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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^* Harvard School of Public Health, Department of Society, Human Development, and Health and Division of Public Health Practice, Boston, Massachusetts
Boston University School of Public Health, Department of Social and Behavioral Sciences, Boston, Massachusetts

ABSTRACT

 
Objective.Previous studies demonstrate significant associations between dating-violence victimization and sexual risk behaviors among adolescent girls; however, a relationship between dating violence and actual sexually transmitted disease (STD)/HIV testing and diagnosis has yet to be investigated among a representative sample. The present study assesses associations between dating violence and STD/HIV testing and diagnosis among a representative sample of sexually active adolescent girls.

Methods.Data from 9th- to 12th-grade female students completing the 1999 and 2001 Massachusetts Youth Risk Behavior Surveys and reporting having ever had sexual intercourse (N = 1641) were examined. Odds ratios for STD/HIV testing and diagnosis that were based on experiences of dating violence and adjusted for STD/HIV risk behaviors and demographics were calculated.

Results.More than one third (38.8%) of adolescent girls tested for STD or HIV and more than half (51.6%) of girls diagnosed with STD/HIV reported experiencing dating violence. Compared with nonabused girls, girls who experienced both physical and sexual dating violence were 3.0 times more likely to have been tested for STD and HIV, and 2.6 times more likely to report an STD diagnosis.

Conclusions.After adjusting for STD/HIV risk behaviors, dating violence remains significantly associated with STD/HIV testing and diagnosis among sexually active adolescent girls.

Key Words: STD/HIV • dating violence • adolescent health • Youth Risk Behavior Survey

Abbreviations: STD, sexually transmitted disease • YRBS, Youth Risk Behavior Survey • CI, confidence interval • OR, odds ratio

Despite reductions in rates of sexual activity and increases in sexual risk-reduction behaviors among adolescents in the past decade, HIV/AIDS rates among 15- to 24-year-olds continue to rise, and sexually transmitted disease (STD) rates remain higher for this age group than for any other. Dating violence is also a major public health concern for adolescents, affecting 1 in 5 high school girls and relating to increased risk for multiple serious health concerns in this population. Several previous representative studies of adolescents have found associations between STD/HIV risk behaviors and physical and sexual dating violence, severe dating violence, and forced or coerced sex in this population.

Studies among adult women demonstrate associations between intimate partner violence and STD/HIV risk behaviors, as well as perceived risk of STD/HIV infection, HIV testing, and STD/HIV diagnosis. However, despite the established links between dating violence and STD/HIV risk behaviors and violence and STD/HIV diagnosis among adult women, the relationship of dating violence to STD/HIV testing and diagnosis among adolescents remains unclear. One recent representative study identified a strong association between lifetime history of forced-sex victimization and history of STD diagnosis among adolescent girls. However, these analyses could not specify relationship to perpetrator; the most proximal STD/HIV risk is embodied in adolescent sexual relationships, which could not be assessed. This distinction is also called for based on evidence of high levels of sexual risk behaviors among abusive male partners. A community-based study of black female adolescents found that physical dating violence was linked with both increased perceived risk for STD (not including HIV) and increased likelihood of STD diagnosis; however, given the higher rates of STD among this population, the findings may not be generalizable to all adolescent females. Additionally, physical and sexual partner violence victimization have not been assessed for their distinct contributions to STD/HIV testing and diagnosis among a representative sample of either adolescents or adults; such analyses may clarify types of violent experiences associated with STD/HIV, thus allowing for improved ability to identify and provide support services and appropriate medical care for both violence and STD/HIV among those identified as abused. The present study utilizes a large, representative sample of female adolescents to assess associations between physical and sexual dating violence and STD/HIV testing and diagnosis.

MATERIALS AND METHODS

 
The Youth Risk Behavior Survey (YRBS) is conducted in a majority of states every 2 years to track the incidence and prevalence of leading causes of morbidity and mortality among high school students. The YRBS is a self-report, written instrument; in Massachusetts, a Spanish translation of the survey is available. Each state is charged with administering the core YRBS survey as designed by the Centers for Disease Control and Prevention. States also have the option of including additional questions to assess other adolescent health concerns. The Massachusetts YRBS was administered in 1999 and 2001 to 9th- through 12th-grade students in randomly selected classrooms within selected public high schools throughout the state. The probability of an individual school being selected was proportional to its enrollment. All students, including those assigned to special education and limited–English-proficiency classrooms, were eligible. In each participating school, 3 to 5 classes were randomly selected to participate. In both 1999 and 2001, 67 schools were selected and 64 elected to participate, resulting in a school participation rate of 96%. In 1999, a total of 4415 of the 5589 students in selected classrooms completed the survey, resulting in a 79% student-participation rate. In 2001, a total of 4204 students of the 5223 in selected classes completed the survey, yielding a participation rate of 80%. Although it is not possible to specify how many students, if any, completed the survey in both years included in the present analyses, the number of students counted twice is likely to be extremely low; a previous study that combined multiple recent Massachusetts YRBS survey years by attempting to calculate this potential overcount using weights supplied by the Centers for Disease Control and Prevention estimated that <2% of 9th- and 10th-grade respondents would have completed the survey 2 years later as 11th- and 12th-grade students. Because these 2 years represent half of the potential respondents, we estimate that <1% of students may be represented more than once in the combined data set. The combined data set was used in these analyses to maximize analytic power for examinations of low-prevalence outcomes such as STD/HIV diagnosis. Scores from individual students were weighted based on demographics of all students attending Massachusetts public high schools to provide rates that accurately reflect this population. These procedures are described in detail elsewhere. All results presented are based on analyses of weighted data.

Sample
Our study included sexually active female participants (those reporting ever having engaged in sexual intercourse; N = 1641), 42.0% of the original female sample (N = 3905) from both survey years. The majority of the present sample was white (75.0%), with smaller percentages of Latino (10.6%), black (8.4%), and Asian (3.0%) respondents. Age distribution is skewed upward, with fewer adolescents 14 years represented among sexually active females (4.9%) and a greater number of females 17 years represented among sexually active students (53.2%; data not shown).

Measures
All variables were assessed by single survey items. Because of the nature of the present analyses, all variables were dichotomized with the exception of age, which was categorized as seen in Table 1. Race/ethnicity was dichotomized as white or nonwhite because of the high percentage of white respondents compared with other racial/ethnic groups.

TABLE 1. Lifetime Prevalence of Violence From Dating Partners and STD/HIV Testing and Diagnosis Among Sexually Active Female Adolescents

 
Dating violence victimization was measured by a single survey item that asked: "Have you ever been hurt physically or sexually by a date or someone you were going out with? This would include being hurt by being shoved, slapped, hit, or forced into any sexual activity." Response choices were: "I have never been on a date or gone out with anyone" (2001 only); "No, I have never been hurt by a date or someone I was going out with"; "Yes, I was hurt physically"; "Yes, I was hurt sexually"; and "Yes, I was hurt both physically and sexually." These responses were then recoded into exclusive dichotomous variables: physical dating violence only, sexual dating violence only, and both physical and sexual dating violence, with the referent group being those who indicated that they had never experienced dating violence or had never been on a date (2001 only). Construct validity has been demonstrated for this assessment. STD/HIV testing was assessed by a single survey item that asked: "Have you ever been tested for HIV infection or other sexually transmitted diseases (STDs) such as genital herpes, chlamydia, syphilis, or genital warts?" Responses included: "No"; "Yes, I have been tested for HIV"; "Yes, I have been tested for other STDs"; and "Yes, I have been tested for both HIV and for other STDs." Diagnosis of STD/HIV was assessed by a single yes/no item that asked: "Have you ever been told by a doctor or other health care professional that you had HIV infection or any other sexually transmitted disease (STD)?" Testing and diagnosis were considered as separate outcomes based on the low correlation among these experiences (r = 0.20) and 23% of those diagnosed with an STD reporting not being tested. Single items were also used to assess sexual risk behaviors (use of a condom at last sex, multiple sex partners [2 in the past 3 months]). Responses to these items were dichotomized as "yes" or "no."

Data Analyses
Lifetime prevalence rates for any physical or sexual dating violence, STD/HIV testing, and STD/HIV diagnosis and 95% confidence intervals (CIs) were calculated for the total sample and demographic groupings (Table 1). Differences in rates of dating violence, STD/HIV testing, and STD/HIV diagnosis based on demographics were assessed by using ² analyses. Logistic-regression models were constructed to calculate odds ratios (ORs) and 95% CIs for STD/HIV testing and diagnosis outcomes based on experiences of physical or sexual dating violence, using respondents indicating no experiences of dating violence as a referent group; models were adjusted for demographics and sexual risk behaviors for STD/HIV (Table 2) to better estimate the contribution of experiences of dating violence to STD/HIV outcomes. Rates of dating violence among those reporting STD/HIV testing and STD/HIV diagnosis were also calculated. SUDAAN was used to conduct all analyses to allow for correct adjustment based on weights for selection probabilities.

TABLE 2. Adjusted ORs for Relationships Between Lifetime Experiences of Violence From Dating Partners and STD/HIV Testing and Diagnosis Among Sexually Active Female Adolescents

Data were adjusted for age, race (white versus nonwhite), condom use at last sex, and 2 sexual partners in last 3 months.

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