COMMENTARY

Partner Abuse in Adolescent Girls Linked to Sexually Transmitted Infections

Anne M. Teitelman, PhD, CRNP, MSN

Disclosures

November 25, 2009

Implications for Healthcare Providers

Counseling sexually active adolescent girls about ways in which they can protect themselves from unsafe situations is an important aspect in the prevention of IPV and the associated risk for HIV and other STIs. The routine discussion of safer-sex practices during wellness visits can assist young women to identify unhealthy partner dynamics that might lead to sexual risk or abuse. The vast majority of young women believe that a healthcare provider should ask them about partner violence. However, it takes patience to develop a patient-clinician relationship in which sensitive topics, such as sexual practices or potentially abusive situations, may be discussed openly. In exchanges with an adolescent patient, conditions that enhance disclosure include trust (eg, knowing that the provider will not take action without her permission), confidentiality, and support.[22] The use of a straightforward, nonjudgmental approach can foster open communication with adolescent girls, which aids in the accurate disclosure of their sexual behaviors. By screening adolescent patients for signs of IPV, healthcare providers can assist girls to identify and control their exposure to risky situations.

Screening and Counseling

Before screening for violence and abuse, know your state reporting requirements and inform your patients about any limits to their confidentiality, should they disclose abuse.

Routine screening for dating violence should take place whenever adolescent girls present for healthcare, particularly reproductive health services. This includes annual gynecologic or family planning examinations, STI/HIV screenings, pregnancy testing visits, and prenatal care. Screening questions that ask about specific behaviors are typically more effective at eliciting accurate information than asking whether abuse is present in the relationship, because the latter can vary depending on one's perception or definition of the term.

Asking questions, such as "Have you ever been hit, kicked, slapped, intimidated, or threatened," are important. However, there are more effective ways to assess for coercive situations that directly affect safer-sex practices. Because STI/HIV prevention occurs in the context of a relationship, it is important to talk about how decisions are made in those relationships and determine the adolescent girl's level of control over safer-sex practices.

For example, a provider may ask the following questions:

  • "OK, so we've talked about how important it is to use condoms or dams to decrease your risk for getting HIV and other STIs. I know that not everyone feels comfortable or safe asking her partners to use them. Would you feel comfortable asking your partner(s) to use a condom or dam? How do you think your partner(s) would respond to your asking them to use protection?" Or, "Have you asked your partner(s) to use a condom or dam before? What has been the reaction?"

  • "A lot of young women I see want to use condoms or dams but worry about their partners not wanting to use them. How often does this happen to you?"

  • "During this visit, we also like to discuss healthy relationships. We now know that a lot of young women don't always get to decide when they have sex. Their partners decide for them. And that can make them feel uncomfortable or upset. Has anything like that ever happened to you?"

  • "A lot of girls who get tested for HIV and other STIs have problems in their relationships. They might feel afraid to ask a partner if he is having sex with other people, or ask him to get tested for HIV and other STIs. How often do you feel uncomfortable discussing these things with your partner?"

  • "We are going to treat your infection today. It is important that your partner(s) are informed about this so that they can get treated, too. What do you think would happen if you were to tell your partner(s) that you have an infection? Would it help for us to invite him or her here and then talk about it together?" Or (if a reportable STI), "Would it be better for you if the local epidemiologist or health department official passed this information along to your sexual partner(s), in which case your name would be kept confidential?"

(Examples above are adapted from Silverman and colleagues.[20])

In screening an adolescent girl for exposure to IPV, the healthcare provider should be alert to any comments that indicate that she is involved in controlling and coercive relationships. An adolescent girl's admission to experiencing any of the following situations is a red flag for exposure to partner violence:

  • Belief that she is unable to talk with a partner about condoms, dams, or other safer-sex strategies, such as limiting the number of sexual partners or getting tested for HIV and other STIs;

  • Belief that she does not have the right to discuss safer-sex strategies with her partner because he provides her with favors, material goods, affection, or intimacy;

  • Fear that a partner might hit, leave, or threaten her when discussing safer-sex strategies;

  • Feeling pressured or coerced by a partner to have unprotected sex when she wants to use a condom or dam;

  • Feeling pressured or coerced to have sex when she doesn't want to;

  • Finding out that her partner is putting her at risk and not letting her know, such as removing the condom during sex; damaging the condom in some way; or having unprotected vaginal, anal, or oral sex with other partners; and

  • Testing positive for HIV or another STI and fearing that a partner might harm her in some way specifically if/when she informs him or her of her infection.

In addition, the patient's reproductive health history can suggest exposure to IPV. Red flags include a frequent history of STI testing or treatment, repeat pregnancy testing or pregnancy history, any prior abuse history, or frequent requests for emergency contraception.

For example, if a healthcare provider at a clinic sees an adolescent girl for treatment of Chlamydia, the provider might notice on the patient's chart that she has been treated for either gonorrhea or Chlamydia several times in the past few months. After asking her a few more questions, the clinician might learn that the patient is having sex with only 1 partner and that she knows her partner has other partners, but is afraid to confront him about it. He gives her gifts and financial support, and she doesn't want to make him angry by appearing jealous. On further questioning, the patient confesses that she expects that all men act the same way and does not consider his seeing other partners as a reason to leave the relationship.

Counseling such a patient about healthy relationships, informing her about the potential consequences of her partner's risky behaviors, and letting her know that help is available should she want it can empower her to safely protect her health. What follows are specific actions that healthcare providers can take to enhance prevention of STIs in adolescent girls.

Prevention Education for All Adolescent Female Patients

Discuss the difference between healthy and unhealthy relationships. For example, a partner in a healthy relationship will usually:

  • Communicate openly with you when problems exist;

  • Give you space to spend time with your friends and family; and

  • Be supportive and respectful.

A partner in an unhealthy relationship may:

  • Control where you go, what you wear, or what you do;

  • Try to stop you from seeing or talking to family or friends;

  • Call you derogatory names, put you down, or criticize you;

  • Threaten or scare you;

  • Hit, slap, push, or kick you; and

  • Force you to do something sexual when you don't want to, including situations that expose you to HIV and other STIs.

Adapted from: Recognize Teen Dating Abuse

Provide teens with resources to recognize unsafe or unhealthy relationship situations:

Refer teens to resources that guide them on how to get out of unhealthy situations or relationships, should they encounter them:

Help your adolescent female patients identify trusted peers or adults, such as a close friend, parent, teacher, guidance counselor, school nurse, or clergyperson, with whom they could safely discuss relationship problems if they were to emerge.

Present a teen dating violence prevention pamphlet or card in case they or a friend might find it useful in the future.

Offer condoms or dams; talk about barrier method negotiation and partner issues that may arise.

For more information, please see womenshealth.gov: Violence Against Women: Healthy Relationships vs. Unhealthy Relationships

If You Do Identify a Controlling or Coercive STI/HIV Risk Situation

Let your adolescent female patients know that they do not deserve to be treated in that way; assure them that they are not alone; and tell them that help is available.

Tell them they that did not cause this, and this is not their fault.

Tell them that you are concerned for their safety.

Validate how challenging it can be when they really care about someone who is also hurting them, controlling them, or limiting their actions.

Take measures to reduce their exposure to HIV or another STI. For example, if a girl's partner continues to have sexual contact with other partners, talk with her about negotiating with her partner to use condoms or dams with her and others.

Ask whether they have thought about leaving the relationship, and if so, how safe they would feel if they broke off ties with their partner.

Assess for immediate safety concerns and follow-up as needed (see below).

Assess for suicidal and homicidal ideation, including intention and plan. If significant suicidal or homicidal intent is identified, keep client safe until emergency psychiatric evaluation is made available.

Get a social worker involved or make other referrals appropriate to the level of urgency.

Document findings carefully. Use the client's own words whenever possible to describe an injury or abusive situation.

If immediate safety is a concern. Ask your patients the following questions:

  • What do you need to be safe? In what ways can I help?

  • What actions have you taken in the past to protect yourself? Did any of these things help? Will any of them help you now?

Healthcare providers can use the danger assessment tool to assess whether the patient's immediate safety is at risk.

Things to consider when managing a high-risk patient:

  • Help her to develop a safety plan and understand when/how to put it into action. (For more information, please see Family Violence Prevention Fund: Create a Teen Safety Plan.[23])

  • Make a referral to emergency housing or shelter, if needed. However, teens under the age of 18 years are typically not allowed to enter a domestic violence shelter (except as a child accompanying a parent who is the domestic violence victim). Local youth shelters may be an option. Contact your local domestic violence organization or the National Teen Dating Abuse Hotline to locate shelters for youth in your area (see below).

  • If legal issues are involved, seek the advice of local partner violence organizations as well as national hotlines, which can also provide counseling.

  • Allow the patient to make the phone calls to organizations, hotlines, and emergency housing from your office.

  • If your patient is under 18 years of age and has reported being harmed, you may need to contact the teen's parent or guardian.

  • Make a follow-up visit with you as her provider to continue to assess her situation

If immediate safety is not a concern. Discuss STI/HIV and contraceptive safety:

  • Offer appropriate STI/HIV testing. Suggest to your patient that her partner be tested for HIV and other STIs. However, inform her that routine STI/HIV testing usually does not include testing either partner for genital herpes. HIV infection may not show up as a positive test until 6 months or more after the infection is acquired. In addition, male patients are not tested for human papillomavirus (HPV). For these reasons, condoms should not be abandoned even when both partners have tested negative for HIV and other STIs.

  • Make female condoms available; although this barrier method is under a young woman's control, it cannot be hidden from her partner.

  • Discuss and distribute or prescribe appropriate contraceptive options; reproductive coercion can lead to unintended pregnancy. An abusive partner can sabotage birth control, eg, destroying oral contraceptive pills. Discuss contraceptive methods that are more resistant to partner sabotage, such as medroxyprogesterone acetate (Depo-Provera®). Although intrauterine devices also provide long-lasting contraception, they can increase the risk for serious STI complications, such as pelvic inflammatory disease in girls whose male partners are having unprotected sex with other partners.

  • Talk about strategies for safer-sex negotiation that might be safely carried out in the relationship. Review when and how a young woman can safely discuss STI/HIV risk behaviors with her partner(s). Offering opportunities to role-play these conversations can help to build her skills and confidence.

  • Discuss violence prevention strategies: Determine who she can talk with about the abusive and risky situation, and provide referrals to reputable resources.

Resources for Teens at Risk

Love Is Respect: National Teen Dating Abuse Helpline
Toll-free: 1.866.331.9474
TTY: 1-866-331-8453
Love Is Respect is a site with useful information about recognizing abusive situations as well as information about the hotline itself.[24] The National Teen Dating Abuse Helpline is geared toward adolescents and young adults and is staffed with peer advocates.

Rape, Abuse & Incest National Network (RAINN) Hotline
Toll-free: 800-656-HOPE (4673)
RAINN is a sexual assault organization working with local rape crisis centers across the United States. On RAINN's Website, an Online Hotline provides live, secure, anonymous crisis support for survivors of sexual assault, their friends, and families. The Online Hotline is free of charge and is available 24 hours a day, 7 days a week.

The National Domestic Violence Hotline (NDVH)
Toll-free: 1.800.799.SAFE (7233)
TTY: 1.800.787.3224
NDVH is an anonymous and confidential service providing assistance to callers 24 hours a day, 7 days a week. Hotline advocates are available for survivors and anyone calling on their behalf to provide crisis intervention, safety planning, information, and referrals to agencies in all 50 states. Assistance is available in English and Spanish, with access to more than 170 languages through interpreter services.

Emergency Telephone Number
If someone is in immediate danger, s/he can always dial 911.

Teens Experiencing Abusive Relationships (TEAR)
TEAR is an organization founded by teens with the mission to prevent dating abuse through education and awareness. The Website provides information for teens on dating abuse and warning signs of abuse. The Website also has links to teen-friendly dating violence hotlines and resources.

Resources for Providers

National Resource Center on Domestic Violence (NRCDV)
NRCDV provides a wide range of free, comprehensive, and individualized technical assistance, training, and specialized resource materials and projects designed to enhance current intervention and prevention strategies.

National Health Resource Center on Domestic Violence
Toll-free: 888-Rx-ABUSE (888-792-2873)
TTY: 800-595-4889
Email: health@endabuse.org
The National Health Resource Center on Domestic Violence is the nation's clearinghouse for information on the healthcare response to domestic violence and provides free technical assistance and materials to thousands of people each year. The Center is 1 of 5 specialized domestic violence resource centers in the country funded by the US Department of Health & Human Services.

Academy on Violence and Abuse
The Academy on Violence and Abuse (AVA) exists to advance health education and research on the prevention, recognition, treatment, and health effects of violence and abuse. On the Website, the AVA provides resources for healthcare clinicians, including tools for practice; resources for patients; professional policies, and links to state laws about violence, abuse, and reporting.

Sexual health is often defined as the absence of HIV and other STIs. However, it also involves choosing whether, when, how, and with whom one wants to become involved sexually. Healthy adolescent relationships allow each person the space to make these decisions comfortably. However, teens may not recognize the signs of unhealthy, abusive, or controlling partner relationships for a variety of reasons. It is important for healthcare providers to understand the many facets of partner violence and how they are linked with increased risk for HIV and other STIs. Providers can then effectively help teens (both boys and girls) identify abusive and controlling situations, including the many ways in which these relationship dynamics may be increasing their sexual risks. This more comprehensive approach to sexual health provides us with expanded opportunities to reduce sexual risk and promote the safety of young women and men.

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