Severe Dating Violence and Quality of Life Among

South Carolina High School Students

Ann L. Coker, PhD, Robert E. McKeown, PhD, Maureen Sanderson, PhD, Keith E. Davis, PhD,
Robert F. Valois, PhD, MPH, E. Scott Huebner, PhD

Background: Little research has addressed the impact of dating violence and forced-sex victimization
and perpetration on adolescent well-being. In this cross-sectional study, we provide
(1) estimates of severe dating violence (SDV) by victimization and perpetration status,
(2) estimates of lifetime forced-sex victimization and perpetration, (3) demographic and
health behaviors correlated with SDV, and (4) associations between SDV and forced sex
and well-being as assessed by (1) health-related quality of life (H-R QOL) and (2) life
satisfaction measures.
Methods: We used a stratified cluster sample of 5414 public high school students, grades 9 through
12, who responded to the 1997 self-administered South Carolina Youth Risk Behavior Survey.
Results: Nearly 12% of adolescents self-reported SDV as a victim (7.6%) or a perpetrator (7.7%),
and SDV rates (victimization/perpetration combined) are higher in girls (14.4%) than
boys (9.1%). Race, aggressive behaviors, substance use, and sexual risk-taking are correlates
of SDV. Among young women, SDV victimization, not perpetration, was associated with
recent poor H-R QOL and suicide ideation or attempts, but not lower life-satisfaction
scores. Among young men, SDV perpetration, not victimization, was strongly associated
with poor H-R QOL and suicide attempts, and lower scores for all domains of life
satisfaction.
Conclusions: This research provides evidence that SDV and forced sex are associated with poor H-R
QOL, low life-satisfaction scores, and adverse health behaviors in adolescent female victims
and male perpetrators. Screening for dating violence is needed to identify and intervene
early to reduce the impact of dating violence.
Medical Subject Headings (MeSH): adolescence, health, personal satisfaction, rape, risk
factors, quality of life, suicide, violence (Am J Prev Med 2000;19(4):220 227) 2000
American Journal of Preventive Medicine

Introduction Epidemiologic surveys indicate that 20% to 50% of

young adult couples engaged in some form of physical

D
ating or courtship violence is viewed by some as
violence in the past 12 months.3,5 8 Severe violence,
the mediating link between observed violence
defined as being hit, kicked, beaten, or attacked with a
in families of origin and subsequent violence in
weapon, was reported less frequently (5% to 20%).
families of procreation.1,2 In one study examining this
Estimates of the prevalence of ever experiencing severe
link, physical violence in a dating relationship was
dating violence (SDV) range from 1% to 24%.9 18
associated with a 51% increased risk of physical vio-
Violence among dating adolescents appears to be more
lence in the first 18 months of marriage in a college-
common than that among married couples.9 Although
based sample.3 Clearly, however, not all who use phys-
males and females appear to report approximately
ical force in dating relationships become batterers, and
equal rates of victimization and perpetration in dating
not all batterers used force in dating relationships.
relationships, females are more likely to report severe
Therefore, understanding dating violence as a distinct
violence and injuries.7,8,10,11,1720
phenomenon is of public health importance.4
Sexual assaults,2124 partner violence,25 and child-
hood and adolescent sexual abuse26 31 have been
From the Department of Epidemiology and Biostatistics (Coker,
McKeown, Sanderson), Department of Psychology (Davis, Huebner), shown to have significant negative impact on mental
and Department of Health Promotion and Education (Valois), and physical health as well as significant psychological
University of South Carolina, Columbia, South Carolina and economic costs. One of the few studies examining
Address correspondence and reprint requests to: Ann L. Coker,
PhD, University of South Carolina, Department of Epidemiology and health correlates specific to dating violence has shown
Biostatistics, Columbia, SC 29208. E-mail: ACOKER@SPH.SC.EDU. that young adult (college-aged) perpetrators of severe

220 Am J Prev Med 2000;19(4) 0749-3797/00/$see front matter

2000 American Journal of Preventive Medicine Published by Elsevier Science Inc. PII S0749-3797(00)00227-0
physical partner violence report fewer social support
resources; more drug or alcohol dependence; and
more anxiety, depression, manic, and psychotic symp-
toms than their nonviolent peers.7 In the same study,
young adult female victims of severe partner violence
reported more anxiety and depression than nonvic-
tims.7 Additional research is needed to address these
associations in younger adolescent populations and to
incorporate a wider range of health and quality-of-life
endpoints.
In this study conducted among students attending
public high schools in South Carolina, we examined
frequency of SDV and prevalence of lifetime forced-sex
victimization and perpetration by gender, and assessed
the demographic and health behavior correlates of
SDV. We hypothesized that experiences of SDV and
forced sex, conceptualized as psychosocial stressors,
would be adversely associated with adolescent well-
being. We expanded the definition of well-being32,33 to
incorporate measures based on traditional mental and
physical health indicators (health-related quality of life,
suicidal ideation, and behavior measures), as well as
more recently developed measures of perceived life
satisfaction (defined as an individuals conscious, cog-
nitive evaluation of the quality of life34 by domains such
as satisfaction with family, friends, self, and
community).
Methods
The 1997 South Carolina Youth Risk Behavior Survey (YRBS)
data were used for these analyses. The YRBS is an ongoing
state and national survey conducted by state contractors for
the Centers for Disease Control and Prevention (CDC),
Division of Adolescent and School Health. The YRBS was
designed to estimate the prevalence of health risk behaviors
among public high school students over time and across the
United States.35
The YRBS uses a three-stage, stratified cluster sampling
design that, when appropriately weighted, reflects the age
race gender composition of the states public high school
population. In the first stage, all high schools in South
Carolina were classified into one of three strata reflecting
enrollment: 114 schools in stratum 1 (small schools, 74 876
students), 52 schools in stratum 2 (medium schools, 887
1284), and 49 schools in stratum 3 (large schools, 1285
2577). In the second stage, individual schools were sampled
from each of these three strata, resulting in a final sample of
63 schools: 24 schools from the first stratum, 20 from the
second, and 19 from the third. To ensure that racial minor-
ities were included in the final sample in a representative
manner, schools in each stratum were rank ordered accord-
ing to minority racial composition using data available from
the state department of education. Schools were selected
systematically using PCSAMPLE (developed by WESTAT)
with probabilities of selection proportionate to enrollment
size across strata. In the third stage, classes were sampled
within schools from a single period until the desired number
of students from each school (approximately 100) was en-
rolled. Although the school is the primary sampling unit, the
individual is the unit of analysis.
School officials consented to allow students to participate.
Children and their parents were informed that a child could
refuse to participate by simply not completeing the question-
naire. Completing the survey was used as indication of
consent to participate. The Institutional Review Board of the
University of South Carolina approved this protocol. The
school response rate was 72% and student response rate was
88%, for an overall response rate of 63%. Response rates did
not differ significantly by strata sampled.
In 1997, the South Carolina YRBS consisted of the core set
of 70 CDC questions and 29 state-specific items. The YRBS
core focuses on demographics and risk-taking or health-
promoting behaviors. The CDC YRBS has been tested and
determined reliable as a self-report instrument.36
Severe Dating Violence
We assessed severe physical dating violence with two questions
modified from the Conflict Tactics Scale37: (1) Being phys-
ically beaten up (like hitting, kicking, or throwing someone
down) can sometimes happen with a person you are dating or
going out with. During the last 12 months, how many times
were you physically beaten up by the person you date or go
out with? (victimization); and (2) During the past 12
months, how many times did you physically beat up the
person you date or go out with? (perpetration).
Given the important distinction of SDV experienced once
versus more than once,4 we created dummy variables indicat-
ing levels of SDV victimization and perpetration as two or
more incidents, one incident, and no incidents in the past 12
months.
To assess construct validity of these SDV items, we com-
pared responses to the SDV questions with the question that
asked adolescents who was involved in their last physical fight.
Among those whose last physical fight was with a boyfriend or
girlfriend, 64.3% reported SDV victimization or perpetration.
Among those reporting no physical fight with a girlfriend/
boyfriend, 10.7% reported SDV. We found good agreement
between the two questions, providing a form of validation for
the SDV questions.
Lifetime Forced Sex
We assessed lifetime forced sex by asking respondents to
answer yes or no to the following questions: (1) Has anyone
ever forced you to have sexual intercourse even though you
did not want to? (victimization); and (2) Have you ever
forced someone to have sex with you? (perpetration).
Perceived Health-Related Quality of Life
(Mental and Physical Health)
We used the four health-related quality-of-life questions (H-R
QOL-4)38 from the YRBS to assess the adolescents percep-
tion of their mental and physical health. The H-R QOL-4 has
good criterion validity39; in this study Cronbach alpha 0.74.
Self-perceived general health status was assessed by the ques-
tion: In general, how would you describe your health? with
responses dichotomized as fair or poor versus good, very
good, or excellent. Recent mental health status (which in-
Am J Prev Med 2000;19(4) 221
Table 1. Severe dating violence frequency and lifetime forced sex among high school students by gender and
victim/perpetrator status, 1997 South Carolina Youth Risk Behavior Survey (YRBS)
Females Males
n2836 n2578
n %b 95% CI n %b 95% CI

Severe dating violence (last 12 months)a

Victim and perpetrator 121 4.2% 3.45.0% 60 2.3% 1.63.0%
Victim only 155 5.5% 4.66.4% 79 3.0% 2.33.0%
Perpetrator only 135 4.7% 3.85.6% 97 3.8% 3.04.6%
No dating violence 2425 85.6% 84.087.2% 2342 90.9% 89.991.9%
Beat dating partner (perpetrator)a 256 8.9% 7.610.2% 157 6.1% 5.07.2%
Once 148 5.2% 4.46.0% 77 3.1% 2.53.7%
23 times 60 2.1% 1.52.7% 23 0.9% 0.61.2%
47 times 20 0.7% 0.50.9% 31 1.2% 0.91.5%
8 times 28 1.0% 0.61.4% 26 1.0% 0.51.5%
No dating violence perpetration 2580 91.0% 89.792.3% 2421 93.9% 92.895.0%
Beaten by dating partner (victim)a 276 9.7% 8.510.9% 139 5.3% 4.36.3%
Once 122 4.2% 3.54.9% 51 1.9% 1.42.4%
23 times 87 3.2% 2.53.9% 32 1.2% 0.81.6%
47 times 37 1.3% 1.01.6% 18 0.7% 0.50.9%
8 times 30 1.1% 0.71.5% 38 1.5% 1.02.0%
No dating violence victimization 2560 90.4% 89.291.6% 2439 94.8% 93.895.8%
Among nonvirgins
Lifetime forced-sex experience Females n1510 Males n1413
Victim and perpetrator 26 1.7% 0.82.5% 29 2.1% 1.23.0%
Victim only 321 21.3% 19.223.4% 102 7.2% 5.78.7%
Perpetrator only 38 2.5% 1.53.5% 61 4.3% 3.15.5%
No forced sex 1125 74.5% 72.376.7% 1221 86.4% 84.788.1%
a
Dating violence experience reported for the last 12 months.
b
Actual N presented, percentage weighted for YRBS design (lower and upper limits of 95% CI for %).
CI, confidence interval

cludes stress, depression, and problems with emotions) and
recent physical health status were assessed as the number of
days in the past 30 that mental or physical health was not
good. Responses to a fourth question, How many days in the
past 30 did poor physical or mental health keep you from
doing your usual activities such as school, recreation, or
work, were dichotomized as 2 days versus 0 2 days.
We assessed adolescents suicide ideation and attempts
using the following questions: Sometimes people may con-
sider attempting suicide, that is, taking some action to end
their life. During the past 12 months, (1) Did you ever
seriously consider attempting suicide? (yes or no) and
(2) How many times did you actually attempt suicide?
Life Satisfaction
We assessed life satisfaction using a modification of the
six-item life satisfaction measure based on the Multidimen-
sional Students Life Satisfaction Scale developed and vali-
dated by Huebner et al.40 43 (We omitted the school satisfac-
tion item.) Our five-item measure had a mean inter-item
correlation of 0.45 with an alpha of 0.85, consistent with those
reported for the six-item version findings.40 The moderate
interitem correlations are consistent with previous adolescent
research42,43 and provide support for the separability of
various life domains. For each domain (family, friends, living
environment, self, and overall life satisfaction), we dichoto-
mized the scores as dissatisfied versus satisfied based on
subjects item responses.
Statistical Analysis
Survey data were stratified, clustered, and subsequently
weighted to reflect South Carolinas high school population,
and analyzed using SUDAAN (SUrvey DAta ANalysis) soft-
ware.44 Weighted frequencies were presented with associated
95% confidence intervals (CI). PROC CROSSTAB in
SUDAAN was used to determine the weighted frequency of
SDV by perpetrator/victimization status by gender (Table 1),
the weighted frequency of forced sex by gender (Table 1), and
the correlates of SDV (Table 2). Chi-square tests for
significant (p0.05) differences in proportions by SDV
were used.
We performed a series of weighted logistic regression
analyses to explore the association between SDV as either a
victim or perpetrator, by frequency (once, or more than once
in the past 12 months), each health-related quality-of-life
(H-R QOL) item, and each domains specific life satisfaction
item (Table 3). Dependent variables included the four H-R
QOL items, suicide ideation and attempts, and the five
life-satisfaction items. We included both SDV victimization
and perpetration in the same model; the referent group was
adolescents experiencing no SDV victimization or perpetra-
tion in the past 12 months. A parallel analysis using forced sex
as either a victim or perpetrator with the same list of four
variables was performed (Table 4). Adolescents who had ever
had sexual intercourse were defined as nonvirgins; only nonvirgins
were included in our analysis of forced sex.

222 American Journal of Preventive Medicine, Volume 19, Number 4

Table 2. Correlates of experiencing severe dating violence (SDV) among high school students, 1997 South Carolina Youth
Risk Behavior Survey (SC YRBS)
Total sample SDV No SDV
N5414 n647 n4767
Among all respondents # %* %* %*

Gender
Female 2836 49.6 61.0** 48.1
Male (referent group) 2758 50.4 39.0 51.9
Age
14 675 11.5 9.0 11.8
15 1464 26.5 26.7 26.4
16 1435 27.1 28.6 26.8
17 1194 22.6 22.9 22.5
18 646 12.5 12.7 12.4
Race/ethnicity
White (ref) 2657 49.4 44.2 50.1
African-American 2403 44.3 45.9 44.1
Hispanic 93 1.8 2.0 1.8
Asian 61 1.1 0.5*** 1.2
Native-American 46 0.9 2.1** 0.7
Other 141 2.6 5.4** 2.2
Living arrangement
Does not live with both parents 2647 48.8 57.1** 47.7
Lives with both parents (ref) 2753 51.2 42.9 52.3
Religious ties
Does not regularly attend religious services 1613 30.2 34.9** 29.6
Does regularly attend services (ref) 3764 69.8 65.1 70.4
Aggressive behaviors
Carried a weapon in the last 30 days 1232 24.3 36.5** 22.7
Did not carry a weapon(ref) 4016 75.7 63.5 77.3
Got into a fight in the last 30 days 1859 35.8 57.5** 33.2
Did not fight in the last 30 days (ref) 3353 64.2 42.5 66.8
Substance use
Current cigarette smoker 1967 36.4 52.8** 34.2
Nonsmoker (ref) 3447 63.6 47.2 65.8
Ever used chewing tobacco or snuff 330 6.5 9.8*** 6.0
Never (ref) 5021 93.5 90.1 94.0
Ever used anabolic steroids 218 4.0 11.3** 3.0
Never (ref) 5192 96.0 88.8 97.0
Ever used illegal drugs (excluding marijuana) 1050 19.6 34.2** 17.8
Never (ref) 4269 80.4 65.8 82.2
Used marjiuana or cocaine in last 30 days 1395 26.9 44.7** 24.7
Did not use (ref) 3884 73.1 55.3 75.3
Drank 5 alcoholic drinks per day in past 30 days 1283 24.6 37.7** 23.0
Drank 5 drinks per day in past 30 days (ref) 3996 75.4 62.3 77.0
Sexual behaviors
Ever had sexual intercourse 3008 61.4 83.5*** 58.7
Never had sexual intercourse (ref) 1940 38.6 16.5 41.3
Early age at first sex: 14 1289 23.9 33.8*** 22.6
14 including virgins (ref) 4125 76.1 66.2 77.4
Sexual risk-taking among nonvirgins
5 lifetime sex partners 880 18.2 35.4*** 16.2
14 lifetime sex partners (ref) 4055 81.8 64.6 83.8
2 sex partners in past month 323 6.9 14.4*** 6.0
02 partners (ref) 4606 93.1 85.6 94.0
First sex partner was aged 18 years 544 11.3 18.8** 10.4
First sex partner was aged 18 years (ref) 4870 88.7 81.3 89.7
Ever pregnant or caused a pregnancy 460 8.5 28.0*** 12.9
Never (ref) 4954 91.5 72.0 87.1
*Percentage weighted for SC YRBS study design; **p 0.05; ***p 0.01 for 2 test of proportions.
(ref), referent group

Am J Prev Med 2000;19(4) 223

Table 3. Severe dating violence and health-related quality of life, suicidal ideation and action, and life satisfaction among
high school students by gender, 1997 South Carolina Youth Risk Behavior Survey (YRBS)
Females Males
SDV Adjusted OR Adjusted OR
frequency
Prevalence in past 12 SDV SDV Prevalence SDV SDV
Health measures % 95% CI months victimization perpetration % 95% CI victimization perpetration

Health-related quality of life

Perceived health was poor to 18.1% 1.4% Once 1.51a,c 1.12a,c 10.1% 1.4% 0.42a,c 2.34*a,c
fair vs good to excellent 2 1.35a,c 1.21a,c 1.18a,c 1.56a,c
2 days in past 30 physical 31.5% 2.0% Once 1.18b,c 0.78b,c 23.6% 1.8% 0.94c,d 1.07c,d
health was not good 2 2.07**b,c 0.75b,c 1.62**c,d 1.96**c,d
2 days in past 30 mental 47.0% 2.4% Once 1.72**ac 1.00ac 29.2% 2.2% 1.79ce 1.38ce
health was not good 2 2.17**ac 0.87ac 1.47ce 1.22ce
2 days in past 30 that poor 22.1% 1.6% Once 1.72**a,c,d 0.91a,c,d 16.1% 1.6% 1.93*ac 1.41ac
health kept adolescent 2 1.88**a,c,d 1.06a,c,d 1.35ac 1.88*ac
from usual activities
Suicidal ideation and actions
Seriously considered suicide 26.3% 2.0% Once 1.72*a,c,d,f,g 1.00a,c,d,f,g 16.2% 1.6% 2.00a,c,e,g 0.83a,c,e,g
in last 12 months: yes vs 2 1.86**a,c,d,f,g 1.06a,c,d,f,g 2.95**a,c,e,g 0.81a,c,e,g
no
Attempted suicide in last 12 11.4% 1.4% Once 1.34a,c,gi 0.89a,c,gi 6.0% 1.0% 1.71ce 3.06**ce
months: yes vs no 2 2.14**a,c,gi 1.53*a,c,gi 1.53ce 3.00*ce
Self-perceived life
satisfaction by domains
(unsatisfied vs satisfied)
Family life 16.4% 1.4% Once 1.20c,gj 1.15c,gj 17.9% 2.0% 2.47**b,c 3.32**b,c
2 0.71c,gj 1.19c,gj 2.55**b,c 2.13*b,c
Friends 6.0% 1.0% Once 1.26c,d 1.21c,d 13.2% 1.8% 2.72**c,k 4.04**c,k
2 1.84*c,d 1.83*c,d 1.50c,k 4.18**c,k
Myself 11.1% 1.4% Once 1.07a,ce 0.78a,ce 14.5% 1.8% 2.13*c 4.06**c
2 1.56a,ce 1.82*a,ce 1.55c 4.27**c
Where I live 16.3% 1.6% Once 1.49c,g,h 1.05c,g,h 19.4% 2.0% 2.24*c,e,g 2.29**c,e,g
2 1.05c,g,h 1.35c,g,h 1.49c,e,g 1.13c,e,g
Overall life satisfaction 8.4% 1.0% Once 0.77c,e 1.29c,e 12.7% 1.6% 3.57**c 3.35**c
2 1.69*c,e 1.24c,e 1.25c 3.62**c
Confounders included in logistic regression models:
a g
Current smoker In a physical fight in last 30 days
b h
Binge drinking in the last month Weapon carrying in last 30 days
c i
Ever forced to have sex Race
d j
Ever use anabolic steroids Regular church attendance
e k
Marijuana or cocaine use last month Early age at first sex (age 14)
f
Age
*p 0.05; **p 0.01; Reference group consisted of those who reported good health.
SDV, severe dating violence; OR, odds ratio; CI, confidence interval

Results were significantly more likely to be female; have self-

Nearly 12% of students self-reported experiencing SDV
in the past 12 months either as a victim (7.7%) or a
perpetrator (7.6%) with some overlap between victim-
ization and perpetrations; SDV rates (victimization/
perpetration combined) are higher in females (14.4%)
than males (9.1%) (Table 1). Among nonvirgins,
16.2% reported ever experiencing forced-sex victimiza-
tion and 5.3% reported perpetration. Further break-
down by gender and victim/perpetrator status is given in
Table 1.
The frequencies of risk factors for SDV investigated
in this study for the total population and for adoles-
cents reporting and not reporting SDV are presented in
Table 2. Among South Carolina high school students,
those reporting SDV (victim/perpetrator combined)
identified race as Native American or other; have
gotten into a physical fight in the past month; have
carried a weapon in the past month; have used illegal
drugs, anabolic steroids, tobacco, or alcohol; and have
been a sexual risk-taker (e.g., be sexually active, been
pregnant or caused a pregnancy, and had more lifetime
and recent sex partners). Caution must be taken in
interpreting the finding that Native American and
other racial groups are at increased risk of SDV given
the small numbers for these comparisons.
Table 3 provides the results for associations between
SDV frequency and selected H-R QOL, suicide, and
life-satisfaction measures by gender and SDV victimiza-
tion/perpetrator status.
Among females, increasing frequency of SDV victim-

224 American Journal of Preventive Medicine, Volume 19, Number 4

Table 4. Lifetime forced sex and health-related quality of life, suicidal ideation and action, and life satisfaction among high
school students by gender, 1997 South Carolina Youth Risk Behavior Survey (YRBS)
Adjusted OR
Females, forced sex Males, forced sex
Victim Perpetrator Victim Perpetrator
Health measures (n369) (n68) (n156) (n111)

Health-related quality of life

Self-perceived health: Poor to fair vs good to excellent 1.52**a,c 0.51a,c 1.09a,c 1.44a,c
2 days in past 30 physical health was not good 1.53**b,c 0.85b,c 1.19c,d 1.33c,d
2 days in past 30 mental health was not good 1.51**a,c 0.70a,c 1.31ce 1.08ce
2 days in past 30 that mental or physical health kept 1.74**a,c,d 1.07a,c,d 1.60*ac 2.34**ac
adolescent from usual activities
Suicidal ideation and actions
Seriously considered suicide in last 12 months: yes vs no 2.36**a,c,d,f,g 1.12a,c,d,f,g 1.77**a,c,e,g 0.84a,c,e,g
Attempted suicide in last 12 months: yes vs no 1.95**a,c,gi 0.68a,c,gi 2.29**ce 1.53ce
Self-perceived life satisfaction by domains
(unsatisfied vs satisfied)
Family life 1.55**c,gj 1.50c,gj 1.73**b,c 1.74*b,c
Friends 1.38c,d 1.99*c,d 1.80**c,k 2.04**c,k
Myself 1.34a,ce 0.84a,eg 1.56*c 2.34**c
Where I live 1.44*c,g,h 1.40c,g,h 1.73*c,e,g 1.71*c,e,g
Overall life satisfaction 1.29c,e 1.77**c,e 1.94**c 2.38**c
Confounders included in logistic regression models:
a g
Current smoker In a physical fight in last 30 days
b h
Binge drinking in the last month Weapon carrying in the last 30 days
c i
Severe dating violence Race
d j
Ever use anabolic steroids Regular church attendance
e
Marijuana or cocaine use last month k
Early age at first sex (aged 14)
f
Age
*p 0.05; **p 0.01; Referent group consisted of those who reported good health.

ization was associated with poor H-R QOL and with
suicide ideation and attempts. SDV perpetration fre-
quency among females was not associated with poor
H-R QOL. Females reporting two or more SDV perpe-
tration incidents, however, were 50% more likely to
report a suicide attempt than were nonperpetrators.
SDV victimization occurring two or more times was
significantly associated only with dissatisfaction with
friends and with ones overall life. SDV perpetration 2
times was significantly associated with dissatisfaction
with friends and with oneself.
Among males, SDV victimization occurring two or
more times was significantly associated with poor per-
ceived physical health and suicide ideation, but not
attempts. SDV victimization among males was associ-
ated with low scores on all domains of life satisfaction,
although not in a frequency-dependent manner. SDV
perpetration occurring two or more times was associ-
ated with poor ratings on two items of H-R QOL, with
suicide attempts, and with low scores on all domains of
life satisfaction.
Table 4 provides adjusted odds ratios (ORs) for
lifetime forced sex experienced as a victim or perpetra-
tor, and the same range of H-R QOL, suicide ideation
and attempts, and life satisfaction measures presented
in Table 3. Among females, when controlling for po-
tential confounders including SDV, forced-sex victim-
ization was associated with low scores on all four H-R
QOL items, with suicide ideation and attempts, and
with being dissatisfied with ones family life and living
situation. Among females, forced-sex perpetration was
not associated with any H-R QOL items nor with suicide
ideation, but was associated with dissatisfaction with
friends and ones overall life. Among males, both
forced-sex victimization and perpetration were associ-
ated with low scores on life satisfaction items and a low
score on one H-R QOL measure. Forced-sex victimiza-
tion, not perpetration, was associated with suicide at-
tempts in males.
Discussion
This investigation represents one of the largest popu-
lation-based samples of adolescents to address dating
violence to date. It is one of the first studies to examine
SDV frequency and lifetime forced sex by gender and
their associations with health-related quality of life,
suicide ideation and attempts, and life satisfaction. SDV
and forced-sex victimization among females and SDV
perpetration among males were associated with self-
reported poor mental and physical health. SDV and
forced-sex perpetration and victimization were signifi-
cantly associated with poor ratings in all domains of life
satisfaction among males. Lifetime forced-sex victimiza-
tion, but not perpetration, was associated with suicide
ideation and attempts among both females and males.

Am J Prev Med 2000;19(4) 225

 Our finding that female SDV victimization and male
SDV perpetration are associated with poor H-R QOL
scores are consistent with the significant gender differ-
ences in mental health outcomes associated with dat-
ing-violence victimization and perpetration found by
Magdol et al.7 Our finding that forced-sex victimization
and perpetration were associated with poor mental and
physical health quality of life among both females and
males is also consistent with previous studies document-
ing the health effects of forced sex on victims.2231
Our estimates of the prevalence of SDV victimization
(7.7%) and perpetration (7.6%) are consistent with
existing studies addressing dating violence among ad-
olescents using the Conflict Tactics Scale (CTS) to
assess severe physical violence.10 16 Among high school
aged adolescents, Foshee11 reported that 14% experi-
enced SDV. In a rural North Carolina adolescent
population, Symons et al.12 found that 24% of females
reported SDV, yet only 2.7% perceived the violence as
abuse.
Our finding that female adolescent SDV victims and
male perpetrators were significantly more likely to
report adverse health outcomes is consistent with stud-
ies showing that adult women are more likely to expe-
rience more frequent and severe violence than
men.7,8,10,11,17,18 Lejeune and Follettes14 finding that
males who report dating violence were less likely than
females to take responsibility for the violence may help
explain the apparent gender differences in reporting
partner violence. Their findings suggest that males
under-report perpetration of violence because they
perceive the violence to be a just response to their
partner and not their responsibility. Females more
accurately report their perpetration of violence because
they do take responsibility for the violence.
By focusing on gender differences in the frequency
of dating violence and not the consequences of this
violence, we may be missing a more fundamental issue.
We propose that the frequency of violence may be less
important than the degree of terror the victim feels or
her risk of physical injury; few men are seriously injured
or terrorized by female partners, yet the case is quite
different for women.17,18 The perceived meaning of
dating or partner violence may also differ by gender.7 It
is unclear whether males are as likely as females to
experience dating or partner violence or whether the
available instruments to assess this violence do not
allow differentiation of the meaning of the violence or
its direction.
Several strengths of our study deserve mention. We
used a stratified, random sampling technique and a
survey instrument with documented reliability for ado-
lescent risk-taking behaviors. We addressed SDV by
victimization and perpetration status for both genders.
Finally, consistent with expanded definitions of well-
being and in an attempt to better understand the
potential impact of SDV on well-being, we assessed
226 American Journal of Preventive Medicine, Volume 19, Number 4
multiple dimensions that yielded a more comprehen-
sive profile of well-being than has been typically
obtained.
Because of limits on the number of questions we
could add to the YRBS, we did not have the opportunity
to more fully characterize dating violence; thus, these
findings may not be generalizable to other more com-
mon and less severe forms of dating violence. In
addition, because these data are cross-sectional, we
cannot address whether dating violence precedes or
follows the H-R QOL or life satisfaction indicators in
time. As with previous studies on dating violence using
the CTS,37 we cannot distinguish aggressors from those
using violence in self-defense. Nor does this study
provide data with which to characterize psychological
perspectives on dating that may be critical to under-
standing the etiology of dating violence.
Patterns of relationship violence that carry over into
marital relationships appear to be established in dating
relationships.3 While our data are not longitudinal,
they do provide a cross section of dating relationships
in adolescence and show levels of SDV that should be of
public health concern. Early interventions may reduce
the severity of dating violence and the potential health
impact of this violence. Screening of adolescent female
and male patients using direct questions about specific
violence has been shown to be accurate in identifying
partner violence.9,45
Community- or school-based prevention interven-
tions are also needed to reduce dating violence. Edu-
cational curricula exist46 52 to intervene effectively.
Based on our findings, curricula should target:
(1) males and females because both report victimiza-
tion and perpetration; (2) forced sex, alcohol and
other drug use, and other violence, as these cluster with
SDV; and (3) adolescents of middle school age because
SDV did not increase with age in our high school
samples suggesting that the pattern is established prior
to beginning high school.
This research was funded in part by Centers for Disease
Control and Prevention, Division of Adolescent and School
Health, Atlanta, Georgia, and the South Carolina Department
of Education (Cooperative Agreement #63/CCU 802750-03).
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