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Exposure to Violence and Associated Health-Risk Behaviors Among Adolescent Girls
Abbey B. Berenson, MD;
Constance M. Wiemann, PhD;
Sharon McCombs, MHSM
Arch Pediatr Adolesc Med. 2001;155:1238-1242.
ABSTRACT
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Objective To examine the relationship between exposure to violence and health-risk
behaviors.
Design Cross-sectional survey.
Setting University-based outpatient family planning clinic.
Patients Sexually active adolescent girls younger than 18 years (N = 517) who
presented for contraceptive care.
Main Outcome Measures Prevalence of witnessing or experiencing violence and the associations
with health-risk behaviors, including high-risk sexual behaviors, substance
use, and self-injury.
Results Compared with adolescents who had not been exposed to violence, those
who had only witnessed violence were 2 to 3 times more likely to report using
tobacco and marijuana, drinking alcohol or using drugs before sex, and having
intercourse with a partner who had multiple partners. Those who had experienced,
but not witnessed violence were at increased risk of these same behaviors
and were 2 to 4 times more likely than those who had neither witnessed nor
experienced violence to report early initiation of intercourse, intercourse
with strangers, multiple partners, or partners with multiple partners, tobacco,
alcohol and drug use, or to have positive test results for a sexually transmitted
disease. Individuals who had both witnessed and experienced violence demonstrated
the greatest risk of adverse health behaviors. These adolescents demonstrated
3 to 6 times greater risk of suicidal ideation (odds ratio [OR], 3.1; 95%
confidence interval [CI], 2.2-4.0) or suicide attempts (OR, 4.5; 95% CI, 2.2-9.4),
self-injury (OR, 5.8; 95% CI, 2.6-12.9), and use of drugs before intercourse
(OR, 6.2; 95% CI, 3.0-12.9) than those who had neither witnessed nor experienced
violence.
Conclusions Adolescents exposed to violence are at increased risk of multiple adverse
health behaviors. Programs designed to improve health outcomes should target
this high-risk group.
INTRODUCTION
PRIOR STUDIES have demonstrated that exposure to violence at a young
age may lead to physical as well as psychological problems, such as depression,
low self-esteem, posttraumatic stress disorder, and a fatalistic view of the
future.1, 2, 3, 4, 5, 6
Furthermore, witnessing and experiencing violence during the childhood or
adolescent years has been shown to be a strong predictor of adverse health
behaviors such as substance abuse,7, 8, 9
an increased number of sexual partners,10 and
violent behavior.1, 11, 12
However, prior studies have not determined if witnessing violence is associated
with the same consequences as experiencing violence because most studies have
merged those who witnessed and experienced violence into a single group or
focused only on those who experienced violence.8, 10, 13, 14
In addition, prior studies have not determined whether the strength of the
association between violence and adverse health behaviors varies according
to whether the adolescent witnessed or experienced violence.
To address this gap in the literature, we conducted a study to evaluate
the relationship between health-risk behaviors and exposure to violence among
a sample of sexually active adolescent girls. We hypothesized that adolescents
who had experienced violence would report a greater number of adverse health
behaviors than adolescents who had only witnessed violence or who had neither
witnessed nor experienced violence. Furthermore, we expected that the risk
of engaging in adverse health behaviors would be stronger among those experiencing
violence or both witnessing and experiencing violence than among those who
had only been a witness or those who reported neither experiencing nor witnessing
violence.
SUBJECTS AND METHODS
The study population consisted of adolescents younger than 18 years
who initiated care at The University of Texas Family Planning Clinic in Galveston
between June 28, 1992, and April 28, 1994. This facility serves an indigent
population of whom more than 80% earn a gross monthly income of less than
133% of the poverty level. As part of standard care, a structured interview
was conducted with each adolescent at her first visit to this facility to
collect information on demographic characteristics, exposure to violence,
and sexual and health-risk behaviors. Adolescents were interviewed consecutively
by trained clinic personnel. Although no patient who received care during
this time refused to be assessed, clinic traffic patterns prevented approximately
5% of patients from being interviewed. Fifty-three (9%) additional subjects
were excluded because we could not accurately assign them to 1 of the violence
groups because of missing data. Complete data were available for 517 adolescents.
There were no significant differences between those who were included and
those who were not with regard to race/ethnicity, school enrollment, or repetition
of more than 1 grade in school. Those who were excluded were approximately
6 months younger, on average, than the sample examined (15.1 vs 15.6 years
old; P = .006).
The structured questionnaire elicited information on demographic characteristics
(age, race/ethnicity, school enrollment, and repetition of  1 grades in
school) and recent use of tobacco, alcohol, and marijuana. Exposure to violence
was assessed with an 11-item questionnaire developed by Gladstein et al,15 using the witness and victim (experienced violence)
subscales. Adolescents were asked if they had seen or experienced any of the
following violent acts in their lifetime: robbery, physical attack, threatened
or completed rape, or threats against their life. In addition, they were asked
if they had witnessed a murder. Information obtained on health-risk behaviors
included suicidal ideation or suicide attempts and high-risk sexual behaviors
engaged in during their lifetime (number of pregnancies, age at first intercourse,
lifetime number of sexual partners, consistency of birth control and condom
use, use of alcohol or other drugs before sex, having a partner who had multiple
partners, or having sex with individuals they did not know well [hereafter
referred to as sex with strangers]). With institutional review board approval,
trained research assistants reviewed the medical records to extract patient
responses to interviews as well as the number of sexually transmitted diseases
(STDs) detected at that visit. All data were entered into a computerized database.
To ensure accuracy, a second trained assistant verified a random 10% of data
entries. Agreement of 99% or greater was observed across all data entries.
VARIABLE IDENTIFICATION
Age at first intercourse was dichotomized as younger than 13 years or
13 years or older, and number of lifetime partners was coded as 1 or 2 or
more. Inconsistent use of birth control was coded as yes if the adolescent
stated that she did not use some type of birth control every time she had
intercourse. Similarly, inconsistent use of condoms was coded as yes if the
adolescent stated that she did not use a condom every time she had intercourse.
Other high-risk sexual behaviors (having a partner with multiple partners,
sex with strangers, use of alcohol or drugs before sex) were each coded as
yes if the patient reported this behavior in the last year. Sexually transmitted
disease was coded as yes if the adolescent had a probe or positive culture
result for gonorrhea, chlamydia, or genital herpes; a positive blood test
result for syphilis; or visual evidence of condyloma acuminata at that clinic
visit.
STATISTICAL ANALYSES
Demographic characteristics, sexual behavior, substance use, and reports
of self-injury were compared among adolescents who reported neither witnessing
nor experiencing violence with (1) those who witnessed, but never experienced
violence; (2) those who experienced, but never witnessed violence; and (3)
those who reported both witnessing and experiencing violence. All 4 groups
were mutually exclusive. Data were analyzed using  2 analyses
and logistic regression models where appropriate. Crude and adjusted odds
ratios (adjusted for race/ethnicity, age, school enrollment, and having repeated
a grade) and 95% confidence intervals are reported for (1) sexual behaviors
(number of pregnancies, multiple partners, sexual debut, birth control use,
partner with multiple partners, sex with strangers, alcohol use before sex,
drug use before sex, frequency of condom use, and presence of an STD); (2)
substance use in the last 12 months; and (3) risk of self-injury. Adjusted
odds ratios from the logistic regression models that were overestimated owing
to a more than 10% incidence rate among those who neither witnessed nor experienced
violence were corrected using the formula suggested by Zhang and Yu.16 Significance was defined as P<.05.
RESULTS
Of 517 girls, 248 (48%) of the sample reported that they had witnessed,
experienced, or both witnessed and experienced a robbery, physical attack,
rape, threat against a life, or murder during their lifetime. From the sample,
108 (21%) girls stated that they had witnessed but not personally experienced
any of these acts, while 72 (14%) stated that they had personally been the
target of a violent act (experienced), but had not witnessed a violent act
inflicted on someone else. Sixty-eight (13%) reported both witnessing and
experiencing violence. The remaining 269 adolescents did not report witnessing
or experiencing any of these violent acts. Comparison of demographic characteristics
demonstrated no significant differences between those who had neither witnessed
nor experienced violence and those who had witnessed, experienced, or both
witnessed and experienced violence (Table
1).
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Table 1. Demographic Characteristics of the Sample by Violence History*
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Adolescents who reported witnessing but not experiencing violence exhibited
5 types of health-risk behaviors significantly more often than those who had
never witnessed or experienced violence; they were approximately twice as
likely to report alcohol or drug use before sex and almost 3 times more likely
to report sex with a partner who had multiple partners (Table 2). Moreover, they reported tobacco and marijuana use in the
last 12 months more often than those who had neither witnessed nor experienced
violence (Table 3). Other high-risk
sexual behaviors, alcohol use in the last 12 months, and risk of self-injury
were not significantly more likely in the witnessed-only group compared with
those who had neither witnessed nor experienced violence (Table 2 and Table 3
and Table 4).
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Table 2. High-Risk Sexual Behavior Reported by Violence History*
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Table 3. Substances Used in the Last 12 Months by Violence History*
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Table 4. Risk of Self-injury by Violence History*
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Adolescents who had personally experienced but not witnessed violence
exhibited a number of health-risk behaviors significantly more often than
did those who had neither witnessed nor experienced violence. These adolescents
were more than twice as likely to have had 2 or more sexual partners, had
sex with someone who had multiple partners, had sex with strangers, used drugs
before sex, and had positive test results for an STD at the clinic visit.
In addition, they were almost 4 times more likely to have had sexual intercourse
for the first time prior to age 13 years (Table 2). Furthermore, adolescents who had only experienced violence
were 2 to 3 times as likely as those who had neither witnessed nor experienced
violence to report tobacco, alcohol, and substance use in the past 12 months
and to have considered or attempted suicide (Table 3 and Table 4).
Associations between health-risk behaviors and violence were strongest
among those who reported both witnessing and experiencing violence. These
adolescents reported tobacco and alcohol use in the last 12 months, having
had sex for the first time prior to age 13 years, having sex with strangers,
having a partner with multiple partners, and using alcohol before sex 2 to
3 times as often as those not exposed to violence (Table 2 and Table 3).
Having considered suicide was reported 3 times more frequently and having
attempted suicide was reported 4.5 times more frequently than in adolescent
girls who had neither witnessed nor experienced violence (Table 4). Marijuana use in the last 12 months, using drugs before
sex, and self-inflicted injury were reported approximately 6 times more often
by this group than those who had neither witnessed nor experienced violence
(Table 2, Table 3 and Table 4).
COMMENT
Most of the prior studies on violence exposure and risky behavior have
not differentiated between those who witnessed and those who experienced violence.
In this study, we separated those who had only witnessed violence from those
who had experienced violence to examine the independent relationship of each
to health-risk behaviors. Adolescents who reported only witnessing violence
exhibited 5 types of health-risk behaviors significantly more often than those
who had neither witnessed nor experienced violence, whereas those who had
only experienced violence were at increased risk for most of the adverse health
behaviors we examined. Adolescents who both witnessed and experienced violence
had the highest risk. Thus, witnessing violence, although damaging, does not
appear to be as damaging as actually being a target of violence.
These findings are in agreement with those reported by Hughes17 in her study of children aged 3 to 12 years who witnessed
vs those who witnessed and experienced violence in their home. In Hughes'
study, a linear trend was observed for both behavioral problems and anxiety
levels, with children who both witnessed and experienced violence showing
the most distress, followed by those who had only witnessed violence and then
by those who had neither witnessed nor experienced violence. Similar to our
study, this study suggests that it is essential to differentiate witnesses
from those who have both witnessed and experienced violence when examining
related behavior.
Mazza and Reynolds18 have postulated
that the relationship between violence and poor mental health may be mediated
by posttraumatic stress disorder. This theory is supported by several studies
that have demonstrated that exposure to domestic or community violence frequently
leads to posttraumatic stress disorder. For example, Horowitz et al5 found that 67 of 79 young urban women who had experienced
between 8 to 55 different types of violent events met Diagnostic
and Statistical Manual of Mental Disorders, Revised Third Edition criteria
for posttraumatic stress disorder. Singer et al3
found exposure to violence to be a salient factor in predicting trauma symptoms
in high school students, with scores for total trauma symptoms directly related
to the amount of exposure to violence. Similarly, we noted that those who
had experienced or witnessed and experienced violence were more likely to
report previously considering suicide. Our finding that those who had only
witnessed violence were not significantly more likely than those who had neither
witnessed nor experienced violence to report self-injury is in line with the
findings of Horowitz et al,5 who found that
witnessing but not experiencing violent events did not significantly correlate
with posttraumatic stress disorder.
Witnesses of violence were at increased risk, however, of tobacco and
marijuana use. These findings are similar to those noted in a previous study
on pregnant adolescents at our institution19
as well as the findings of others.9, 10, 13, 20
In a recent study of more than 4000 adolescents, Kilpatrick and associates9 noted that those who had witnessed violence, as well
as those who had experienced physical or sexual assault, were more likely
to meet Diagnostic and Statistical Manual of Mental Disorders,
Fourth Edition criteria for substance abuse or dependence. Furthermore,
drug users who had experienced violence reported using a given substance for
the first time at an earlier age than those who had not experienced violence.
The authors speculated that exposure to violence may lead to maladaptive coping
responses and thus substance use may be an attempt to self-medicate. Alternatively,
however, the coexistence of violence and substance use may emerge from unconventionality
in the adolescent's personality, environment, and behavioral experiences.21 Experiencing or witnessing violence may expose the
adolescent to an unconventional situation and alter his or her personality
(via self-esteem mechanisms, depressive symptomatology), environment (introducing
fear, feelings of learned helplessness), and behaviors (unwanted initiation
of adult behaviors). According to the theory, problem experiences and behaviors
cluster together, leading the adolescent to engage in risky behaviors, such
as experimentation with drugs or reckless driving.22
Experiencing violence was noted to increase significantly the likelihood
of an adolescent engaging in multiple high-risk sexual behaviors. Those who
reported experiencing violence or both witnessing and experiencing violence
exhibited 6 high-risk sexual behaviors significantly more often than those
who had neither witnessed nor experienced violence. Some of this effect may
be related, at least in part, to the high incidence of early initiation of
sexual intercourse among those who had experienced violence. In this study,
both those who had experienced and those who had witnessed and experienced
violence were significantly more likely than those who had neither witnessed
nor experienced violence to have had their first sexual encounter before the
age of 13 years. It is highly likely that, in many cases, this first act of
sexual intercourse was involuntary. Whether voluntary or involuntary, early
onset of sexual activity is known to lead to an increased risk of multiple
partners and decreased discrimination of partner selection,23
both of which place the adolescent at risk of STDs and pregnancy. Gender-specific
approaches to understanding risk behavior would suggest that the proposed
association between exposure to violence and the performance of risk behaviors
may be particularly strong among adolescent girls by virtue of their unequal
social status and vulnerability, particularly with regard to sexual behaviors.24
Our study has several limitations. First, we could not determine causality
because we used a cross-sectional study design. Second, we conducted this
survey among adolescents motivated to seek family planning services. Thus,
our results may not be applicable to the general population. Third, we used
an instrument to assess exposure to violence that was not standardized because
we were unable to locate a standardized instrument in the literature. However,
the percentage of adolescent girls in our sample who experienced each of the
violent acts was noted to be similar to that observed by Gladstein et al15 in their female subjects. Finally, we relied on self-report
of violence and risk behaviors that may have led to recall bias. Prior studies,
however, have demonstrated that self-report of sensitive behavior by adolescents
is reliable and valid.25, 26
In summary, exposure to violence is clearly associated with an increased
likelihood of engaging in multiple health-risk behaviors, with adolescent
girls who both experience and witness violence at greatest risk. Additional
research is needed to determine the temporal sequence of this association
as well as to determine the effect of potentially confounding variables. If
it is confirmed that experiencing violence leads to high-risk behaviors during
adolescence, then clinicians should consider screening adolescent girls under
their care for prior exposure to violence. Those who screen positive should
be examined more closely for risk-taking behaviors, such as substance use.
In addition, these adolescent girls need careful screening for mental health
disorders, as well as STDs, and referral to a mental health professional when
appropriate.
AUTHOR INFORMATION
Accepted for publication June 12, 2001.
Presented at the Seventh Annual European Congress on Pediatric and Adolescent
Gynecology, Vienna, Austria, March 15, 1997.
What This Study Adds
Witnessing and experiencing violence during the childhood or adolescent
years have been shown to be strong predictors of adverse health behaviors.
However, prior studies have not determined if witnessing violence is associated
with the same consequences as experiencing violence because most studies have
merged those who witnessed and experienced violence into a single group or
focused only on those who experienced violence. To address this gap in the
literature, we conducted a study to evaluate the relationship between health-risk
behavior and witnessing or experiencing violence among a sample of sexually
active adolescent girls.
Adolescents who reported witnessing but not experiencing violence exhibited
an increased risk of 5 types of adverse health behaviors more often than those
who had never witnessed or experienced violence. Those who had experienced
but not witnessed violence were at increased risk of 11 different adverse
behaviors, whereas those individuals who had both witnessed and experienced
violence demonstrated an increased risk for 12 adverse health behaviors. Programs
designed to improve health outcomes should differentiate between adolescents
who only witness and those who directly experience violence to target those
at greatest risk.
From the Divison of Pediatric and Adolescent Gynecology, Department
of Obstetrics and Gynecology, The University of Texas Medical Branch at Galveston.
Corresponding author and reprints: Abbey B. Berenson, MD, Division
of Pediatric and Adolescent Gynecology, Department of Obstetrics and Gynecology,
The University of Texas Medical Branch at Galveston, 301 University Blvd,
Galveston, TX 77555-0587 (e-mail: abberens{at}utmb.edu).
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