Martha, a school nurse, was hurrying back to her office after a meeting. She overheard someone crying and a deep voice ordering the crying to stop. She turned to see Alex and Kim in the hallway. She knew Kim well because she frequently visited her office. When Martha asked Kim what was wrong, it was Alex who answered that Kim had just had another one of her “accidents.” Kim looked down so her hair would cover her face and the bruise that was developing. Martha put her hand on Kim’s arm and asked her again what was wrong. Before Kim could answer, Alex nudged her and said, “Tell her you’re all right.” Kim nodded, and the two walked away.

While people readily accept domestic violence as a major concern in our society, the problem of violence within dating relationships remains somewhat unknown. Many similarities exist between dating and domestic violence. Just as with domestic violence, dating violence occurs to people from all racial, social, cultural, and economic groups. It transpires in both heterosexual and homosexual relationships. Violence can include physical, sexual, and psychological acts. Victims of both types of violence often feel as if they are to blame for the abuse and are reluctant to tell anyone that it is happening. While both occur within the context of an interpersonal relationship, dating relationships do not usually involve the legal and financial commitments of marriage. However, interpersonal relationships are afforded a degree of privacy within our society. These factors contribute to the hidden nature of dating violence in our society.

Violence occurs in about 33% of the dating relationships of adolescents.¹ Physical violence includes acts such as pushing, shoving, slapping, kicking, biting, hitting with fists or objects, beating, and use of or threats of using weapons. Most commonly reported are slapping, pushing, and shoving. Physical violence can also include pinching, hair pulling, or scratching. Common reasons adolescents give for hitting or being hit by a dating partner are real or perceived betrayal and jealousy. Many adolescents believe that abuse is justified if one feels betrayed. Boys and girls are just as likely to hit a dating partner as they are to be hit by a dating partner.¹ However, while adolescent girls do report injury from physical abuse, boys are less likely to report injury.² This must be viewed with caution, as adolescent boys might not report injury in an attempt to appear more masculine.

Unlike physical violence where both boys and girls report being victims, girls are the usual victims of sexual violence, while boys are most often perpetrators.³ Sexual violence can refer to forced sexual activity, rough or painful sexual activity, gang rape, and sexual exploitation of younger or intoxicated victims.³ Sexual activity may be engaged by coercive methods, such as using emotional pressure or threatening violence. Emotional pressure can include threats of a breakup if sexual activity does not occur or calling a girl immature or inadequate if she does not agree to sexual activity. This emotional manipulation for sexual activity most commonly occurs with younger girls who are often insecure about their own sexuality. Date rape or forced sexual activity can have long-term physical and emotional health consequences for victims, such as feelings of helplessness, powerlessness, anxiety, posttraumatic stress disorder, multiple physical complaints, and genital injuries.³

Psychological abuse is important because it often precedes and serves as a predictor of physical abuse. Emotional abuse includes harsh or denigrating comments, remarks that belittle, or even cold and ignoring behavior. Adolescents also report threats and harassment from a partner after a breakup. Controlling behavior, extreme jealousy, possessiveness, and stalking are all forms of emotional abuse that increase the isolation and vulnerability of the victim.

Origins of relationship violence

Adolescent dating violence is a complex and multifaceted phenomenon. An examination of individual, societal, and familial factors is necessary. Adolescence marks the developmental stage in which individuals learn more about themselves while becoming independent. Identity formation takes place within the context of the dating experience. Through dating, adolescents are able to try out and practice the roles adults assume in social relationships. The practicing of adult roles can serve both negative and positive purposes. Adolescents have the opportunity to develop interpersonal skills, such as negotiation, conflict resolution, listening, and compromise. Unfortunately, many adolescents have difficulty mastering relationship skills, and conflict may ensue.

Dating is a societal process for mate selection that also has recreational and social functions. It most commonly involves two individuals who exclusively see each other in a relationship that may progress to deeper commitment. However, adolescents also date informally, such as group dates or arranging to meet each other at an event or even at the mall or park. Some individuals view dating as a stepping-stone to “going together” or a serious relationship. Others may see dating as a way to be sexually active or even test their popularity. Problems can arise from differing expectations of dating.

Many adolescents view violence as an integral part of a relationship,⁴ leading to a peer-group norm that confuses violence with love. Violence, along with jealousy and possessiveness, is thought to be indicative of love. This contributes to our understanding of why individuals remain in abusive relationships. Perhaps the factor that most influences the individuals’ use and acceptance of violence is the experience of violence within the family of origin. Many adolescents have experienced or witnessed violence within their own families. Adolescents may mimic the interpersonal behavior of their parents in their own interpersonal relationships, even when that behavior is dysfunctional. Adolescents who have been victims of child abuse are more likely to become victims and perpetrators of violence in other relationships.⁵

Violence in the family, community, and school can also affect the adolescent’s acceptance and use of violence. Violence within the family of origin —  both being a victim of child abuse and witnessing interparental aggression —  has been explored as an antecedent of dating violence. Social learning theory has also been used to explain the occurrence of dating violence. Social learning theory suggests that children model the behavior of their parents and would then mimic interparental aggression within their own dating relationships. So far, evidence supports an association, for males, between violence within the family of origin and the perpetration of violence within the dating relationship, while data on females is inconclusive.⁶

Violence in interpersonal relationships occurs within the context of the larger society. American society can be construed as patriarchal, where men have power in relationships. Men invite women on dates and assume financial responsibility for the date. A ritual of dating involves men trying to obtain sexual activity, while women are given responsibility to regulate the sexual activity. For adolescents who are struggling with the developmental task of identity, mastering this balance of roles and responsibilities may be difficult. Those adolescents who are insecure or have identity issues may cling to traditional gender roles that include male dominance. Males also may find support for violence against women within their peer group. Certain groups, such as athletes and fraternities, have been associated with a culture that encourages male dominance and violence against women.⁷

Risk factors

In identifying those at risk for dating violence, the nurse can explore factors that are related either to the person or to the relationship. Personal factors identified in victims and perpetrators include an attitude that justifies the use of aggression, substance abuse, and a history of violence.⁸ Teens are at risk for being victims of dating violence if they are involved with an individual who demonstrates dominance, jealousy, poor anger management skills, and controlling behavior.⁸

Compared to adults, teens are at higher risk for abuse during pregnancy.² However, men who abuse women before pregnancy may likely continue the abuse during the pregnancy, which places the mother and child at risk for complications.⁷ Ironically, more serious relationships present greater risk of dating violence, probably due in part to the social isolation that close relationships can bring. As is expected, relationships with conflict are more at risk for dating violence.

Once Martha is in her office, she continues to think about Alex and Kim. She pulls Kim’s file and notes numerous visits for multiple injuries. She calls the school counselor to talk about the girl. The two decide to meet with Kim.

Initiating a discussion

Effective identification of a problem is rooted in an understanding of adolescent behavior. Because many adolescents believe that violence in relationships is normal, they may not report or minimize the effect of the violence. The teen could feel that every other dating couple experiences violence.

Just as battered women don’t readily see themselves as battered, teens may not view their relationships as abusive. Therefore, nurses should avoid the use of emotionally loaded words, such as abuse, rape, or violence.⁴ Additionally, date rape tends to be minimized or underreported. Many times, victims are uncertain as to whether rape occurred. An adolescent girl might feel that since she agreed to the date, it wasn’t really rape. Or she may feel that because she knows the boy, it cannot be rape. She could also believe that she is responsible for the rape, especially if she had been drinking or using drugs.

Assessing for violence

Screening tools, such as the Abuse Assessment Screen (AAS), provides questions to guide nurses in assessing the frequency, severity, and perpetrator of abuse against women.⁹ AAS questions are listed in the sidebar entitled “Abuse Assessment Screen Questions.” Other useful instruments can be obtained from the Family Violence Prevention Fund’s website at www.endabuse.org. ⁴

Nurses should screen for violence in every client meeting. Many adolescent and adult women are reluctant to disclose violence and may need several prompts to initiate a discussion of partner abuse.⁴ The risk of abuse to young women is great, and abuse can have deleterious consequences for them.⁴ However, adolescent boys are equally likely to be victims of dating violence and will be just as reluctant to disclose it, so their screening is also essential. Nurses can make questioning less threatening by assuring clients that these questions are offered to all clients. Screening is important to stop ongoing abuse, soften the effects of past and current abuse, and halt further occurrences.⁴

Direct questions that mention specific behaviors should be used to elicit information. For example, the nurse should ask, “Have you ever been kicked, pushed, or forced to have sex with a dating partner?” Open-ended questions can gather information about the nature of the relationship. For example, a nurse might ask, “Does your partner tell you how to dress?” or “Does your partner ever follow you?” The inquiry should also focus on how conflict is handled within the relationship and how the adolescent feels about violence. Attitudes toward violence can be elicited by describing situations and then asking if hitting or slapping would be justified. Nurses could ask, “Is hitting appropriate when your partner…threatens to break up with you, flirts with someone else, observes you flirting with someone else, or hits you first?” For each situation, the teen can identify if violence would be justified as a reaction.

Both verbal and nonverbal clues may reveal a pattern of violence. Responses that would suggest an abusive relationship might include offering excuses for injuries; unwarranted delay between time of injury and of seeking treatment; references to the partner’s having a temper; anxious affect or depressed mood; unexplained injuries; use of makeup, clothing, or hair to cover injuries; and fear of the partner.⁴

A teen may feel afraid, yet not be able to trust his or her own instincts. Nurses should stress that they are listening and believe what teens are saying. Disclosure can be emotionally upsetting, so nurses have to work at supporting the self-esteem of victims. Trust and rapport are essential for effective intervention.

Physical exam

When nurses examine patients, injuries consistent with abuse can be differentiated from those occurring by accident. The latter are more likely to occur to one side of the body, while the former are often multiple injuries on more than one side of the body. Signs of injury consistent with abuse would be contusions or lacerations to the breast, face, torso, or genital area.⁴ These injuries are often located in sites that can be hidden by clothing. Other clues include inconsistencies in the injury and how the teen says it occurred and having a pattern of repetitive injuries. Careful assessment and documentation are essential in that a pattern of injury can be identified. A body map can accurately record injuries. Photographs are useful if the criminal justice system is involved.

In forced sexual activity or rape, the nurse must ensure that all medical and legal procedures for rape or sexual assault are followed. Referral to a hospital ED is indicated for treatment of injuries and follow-up. Pregnancy testing, emergency contraception, and testing for sexually transmitted diseases are strongly recommended. Rape represents a major assault on the body. Rape survivors report multiple physical complaints. The mental health symptoms associated with rape trauma, anxiety, and depression may also occur.³ It is important to initiate referrals to community agencies available for rape survivors.

Kim initially denies that any problems exist in her relationship with Alex. Because Martha is gentle and supportive, Kim begins to cry. She tells the nurse and counselor how afraid she is. Kim says that whenever she speaks of ending the relationship, Alex threatens to kill her and then himself. She is afraid he will do it because he has been so mean to her and has physically hurt her. Kim also says that Alex has become more violent over the last few weeks. Kim agrees to a meeting with her parents and Martha. She seems relieved that she has help with her problem.

Planning for safety

When Martha and the counselor meet with Kim, the goal is to provide support and ensure her safety. They speak with her privately and use compassion. Kim could be fearful of talking to anyone. She may fear retaliation from Alex if he finds out. Providers should convey that the abuse is not the victim’s fault and that she does not deserve to be abused. Violence slowly erodes the self-esteem of the victim, so this message may need to be repeated several times. Education about healthy relationships may be needed. Finally, a discussion of how people demonstrate caring and affection can help clarify any misperceptions.

Safety planning is an important part of intervention. The nurse needs to assess Kim’s level of safety within the relationship by inquiring about the use or availability of weapons and substance abuse. The nurse must initiate a discussion about a plan for her safety, including how she can get away from her boyfriend if he becomes abusive, in addition to discussing how she will remain safe after she ends the relationship. Often women are at greater risk for abuse or violent acts after ending the relationship.⁴ Key things to discuss may include using a cell phone, having friends stay near, and dating only with a group present. Encourage the teen to plan for an emergency. By having the teen discuss past violent acts, the partner’s use of alcohol or illicit drugs, and the presence of weapons, the nurse can help the teenager problem-solve to identify escape, if future violence occurs.

The nurse should refer teens to community agencies that deal with intimate violence. Crisis lines or hotlines can provide information about support groups and advocacy services. Look for sidebars with Internet websites and books that may be helpful elsewhere in this article. Involvement in school, community, or church-based activities might help the teen develop a support network and constructive outlets for free time.

Depending on the severity of the situation, the criminal justice system may need to be involved. Dating violence in itself is not a crime. However, the acts that may be committed all constitute criminal activity. For example, physical violence is battery or assault, and forced sex is rape or sexual assault. Victims may not want to report date rape due to fears of being stigmatized, revictimized, or not believed.

Dating violence in an adolescent population can become complicated in the legal systems. In most states, adolescents are not considered adults and do not have the same legal rights. In some, adolescents may be unable to press charges and may need an adult guardian to do so. Many of the legal resources, such as restraining orders, may also be available to adolescents only through an adult. The nurse must carefully assess the adolescent’s family, support system, and school resources for an adult who can adequately represent the teenager. The nurse must know and follow the laws in the area that determine when child abuse or sexual assault must be reported.

Prevention efforts

Nurses can intervene through primary and secondary prevention of dating violence. Primary prevention involves identifying stressors and teaching to provide skills to successfully manage or avoid stressors. Secondary prevention involves intervention after the stressor has occurred to return the person to the previous level of health. Primary prevention efforts can take the form of large- or small-group educational programs that would present information on violence within relationships and ways to prevent, deter, and cope with aggression from a dating partner. Effective education challenges the belief that violence is a normal part of a loving relationship. Discussions of what constitutes appropriate or healthy loving relationships and how love is demonstrated can provide a starting place for addressing violence in relationships.

Gender-specific presentations can reduce confusion about violence within dating relationships. For example, instruction to girls in school settings as a part of health education or in special workshops can be effective. An open discussion of dating and what rules of behavior adolescents follow in dating can be helpful in identifying and confronting specific issues that need to be addressed, including adolescents’ stereotypical beliefs, behaviors, and roles.

Male students can benefit from similar interventions. Small-group discussions on what it means to be a male partner in a relationship might confront stereotypical behavior. The use of male facilitators can be useful in discussing, hearing, accepting, and respecting “no” from female partners. Male adolescents can also benefit from hearing information about what to do if a partner becomes physically or emotionally abusive toward them. Due to gender roles that dictate that men and boys are “tough and strong,” males may not report being a victim of dating violence and may minimize the consequences. Violence can also occur in gay and lesbian relationships, where people may already feel isolated due to their sexuality and may have difficulty reaching out for help.

Nurses can use media examples to stimulate discussion. For example, some popular music contains pro-violence lyrics against women. Much of the music seen and heard on MTV and BET contains misogynistic messages and uses videos that objectify women. Movies or television shows may also be used to stimulate discussion. Couples from popular television shows may be used to initiate discussions on healthy relationships and male-female interactions. Discussions of the lyrics or scripts can identify attitudes about violence and provide an opportunity for clarification of ideas and potential change.

Secondary prevention in the form of small-group intervention can be targeted to either victims or perpetrators of violence. Group intervention affords the opportunity for peer support and feedback. By meeting with peers who are having similar problems, a teen can realize that he or she is not the only person in that situation. This knowledge can be comforting and provide inspiration for changing behaviors. Group formats also provide the opportunity for participants to learn from the experience of others and have the chance to help another, boosting self-esteem. Both perpetrators and victims need to discuss healthy relationships. Victims need information about assertiveness skills and safety planning. Perpetrators must learn how to build healthy, trusting relationships and how to adaptively manage jealousy and anger.

Prevention efforts should also include parents. It is not uncommon for adults to dismiss dating violence as typical adolescent behavior, believing that “boys will be boys.” Societal messages, such as “love means never having to say you’re sorry,” present the idea that problems are inevitable, but a happy ending will occur. However, parents need to understand that dating violence can threaten the health of their children. They need to know the signs that may indicate an abusive relationship and be alert to changes from the usual behavior of their child, such as withdrawn behavior or signs of fear. Nurses can provide parents with information that can help them build an alliance with their children and the scripts that will assist them in discussing healthy relationships and developing conflict resolution skills in their teens.

Adolescent dating violence is a serious yet hidden problem that threatens the mental and physical health of teens. Nurses can be involved in the primary prevention of its occurrence, as well as its recognition through interactions with teens in schools, pediatric units, and health clinics. Their understanding can result in successful interventions with those who are at risk for dating violence.

Martha saw Kim in the cafeteria. She was smiling and joking with a group of friends. Kim came over to tell Martha thanks. Martha told Kim how good it was to see her and how good it was that she hadn’t seen her in a long time. They both smiled.