COMMENTARY

Partner Abuse in Adolescent Girls Linked to Sexually Transmitted Infections

Anne M. Teitelman, PhD, CRNP, MSN

Disclosures

November 25, 2009

Understanding Partner Abuse Opens New Avenues for Identifying and Preventing Sexual Risk and Promoting Girls' Safety

Many adolescent relationships with intimate partners are healthy ones, in which both partners respect each other, make decisions together, and communicate well, but other relationships are unhealthy, involving violence and controlling behaviors. Adolescent partner abuse has many physical and psychological consequences, but the association with sexually transmitted infections (STIs), including HIV, has recently gained increasing attention in research. Understanding the connections between HIV and other STIs and partner abuse can open additional opportunities to assist adolescent girls to recognize and manage their exposure to risky situations.

Why Partner Abuse Makes It Harder for Adolescent Girls to Have Safer Sex

Until recently, little research has been available about the links between partner abuse and unsafe sex practices, especially among adolescents, but that is beginning to change. In a recent study that looked at a large representative sample of the US general population of women from 20 to 65+ years of age, approximately 12% of HIV/AIDS infections among women in relationships were found to be attributed to intimate partner violence (IPV).[1] Among adolescent girls diagnosed with HIV or another STI, more than 50% report experiencing either physical or sexual IPV. To put it another way, compared with their nonabused peers, girls who experience IPV are more than 2.5 times more likely to report being infected with HIV or another STI.[2] To explore such findings further, several researchers have examined sexual risk factors and abuse history. A recent review indicated that girls with a history of physical IPV are more likely to report having had multiple sex partners and sex without condoms, both of which increase the risk of contracting HIV or another STI.[3] A closer look at the subtle and overt forms of coercion associated with IPV helps to explain why girls in abusive and controlling relationships are prone to participating in high-risk sexual behaviors.

IPV: a multilayered abuse. IPV is defined by the US Centers for Disease Control and Prevention (CDC) as physical or sexual violence -- either actual or threatened -- and psychological and emotional abuse when accompanied by physical or sexual violence or threats. IPV can be directed toward a current or former spouse, boyfriend or girlfriend, or dating partner.[4] IPV among adolescents is often referred to as teen dating violence. Dating violence, according to the National Women's Health Information Center, occurs when a person purposely causes or threatens either physical or mental harm to another, and includes physical abuse, psychological or emotional abuse, sexual assault, isolation, and controlling behaviors.[5]

Adolescent IPV is very common and usually begins to emerge around age 15 years but can also affect middle-school youth. IPV can occur in serious or casual relationships and in same-sex or opposite-sex relationships. The National Youth Risk Behavior Survey estimated that the rate of physical IPV victimization among high school-aged youth was 10% in 2007.[6] For some segments of the population, the rates of partner abuse are higher. For example, approximately 18% of sexually active, high school-aged girls have experienced physical dating violence.[7] In a study examining the prevalence of IPV among girls aged 14-17 years who attend family planning clinics, 44% had experienced physical abuse and 41% had experienced verbal abuse.[8] Although rates of physical IPV victimization are similar between boys and girls, the motivations behind these events often differ. One of the primary motivations for physical partner violence perpetrated by boys is to control a female partner, whereas for girls, violence toward a male partner is more typically motivated by self-defense.[9,10]

Groups at risk for sexual violence. Although both sexes can be victims of partner abuse, the majority of sexual violence is directed at girls.[6] The reasons for this are undoubtedly complex, and according to the CDC, risk factors for sexual violence perpetration include being male, witnessing or experiencing violence as a child, alcohol or other drug use, and being exposed to social norms or shared beliefs that support sexual violence.[11] Adolescent girls who have been previously sexually assaulted in childhood are more likely than their nonabused counterparts to experience sexual IPV in adolescence and be at increased risk for HIV and other STIs as a result of unprotected sex with multiple partners.[12,13] Several hypotheses for this association suggest that childhood sexual abuse often results in disrupted cognitive processes if not adequately processed with the help of supportive adults. These disrupted processes, in turn, can lead in adolescence to an altered ability to evaluate and judge the risks and benefits of a particular behavior as well as to difficulty in negotiating for safer sex. In addition, a history of childhood sexual abuse can alter a young woman's relationship to sex and interpersonal relationships in general, which may result in increased engagement in risky sexual behaviors and an increased vulnerability to nonvoluntary sexual activity. For a more detailed discussion of this association, see the article on childhood sexual abuse by Noell and colleagues.[13]

How a History of IPV Increases the Risk for STIs

Partner violence is often an indication of imbalances in power within a relationship.[14] In intimate relationships in which one partner dominates, the other partner may be coerced into participating in risky sexual behaviors that increase the risk for HIV and other STIs. The imbalance of power may manifest in subtle and overt ways:

  • Lower relationship power can reduce a young woman's ability to negotiate for safer sex and has been associated with lower condom use.[15] These power imbalances are especially evident among adolescent girls with older male partners who may have greater financial resources and a greater role in sexual decision-making. In such relationships, condom use is less frequent than that found among same-age partners.[16]

  • Some adolescent girls in abusive relationships have reported their partners secretly damaging condoms with the aim of getting them pregnant.[17] Such condom manipulation can also increase risk for HIV and other STIs among adolescent girls.

  • Young men who perpetrate IPV (physical or sexual) are more likely to have HIV or other STIs, and they are more likely to coerce partners into nonuse of condoms, have other partners, and engage in transactional sex.[18]

  • Women who are pressured or forced into unwanted sex are at greater risk for HIV and other STIs. Coerced women are more likely to have also experienced physical partner violence and more likely to perceive that requesting condom use with male partners would result in a potentially violent situation.[19] Adolescent male perpetrators of abuse report believing that using a condom during a rape or sexual assault will allow their partner time to get away and, for this reason, do not use condoms.[20]

  • If a young woman tests positive for HIV or another STI, she may fear violence or experience violence as a consequence of her disclosure to her partner.[21]

Controlling and coercive STI/HIV risk situations are often not easy for girls to recognize, especially given their relative inexperience in navigating relationship issues more generally. For example, if she were pressured to have sex and finally give in, she might not perceive this as an abusive situation. Or, if adolescent girls recognize the danger or seriousness of such behaviors, they may not know how to respond without increasing their own risk for victimization. For these reasons, healthcare providers who see adolescent patients for wellness and reproductive health visits have an important role to educate these young women about safer sex practices and to intervene in cases in which abuse is detected.

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