J Child Fam Stud (2012) 21:825832 DOI 10.

1007/s10826-011-9543-3

ORIGINAL PAPER

Dating Violence Victimization and Unprotected Sex Acts Among Adolescents in Mental Health Treatment
Christie J. Rizzo Heather L. Hunter Delia L. Lang Cassandra Oliveira Geri Donenberg Ralph J. DiClemente Larry K. Brown Project STYLE Study Group

Published online: 11 November 2011 Springer Science+Business Media, LLC 2011

Abstract The objective of this study was to explore the relationship between dating violence victimization and unprotected sex acts among youth in mental health treatment. Sexually-active adolescents (n = 261; ages 1318) enrolled in mental health treatment completed an audioassisted computerized self-interview (ACASI) to assess recent dating violence victimization, unprotected sex acts, depression symptoms, and recent alcohol use. Path analysis revealed that dating violence victimization was related to unprotected sex acts both directly and indirectly via its association with depression and condom use self-efcacy. These ndings suggest that in order to reduce HIV-related risk behaviors among dating violence victims, treatment providers should consider depressive symptomatology and associated affect around sexual situations. Keywords Adolescents Dating violence Mental health Unprotected sex

Introduction Adolescence represents a high risk period for HIV infection. Adolescents contract almost 4 million of the 15

C. J. Rizzo (&) H. L. Hunter C. Oliveira L. K. Brown Bradley Hasbro Childrens Research Center/Rhode Island Hospital and the Warren Alpert Medical School of Brown University, Providence, RI 02903, USA e-mail: crizzo@lifespan.org D. L. Lang R. J. DiClemente Emory University, Atlanta, GA, USA G. Donenberg University of Illinois at Chicago, Chicago, IL, USA

million new cases of sexually transmitted diseases (STDs) diagnosed each year (CDC 2006). Combined with young adults, adolescents account for 50% of new HIV infections on an annual basis (CDC 2001). Research has shown that the majority of adolescents are infected with HIV/STDs through sexual risk behavior. As a result, numerous investigations have sought to understand the developmental pathways that lead to sexual risk behavior in this age group. In particular, one pathway that has received empirical attention involves the contribution of violent relationship dynamics to the development of sexual risk. Emerging literature suggests that adolescents involved in abusive and coercive relationships are more likely to exhibit a spectrum of unhealthy sexual behaviors. Findings have linked dating violence with inconsistent condom use, multiple sex partners, and alcohol use prior to sexual encounters (Roberts et al. 2005; Teitelman et al. 2007; Wingood et al. 2001). Among female adolescents, dating violence exposure is associated with an increased risk for pregnancy and younger age at rst intercourse (Silverman et al. 2004). One way that dating violence may affect the sexual behavior of adolescents is by reducing their selfefcacy to use condoms. Self-efcacy reects a persons level of condence in his or her ability to control the environment (Bandura 1977, 1986, 1997). Self-efcacy relates to sexual risk behaviors when it impacts a persons condence in their ability to negotiate condom use. Dating violence is likely to impact condom use self-efcacy because youth who are victimized may not feel condent in their ability to discuss condom use with their partner if that discussion could lead to conict or violence. Yet another way that dating violence may increase sexual risk behavior is through its association with depressive symptoms. A number of studies have established that depression is a common correlate of dating

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violence (e.g. Coker et al. 2002; Holt and Espelage 2005; Wolitzky-Taylor et al. 2008). Depressive symptoms have also been found to have signicant associations with sexual risk in teens. For example, there is some evidence that adolescents with high levels of depressive symptoms also have higher odds of engaging in sexual activity (Rubin et al. 2009) and report using condoms inconsistently (Mazzaferro et al. 2006). There are a number of ways that depression may relate to sexual risk behavior. Depression symptoms (e.g. not caring about ones own wellbeing, hopelessness for the future) may directly impact sexual risk by undermining motivation to protect ones health. Moreover, since depression is known to reduce self-efcacy across a variety of domains (Dill et al. 2007; John et al. 2004), depressive symptoms may indirectly relate to sexual risk, by reducing self-efcacy for condom use. A third mechanism by which dating violence may increase sexual risk behavior is via alcohol use. Increasing evidence suggests that youth exposed to dating violence report high rates of alcohol use and abuse (e.g. Ackard et al. 2003; Coker et al. 2000; Howard and Wang 2003). Alcohol use is also a basic risk factor for sexual risk behaviors among teens. Alcohol has been proximally linked to unprotected sex during adolescents rst sexual encounters and globally linked to unprotected sex across a number of studies (see Leigh and Stall 1993 for a review). Unlike dating violence and depression, there is little research evidence to suggest that alcohol use specically decreases condom use self-efcacy. Rather, the effects of alcohol intoxication appear to elicit disinhibited sexual behavior among teens, especially those who are sexually inexperienced or engaging in a rst sexual encounter (Cooper 2002). Although the interplay of dating violence and sexual risk behaviors can certainly be examined in a community sample of adolescents, in the current study we chose to explore these variables among youth in mental health treatment. Youth in mental health treatment are particularly vulnerable to both dating violence and HIV infection. Youth with psychiatric disorders have been found to report inconsistent condom use, substance use before sex, concurrent partnerships, lower self-efcacy, poor communication (Seth et al. 2009), sexually transmitted infections (Brown et al. 2010; Baker and Mossman 1991; Seth et al. 2009), and earlier sexual debut (Baker and Mossman 1991). Moreover, in a study of psychiatrically hospitalized teens, just over 26% of adolescents who had started dating had experienced physical or sexual dating violence in the past year (Rizzo et al. 2010). This compares to nationwide data collected from the Youth Risk Behavior Surveillance where 9.5% of high school students indicated that they had been hit, slapped, or physically hurt on purpose by their boyfriend or girlfriend during the past 12 months (Grunbaum et al. 2004). Given the high rates of dating violence and HIV-related risk

behaviors in psychiatric settings, it makes sense to study these factors among youth in mental health treatment. To date, research on adolescent sexual risk behavior has begun to examine the role of dating violence, but important potential mediators such as condom use self-efcacy, depressive symptoms, and alcohol use have not been tested in a comprehensive model. Moreover, these factors have not been examined among adolescents enrolled in mental health treatment. In the present study the principal objective was to examine the impact of dating violence on acts of unprotected sex among youth in mental health treatment, as well as to test the impact of three potential mediators using path analysis. We tested the following hypothesis: (1) dating violence victimization was expected to be directly associated with unprotected sex acts in this sample of youth in mental health treatment, (2) condom use self-efcacy was expected to mediate the relationship between dating violence victimization and unprotected sex acts, (3) depressive symptoms and alcohol use were also expected to mediate the relationship between dating violence victimization and unprotected sex acts, (4) since depressive symptoms are known to erode self-efcacy, we hypothesized that depressive symptoms, but not alcohol use, would lead indirectly to unprotected sex acts through condom use selfefcacy. Whereas previous researchers have individually tested some of the bivariate relationships described above, the present study is, to our knowledge, the rst to examine the associations among these variables in a single model.

Methods Study Sample Data were collected as part of a multisite, family-based randomized controlled HIV prevention trial designed to evaluate the efcacy of an intervention to reduce HIV transmission risk behaviors among adolescents diagnosed with a psychological disorder (Project STYLE; Brown et al. 2010). Although the participants were followed over time, only the baseline data were used for the current study. Adolescents were eligible if they were between the ages of 13 and 18, received in- or out-patient mental health treatment at one of the study recruitment sites, lived with a parent or guardian who was also willing to participate in the study, and provided informed consent/assent. Adolescents were excluded from the study if they had a history of perpetrating sexual aggression (i.e., sexual assault or molestation), were currently pregnant, were known to have tested positive for HIV, or had cognitive decits precluding them from completing the assessment or participating in group activities. Participants were enrolled in the study at three recruitment sites: Rhode Island Hospital in

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Providence, University of Illinois in Chicago, and Emory University in Atlanta. Clinics and hospitals providing mental health services to adolescents served as recruitment sites. Of 1,102 adolescents who met eligibility criteria, 891 (81%) agreed to participate and subsequently completed baseline assessments. For the purposes of this study, the sample was restricted to adolescents reporting they had engaged in penile-vaginal sex in the past 3 months and provided answers to questions regarding dating violence history (N = 261). The mean age was 15.4 years (SD = 1.2). The ethnic break-down was as follows: 49.4% Black, African American or Haitian; 32.6% White; .8% Pacic Islander or Native Hawaiian; .4% Asian; and .4% Native American or Alaska Native. The majority of participants were enrolled in school, with only 1.5% having dropped out. Fifty-eight percent of participants qualied for a free or reduced-price lunch. Thirtynine percent of families reported a total annual income of less than $20,000. Thirty-seven percent of participants were hospitalized overnight in a psychiatric hospital during the past 3 months. Procedures The Institutional Review Boards at Rhode Island Hospital, University of Illinois, and Emory University approved the study protocol. Adolescents under 18 years of age gave assent; parents gave informed consent for their childs participation and their own participation. Adolescents over 18 years of age gave informed consent. Participants were asked to complete a private, 90-min audio computerassisted self-interview (ACASI). Adolescents and parents were compensated $50 each for their time and effort. Measures Background Factors Demographic information gathered included gender, age, race, and ethnicity. Parents also reported on adolescent history of psychiatric hospitalization in the past 3 months (yes/no), their childs utilization of free or reduced price lunch programs (yes/no), and household income. Sexual Behaviors The Adolescent Risk Behavior Assessment (ARBA) (Donenberg et al. 2001) is a computer-assisted structured interview designed specically for use with adolescents to assess sexual and drug behaviors that are associated with HIV infection. This measure is derived from ve well-established measures of sexual behavior and drug use (Dowling-Guyer et al. 1994; Needle et al. 1995; Weatherby et al. 1994).

Unprotected sex was measured by asking adolescents about the number of unprotected penile-vaginal sex acts they engaged in within the past 3 months. Since responses to this question had a zero-inated Poisson distribution, the variable was dichotomized to reect having had any unprotected sex act in the past 3 months versus no unprotected sex acts and responses were dummy coded (yes/no). Dating Violence Dating violence history was obtained by asking participants who had engaged in penile-vaginal sex if in the past 3 months their partner had hit or slapped [them] or forced [them] to have sex. Participants were asked to report on the behavior of up to four partners over this 3 month period. Alcohol Use Alcohol use was measured by asking adolescents about whether they drank alcohol in the past 30 days (yes/no). Major Depression The Computerized Diagnostic Interview Schedule for Children (C-DISC-IV) is a structured audio computerassisted diagnostic interview that screens for a full range of DSM-IV diagnoses (Shaffer et al. 2000) and was administered to adolescents. The Present State Youth version was used with variable timelines for each diagnosis and for specic symptoms. Reliability and validity of the C-DISC are acceptable and represent the gold standard in the eld (Shaffer et al. 2000). In the study sample, rates of diagnoses from the C-DISC-IV were MDD (32%), GAD (34%), PTSD (19%), mania (24%), hypomania (22%), ODD (66%), CD (44%), ADHD (58%), and no diagnosis (12%). For the purposes of this study, symptom counts for major depressive disorder were analyzed. Self-Efcacy for Condom Use The Self-Efcacy for Condom Use Scale (Prochaska et al. 1994) contains 13 items (alpha = .94, range 1352) reecting participants beliefs in their abilities to use condoms in various contexts (e.g. How sure are you that you could use a condom when your partner doesnt want to use one, you are depressed). Participants responded on a 4-point scale (very sure I could to very sure I could not).

Data Analyses First, bivariate relationships between demographic and study variables were examined using Chi square and t tests.

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Next, to determine if the relationship between dating violence and acts of unprotected sex can be accounted for by condom use self-efcacy, depressive symptoms, and alcohol use, a path model was tested using Mplus Version 5 n and Muthe n 2007). Weighted least squares esti(Muthe mation with mean- and variance-adjustment (WLSMV) was used, as this addresses missing data for dichotomous outcomes. Robust inference was provided by bootstrapped standard errors calculated from 1,000 random draws (Dietz et al. 1987).

Rates of Physical/Sexual Dating Violence Victimization Analyses indicated that 12.6% of participants had been hit or slapped by a dating partner in the past 3 months, 3.8% had been forced into sex and 2.7% were victims of both types of violence. Thus, 19.1% of participants were victims of physical or sexual dating violence. When examining victimization from more than one partner, 77.6% of all victims reported having one violent partner during the past 3 months, whereas 22.4% had more than one. There were no signicant gender differences in rates of dating violence victimization, aside from signicantly more females reporting forced sex by a dating partner, v2 (263, 1) = 3.8, p = .05. Hypothesis 1: Dating Violence is Directly Associated with Acts of Unprotected Sex In the bivariate analyses, participants who reported unprotected sex acts in the past 3 months were more likely to report dating violence victimization in the past 3 months, as well as alcohol use in the past 30 days, greater levels of depressive symptoms and lower condom use self-efcacy (see Table 1). This hypothesis was also tested in the path model (see Fig. 1). As expected, the

Results Table 1 provides the baseline characteristics for the participants based on their history of recent unprotected sex and dating violence victimization. Of the demographic variables, only gender was signicantly different across groups, with females more likely to report a recent history of unprotected sex acts. As a result, gender was entered as a covariate in the path analysis for all endogenous variables and was signicant for depressive symptoms (b = 3.75, SE = .61, b = .34, p \ .01) and condomuse self-efcacy (b = -1.84, SE = .94, b = -.11, p \ .05).

Table 1 Descriptives Unprotected sex M (SD)/N (%) Demographics Age Gender (% female) Reduced price lunch Hispanic Non-white Depression symptom count Alcohol use Condom use self-efcacya Unprotected sex Dating violence victim 15.4 (1.2) 105/154 (68%) 77/143 (54%) 22/153 (14%) 92/145 (63%) 8.2 (5.3) 15.4 (1.2) 55/107 (51%) 62/98 (63%) 8/106 (8%) 69/101 (68%) 5.9 (5.2) t = 0.10
2 ns

No unprotected sex M (SD)/N (%)

v2/t

Dating violence M (SD)/N (%)

No dating violence M (SD)/N (%)

v2/t

Total sample M (SD)/N (%)

15.5 (1.3) 30/51 (59%) 26/44 (59%) 6/51 (12%) 37/49 (76%) 9.8 (5.6)

15.3 (1.2) 130/210 (62%) 113/197 (57%) 24/208 (12%) 124/197 (63%) 6.6 (5.2)

t = -1.1 v = 0.16 v2 = 0.74 v2 = 0.00 v = 2.74

2 2

ns ns

15.4 (1.2) 160/261 (61%) 139/241 (58%) 30/259 (12%) 161/246 (65%) 7.4 (5.4)

v = 7.49* v2 = 2.17 v2 = 2.85 v = 0.62

2 ns

ns

ns ns

ns ns

t = -3.27*

t = -3.67*

67/154 (44%) 20.8 (8.9) 40/154 (26%)

34/107 (32%) 15.9 (4.1) 10/107 (9%)

v2 = 3.86* t = -5.74* v = 11.99*

2

27/51 (53%) -21.6 (10) 41/51 (80%)

74/210 (35%) -18.1 (6.9) 113/210 (54%)

v2 = 5.42* t = 2.88* v2 = 11.99*

101/261 (39%) 19.0 (7.9) 154/261 (59%) 50/261 (19%)

ns vary due to random patterns of missing data * p \ .05

a

Higher score indicates lower self efcacy

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J Child Fam Stud (2012) 21:825832 Fig. 1 Path model with standardized coefcients. Note All paths signicant at p \ .05. Signicant indirect path in bold. All endogenous variables regressed on gender
Dating Violence Victimization

829
ens

Depressive Symptoms

a = .23

d = -.27

cns

Condom Use Self Efficacy

f = -.41

Unprotected Sex Acts

b = .19
Alcohol Use

ins gns h= .19

direct effect of dating violence victimization on unprotected sex was signicant (path h; b = 0.53, SE = .25, b = .19, p \ .05). Hypothesis 2: Condom Use Self-Efcacy Mediates the Relationship Between Dating Violence Victimization and Unprotected Sex Acts Direct paths With depressive symptoms and alcohol use included in the path model, dating violence victimization was not signicantly associated with condom use selfefcacy (path c; b = -2.03, SE = 1.35, b = -.10, ns). However, condom use self-efcacy did signicantly predict unprotected sex acts (path f; b = -.06, SE = .01, b = -.41, p \ .001). Indirect paths The indirect effect of dating violence victimization on unprotected sex, mediated through condom use self-efcacy was non-signicant (c & f; b = .11, SE = .08, b = .04, ns).

b = .002, ns) and alcohol use (paths b & g; b = .05, SE = .06, b = .02, ns) were also non-signicant. Hypothesis 4: Depressive symptoms, but not alcohol use, lead indirectly to unprotected sex acts through condom use self-efcacy. Direct paths As hypothesized, the direct path between depressive symptoms and condom use self-efcacy was signicant (path d; b = -.39, SE = .11, b = -.27, p \ .001) and the direct path between alcohol use and condom use self-efcacy was non-signicant (path i; b = -.30, SE = .57, b = -.04, ns). Indirect paths As expected, the indirect effect of dating violence victimization on unprotected sex, mediated through depressive symptoms and condom use self-efcacy was signicant (paths a, d, & f; b = .07, SE = .03, b = .03, p \ .05). Moreover, the indirect effect of dating violence victimization on unprotected sex, mediated through alcohol use and condom use self-efcacy was non-signicant (paths b, i, & f; b = .008, SE = .02, b = .003, ns). In sum, these ndings suggest that dating violence victimization exerts its inuence on unprotected sex both directly (path h) and indirectly (paths a, d, & f). In the indirect path, dating violence victimization is associated with increased depressive symptoms which, in turn, are associated with decreased self-efcacy for condom use. This decreased self-efcacy was then associated with more unprotected sex acts. Although alcohol use was related to dating violence victimization (path b), it was not signicantly associated with unprotected sex in this model (path g). In that the dichotomous outcome of unprotected sex is considered a proxy for an underlying continuous variable, the pseudo-R2 serves as an estimate of the percentage of variance accounted for by the model in this underlying scale (DeMaris 2002). Using the pseudo-R2 recommended

Hypothesis 3: Depressive Symptoms and Alcohol Use Mediate the Relationship Between Dating Violence Victimization and Unprotected Sex Acts Direct paths As expected, dating violence victimization was signicantly associated with depressive symptomatology (path a; b = 3.16, SE = .78, b = .23, p \ .001) and alcohol use (path b; b = .50, SE = .21, b = .19, p \ .05). In contrast, alcohol use (path g; b = .10, SE = .10, b = .10, ns) and depressive symptoms (path e; b = .002, SE = .02, b = 0.01, ns) were not directly associated with unprotected sex. Indirect paths Contrary to our expectations, the indirect paths from dating violence to unprotected sex via depressive symptomatology (paths a & e; a = .006, SE = .06,

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by McKelvey and Zavoina (1975), about 30.3% of the variance in unprotected sex was accounted for by the path model.

Discussion The overarching goals of the study were to investigate the association between dating violence victimization and unprotected sex in a sample of adolescents in mental health treatment, as well as to test putative mechanisms for this association. Our ndings replicated prior work which revealed that, when holding gender constant, dating violence was associated with a higher likelihood of engaging in unprotected sex. When hypothesized mechanisms of the relationship between dating violence victimization and unprotected sex acts were tested, depressive symptoms and their impact on self-efcacy for condom use appeared to account for a signicant portion of the relationship. Given the crosssectional nature of this data set, we can not conclude that dating violence is causally linked to depressive symptomatology or that depressive symptomatology necessarily precipitates erosion in condom use self-efcacy. However, our ndings do suggest that the interplay of dating violence with depressive symptoms and self-efcacy for condom use is important in understanding incidents of unprotected sex in this population. More specically, attempts to increase self-efcacy for condom use may be improved by addressing the depressive symptoms of dating violence victims. In addition, clinicians who are working with depressed youth should assess for dating violence victimization and incorporate treatment components aimed at improving self-efcacy and reducing sexual risk behavior among youth victims. Consistent with prior research, we did nd greater alcohol use during the past 30 days among the recent dating violence victims; however we could not conclude that the use of alcohol was related to unprotected sex acts. Indeed, research on the link between alcohol use and sexual decision making has been mixed. Research ndings regarding alcohol use during sex suggest that proximal effects on condom use are primarily observed during sexual debut (Weinhardt and Carey 2000). In addition, the psychological characteristics of youth who use alcohol that may account for global effects on condom use, such as the propensity for risk taking behavior and sensation seeking were not measured here. Future longitudinal studies that examine both global and proximal effects of alcohol are needed to esh out the true impact of alcohol use on condom use among dating violence victims. Although there are a number of strengths to this study there are also a number of caveats. The path model tested

on our analysis explained a good deal of variance in unprotected sex outcomes (30.3%); however there is still a great deal of variability that was unexplained. The mental health disorders experienced by our sample may impact relations between our study variables and may impact the generalizability of our ndings. In focusing on depressive symptoms and alcohol use we hoped to capture the inuence of two mental health issues that are commonly linked with dating violence; however we recognize that other mental health symptoms may have an important role to play. Since our study was cross sectional, temporal relationship between variables could not be tested and causal conclusions could not be made. Our data were also limited by the fact that the condom use variable was aggregated across multiple partners and then separated by dating violence history (yes/no). As a result, this paper did not examine potential differences in reports of condom use during sexual encounters with violent versus non-violent partners. However dating violence victimization may exert an inuence on sexual behavior in concurrent violent relationships that carries over to future non-violent relationships. Relatedly, our study would have been improved by a measure of condom use intentions, since past behavior does not necessarily reect what our participants intended to do in the future. In addition, we relied on two items to ascertain the prevalence of dating violence in this sample, the reliability of which in this population is unknown. However, the specicity of the dating violence items, including the short 3 month period of measurement, reduces concerns about recall problems and misinterpretation, which is a common limitation of studies reporting retrospective data. Lastly, although we statistically controlled for gender in our analysis, this analytic approach does not allow for a detailed understanding of potential differences between males and females on study variables. While there were no signicant differences between genders and the rate of dating violence, aside from females reporting higher rates of sexual victimization, it cannot be concluded that females and males are equally affected. Female violence may be primarily defensive (a reaction to male-initiated violence) and so the impact of this violence on male victims may be less severe in nature than the impact of male violence perpetration on female victims. Since we did not ask participants to answer questions pertaining to the nature of their victimization, we cannot conclude that the violence was experienced similarly by both males and females. A future study examining gender differences would greatly add to the literature. Furthermore, although we did not assess for posttraumatic stress disorder (PTSD) associated with dating violence, PTSD symptoms are known to be elevated among victims of dating violence and may play a role in their sexual behavior. Future studies should explore

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the contribution of PTSD in addition to depressive symptomatology, to high rates of unprotected sex among adolescent dating violence victims. Aside from the limitations inherent in our cross-sectional study, there are a number of important implications. First, outpatient mental health treatment by nature does not typically include a component related to sexual risk prevention. Given the prevalence of dating violence exposure among youth in mental health treatment and the link between dating violence and unprotected sex in this population, our data suggest that mental health treatment providers should assess for and address dating violence victimization in tandem with associated sexual risks to offset their clients risk for HIV/STD infection. Second, depressive symptoms appears to be an essential mechanism in reducing self-efcacy for condom use and thus, contribute to unprotected sex acts among youth victims of dating violence. It is therefore important for clinicians to recognize that depression treatment needs to be tied to affect around sexual situations for these youth. Treatment providers can effectively increase an adolescents selfefcacy for condom use by both increasing their knowledge regarding condom use skills and decreasing depressive symptoms that are eroding self-efcacy across a variety of domains. Lastly, HIV and sexual risk prevention initiatives are typically delivered outside of mental health treatment settings in community based organizations (CBOs) and schools. These settings do not ordinarily consider mood state and mental health factors in their service delivery. Our ndings suggest that organizations providing sexual risk prevention programming in the community need to assess mental health concerns such as depression in order to effectively reach those youth who have histories of dating violence victimization and provide referrals to appropriate clinical services. In sum, although a number of studies have begun to document the link between dating violence victimization and sexual health variables, none have examined this link among adolescents in mental health treatment. This investigation is important, as youth in mental health treatment are at particular risk for STDs/HIV due to their risky sexual practices. Uncovering variables that make a signicant contribution to this risk, such as dating violence exposure, could inform the development of targeted intervention strategies for this vulnerable population and assist in the development of more effective sexual risk prevention strategies for youth in mental health treatment.
Acknowledgments This research was supported by NIMH grant R01 MH63008 awarded to Rhode Island Hospital (P.I. Larry K. Brown, M.D.) and the Lifespan/Tufts/Brown Center for AIDS Research. We are grateful for the support of Project STYLE Study Group members Chinmayee Barve, Ph.D., Richard Crosby, Ph.D., Wendy Hadley, Ph.D., Celia Lescano, Ph.D. and Cami McBride, Ph.D.

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