Partner Violence, Reproductive Coercion Are Teen Problems

If your practice sees adolescent patients and you’re not identifying intimate partner violence or coercion on a regular basis, it’s time to ask, "Why not?"

It’s there, it’s more common than you may suspect, and it often produces lifelong health consequences. Not enough teenagers are reporting it – and not enough physicians are asking about it – for a slew of reasons.

Increased attention to these problems in recent years has generated some handy resources for physicians to improve prevention, detection, and responses to intimate partner violence and sexual or reproductive coercion.

Sherry Boschert/IMNG Medical Media

More than half (53%) of 1,278 women aged 16-29 years who were seen at family planning clinics reported physical or sexual violence by intimate partners, 19% reported pregnancy coercion, and 15% reported birth control sabotage in one study (Contraception 2010;81:316-22).

Some 40% of 448 females aged 14-20 years who were seen at five urban adolescent clinics said they had experienced intimate partner violence in a separate study (Matern. Child Health J. 2010;14:910-7). A survey of 10th and 11th graders found that more than half of the girls and 13% of boys reported sexual coercion, defined as sexual behaviors involving verbal coercion, threats of force, or use of drugs or alcohol (Violence Vict. 1995;10:299-313).

In a survey of 1,430 seventh graders in three states that was conducted by the Robert Wood Johnson Foundation, 37% said they had witnessed physical dating violence against a peer, 37% reported experiencing psychological dating abuse, and – during the prior 6 month – 15% experienced physical dating abuse and 31% experienced electronic dating aggression.

In a survey of 305 school counselors, the majority (71%) had not received formal training on adolescent dating violence (ADV). Eighty-one percent said their school did not have a protocol to respond to incidents of ADV, and 83% said the school did not conduct periodic student surveys that included questions that mentioned ADV (Pediatrics 2012;130:202-10).

Adolescents overwhelmingly want health care providers to ask about intimate partner violence and coercion, other studies have shown. So, why aren’t they telling you about it, even if you ask?

You may not be asking in the right way, nor asking often enough, Dr. Harise Stein said at Stanford (Calif.) University’s annual pediatric update and preconference.

Teens aged 15-19 years have the highest rates of intimate partner violence and stalking of any age group, yet they report only an estimated 1 in 11 episodes of dating-related violence, said Dr. Stein, an ob.gyn at the university. She is a member of the Santa Clara County (Calif.) Domestic Violence Council.

One in six U.S. women experience rape – "which I think is a national disgrace," she said – and 32% of first rapes occur in female victims aged 12-17-years. In that age group, 36% of rapists are intimate partners, and 33% are acquaintances, according to a 2006 U.S. Department of Justice report.

Abuse during adolescence interferes with emotional development and has been associated with mental and physical illness both during the teen years and carried forward into adulthood, she said. It can exacerbate asthma, headaches, or other chronic illnesses. Consider abuse in the diagnostic differential when you see an adolescent who has developed school problems, increased isolation, personality changes, mental health issues, an eating disorder, substance abuse, cutting and other forms of self-harm, or suicidal ideology, Dr. Stein said.

Vague physical symptoms or symptoms that don’t make sense are red flags for possible abuse, as are chronic pain symptoms (especially headaches), or unexplained worsening of chronic illness. New sexually transmitted infections, an unplanned pregnancy, or a request for emergency contraception open a window to ask about abuse.

Suspicious injuries may result from abuse. Slap marks, scratches, bruises, welts, cuts, or muscle sprains are typical signs in adolescents, but most common are soft tissue injuries of the forearms (held up to defend against blows), face, head, and neck, Dr. Stein said.

Sherry Boschert/IMNG Medical Media

The prevalence of being choked to unconsciousness is "very underappreciated by health care workers" because half the time choking leaves no immediate external signs on the neck, she said. The teenager may wake up on the floor and not remember what happened. Only 10 seconds of strangulation can induce unconsciousness, and every second after that causes brain damage. Laryngeal edema over the following 24-48 hours can create airway emergencies. Brain cell death from the choking may cause problems in memory, reasoning, and concentration for several weeks. At least 10% of adult abused women who obtain restraining orders are estimated to have been choked to unconsciousness. Data are lacking for teens.

Teens in abusive relationships are four to six times more likely to get pregnant than are other teens, and 25% of pregnant teens are in abusive relationships, compared with 4%-8% of pregnant adults, Dr. Stein said.

The American Academy of Pediatrics and the American College of Obstetricians and Gynecologists (ACOG) recommend screening for dating abuse (Pediatrics 2009;124:393-402; Obstet. Gynecol. 2012;119:412-7) – perhaps starting as early at age 11, according to AAP’s Bright Futures – and educating preteens and teens about healthy relationships, she said.

Remember a key lesson from Adolescence 101: Teens are more likely to open up if you start with open-ended questions like "How’s school?" instead of pointed questions, or if you approach the topic obliquely by bringing up bullying as something a lot of people are talking about, and use that as a lead-in to talking about relationships. Focus on behaviors, not "abuse," Dr. Stein said.

Adolescents get most of their advice on health topics from peers, so use that to your advantage by giving your patients materials about healthy relationships and resources for abused teens, and telling them it’s "for a friend," if you suspect the patient or a friend is at risk.

To detect intimate partner violence and coercion, watch for it– but also make your office a place where teens will feel comfortable talking about it. Make informational materials available in nonconspicuous places. Explain confidentiality up front in teen visits.

Sherry Boschert/IMNG Medical Media

Dr. Eve Espey learned some of these lessons in a vivid way. A patient and her boyfriend came to the emergency department, and an HCG test suggested that she had an ectopic pregnancy. She refused emergency treatment. Once the boyfriend left the room, she admitted that she’d just had an abortion, and didn’t want him to know because she feared he’d be violent. A nurse had screened her and asked specifically about domestic violence, but with the boyfriend in the room, she couldn’t discuss it.

"We made changes after that," said Dr. Espey, professor of ob.gyn. at the University of New Mexico, Albuquerque, and chair of ACOG’s Working Group on Long-Acting Reversible Contraception. "We talk to every woman by herself. We tell them it’s part of our protocol," she said at ACOG’s annual meeting.

A February 2012 opinion published by ACOG’s Committee on Health Care for Underserved Women calls on physicians to screen all women for intimate partner violence at periodic intervals, to offer ongoing support, and to review prevention and referral options with patients. Intimate partner violence is most common during the reproductive years, so it’s important to screen several times during obstetric care, including at the first prenatal visit, at least once per trimester, and at the postpartum checkup, the committee recommended. The opinion paper includes sample questions (Obstet. Gynecol. 2012;119:412-7).

Dr. Espey recommends that ob.gyns. screen patients for intimate partner violence and reproductive coercion at most contraceptive visits, again not by immediate blunt questions like, "Are you safe at home?" but in a more circuitous, conversational way.

"The goal is not disclosure. Just engaging in the conversation is a great first step," she said.

When a patient does reveal intimate partner violence but is not ready to make changes, help the patient avoid unintended pregnancy by separating out the issue of reproductive coercion (in which a partner sabotages birth control or coerces the person to have or terminate a pregnancy), Dr. Espey said.

Talk about contraceptive methods that are less detectable by partners, for example. Long-acting reversible contraceptive methods are less vulnerable to tampering, but hormonal methods that eliminate periods may not work for women whose cycles are being closely monitored by a partner. The string on an IUD can be cut before insertion so that a partner cannot pull it out. If the IUD already is inserted, you’ll need to remove it and cut the string and reinsert it, because cutting the string just at the cervix leaves it potentially detectable, she said. Pills for emergency contraception can be stored in a vitamin bottle to avoid detection.

Her practice keeps laminated copies handy of a color-coded chart from the Centers for Disease Control and Prevention that helps clinicians quickly identify which forms of contraception are medically appropriate for particular patients – and showing that long-active contraceptives usually are an option. The "Summary Chart of U.S. Medical Eligibility Criteria for Contraceptive Use" is free.

She also lets patients who get an abortion know that they can say they’ve had a miscarriage, if they need to. "Women don’t realize that abortion cannot be detected. Tell them," she said.

These discussions plant the seeds for women to grow into readiness to leave abusive relationships, Dr. Espey said. Of course, keep in mind any legal requirements in your state to report abuse.

Adolescents often feel more comfortable being asked initially about abuse and coercion if it’s asked electronically, Virginia A. Duplessis said at ACOG’s annual meeting. In live conversations, "We’re moving from ‘Have you ever been punched, slapped, or kicked?’ to more nuanced conversation," said Ms. Duplessis, a program manager for Futures Without Violence, a nonprofit organization formerly known as the Family Violence Prevention Fund, headquartered in San Francisco.

Teens may not understand that violence and coercion are not acceptable ways to show love, she said.

Dr. Stein also pointed to a segment of the Tyra Banks television talk show that’s posted online, in which adolescents in the audience had trouble identifying types of abuse other than physical abuse.

Other times, the patient may have the knowledge, but feel unable to act on it. Ms. Duplessis described her frustration in a previous job as a community educator when teens who had condoms or birth control pills and knew how to use them kept reporting that they weren’t used. It’s not that they were dumb or apathetic, she finally learned; reproductive coercion often was the problem. The girls feared the consequences of negotiating condom use more than they feared pregnancy, or their partners threw away their pills.

That frustration with patients who do not follow a plan of care is one reason that clinicians don’t screen for intimate partner violence, she said. They also may not be comfortable starting conversations on this topic, or don’t ask because they don’t know what to do if a patient discloses intimate partner violence or coercion.

Futures Without Violence offers free materials to clinicians to simplify screening, such as folding wallet-size "safety cards" to give patients that list screening questions and resources.

Ms. Duplessis manages Project Connect, a national public health initiative to prevent violence against women through efforts focused on adolescent health, reproductive health, and home visiting programs. Funded by the U.S. Office on Women’s Health, Project Connect’s 10 geographically and ethnically diverse sites explore new ways to prevent, identify, and respond to domestic and sexual violence.

In a randomized, controlled pilot trial, a community-based intervention achieved some success (Contraception 2011;83:274-80). Clinicians asked 906 women at four family planning clinics questions about intimate partner violence and sexual and reproductive coercion, and reviewed the "safety cards" they gave to patients. The intervention took less than a minute of time in some cases, or longer if a positive screen led to more discussion.

Among women who had experienced recent partner violence, those in the intervention group were 71% less likely to report pregnancy coercion and 63% more likely to end an unhealthy or unsafe relationship, compared with a control group who got usual care.

Data suggest that reducing adolescent relationship abuse should reduce rates of substance abuse, teen pregnancy, depression, eating disorders, suicide, school dropouts, and adult intimate partner violence, Dr. Stein said.

For the past 4 years, she has reviewed the literature on the effects of abuse and has sent out monthly updates to interested parties. During that time, her monthly summary has grown from three to six pages. Attention to intimate partner violence and coercion is increasing, and every clinician plays a role, she said.

Dr. Stein, Dr. Espey and Ms. Duplessis recommended the following resources:

• ACOG and Futures Without Violence cobranded a guide for clinicians, "Addressing Intimate Partner Violence, Reproductive and Sexual Coercion." The 56-page pamphlet includes sample scripts for talking with patients, advice on managing someone who screens positive, quality assessment tools for clinical practices, and links to resources including a clinician training kit, "safety cards" for patients, and more.

• The "Healthcare Education, Assessment and Response Tool for Teen Relationships (HEART) Primer" is another free comprehensive toolkit to help clinicians recognize and decrease adolescent relationship abuse and sexual and reproductive coercion, offered by the California Adolescent Health Collaborative.

• The National Center for Youth Law created legal guides for Arizona, California, Maine, Michigan, and Ohio for "When Teens Disclose Dating Violence to Health Care Providers: A Guide to Confidentiality and Reporting Laws."

• Dr. Stein sends monthly e-mail updates about the literature on the effects of abuse. To get on her list, e-mail [email protected].

Dr. Stein, Dr. Espey, and Ms. Duplessis reported having no financial disclosures.

If your practice sees adolescent patients and you’re not identifying intimate partner violence or coercion on a regular basis, it’s time to ask, "Why not?"

It’s there, it’s more common than you may suspect, and it often produces lifelong health consequences. Not enough teenagers are reporting it – and not enough physicians are asking about it – for a slew of reasons.

Increased attention to these problems in recent years has generated some handy resources for physicians to improve prevention, detection, and responses to intimate partner violence and sexual or reproductive coercion.

Sherry Boschert/IMNG Medical Media

More than half (53%) of 1,278 women aged 16-29 years who were seen at family planning clinics reported physical or sexual violence by intimate partners, 19% reported pregnancy coercion, and 15% reported birth control sabotage in one study (Contraception 2010;81:316-22).

Some 40% of 448 females aged 14-20 years who were seen at five urban adolescent clinics said they had experienced intimate partner violence in a separate study (Matern. Child Health J. 2010;14:910-7). A survey of 10th and 11th graders found that more than half of the girls and 13% of boys reported sexual coercion, defined as sexual behaviors involving verbal coercion, threats of force, or use of drugs or alcohol (Violence Vict. 1995;10:299-313).

In a survey of 1,430 seventh graders in three states that was conducted by the Robert Wood Johnson Foundation, 37% said they had witnessed physical dating violence against a peer, 37% reported experiencing psychological dating abuse, and – during the prior 6 month – 15% experienced physical dating abuse and 31% experienced electronic dating aggression.

In a survey of 305 school counselors, the majority (71%) had not received formal training on adolescent dating violence (ADV). Eighty-one percent said their school did not have a protocol to respond to incidents of ADV, and 83% said the school did not conduct periodic student surveys that included questions that mentioned ADV (Pediatrics 2012;130:202-10).

Adolescents overwhelmingly want health care providers to ask about intimate partner violence and coercion, other studies have shown. So, why aren’t they telling you about it, even if you ask?

You may not be asking in the right way, nor asking often enough, Dr. Harise Stein said at Stanford (Calif.) University’s annual pediatric update and preconference.

Teens aged 15-19 years have the highest rates of intimate partner violence and stalking of any age group, yet they report only an estimated 1 in 11 episodes of dating-related violence, said Dr. Stein, an ob.gyn at the university. She is a member of the Santa Clara County (Calif.) Domestic Violence Council.

One in six U.S. women experience rape – "which I think is a national disgrace," she said – and 32% of first rapes occur in female victims aged 12-17-years. In that age group, 36% of rapists are intimate partners, and 33% are acquaintances, according to a 2006 U.S. Department of Justice report.

Abuse during adolescence interferes with emotional development and has been associated with mental and physical illness both during the teen years and carried forward into adulthood, she said. It can exacerbate asthma, headaches, or other chronic illnesses. Consider abuse in the diagnostic differential when you see an adolescent who has developed school problems, increased isolation, personality changes, mental health issues, an eating disorder, substance abuse, cutting and other forms of self-harm, or suicidal ideology, Dr. Stein said.

Vague physical symptoms or symptoms that don’t make sense are red flags for possible abuse, as are chronic pain symptoms (especially headaches), or unexplained worsening of chronic illness. New sexually transmitted infections, an unplanned pregnancy, or a request for emergency contraception open a window to ask about abuse.

Suspicious injuries may result from abuse. Slap marks, scratches, bruises, welts, cuts, or muscle sprains are typical signs in adolescents, but most common are soft tissue injuries of the forearms (held up to defend against blows), face, head, and neck, Dr. Stein said.

Sherry Boschert/IMNG Medical Media

The prevalence of being choked to unconsciousness is "very underappreciated by health care workers" because half the time choking leaves no immediate external signs on the neck, she said. The teenager may wake up on the floor and not remember what happened. Only 10 seconds of strangulation can induce unconsciousness, and every second after that causes brain damage. Laryngeal edema over the following 24-48 hours can create airway emergencies. Brain cell death from the choking may cause problems in memory, reasoning, and concentration for several weeks. At least 10% of adult abused women who obtain restraining orders are estimated to have been choked to unconsciousness. Data are lacking for teens.

Teens in abusive relationships are four to six times more likely to get pregnant than are other teens, and 25% of pregnant teens are in abusive relationships, compared with 4%-8% of pregnant adults, Dr. Stein said.

The American Academy of Pediatrics and the American College of Obstetricians and Gynecologists (ACOG) recommend screening for dating abuse (Pediatrics 2009;124:393-402; Obstet. Gynecol. 2012;119:412-7) – perhaps starting as early at age 11, according to AAP’s Bright Futures – and educating preteens and teens about healthy relationships, she said.

Remember a key lesson from Adolescence 101: Teens are more likely to open up if you start with open-ended questions like "How’s school?" instead of pointed questions, or if you approach the topic obliquely by bringing up bullying as something a lot of people are talking about, and use that as a lead-in to talking about relationships. Focus on behaviors, not "abuse," Dr. Stein said.

Adolescents get most of their advice on health topics from peers, so use that to your advantage by giving your patients materials about healthy relationships and resources for abused teens, and telling them it’s "for a friend," if you suspect the patient or a friend is at risk.

To detect intimate partner violence and coercion, watch for it– but also make your office a place where teens will feel comfortable talking about it. Make informational materials available in nonconspicuous places. Explain confidentiality up front in teen visits.

Sherry Boschert/IMNG Medical Media

Dr. Eve Espey learned some of these lessons in a vivid way. A patient and her boyfriend came to the emergency department, and an HCG test suggested that she had an ectopic pregnancy. She refused emergency treatment. Once the boyfriend left the room, she admitted that she’d just had an abortion, and didn’t want him to know because she feared he’d be violent. A nurse had screened her and asked specifically about domestic violence, but with the boyfriend in the room, she couldn’t discuss it.

"We made changes after that," said Dr. Espey, professor of ob.gyn. at the University of New Mexico, Albuquerque, and chair of ACOG’s Working Group on Long-Acting Reversible Contraception. "We talk to every woman by herself. We tell them it’s part of our protocol," she said at ACOG’s annual meeting.

A February 2012 opinion published by ACOG’s Committee on Health Care for Underserved Women calls on physicians to screen all women for intimate partner violence at periodic intervals, to offer ongoing support, and to review prevention and referral options with patients. Intimate partner violence is most common during the reproductive years, so it’s important to screen several times during obstetric care, including at the first prenatal visit, at least once per trimester, and at the postpartum checkup, the committee recommended. The opinion paper includes sample questions (Obstet. Gynecol. 2012;119:412-7).

Dr. Espey recommends that ob.gyns. screen patients for intimate partner violence and reproductive coercion at most contraceptive visits, again not by immediate blunt questions like, "Are you safe at home?" but in a more circuitous, conversational way.

"The goal is not disclosure. Just engaging in the conversation is a great first step," she said.

When a patient does reveal intimate partner violence but is not ready to make changes, help the patient avoid unintended pregnancy by separating out the issue of reproductive coercion (in which a partner sabotages birth control or coerces the person to have or terminate a pregnancy), Dr. Espey said.

Talk about contraceptive methods that are less detectable by partners, for example. Long-acting reversible contraceptive methods are less vulnerable to tampering, but hormonal methods that eliminate periods may not work for women whose cycles are being closely monitored by a partner. The string on an IUD can be cut before insertion so that a partner cannot pull it out. If the IUD already is inserted, you’ll need to remove it and cut the string and reinsert it, because cutting the string just at the cervix leaves it potentially detectable, she said. Pills for emergency contraception can be stored in a vitamin bottle to avoid detection.

Her practice keeps laminated copies handy of a color-coded chart from the Centers for Disease Control and Prevention that helps clinicians quickly identify which forms of contraception are medically appropriate for particular patients – and showing that long-active contraceptives usually are an option. The "Summary Chart of U.S. Medical Eligibility Criteria for Contraceptive Use" is free.

She also lets patients who get an abortion know that they can say they’ve had a miscarriage, if they need to. "Women don’t realize that abortion cannot be detected. Tell them," she said.

These discussions plant the seeds for women to grow into readiness to leave abusive relationships, Dr. Espey said. Of course, keep in mind any legal requirements in your state to report abuse.

Adolescents often feel more comfortable being asked initially about abuse and coercion if it’s asked electronically, Virginia A. Duplessis said at ACOG’s annual meeting. In live conversations, "We’re moving from ‘Have you ever been punched, slapped, or kicked?’ to more nuanced conversation," said Ms. Duplessis, a program manager for Futures Without Violence, a nonprofit organization formerly known as the Family Violence Prevention Fund, headquartered in San Francisco.

Teens may not understand that violence and coercion are not acceptable ways to show love, she said.

Dr. Stein also pointed to a segment of the Tyra Banks television talk show that’s posted online, in which adolescents in the audience had trouble identifying types of abuse other than physical abuse.

Other times, the patient may have the knowledge, but feel unable to act on it. Ms. Duplessis described her frustration in a previous job as a community educator when teens who had condoms or birth control pills and knew how to use them kept reporting that they weren’t used. It’s not that they were dumb or apathetic, she finally learned; reproductive coercion often was the problem. The girls feared the consequences of negotiating condom use more than they feared pregnancy, or their partners threw away their pills.

That frustration with patients who do not follow a plan of care is one reason that clinicians don’t screen for intimate partner violence, she said. They also may not be comfortable starting conversations on this topic, or don’t ask because they don’t know what to do if a patient discloses intimate partner violence or coercion.

Futures Without Violence offers free materials to clinicians to simplify screening, such as folding wallet-size "safety cards" to give patients that list screening questions and resources.

Ms. Duplessis manages Project Connect, a national public health initiative to prevent violence against women through efforts focused on adolescent health, reproductive health, and home visiting programs. Funded by the U.S. Office on Women’s Health, Project Connect’s 10 geographically and ethnically diverse sites explore new ways to prevent, identify, and respond to domestic and sexual violence.

In a randomized, controlled pilot trial, a community-based intervention achieved some success (Contraception 2011;83:274-80). Clinicians asked 906 women at four family planning clinics questions about intimate partner violence and sexual and reproductive coercion, and reviewed the "safety cards" they gave to patients. The intervention took less than a minute of time in some cases, or longer if a positive screen led to more discussion.

Among women who had experienced recent partner violence, those in the intervention group were 71% less likely to report pregnancy coercion and 63% more likely to end an unhealthy or unsafe relationship, compared with a control group who got usual care.

Data suggest that reducing adolescent relationship abuse should reduce rates of substance abuse, teen pregnancy, depression, eating disorders, suicide, school dropouts, and adult intimate partner violence, Dr. Stein said.

For the past 4 years, she has reviewed the literature on the effects of abuse and has sent out monthly updates to interested parties. During that time, her monthly summary has grown from three to six pages. Attention to intimate partner violence and coercion is increasing, and every clinician plays a role, she said.

Dr. Stein, Dr. Espey and Ms. Duplessis recommended the following resources:

• ACOG and Futures Without Violence cobranded a guide for clinicians, "Addressing Intimate Partner Violence, Reproductive and Sexual Coercion." The 56-page pamphlet includes sample scripts for talking with patients, advice on managing someone who screens positive, quality assessment tools for clinical practices, and links to resources including a clinician training kit, "safety cards" for patients, and more.

• The "Healthcare Education, Assessment and Response Tool for Teen Relationships (HEART) Primer" is another free comprehensive toolkit to help clinicians recognize and decrease adolescent relationship abuse and sexual and reproductive coercion, offered by the California Adolescent Health Collaborative.

• The National Center for Youth Law created legal guides for Arizona, California, Maine, Michigan, and Ohio for "When Teens Disclose Dating Violence to Health Care Providers: A Guide to Confidentiality and Reporting Laws."

• Dr. Stein sends monthly e-mail updates about the literature on the effects of abuse. To get on her list, e-mail [email protected].

Dr. Stein, Dr. Espey, and Ms. Duplessis reported having no financial disclosures.

If your practice sees adolescent patients and you’re not identifying intimate partner violence or coercion on a regular basis, it’s time to ask, "Why not?"

It’s there, it’s more common than you may suspect, and it often produces lifelong health consequences. Not enough teenagers are reporting it – and not enough physicians are asking about it – for a slew of reasons.

Increased attention to these problems in recent years has generated some handy resources for physicians to improve prevention, detection, and responses to intimate partner violence and sexual or reproductive coercion.

Sherry Boschert/IMNG Medical Media

More than half (53%) of 1,278 women aged 16-29 years who were seen at family planning clinics reported physical or sexual violence by intimate partners, 19% reported pregnancy coercion, and 15% reported birth control sabotage in one study (Contraception 2010;81:316-22).

Some 40% of 448 females aged 14-20 years who were seen at five urban adolescent clinics said they had experienced intimate partner violence in a separate study (Matern. Child Health J. 2010;14:910-7). A survey of 10th and 11th graders found that more than half of the girls and 13% of boys reported sexual coercion, defined as sexual behaviors involving verbal coercion, threats of force, or use of drugs or alcohol (Violence Vict. 1995;10:299-313).

In a survey of 1,430 seventh graders in three states that was conducted by the Robert Wood Johnson Foundation, 37% said they had witnessed physical dating violence against a peer, 37% reported experiencing psychological dating abuse, and – during the prior 6 month – 15% experienced physical dating abuse and 31% experienced electronic dating aggression.

In a survey of 305 school counselors, the majority (71%) had not received formal training on adolescent dating violence (ADV). Eighty-one percent said their school did not have a protocol to respond to incidents of ADV, and 83% said the school did not conduct periodic student surveys that included questions that mentioned ADV (Pediatrics 2012;130:202-10).

Adolescents overwhelmingly want health care providers to ask about intimate partner violence and coercion, other studies have shown. So, why aren’t they telling you about it, even if you ask?

You may not be asking in the right way, nor asking often enough, Dr. Harise Stein said at Stanford (Calif.) University’s annual pediatric update and preconference.

Teens aged 15-19 years have the highest rates of intimate partner violence and stalking of any age group, yet they report only an estimated 1 in 11 episodes of dating-related violence, said Dr. Stein, an ob.gyn at the university. She is a member of the Santa Clara County (Calif.) Domestic Violence Council.

One in six U.S. women experience rape – "which I think is a national disgrace," she said – and 32% of first rapes occur in female victims aged 12-17-years. In that age group, 36% of rapists are intimate partners, and 33% are acquaintances, according to a 2006 U.S. Department of Justice report.

Abuse during adolescence interferes with emotional development and has been associated with mental and physical illness both during the teen years and carried forward into adulthood, she said. It can exacerbate asthma, headaches, or other chronic illnesses. Consider abuse in the diagnostic differential when you see an adolescent who has developed school problems, increased isolation, personality changes, mental health issues, an eating disorder, substance abuse, cutting and other forms of self-harm, or suicidal ideology, Dr. Stein said.

Vague physical symptoms or symptoms that don’t make sense are red flags for possible abuse, as are chronic pain symptoms (especially headaches), or unexplained worsening of chronic illness. New sexually transmitted infections, an unplanned pregnancy, or a request for emergency contraception open a window to ask about abuse.

Suspicious injuries may result from abuse. Slap marks, scratches, bruises, welts, cuts, or muscle sprains are typical signs in adolescents, but most common are soft tissue injuries of the forearms (held up to defend against blows), face, head, and neck, Dr. Stein said.

Sherry Boschert/IMNG Medical Media

The prevalence of being choked to unconsciousness is "very underappreciated by health care workers" because half the time choking leaves no immediate external signs on the neck, she said. The teenager may wake up on the floor and not remember what happened. Only 10 seconds of strangulation can induce unconsciousness, and every second after that causes brain damage. Laryngeal edema over the following 24-48 hours can create airway emergencies. Brain cell death from the choking may cause problems in memory, reasoning, and concentration for several weeks. At least 10% of adult abused women who obtain restraining orders are estimated to have been choked to unconsciousness. Data are lacking for teens.

Teens in abusive relationships are four to six times more likely to get pregnant than are other teens, and 25% of pregnant teens are in abusive relationships, compared with 4%-8% of pregnant adults, Dr. Stein said.

The American Academy of Pediatrics and the American College of Obstetricians and Gynecologists (ACOG) recommend screening for dating abuse (Pediatrics 2009;124:393-402; Obstet. Gynecol. 2012;119:412-7) – perhaps starting as early at age 11, according to AAP’s Bright Futures – and educating preteens and teens about healthy relationships, she said.

Remember a key lesson from Adolescence 101: Teens are more likely to open up if you start with open-ended questions like "How’s school?" instead of pointed questions, or if you approach the topic obliquely by bringing up bullying as something a lot of people are talking about, and use that as a lead-in to talking about relationships. Focus on behaviors, not "abuse," Dr. Stein said.

Adolescents get most of their advice on health topics from peers, so use that to your advantage by giving your patients materials about healthy relationships and resources for abused teens, and telling them it’s "for a friend," if you suspect the patient or a friend is at risk.

To detect intimate partner violence and coercion, watch for it– but also make your office a place where teens will feel comfortable talking about it. Make informational materials available in nonconspicuous places. Explain confidentiality up front in teen visits.

Sherry Boschert/IMNG Medical Media

Dr. Eve Espey learned some of these lessons in a vivid way. A patient and her boyfriend came to the emergency department, and an HCG test suggested that she had an ectopic pregnancy. She refused emergency treatment. Once the boyfriend left the room, she admitted that she’d just had an abortion, and didn’t want him to know because she feared he’d be violent. A nurse had screened her and asked specifically about domestic violence, but with the boyfriend in the room, she couldn’t discuss it.

"We made changes after that," said Dr. Espey, professor of ob.gyn. at the University of New Mexico, Albuquerque, and chair of ACOG’s Working Group on Long-Acting Reversible Contraception. "We talk to every woman by herself. We tell them it’s part of our protocol," she said at ACOG’s annual meeting.

A February 2012 opinion published by ACOG’s Committee on Health Care for Underserved Women calls on physicians to screen all women for intimate partner violence at periodic intervals, to offer ongoing support, and to review prevention and referral options with patients. Intimate partner violence is most common during the reproductive years, so it’s important to screen several times during obstetric care, including at the first prenatal visit, at least once per trimester, and at the postpartum checkup, the committee recommended. The opinion paper includes sample questions (Obstet. Gynecol. 2012;119:412-7).

Dr. Espey recommends that ob.gyns. screen patients for intimate partner violence and reproductive coercion at most contraceptive visits, again not by immediate blunt questions like, "Are you safe at home?" but in a more circuitous, conversational way.

"The goal is not disclosure. Just engaging in the conversation is a great first step," she said.

When a patient does reveal intimate partner violence but is not ready to make changes, help the patient avoid unintended pregnancy by separating out the issue of reproductive coercion (in which a partner sabotages birth control or coerces the person to have or terminate a pregnancy), Dr. Espey said.

Talk about contraceptive methods that are less detectable by partners, for example. Long-acting reversible contraceptive methods are less vulnerable to tampering, but hormonal methods that eliminate periods may not work for women whose cycles are being closely monitored by a partner. The string on an IUD can be cut before insertion so that a partner cannot pull it out. If the IUD already is inserted, you’ll need to remove it and cut the string and reinsert it, because cutting the string just at the cervix leaves it potentially detectable, she said. Pills for emergency contraception can be stored in a vitamin bottle to avoid detection.

Her practice keeps laminated copies handy of a color-coded chart from the Centers for Disease Control and Prevention that helps clinicians quickly identify which forms of contraception are medically appropriate for particular patients – and showing that long-active contraceptives usually are an option. The "Summary Chart of U.S. Medical Eligibility Criteria for Contraceptive Use" is free.

She also lets patients who get an abortion know that they can say they’ve had a miscarriage, if they need to. "Women don’t realize that abortion cannot be detected. Tell them," she said.

These discussions plant the seeds for women to grow into readiness to leave abusive relationships, Dr. Espey said. Of course, keep in mind any legal requirements in your state to report abuse.

Adolescents often feel more comfortable being asked initially about abuse and coercion if it’s asked electronically, Virginia A. Duplessis said at ACOG’s annual meeting. In live conversations, "We’re moving from ‘Have you ever been punched, slapped, or kicked?’ to more nuanced conversation," said Ms. Duplessis, a program manager for Futures Without Violence, a nonprofit organization formerly known as the Family Violence Prevention Fund, headquartered in San Francisco.

Teens may not understand that violence and coercion are not acceptable ways to show love, she said.

Dr. Stein also pointed to a segment of the Tyra Banks television talk show that’s posted online, in which adolescents in the audience had trouble identifying types of abuse other than physical abuse.

Other times, the patient may have the knowledge, but feel unable to act on it. Ms. Duplessis described her frustration in a previous job as a community educator when teens who had condoms or birth control pills and knew how to use them kept reporting that they weren’t used. It’s not that they were dumb or apathetic, she finally learned; reproductive coercion often was the problem. The girls feared the consequences of negotiating condom use more than they feared pregnancy, or their partners threw away their pills.

That frustration with patients who do not follow a plan of care is one reason that clinicians don’t screen for intimate partner violence, she said. They also may not be comfortable starting conversations on this topic, or don’t ask because they don’t know what to do if a patient discloses intimate partner violence or coercion.

Futures Without Violence offers free materials to clinicians to simplify screening, such as folding wallet-size "safety cards" to give patients that list screening questions and resources.

Ms. Duplessis manages Project Connect, a national public health initiative to prevent violence against women through efforts focused on adolescent health, reproductive health, and home visiting programs. Funded by the U.S. Office on Women’s Health, Project Connect’s 10 geographically and ethnically diverse sites explore new ways to prevent, identify, and respond to domestic and sexual violence.

In a randomized, controlled pilot trial, a community-based intervention achieved some success (Contraception 2011;83:274-80). Clinicians asked 906 women at four family planning clinics questions about intimate partner violence and sexual and reproductive coercion, and reviewed the "safety cards" they gave to patients. The intervention took less than a minute of time in some cases, or longer if a positive screen led to more discussion.

Among women who had experienced recent partner violence, those in the intervention group were 71% less likely to report pregnancy coercion and 63% more likely to end an unhealthy or unsafe relationship, compared with a control group who got usual care.

Data suggest that reducing adolescent relationship abuse should reduce rates of substance abuse, teen pregnancy, depression, eating disorders, suicide, school dropouts, and adult intimate partner violence, Dr. Stein said.

For the past 4 years, she has reviewed the literature on the effects of abuse and has sent out monthly updates to interested parties. During that time, her monthly summary has grown from three to six pages. Attention to intimate partner violence and coercion is increasing, and every clinician plays a role, she said.

Dr. Stein, Dr. Espey and Ms. Duplessis recommended the following resources:

• ACOG and Futures Without Violence cobranded a guide for clinicians, "Addressing Intimate Partner Violence, Reproductive and Sexual Coercion." The 56-page pamphlet includes sample scripts for talking with patients, advice on managing someone who screens positive, quality assessment tools for clinical practices, and links to resources including a clinician training kit, "safety cards" for patients, and more.

• The "Healthcare Education, Assessment and Response Tool for Teen Relationships (HEART) Primer" is another free comprehensive toolkit to help clinicians recognize and decrease adolescent relationship abuse and sexual and reproductive coercion, offered by the California Adolescent Health Collaborative.

• The National Center for Youth Law created legal guides for Arizona, California, Maine, Michigan, and Ohio for "When Teens Disclose Dating Violence to Health Care Providers: A Guide to Confidentiality and Reporting Laws."

• Dr. Stein sends monthly e-mail updates about the literature on the effects of abuse. To get on her list, e-mail [email protected].

Dr. Stein, Dr. Espey, and Ms. Duplessis reported having no financial disclosures.