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“The only thing necessary for these diseases to the triumph is for good people and governments to do nothing.”


     

Dating Violence and Sexually Transmitted Disease/HIV Testing and Diagnosis Among Adolescent Females

Michele R. Decker, MPH*, Jay G. Silverman, PhD* and Anita Raj, PhD

http://pediatrics.aappublications.org/cgi/content/full/116/2/e272

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RESULTS

  
Descriptive Statistics on Dating Violence and STD/HIV Testing and Diagnosis and Associations With Demographics
Approximately 1 in 3 (31.5%) sexually active adolescent girls reported ever experiencing physical or sexual violence from dating partners (Table 1; physical dating violence only: 15.3%; sexual dating violence only: 6.7%; both physical and sexual dating violence: 9.5%; data not shown). A similar percentage (32.9%) reported ever being tested for STD or HIV (HIV test only: 4.3%; STD test only: 10.0%; both HIV and STD tests: 18.6%; data not shown). A much smaller percentage (4.7%) reported being diagnosed with an STD including HIV. Older sexually active female adolescents were more likely to be tested for STD or HIV than their younger peers (P < .01). Neither age nor race/ethnicity was related to dating violence or STD/HIV diagnosis for this sample. Experiences of physical or sexual dating violence were reported by 38.8% of those tested for any STD or HIV and by 51.6% diagnosed with STD or HIV (data not shown).

Relationships Between Dating Violence and STD/HIV Testing
The odds of testing for STD (but not HIV) were significantly greater for girls reporting both physical and sexual dating violence (OR: 2.41; 95% CI: 1.38–4.22; Table 1) and for girls reporting physical dating violence only (OR: 1.63; 95% CI: 1.02–2.62) compared with girls reporting no dating violence. There was not a significant relationship between testing for STD (but not HIV) and sexual dating violence; there were also no significant associations between dating violence (physical, sexual, or combined) and testing for HIV (but not other STD). The odds of testing for both STD and HIV were significantly greater for girls reporting both physical and sexual dating violence (OR: 3.00; 95% CI: 1.93–4.66) and for girls reporting sexual dating violence (OR: 1.93; 95% CI: 1.02–3.63) compared with girls reporting no dating violence.

Relationships Between Dating Violence and STD/HIV Diagnosis
The odds of STD/HIV diagnosis were significantly greater for both girls reporting physical dating violence (OR: 2.18; 95% CI: 1.13–4.21) and those reporting both physical and sexual dating violence (OR: 2.59; 95% CI: 1.05–6.35) compared with girls with no such experiences. There was no significant relationship between sexual dating violence and STD/HIV diagnosis.


DISCUSSION

 
Girls reporting physical and sexual violence from dating partners were more likely to have been both tested for and diagnosed with STD/HIV than girls not experiencing dating violence, even after accounting for STD/HIV sexual risk behaviors. These results are consistent with previous research that demonstrated higher levels of HIV testing and STD/HIV diagnosis among adult women experiencing intimate partner violence. Findings from this representative adolescent sample also support results found among black female adolescents presenting at an urban health center, which linked physical dating violence with both increased perceived risk for STD and increased likelihood of STD diagnosis.

New to this body of work, the present findings indicate unique patterns of STD/HIV testing and diagnosis among sexually active girls based on the forms of dating violence experienced. We interpret these results within the context of current knowledge regarding STD/HIV testing behaviors among adolescents. Because both national YRBS data and studies of physicians indicate that a large portion of at-risk girls are not being routinely screened or counseled regarding STD and HIV, STD/HIV testing among many adolescents may be a result of self-referral based on perception of risk or symptoms of infection. Girls in the present sample who reported sexual dating violence were more likely to be tested for both STD and HIV than girls not victimized through dating violence; however, they were not at increased risk for actual infection. One potential explanation for this pattern of results is that reports of sexual violence not involving physical violence may relate to singular incidents outside of relationships (eg, occurrences of "date rape"), which lead these individuals to either perceive STD/HIV risk and seek testing for both STD and HIV or to seek other services for sexual assault and thus be referred for testing for both STD and HIV from such programs, as is recommended.

In contrast, girls reporting physical violence reported greater likelihood of STD testing only (but not HIV testing) than their nonabused peers and also reported higher rates of infection. We suggest that girls experiencing physical dating violence only may also be chronically exposed to coercive sex that may not involve a level of force labeled as abusive. Because physically abused girls may be less likely to enact safer sex practices and the abusive male partners of these girls may be involved in higher STD/HIV risk behaviors, seeking STD testing may be a result of their becoming symptomatic. Thus, these girls are more likely to be tested for STD only and not HIV and experience greater actual diagnosed infection.

Girls reporting both physical and sexual dating violence, however, may be experiencing both chronic coerced and forced sex and, therefore, perceive greater sexual risk than girls reporting physical violence only based on more clear experiences of sexual violence, leading them to test for both HIV and other STDs, as presently reported. Finally, greater contact with medical settings by girls experiencing both physical and sexual dating violence, perhaps because of increased severe physical violence or their seeking nonbarrier methods of contraception because of fears of condom negotiation, may result in higher levels of disclosure of abuse or STD/HIV risk behaviors, leading to greater testing and subsequent diagnoses.

Dating violence, in any form, was not associated with HIV testing in the absence of STD testing. This may be because testing for HIV only is the least common form of testing (4% vs 10% for testing for STD only and 19% for testing for both STD/HIV; data not shown); additionally, as discussed above, girls that perceive risk for sexually transmitted infections may seek testing for both HIV and other STDs.

     

The present findings are best viewed in light of several limitations. Cross-sectional analyses, as well as measurement time-frame discrepancies (eg, lifetime experience of dating violence and STD/HIV testing versus condom use at last intercourse) do not allow us to determine if there is a causal relationship between dating violence and STD/HIV testing and diagnosis. For example, there may be situations in which STD/HIV testing and diagnosis may increase adolescents’ vulnerability to dating violence given evidence indicating a high level of HIV-related partner violence among adult women recently diagnosed with HIV. Single-item measures for dating violence and STD/HIV testing and diagnosis preclude a more thorough understanding of dating-violence experiences and associated outcomes; however, disclosure of dating violence on a single-item measure is likely to be reduced relative to that for a multi-item inventory, thus biasing present results toward the null. Similarly, the measure of STD testing did not include gonorrhea in the list of examples of STDs, possibly leading those tested for this infection to respond negatively to this item and, again, biasing present results toward the null. The low correlation between testing and diagnosis is likely a result of inconsistencies in the testing and diagnosis sequence and potential confusion on the part of the adolescents. For example, symptomatic STD such as genital warts is often visually diagnosed without a formal test. Additionally, evidence indicates that many adolescents tested for STD/HIV may neither know nor accurately report their STD status, particularly when they have tested positive. Thus, STD/HIV testing behaviors and/or diagnoses may have been underreported, again minimizing the likelihood of detecting the associations described. However, STD/HIV infection estimates presently reported are consistent with those from a recent national sample of sexually active female adolescents in which 4.7% reported a diagnosis of at least 1 STD. Finally, the Massachusetts YRBS was designed to be representative of public high school students in Massachusetts; it is not known how well these results will generalize to adolescents in other geographical areas. Furthermore, higher-risk adolescents such as those who have dropped out of school or those with low school attendance may not be represented in the present study. Again, however, lower representation of higher-risk individuals would likely result in a conservative biasing of present estimates.

The present findings clearly demonstrate a link between dating violence and STD/HIV testing behaviors and diagnosis among sexually active female adolescents; however, additional work is needed to elucidate the direction of and mechanisms responsible for these associations. For example, studies with nonrepresentative samples have indicated that condom nonuse related to fear of abusive consequences of negotiating such protection is common in the context of abusive relationships; it is critical that these issues be explored among representative adolescent samples. Future studies should also include perpetrators of dating violence, as well as victims, to allow for a comprehensive assessment of how dating violence (both perpetration and victimization) relates to STD/HIV risk and resulting testing behaviors and infection. An improved understanding of such mechanisms would greatly contribute to development and implementation of both STD/HIV–and dating-violence–prevention programs to address these concerns.

Despite described limitations and the need for additional research, the current findings have implications for adolescent prevention-service providers and health care practitioners. Primary and secondary prevention programming for both dating violence and STD/HIV should be developed and supported to address the association between these 2 prevalent public health issues. Consideration of the relationship context may be essential to improving current adolescent sexual health promotion strategies. Discussion of relationship dynamics and screening for dating violence in clinical settings allows for more comprehensive sexual health promotion. Asking patients about barriers to their use of condoms or other contraceptives and their concerns regarding partner responses to STD/HIV testing or diagnosis may facilitate identification of dating violence. Finally, medical professionals should make information regarding dating-violence support services available to all patients regardless of abuse disclosure in light of the heightened risk seen among this population.

     


ACKNOWLEDGMENTS

 
Creation of this article was supported through grant S3062-23-23 to J.G.S. from the Division of Reproductive Health of the Centers for Disease Control and Prevention.

We acknowledge the Massachusetts Department of Education for provision of the 1999 and 2001 Massachusetts Youth Risk Behavior Survey data, and Jessica Murray, MPH, of the Boston University School of Public Health Data Coordinating Center for analysis of data.


FOOTNOTES

 
Accepted Feb 28, 2005.

Address correspondence to Michele R. Decker, MPH, Harvard School of Public Health, 677 Huntington Ave, Kresge 705, Boston, MA 02115. E-mail: mdecker@hsph.harvard.edu

No conflict of interest declared.


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