention of ARA will be discussed here. Date rape, evaluation and management of adolescent sexual assault, and human trafficking are discussed separately.

(See "Date rape: Risk factors and prevention".)

(See "Date rape: Identification and management".)

(See "Evaluation and management of adult and adolescent sexual assault victims in the emergency department".)

(See "Human trafficking: Identification and evaluation in the health care setting".)

TERMINOLOGY

Definition — ARA includes physical, sexual, or psychological/emotional abuse of a romantic, sexual, or intimate partner that occurs in person, through texting, online, or through someone else (eg, a peer who delivers a threat or message) [1].

Other terms that are used interchangeably with ARA include "teen dating violence" and "adolescent dating violence." We prefer "ARA" as the umbrella term because [2]:

Abusive and controlling behaviors occur outside the teenage years, from early adolescence (preteens) through young adulthood.

Adolescents may use terms other than "dating" to refer to their romantic, sexual, and intimate relationships.

Abusive behaviors may be controlling or possessive rather than violent.

Types of adolescent relationship abuse

Physical abuse – Threatening to use or using physically assaultive behaviors (eg, hitting, slapping, beating, grabbing, shoving, kicking, biting).

Sexual abuse – Unwanted sexual touching, forcing someone to engage in unwanted sexual activity, threatening to engage in unwanted sexual activity.

Psychological/emotional abuse – A variety of controlling behaviors, including:

Isolation (cutting someone off from friends and family, using jealousy to justify behavior); this may include [3,4]:

-Monitoring a person's whereabouts

-Tracking their cell phone use

-Controlling with whom they hang out

Humiliation (making someone feel as if they are to blame for the abuse they are experiencing)

Intimidation (making someone feel afraid by using threats, abuse of animals, destruction of property, verbal aggression)

Coercion (threatening to hurt themselves or the partner if the partner does not comply or tries to leave; insisting on receiving nude or seminude photos of the partner)

Bilateral or reciprocal violence – Involves victimization and perpetration by both partners.

Reproductive coercion – Reproductive coercion is common during adolescence and associated with unintended pregnancy [5]. Examples of reproductive coercion include:

Pressuring a partner to become pregnant

Interfering with contraceptive use

Manipulating condoms (eg, breaking condoms, removing condoms during sex, refusing to use condoms) [6]

Cyber dating abuse – Using digital technologies (eg, texting, social networking sites, chat programs) to retain control in a relationship or to stalk, harass, or threaten a dating (or former) partner; cyber dating abuse is associated with other coercive and violent behaviors [7-11].

EPIDEMIOLOGY

Prevalence – The prevalence of adolescent physical and sexual teen dating violence (adolescent dating violence [ADV]) is increased throughout adolescence and peaks in young adulthood [12,13]. Rates of ADV vary across race and ethnic groups from 7 percent among Asian youth to 18 percent among American Indian or Alaska Native youth [14]. Less information is available about the prevalence of other types of ARA (eg, psychological/emotional abuse, reproductive coercion, cyber dating abuse, economic abuse).

Adolescent dating violence – In a 2021 national cross-sectional survey of high school students in the United States, 8 percent of respondents indicated that they had been hurt on purpose (eg, hit, injured with a weapon or object) by someone they were dating or going out with in the past year [14]. Physical dating violence victimization was more common among female than male students (10 versus 7 percent). In the same survey, 10 percent of students reported being forced to do "sexual things" (eg, kissing, touching, having sexual intercourse) by someone they were dating or going out with in the past year. Sexual dating violence was more common among female than male students (15 versus 4 percent). In this survey, physical and sexual dating violence is reported more than twice as often among female than male students (19 versus 8 percent) [14].

-Sexual and gender minority adolescents – In state and national surveys of high school students, sexual and gender minority students report higher rates of ADV in the past year than heterosexual and cisgender students [15-19].

In national cross-sectional surveys of high school students in the United States (2015 to 2021), physical dating violence victimization was more common among self-identified gay, lesbian, bisexual, and not sure students than among self-identified heterosexual students (13 to 18 versus 6 to 9 percent) [14,18,20,21]. Sexual dating violence was also more common among self-identified gay, lesbian, bisexual, and not sure students than among self-identified heterosexual students (15 to 26 versus 5 to 10 percent). The surveys did not specify the gender of the perpetrators in these relationships. (See "Lesbian, gay, bisexual, and other sexual minoritized youth: Epidemiology and health concerns", section on 'Sexual victimization'.)

In single-state surveys, physical dating violence was more common among self-identified transgender or gender-expansive youth (eg, responded "don't know" or "I do not identify as female, male, or transgender") than among those who self-identified as female or male [16,19]. For example, in one study, rates of physical dating violence were 16 percent among transgender youth, 13 percent among gender-expansive youth, and 7 percent among self-identified males and females [19]. Psychological dating violence was also more common among self-identified transgender youth (30.4 percent) than self-identified males (10 percent) and females (20 percent) and more common among transgender than gender-expansive youth (24 percent) [19].

Cyber dating abuse – In observational studies, cyber dating abuse has been reported in up to 40 percent of adolescents [3,9,10,22]. As an example, in a nationally representative survey of 2218 students age 12 to 17 years, 28 percent of those who were in a dating relationship in the past year reported cyber dating abuse [10]. Male students reported cyber dating victimization more frequently than female students (32 versus 24 percent). However, in a separate national cross-sectional survey of high school students in the United States from 2021, 16 percent of students reported having been cyberbullied [14]. Cyberbullying was reported approximately twice as often among female than male students (20 versus 11 percent). Cyber dating abuse is associated with other coercive and violent behaviors [3,10].

Reproductive coercion – In a cross-sectional survey of 550 sexually active female high school students, 12 percent reported reproductive coercion in the previous three months [5].

Bilateral/reciprocal ADV – Some evidence suggests that >50 percent of ADV can be classified as bilateral or reciprocal, in which both partners are perpetrators (ie, use violence) as well as victims [23].

Age at first experience – Intimate partner violence (IPV) often begins in adolescence or young adulthood. In the 2015 National Intimate Partner and Sexual Violence Survey, 26 percent of female victims and 15 percent of male victims of IPV (defined as contact sexual violence [ie, rape, being made to penetrate someone else, sexual coercion, and/or unwanted sexual contact], physical violence, and/or stalking by an intimate partner) first experienced IPV before age 18 years; 71 percent of female victims and 56 percent of male victims first experienced IPV before age 25 years [24]. In another survey, a nationally representative cohort of students in grades 7 through 12 who reported only opposite-sex romantic or sexual relationships were followed through age 24 to 27 years [13]. Among participants who reported only opposite-sex romantic or sexual relationships, 40 percent reported physical or sexual violence by young adulthood: 8 percent only during adolescence, 25 percent only in young adulthood, and 7 percent in both adolescence and young adulthood.

RISK AND PROTECTIVE FACTORS

Risk factors – Factors associated with ARA victimization include [25-30]:

Physical or sexual abuse in childhood (increases risk of abusive relationships and/or recruitment into sex work)

Early onset puberty

Early onset of sexual activity

Substance use, including marijuana use and nonmedical use of prescription drugs; substance use may increase the risk of ARA (by making the adolescent more vulnerable to an abuser who wishes to exploit their addiction), has been associated with cyber dating abuse, and may be a maladaptive strategy to cope with ARA

Being pregnant or postpartum, particularly during the first three months after delivery [31-34]; pregnant adolescents may be perpetrators as well as victims of intimate partner violence [23,35]

"Sexting" (ie, sending naked or sexually suggestive pictures to someone electronically [eg, text message or electronic mail]) [36]

Sexual minority status (ie, same-sex attraction or sexual contacts; gay, lesbian, or bisexual sexual identity) or gender minority status (eg, transgender, gender diverse, gender expansive, nonbinary gender identity) [15-18,37]

Socioeconomic disadvantage (eg, low income, unemployment), which disproportionately affects youth from underrepresented racial/ethnic groups

Involvement with the child protection system or placement in foster care or group home settings (eg, because of child maltreatment or exposure to violence or substance use in the home) [38-41]

Involvement with the juvenile justice system [42]

Youth homelessness (which increases the risk of sexual exploitation)

Gang-affiliated partners and less equitable gender attitudes (including beliefs supportive of rigid gender norms, objectification of female bodies and sexuality) [43,44]

Protective factors Factors that protect against ARA victimization include:

Participation in prevention programs (see 'Structured preventive/early intervention programs' below)

Knowledge of sexual consent and skills to communicate about desire and consent [45]

Exposure to positive parenting practices (eg, support, warmth, responsiveness, appropriate and consistent discipline) and strong family functioning [45-47]

Prosocial peers (eg, involvement in community activities, including civic engagement, service, and faith-based group activities) [47]

Family and school support [17]

IMPACT ON HEALTH — ARA victimization is associated with adverse effects on sexual, mental, and general physical health [48,49]. It is also associated with risk of intimate partner violence (IPV) in adulthood [49].

Although the rates of violence perpetration against intimate partners are similar among females and males, females experience more severe consequences from victimization because they are more often victims of severe physical violence (eg, being hit with a fist or something hard, kicked, choked, suffocated, burned on purpose, injured with a knife or gun) [24,50]. In the 2015 National Intimate Partner and Sexual Violence Survey, more female than male victims of IPV experienced severe physical violence (21 versus 15 percent) [24]. Female victims are also more likely to be killed by their partners than male victims. Among the 150 adolescent homicides classified as intimate partner homicide by the National Violent Death Reporting System from 2006 to 2016, 135 (90 percent) were female [51].

Cyber dating abuse victimization also appears to be associated with severe mental health outcomes for female adolescents (eg, suicidality, heavy episodic alcohol use) [7,52].

Sexual health – ARA has been associated with poor sexual health outcomes, including unintended or unwanted pregnancy, human immunodeficiency virus (HIV) infection and other sexually transmitted infections (STIs), endometriosis, and problems with ovulation and menstruation [48,53-56]. Even if they are not experiencing reproductive coercion, youth experiencing ARA may not be able to assert sexual agency or negotiate condom use with their sex partners, which increases their risk of unintended pregnancy and STI [57-59]. Younger victims of ARA may be at particularly elevated risk for HIV and STI because they experience greater levels of sexual violence (which increases the risk of tissue trauma and subsequent infection), inability to refuse sex, difficulty negotiating condom use, and inadequate access to health care [58].

Youth in abusive situations may be coerced to have abortions and may not have access to abortions that are safe and legal [60].

Sexual violence affects an adolescent's ability to navigate future healthy sexual relationships. Comprehensive and compassionate reproductive health care for youth who have experienced violence is vital. (See 'Healing-centered approach to care' below.)

Mental health and education – ARA victimization has been associated with poor mental health outcomes (eg, depression, suicidality, substance use, disordered eating), somatic complaints (eg, poor sleep, chronic headaches, chronic fatigue, dizziness, pelvic pain), and poor academic achievement [48,49,56,61,62].

Some victims of ARA are provided with drugs or alcohol by their abuser to make it easier for them to be controlled or to get them addicted and thus dependent on the relationship. Other youth may begin using substances to cope with the trauma of their experiences.

General physical health – Victims of ARA may have poor health status at baseline. Factors such as poverty and discrimination that increase susceptibility to ARA are also associated with poor health [63]. Victims of ARA who have underlying medical problems (eg, asthma, diabetes) may have exacerbations of their illness if they are unable to access treatment. In addition, persistent fear and stress from violence may lead to other chronic health conditions [64].

Physical injuries sustained in ARA may include hitting, kicking, choking, burning, and cutting [65]. Victims of ARA who sustain head trauma may present with chronic headaches, dizziness, poor memory, or frequent falls [66]. (See "Concussion in children and adolescents: Clinical manifestations and diagnosis".)

POSSIBLE WARNING SIGNS — Although no single symptom or sign is predictive of ARA, certain signs and symptoms are associated with ARA, particularly if they occur in combination. Providers should be alert to the following clinical findings, which are either sequelae of ARA or are frequently associated with ARA (table 1) [2,5]:

Symptoms and signs of trauma/injuries

Nonspecific complaints (eg, recurrent headaches, poor sleep, abdominal pain, fatigue)

Depression

Anxiety

Suicidal ideation

Substance use or misuse of prescription drugs

Frequent requests for pregnancy testing, testing for sexually transmitted infections, or use of emergency contraception (all of which may suggest reproductive coercion)

Multiple abortions

Sexual activity with older partners

Sexual activity with multiple partners in a short period of time

Sexual activity at age ≤13 years

"Partner" insisting on staying in the examination room

School absenteeism due to feeling unsafe [67]

PRACTICE CONSIDERATIONS — Given the prevalence of ARA and the variety of physical and mental health sequelae, health care providers are likely to care for adolescents who have been exposed to ARA, particularly if they practice in family planning clinics or school-based health centers [53,54,68]. Health care providers for adolescents are uniquely positioned to recognize signs and symptoms of ARA and to support agency for survivors by providing compassionate, comprehensive care [69].

Healing-centered approach to care — A healing-centered approach to care is appropriate for all adolescents − not just those who have been identified as victims of violence. Adolescent victims of ARA are more likely to seek care for physical, sexual, or mental health consequences of ARA than to present with ARA as a chief concern. They may not be identified as victims of ARA or may not be ready to disclose ARA, particularly if they remain in an abusive situation.

Goals – The goals of healing-centered care for ARA are to ensure that adolescent patients:

Receive relevant information and resources (whether or not they disclose ARA)

Are reassured that they are not alone

Are motivated to take steps to improve their safety

Given these goals, we provide all of our adolescent patients with education and anticipatory guidance about healthy/unhealthy relationships and information about resources that are available to adolescents who experience violence. It is not necessary to know whether the patient has experienced ARA to achieve these goals. In addition to providing education about healthy relationships, this approach reduces the stigma associated with ARA and lets patients know that they can talk with us if they have concerns about ARA and that we can help them access supports and services. (See 'Addressing adolescent relationship abuse' below.)

Trauma-sensitive approach – Providers should treat all patients in a way that is sensitive to the possibility they have experienced trauma (table 2) [69,70]. Patients should be encouraged to seek information, understand their options, and assert their choices. (See 'Patient-centered evaluation' below.)

Victims of ARA may not disclose ARA for a variety of reasons. Experiences of trauma (eg, exposure to violence, being in an abusive relationship) affect help- and care-seeking behaviors [71,72]. It can be difficult to disclose interpersonal violence to anyone – not just to a health care provider [73]. Victims of ARA may feel ashamed, may be afraid of consequences related to disclosure (eg, damage to relationship, further violence), may not recognize the experience as abuse, may feel loyalty toward their partner, may have been instructed to lie to providers, may not know that services are available to help them, or may perceive that the services are only available in a crisis [74,75].

Practice personnel (eg, front-desk staff, medical assistants, nurses, health educators) should be trained about the impact of trauma so they can avoid revictimization and can provide empathic attention in all patient interactions. Clinics should develop policies and protocols related to ARA, including confidentiality and how mandatory reporting requirements are handled. All staff should be trained on why these protocols exist as well as how to implement them. (See 'Privacy and confidentiality' below.)

Breaches of confidentiality, judgmental comments, and probing unnecessarily or without sensitivity for details about ARA can exacerbate mistrust and fear of the health care system. By contrast, a nonjudgmental, comforting approach to potential victims helps to reinforce that no one deserves to be hurt and that everyone deserves to be treated with respect.

Establishing a safe space — Although disclosure of ARA is not the goal of healing-centered care, it is important to convey that the clinic is a safe and confidential place for adolescents to talk about ARA (as well as other behaviors that affect health), to seek assistance, and to be connected to resources and support.

Establishing a safe space encompasses helping adolescents understand that ARA is common, that it is not their fault, that it is a topic that can be discussed in the clinic setting, and that help is available. Some steps that providers can take to establish the clinic as a safe space in which to discuss ARA include:

Having posters and brochures related to healthy relationships; the materials should reflect a diversity of cultures, relationships, and gender expression and provide key information about ARA, including hotline numbers.

Educational materials that center on adolescents and that include concrete examples of relationship abuse communicate that clinic staff care about and are familiar with these issues and that these are safe topics for discussion with health care providers.

Relevant educational materials are available from the National Domestic Violence Hotline and Futures Without Violence.

Assuring privacy during the visit. (See 'Privacy and confidentiality' below.)

Providing education about healthy/unhealthy relationships to all patients. (See 'Addressing adolescent relationship abuse' below.)

Being prepared for adolescents who disclose ARA by becoming familiar with community resources and knowing how to access them; local resources may include victim advocates, mental health care providers, social workers, behavioral health care providers, and/or adolescent medicine specialists. (See 'Managing disclosures' below.)

Privacy and confidentiality — Given the fear and stigma associated with being in an abusive relationship, privacy and confidentiality are especially important to youth experiencing ARA. The health care provider must balance creating a practice environment in which the patient may be willing to discuss ARA with the safety of the patient and mandatory reporting requirements, which vary from state to state.

Privacy – Having a clinic policy that clearly states that all adolescent patients are seen in private at some point during the visit is helpful in establishing a safe space in which to discuss ARA. Clinicians must prepare for the possibility that a patient may be accompanied to the clinic by a perpetrator.

All adolescent patients should have time alone with their health care provider (with or without a chaperone if a chaperone is necessary) without whomever accompanied them to the clinic. Although some patients may indicate that they would like the person who accompanied them be present, they may be afraid to ask for time alone with the health care provider.

Confidentiality The health care provider should discuss confidentiality and the limits of confidentiality with adolescents (and adult patients in accordance with state laws) before they begin to discuss healthy relationships. As an example, the provider can say:

"I am so glad you are here today. Before we get started, I want to remind you that I value your privacy. That said, I also want to make sure you know that there are various laws in this state to help keep young people safe. So, if I have a young person in clinic who is going to hurt herself or himself or someone is hurting them, I sometimes have to get other adults involved to help keep them safe. What questions do you have about that?" [2]

Providers must be aware of their state's minor consent and confidentiality requirements as well as mandated reporting laws. Information about state statutes on mandatory reporting (eg, of domestic violence or human trafficking) is available from the Child Welfare Information Gateway. Many situations of ARA are not reportable, and reporting them may be harmful and/or breach confidentiality. (See "Confidentiality in adolescent health care" and "Consent in adolescent health care".)

Providing support to an adolescent while keeping them safe may require consultation with experienced advocates (eg, social workers, rape crisis centers, intimate partner violence agencies) [2]. Making a report to child protective services without considering the adolescent's safety may increase the risk of harm to the adolescent.

Patient-centered evaluation — In a patient-centered evaluation, all stages of the clinical encounter focus on the patient. Patients should feel that their voice is being heard and valued. They should be offered choices whenever possible. This is particularly important for victims of abuse; being the victim of unpredictable abusive behaviors creates a chronic lack of control. Encouraging the patient's participation in decision making throughout the clinical encounter helps to prevent inadvertent retraumatization of patients who have been victimized. Certain aspects of the examination (eg, particular body positions or types of touch, being in a confined space) may remind the patient of their trauma [69].

Providers must look for signs of medical conditions that were not discussed in the medical history. Patients who have experienced abuse or exploitation may not always share all of their complaints or respond to questions honestly due to fear, mistrust, or shame.

Components of a patient-centered evaluation include:

Shared decision making – Patients should be invited to provide guidance on how they would like the examination to proceed or how the examination could be made more comfortable (eg, by having the provider describe every step, by listening to music).

Studies have shown that shared decision making is associated with improved adherence to prescribed treatment and greater involvement in managing follow-up care [76-78].

Predictability – The clinical encounter should be as predictable as possible. Providers should review the steps of the physical examination before the patient is asked to change into a gown. It may be helpful to let patients know that the examination may remind patients who have experienced abuse of their previous victimization.

Clear communication regarding what will happen during the examination before it happens is critical to keep the patient informed and empowered. Each step of the examination should be explained throughout the evaluation, and the patient should understand that they may refuse any portion of the examination at any time.

Informed and voluntary patient participation – Patients should be educated about the evaluation and/or procedures and agree to their being performed.

Use of verbal, written, and visual tools can help to communicate and improve informed consent, particularly for patients with low literacy. Explanations about medical problems and procedures should be basic, with opportunities for the adolescent to "teach back" what they heard. Many adolescents have limited knowledge about human anatomy and physiology. For example, they may not know how antibiotics or contraception work, how much damage a sexually transmitted infection (STI) can do to their bodies, or that some STIs are incurable. The examination can provide an opportunity to educate youth about their bodies and how they work, and empower them to take an active role in their own care.

Providers should emphasize the voluntary nature of the clinical history, examination, and services, and offer multiple opportunities for patients to ask questions and/or opt not to continue. Checking with the patient throughout the evaluation can allay fears and provide a sense of control. The physical examination, particularly the pelvic examination, can be difficult and retraumatizing for patients who have experienced violence. The right to refuse should be repeated at regular and appropriate stages during complicated, lengthy, or stressful procedures. In some patients, the examination may trigger flashbacks, during which the patient may "zone out," appear to be in a different place, stop responding to questions, hyperventilate, or have near-syncope.

ADDRESSING ADOLESCENT RELATIONSHIP ABUSE

Universal education and anticipatory guidance — We provide education about healthy relationships and brief counseling about ARA to all adolescents rather than providing information only to those who disclose ARA through screening questions, surveys, or checklists. Every interaction with an adolescent patient is considered an opportunity to discuss healthy relationships, the impact of unhealthy relationships on health, and the readiness of health care providers to support those who are experiencing ARA. Provision of education about ARA is particularly important for adolescents engaging in substance use, given the correlation between exposure to violence and substance use.

Why we provide universal education – We consider universal education to be best practice for several reasons:

It contributes to an environment that supports patient-centered care

It allows both victims and perpetrators of ARA to understand what ARA is – and that it is not okay

Adolescents may have complaints that are related to ARA (eg, symptoms of depression or anxiety) but may not perceive their relationship to be unhealthy (eg, abusive, exploitative) or may not disclose that they are in an unhealthy relationship [2].

It lets adolescents know that ARA is a topic that is open for discussion with the health care provider and that the provider can be a source of advocacy and support

It provides the context for subsequent questions about ARA

It reduces stigma for adolescent victims of ARA by letting them know that they are not alone

It offers adolescents information about how they can help a friend who may be experiencing ARA

How to introduce the discussion – Given that adolescents may disclose ARA to a friend before (or instead of) a parent, caregiver or other adult, health care providers can introduce the topic of ARA as something that may affect their peer group as a whole, without singling out the individual patient [2]. Examples of how to introduce the topic include:

We discuss healthy and unhealthy relationships with all of our patients. You may know someone who would benefit from the information. If you are worried about a friend, this is a safe place to bring them.

Many of our patients have told us about situations in their relationships that made them uncomfortable or afraid. Because these kinds of unhealthy relationships can affect health, we talk to all of our patients about their relationships. As health care providers, you and your health are important to us.

What to discuss – The components of education and anticipatory guidance include:

The importance of healthy relationships, including asking a young person what a respectful relationship looks like to them. Adolescents who are considering sexual activity or already sexually experienced may also benefit from a discussion about the critical importance of communication about sex, including how to discuss desire and consent with a partner. The American College of Obstetricians and Gynecologists provides guidance for promoting healthy relationships in adolescents, including sample questions.

A description of unhealthy relationships, with concrete examples of behaviors that occur in unhealthy relationships, and a discussion of potential consequences of unhealthy relationships. Some adolescents may not recognize ARA. Those who grew up in abusive or violent households or experience sexual abuse may be conditioned to believe that abusive behavior is acceptable or even normal.

Having a clear understanding of ARA and better sexual communication skills may enable the adolescent to have healthier sexual relationships and reduce the risk of unintended pregnancy and sexually transmitted infections (STIs).

Provision of information about advocacy and resources related to prevention and support for victims of ARA, including sexual violence and exploitation (eg, a safety card available from Futures Without Violence that includes toll-free hotlines for ARA and other safety concerns). (See 'Universal provision of resources' below.)

We encourage patients to share the information about ARA with their friends. Suggesting that the information may be helpful to a friend can reduce the stigma associated with ARA. It also may encourage adolescents to speak up and/or intervene if they witness ARA among peers.

Universal inquiry

General approach — We ask all adolescent patients about ARA. The approach varies with the clinical situation and provider preference. Some providers start by providing education and resources and then proceed to asking whether the adolescent has experienced ARA directly. Other providers ask about ARA in the context of provision of education and anticipatory guidance. For example [2]:

We talk with all of our patients about healthy relationships because everyone deserves to be treated with trust and respect. Some patients have told us that the person they are seeing is always putting them down or checking up on them. Has something like that ever happened to you?

As patients become accustomed to being asked about their experiences, they may be more comfortable sharing that information and asking for help.

High-risk adolescents — For adolescents with possible warning signs of ARA (table 1), more extensive evaluation is warranted. Routine inquiry includes open-ended and specific questions about ARA.

Whether or not the adolescent discloses ARA, the inquiry should be accompanied by offers of strategies to reduce the risk of ARA and provision of information about resources in the community that support victims of violence. (See 'Universal provision of resources' below.)

Inquiry based on risk factor(s) – Knowledge of the adolescent's particular history can be used to ask about ARA and/or offer harm reduction strategies. As examples [2]:

For adolescents who have been smoking a lot of marijuana, the provider can say:

-A lot of my patients have talked to me about using marijuana to help with stress, and sometimes that stress can come from relationships that they are in. Is that part of what might be going on for you?

-Some of my patients tell me that being on social media all the time can be exhausting and stressful. How has it been for you? Do you have any friends who have experienced bullying or sexual harassment online?

For adolescents who have been diagnosed with an STI and whose partner(s) need treatment, the clinician can:

-Indirectly probe for ARA by asking, "How is your partner going to react when they hear that they need treatment?"

To reduce harm and keep the patient safer, the clinician can offer to notify the patient's partner(s) and provide treatment, offer to contact the partner anonymously by phone, or help the patient to use an anonymous website for partner notification.

-Indirectly probe about coercion into sex work by asking, "How hard will it be for you to contact people you have had sex with to let them know about the need for treatment?"

For an adolescent who has had multiple STIs or other warning signs of ARA or exploitation, the clinician can say [2]:

-When I see patients with multiple STIs, it makes me worry that someone is making them do sexual things that they did not want to do. Has that ever happened to you?

If the provider is concerned about reproductive coercion, they can offer harm reduction strategies (eg, using less detectable methods of contraception or a contraceptive method less able to be manipulated by a partner, such as an intrauterine device).

When the clinician is particularly concerned about ARA, it may be helpful to normalize how difficult it can be to disclose information about abusive experiences and to provide specific resources:

I am concerned that something has happened to you, but I also understand that it does not always feel safe to share that kind of information with someone you just met, and that there are a lot of reasons why someone might not want to talk about it. In case there is something going on, I want to share some resources with you that I think could be helpful. Would that be alright?

(See 'Universal provision of resources' below.)

Specific questions related to ARA – Specific questions for youth at increased risk of ARA include whether their partner [2]:

Ever tells them where they can go or who they can talk to

Needs to know where they are all the time

Checks their cell phone to see everyone they have called

Ever tries to make them have sex when they do not want to

Ever "totally loses it" or throws things

Has ever threatened to hurt them

Has a weapon

Specific questions related to sexual exploitation – Specific questions related to sexual exploitation include whether anyone has ever [79]:

Asked them to do something sexual in exchange for something they wanted or needed (eg, something to eat, a place to stay)

Asked them to do something sexual with another person

Taken sexual pictures of them that they did not think were okay or posted sexual pictures of them online

Universal provision of resources — We provide informational resources related to ARA to adolescent patients whether or not they disclose ARA because they may not perceive their relationship to be unhealthy, may not feel comfortable disclosing ARA at a particular visit, or may know someone who would benefit from the information.

Adolescent relationship abuse not disclosed — When an adolescent says that they have not experienced ARA, it is important to ensure that they know what resources are available by asking:

If something like this ever happened to you or someone you care about, would you know where to turn for help?

This question provides an opportunity to share resources in your community or engage in hypothetical safety planning for a dangerous situation.

When providing information to patients who have not disclosed ARA, we provide an opening for future disclosure and try to reduce the stigma associated with ARA by saying something like:

I am glad you are in a healthy relationship now, but relationships can change. If you ever are in an unhealthy or unsafe relationship, I would like you to know what kind of help is available. If you are comfortable taking this information, it may be good to have on hand. If you are interested, please take this with you. You can take two or three – maybe you have a friend who could use it.

We provide this information to all of our patients because unhealthy relationships can have such negative effects on health, and because you may know someone who could use the information. We want to make sure you know that this is a safe place to talk about whatever concerns you.

This trauma-sensitive approach can help to build trust. Over time, patients who have experienced abuse may become more open to sharing their stories, discussing the impact on their health, and/or asking for help [80].

Adolescent relationship abuse disclosed or strongly suspected — Provision of resources to patients who have disclosed ARA or in whom it is strongly suspected is discussed below. (See 'Managing disclosures' below.)

Available resources — The resources that are provided vary depending upon the availability of resources in particular communities. Many communities have resources specifically for adolescent victims of ARA or sexual exploitation. If adolescent-specific services are available locally, it is helpful to establish formal agreements and connections with them to make it easier for adolescent patients to access services when necessary.

Other locally available resources may include:

Domestic violence agencies

Rape crisis centers

Child protection services

Legal advocacy

Mental health counseling

Children's advocacy centers

Local resources related to basic needs (eg, food, shelter, advocacy, education, job skills development)

We keep materials from these local agencies readily available in examination rooms. Describing the scope of services available and normalizing the need for services may facilitate awareness and use of services, improve mental health symptoms, and reduce revictimization [81,82].

In addition to local resources, the following websites provide information and resources for patients and/or providers:

American College of Obstetricians and Gynecologists resources on promoting healthy relationships in adolescents

Centers for Disease Control and Prevention information about preventing teen dating violence, including the Dating Matters toolkit

Futures Without Violence

Hanging out or hooking up: Clinical guidelines on responding to adolescent relationship abuse: An integrated approach to prevention and integration

Protocol for Adolescent Relationship Abuse Prevention and Intervention

National Domestic Violence Hotline

National Human Trafficking Hotline (888-373-7888 in the United States)

The National Sexual Violence Resource Center

Managing disclosures — The following guidelines can be used when ARA is disclosed or strongly suspected (table 2):

Be supportive. Assure the patient that you believe them and that the abuse is not their fault. Avoid questions that may seem judgmental (eg, "Why didn't you leave?" or "Why haven't you told anyone before?").

As much as possible, the medical problems that the patient identified as the reason for the visit (eg, possible STI, unintended pregnancy, anxiety) should be prioritized. (See 'Patient-centered evaluation' above.)

Be clear about the limits of confidentiality and what information you may need to share with outside agencies. Do not make promises that cannot be kept (eg, "I won't tell anyone" or "I will make sure you are safe"). Knowledge of local laws regarding reporting adolescent dating and sexual violence is essential. In the United States, information about state statutes on mandatory reporting (eg, of domestic violence or human trafficking) is available from the Child Welfare Information Gateway. (See 'Privacy and confidentiality' above.)

Legislation related to civil protection orders for adolescent dating violence varies from state to state (eg, whether a minor can file on their own behalf, whether dating relationships quality) [83].

Establish a safety plan with the patient in consultation with a victim service advocate (preferred if available), mental health provider, and/or social worker. We keep the contact information for these consultants readily available so that we can consult them quickly in an emergency.

If possible, providers should directly connect patients to the victim service advocate rather than just giving them a telephone number [2]. Direct connection may occur in person, by telephone (using a phone in the clinic rather than the patient's cell phone, which the abuser may track), or through telemedicine.

Ensure that the patient will have access to ongoing care and identify a confidential way for patients to receive test results (if tests are necessary).

Provide access to a mental health clinician who can provide detailed assessment to identify specific treatment needs.

Confirm that patients are connected to resources and services to address multiple needs, including food, shelter, advocacy, mental health support, education, and job skills development, which are all critical to the health and well-being of victims of ARA.

STRUCTURED PREVENTIVE/EARLY INTERVENTION PROGRAMS — Studies evaluating risk and protective factors for ARA highlight the importance of violence prevention during school-age and early adolescence and education about healthy and unhealthy relationships [46,84-87]. While more prevention studies are needed to identify optimal types, timing for, and outcomes of specific interventions [88], most experts identify middle school (around the time of pubertal onset) as a prime time to focus on ARA prevention as youth are just starting to explore relationships, sexuality, intimacy, and their identity. There is emerging evidence that sexual and reproductive health and ARA interventions in pediatric primary care settings can be effective at improving health outcomes, including ARA [89].

Strategies for the general population – Prevention strategies for school-age children and early adolescents focus on challenging and changing gender norms that contribute to ARA and other forms of relationship violence (eg, gender norms that condone violence within a relationship or encourage sexual dominance among males) before the gender norms are internalized [90-95]. In a cluster-randomized trial, Dating Matters (a multicomponent intervention for middle school students that includes education in the classroom, parent/caregiver training, educator training, and a youth communications program) reduced teen dating violence perpetration, victimization, and negative conflict resolution strategies [96].

Another prevention strategy focuses on bystander behavior [97]. In a cluster-randomized trial, the Green Dot bystander behavior program (in which bystanders are trained to intervene in potentially harmful situations) reduced sexual violence perpetration and victimization, sexual harassment, stalking, and dating violence perpetration and victimization [98]. In additional cluster-randomized trials, a gender violence prevention program for male middle school (age 11 to 14) and high school athletes delivered by athletic coaches ("Coaching Boys Into Men") was effective in increasing positive bystander behaviors at the end of the sports season and reducing relationship abuse perpetration one year later [85,86,99,100]. Even with the challenges of implementation in middle schools (eg, shorter practice times and sports seasons, which decreased time for curriculum delivery), the program appeared to be effective in reducing sexual violence and relationship abuse. Studies of changing bystander behaviors among college athletes are ongoing [101].

Strategies for at-risk individuals – Prevention strategies for adolescents with a history of exposure to violence, which is a risk factor for ARA, have focused on building skills to prevent violence through cognitive behavioral therapy and other interventions.

In 10-year follow-up of a randomized trial that compared a parent/caregiver support intervention with no treatment for preschoolers at risk for conduct problems, female adolescents whose caregiver received the intervention had a lower risk of exposure to ARA in their peer group than female adolescents in the control group [46]. In another randomized trial of adolescent females with a history of dating violence and involvement in family court, the Date SMART prevention program (a cognitive-behavioral skill building group intervention) was associated with reductions in physical, sexual, and cyber dating violence, as well as reduced sexual behavior [102]; this intervention has also been shown to reduce depression in females with prior exposure to dating violence [103]. In a longitudinal study, an increased number of Expect Respect Support Group (a school-based violence prevention program) sessions attended was associated with decreased aggression in males and females and decreased adolescent dating violence perpetration and victimization in males (but not females) compared with "treatment as usual" controls [104].

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Sexual assault".)

SUMMARY AND RECOMMENDATIONS

Terminology – Adolescent relationship abuse (ARA) includes physical, sexual, or psychological/emotional abuse of a romantic, sexual, or intimate partner that occurs in person, through texting, online, or through someone else. Other interchangeable terms for ARA include "teen dating violence" and "adolescent dating violence." In addition to physical, sexual, and psychological/emotional abuse, ARA includes reproductive coercion and cyber dating abuse. (See 'Terminology' above.)

Epidemiology – Approximately 7 to 10 percent of high school students in the United States report physical or sexual dating violence. The prevalence of ARA increases throughout adolescence and peaks in young adulthood. (See 'Epidemiology' above.)

Risk and protective factors – Factors associated with ARA victimization include physical or sexual abuse in childhood, early onset puberty or sexual activity, substance use and/or misuse of prescription drugs, being pregnant or postpartum, sexual or gender minority status, socioeconomic disadvantage, involvement with child protection or juvenile justice services, placement in foster care, and youth homelessness. Protective factors include participation in prevention programs, knowledge of effective sexual consent, positive parenting practices, and prosocial peers. (See 'Risk and protective factors' above.)

Impact on health – ARA victimization is associated with adverse effects on sexual, mental, and general physical health (eg, sexually transmitted infections, unintended pregnancy, depression, substance use, physical injury). Although the rates of violence perpetration against intimate partners are similar among males and females, females experience more severe consequences, including death. (See 'Impact on health' above.)

Possible warning signs – Although no single symptom or sign is predictive of ARA, certain findings are associated with ARA, particularly if they occur together (table 1). (See 'Possible warning signs' above.)

Practice considerations

A healing-centered approach to care is appropriate for all adolescents−not just those who have been identified as victims of violence. Adolescent victims of ARA may not be identified as victims of ARA or may not be ready to disclose ARA. Privacy and confidentiality are especially important for youth experiencing ARA−but must be balanced with patient safety and mandatory reporting requirements. (See 'Healing-centered approach to care' above and 'Privacy and confidentiality' above.)

A patient-centered evaluation is crucial to trauma-sensitive care. This includes shared-decision making, predictability, and informed and voluntary participation throughout the evaluation. (See 'Patient-centered evaluation' above.)

Addressing ARA

We provide education about healthy relationships and brief counseling about ARA to all adolescents – not just those who disclose. We routinely ask about ARA, although the approach varies with the clinical situation (eg, warning signs (table 1)). Prior to any direct assessments, we give all patients information/handouts about healthy/unhealthy relationships and support services for victims of ARA, including sexual violence and exploitation (eg, a safety card available from Futures Without Violence that includes toll-free hotlines for ARA and other safety concerns). (See 'Universal education and anticipatory guidance' above and 'Universal inquiry' above and 'Universal provision of resources' above.)

The following guidelines can be followed if a patient discloses ARA (see 'Managing disclosures' above):

-Assure the patient that you believe them and that the abuse is not their fault

-Prioritize the medical problems that the patient identified as the reason for the visit

-Be clear about the limits of confidentiality and what information may need to be shared with outside agencies

-Establish a safety plan in consultation with a victim service advocate (preferred if available), mental health provider, and/or social worker

-Ensure that the patient will have access to ongoing care; identify a confidential way for the patient to receive test results

-Provide access to a mental health clinician who can provide detailed assessment to identify specific treatment needs

-Confirm the patient is connected to resources and services to address multiple needs (eg, food, shelter, education)

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Topic 121477 Version 15.0

References

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