LETTERS MEASUREMENT OF GENDER EQUITY: A CLARIFICATION I applaud McCauley et al. for highlighting the important role of gender equity in perpetration of dating violence among US high school athletes.1 Gender-equitable attitudes are influential in a range of sexual-health outcomes beyond violence, including the negotiation of safer sex and sexually transmitted infections.2 This is a clearly significant target for intervention. However, I feel clarification is needed regarding the measurement of gender equity. The Gender-Equitable Norms Scale used in the article was developed for and tested on a group of Brazilian young men aged 15 to 24 years, and 22% of those young men were married.2 McCauley et al. provide grade levels rather than age ranges for their participants; the oldest age range typically seen in US high school students was 18 to19 years of age. Thus, the US male student athletes could potentially be quite a bit younger than their Brazilian counterparts. Also, regardless of age, Brazilian men’s perceptions may not be comparable to those of US male high school athletes. Furthermore, the authors use a modified version of the Gender-Equitable Norms Scale in their study. With only three items provided
as an example, it is difficult to know how similar this modified scale is to the original. While McCauley et al. emphasize the use of pilot testing for the other modified scales in their study, it is not clear if the modifications to the Gender-Equitable Norms Scale were validated prior to use. Additionally, known risk factors of male dating violence were not included in the study. Although the authors discuss the role of witnessing violence by peers and its association with dating violence perpetration, the impact of experiencing and witnessing violence in the home is not covered. Childhood maltreatment and witnessing interparental violence have been shown to increase the risk of dating violence, especially among men.3---5 This issue also has implications for selection bias, because the main reason students did not participate in this study was said to be lack of parental consent. Parents dealing with violence within their homes may be less likely to consent to their child’s participation in a study focused on violence, given the stigma surrounding domestic violence. It is possible that the study is not controlling for a potentially important confounder and is also missing the group most likely to perpetrate dating violence. j Joy D. Scheidell, MPH
Letters to the editor referring to a recent Journal article are encouraged up to 3 months after the article's appearance. By submitting a letter to the editor, the author gives permission for its publication in the Journal. Letters should not duplicate material being published or submitted elsewhere. The editors reserve the right to edit and abridge letters and to publish responses. Text is limited to 400 words and 10 references. Submit online at www. editorialmanager.com/ajph for immediate Web posting, or at ajph.edmgr.com for later print publication. Online responses are automatically considered for print publication. Queries should be addressed to the Editor-in-Chief, Mary E. Northridge, PhD, MPH, at [email protected].
e6 | Letters
About the Author Joy D. Scheidell is with the Department of Epidemiology, College of Public Health and Health Professions and College of Medicine, University of Florida, Gainesville. Correspondence should be sent to Joy D. Scheidell, MPH, 2004 Mowry Road, PO Box 100231, Gainesville Florida 32610 (e-mail: jdbscheidell722@ufl.edu). Reprints can be ordered at http://www.ajph.org by clicking the “Reprints” link. This letter was accepted October 26, 2013. doi:10.2105/AJPH.2013.301779
References 1. McCauley HL, Tancredi DJ, Silverman JG, et al. Gender-equitable attitudes, bystander behavior, and recent abuse perpetration against heterosexual dating partners of male high school athletes. Am J Public Health. 2013;103(10):1882---1887. 2. Pulerwitz J, Barker G. Measuring attitudes toward gender norms among young men in Brazil: development
and psychometric evaluation of the GEM scale. Men Masc. 2008;10(3):322---338. 3. Gover AR, Jennings WG, Tomsich EA, Park M, Rennison CM. The influence of childhood maltreatment and self-control on dating violence: a comparison of college students in the United States and South Korea. Violence Vict. 2011;26(3):296---318. 4. Wekerle C, Leung E, Wall AM, et al. The contribution of childhood emotional abuse to teen dating violence among child protective services-involved youth. Child Abuse Negl. 2009;33(1):45---58. 5. Heyman RE, Smith Slep AM. Do child abuse and interparental violence lead to adulthood family violence? J Marriage Fam. 2002;64(4):864---870.
MCCAULEY AND MILLER RESPOND We appreciate Scheidell’s interest in our study. Indeed, the Gender-Equitable Norms scale was originally developed and tested among a sample of Brazilian young men1 and has been used in modified form by researchers in numerous settings in the United States and elsewhere, among both adolescents and adults.2,3 Our team previously tested a version of the scale among a clinic-based sample of 14to 20-year-old males in the Northeastern United States and found that, similar to the Coaching Boys into Men (CBIM) study, boys holding traditional gender attitudes were more likely to report dating violence perpetration.3 Because the psychometric properties of any scale are dependent on the population in which data are collected, we then conducted extensive pilot testing of these measures for the CBIM study in collaboration with Futures Without Violence and the Waitt Institute for Violence Prevention (nonprofit violence prevention organizations). Formative research included cognitive interviewing with both coaches and athletes after which we adjusted behaviors to be less focused on sexual content attributable to the younger age of the high school age athletes compared with the Brazilian cohort. Research on the measurement of gender attitudes, and in particular how they are associated with interpersonal violence, is a field largely based in the global health literature.4---6 We have embarked on additional research on
American Journal of Public Health | March 2014, Vol 104, No. 3
LETTERS
the emergence of gender-inequitable attitudes and how such attitudes are related to enacting proscribed gender roles and behaviors to inform the further refinement of these measures with the goal of elucidating how gender attitudes are associated with adolescent relationship abuse. We also appreciate Scheidell’s attention to adverse childhood experiences (ACES), including abuse, maltreatment, and witnessing domestic violence, which are important predictors of abuse perpetration and have been discussed in our previous work.7 Because the parent study was an evaluation of CBIM, a sexual violence prevention program that does not address ACES, and because participating school districts were involved in reviewing the program and associated survey tools, study measures did not include ACES assessment. We agree that examining the association of ACES with the emergence of gender attitudes and relationship abuse is needed. While selection bias is a potential concern, as noted in our article, the study did not purposefully exclude youths with histories of ACES, and the potential exclusion of this particularly high-risk group of youths from the study would result in an underestimation of the relationship between gender-equitable attitudes and recent relationship abuse perpetration. j
Resources Administration National Research Service Award for Primary Care (NRSA T32HP22240).
References 1. Pulerwitz J, Barker G. Measuring attitudes toward gender norms among young men in Brazil: development and pscyhometric evaluation of the GEM scale. Men Masculinities. 2007;10:322. 2. Das M, Ghosh S, Verma R, et al. Gender attitudes and violence among urban adolescent boys in India. Int J Adolesc Youth. 2012;Epub ahead of print. 3. Reed E, Silverman JG, Raj A, Decker MR, Miller E. Male perpetration of teen dating violence: associations with neighborhood violence involvement, gender attitudes, and perceived peer and neighborhood norms. J Urban Health. 2011;88(2):226---239. 4. Barker G, Ricardo C, Nascimento M. Engaging Men and Boys in Changing Gender-Based Inequity in Health: Evidence From Programme Interventions. Geneva, Switzerland: World Health Organization; 2007. 5. Christine AV. How Gender roles influence sexual and reproductive health among South African adolescents. Stud Fam Plann. 2003;34(3):160---172. 6. Dalal K, Lee MS, Gifford M. Male adolescents’ attitudes toward wife beating: a multi-country study in South Asia. J Adolesc Health. 2012;50(5):437---442. 7. Miller E, Breslau J, Chung W-JJ, Green JG, McLaughlin KA, Kessler RC. Adverse childhood experiences and risk of physical violence in adolescent dating relationships. J Epidemiol Community Health. 2011;65 (11):1006---1013.
Heather L. McCauley, ScD, MS Elizabeth Miller, MD, PhD
About the Authors The authors are with the Department of Pediatrics, University of Pittsburgh School of Medicine, and the Division of Adolescent Medicine, Children’s Hospital of Pittsburgh of UPMC, Pittsburgh, PA. Correspondence should be sent to Heather L. McCauley, ScD, MS, University of Pittsburgh School of Medicine, 3414 Fifth Avenue, CHOB 121, Pittsburgh, PA 15213 (e-mail: [email protected]). Reprints can be ordered at http://www.ajph.org by clicking the “Reprints” link. This letter was accepted November 10, 2013. doi:10.2105/AJPH.2013.301795
Contributors H. L. McCauley and E. Miller were both responsible for drafting and revising the letter.
Acknowledgments The parent study was funded by the Centers for Disease Control and Prevention (grant CE001561-01). H. L. McCauley is supported by a Health Services and
March 2014, Vol 104, No. 3 | American Journal of Public Health
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as an example, it is difficult to know how similar this modified scale is to the original. While McCauley et al. emphasize the use of pilot testing for the other modified scales in their study, it is not clear if the modifications to the Gender-Equitable Norms Scale were validated prior to use. Additionally, known risk factors of male dating violence were not included in the study. Although the authors discuss the role of witnessing violence by peers and its association with dating violence perpetration, the impact of experiencing and witnessing violence in the home is not covered. Childhood maltreatment and witnessing interparental violence have been shown to increase the risk of dating violence, especially among men.3---5 This issue also has implications for selection bias, because the main reason students did not participate in this study was said to be lack of parental consent. Parents dealing with violence within their homes may be less likely to consent to their child’s participation in a study focused on violence, given the stigma surrounding domestic violence. It is possible that the study is not controlling for a potentially important confounder and is also missing the group most likely to perpetrate dating violence. j Joy D. Scheidell, MPH
Letters to the editor referring to a recent Journal article are encouraged up to 3 months after the article's appearance. By submitting a letter to the editor, the author gives permission for its publication in the Journal. Letters should not duplicate material being published or submitted elsewhere. The editors reserve the right to edit and abridge letters and to publish responses. Text is limited to 400 words and 10 references. Submit online at www. editorialmanager.com/ajph for immediate Web posting, or at ajph.edmgr.com for later print publication. Online responses are automatically considered for print publication. Queries should be addressed to the Editor-in-Chief, Mary E. Northridge, PhD, MPH, at [email protected].
e6 | Letters
About the Author Joy D. Scheidell is with the Department of Epidemiology, College of Public Health and Health Professions and College of Medicine, University of Florida, Gainesville. Correspondence should be sent to Joy D. Scheidell, MPH, 2004 Mowry Road, PO Box 100231, Gainesville Florida 32610 (e-mail: jdbscheidell722@ufl.edu). Reprints can be ordered at http://www.ajph.org by clicking the “Reprints” link. This letter was accepted October 26, 2013. doi:10.2105/AJPH.2013.301779
References 1. McCauley HL, Tancredi DJ, Silverman JG, et al. Gender-equitable attitudes, bystander behavior, and recent abuse perpetration against heterosexual dating partners of male high school athletes. Am J Public Health. 2013;103(10):1882---1887. 2. Pulerwitz J, Barker G. Measuring attitudes toward gender norms among young men in Brazil: development
and psychometric evaluation of the GEM scale. Men Masc. 2008;10(3):322---338. 3. Gover AR, Jennings WG, Tomsich EA, Park M, Rennison CM. The influence of childhood maltreatment and self-control on dating violence: a comparison of college students in the United States and South Korea. Violence Vict. 2011;26(3):296---318. 4. Wekerle C, Leung E, Wall AM, et al. The contribution of childhood emotional abuse to teen dating violence among child protective services-involved youth. Child Abuse Negl. 2009;33(1):45---58. 5. Heyman RE, Smith Slep AM. Do child abuse and interparental violence lead to adulthood family violence? J Marriage Fam. 2002;64(4):864---870.
MCCAULEY AND MILLER RESPOND We appreciate Scheidell’s interest in our study. Indeed, the Gender-Equitable Norms scale was originally developed and tested among a sample of Brazilian young men1 and has been used in modified form by researchers in numerous settings in the United States and elsewhere, among both adolescents and adults.2,3 Our team previously tested a version of the scale among a clinic-based sample of 14to 20-year-old males in the Northeastern United States and found that, similar to the Coaching Boys into Men (CBIM) study, boys holding traditional gender attitudes were more likely to report dating violence perpetration.3 Because the psychometric properties of any scale are dependent on the population in which data are collected, we then conducted extensive pilot testing of these measures for the CBIM study in collaboration with Futures Without Violence and the Waitt Institute for Violence Prevention (nonprofit violence prevention organizations). Formative research included cognitive interviewing with both coaches and athletes after which we adjusted behaviors to be less focused on sexual content attributable to the younger age of the high school age athletes compared with the Brazilian cohort. Research on the measurement of gender attitudes, and in particular how they are associated with interpersonal violence, is a field largely based in the global health literature.4---6 We have embarked on additional research on
American Journal of Public Health | March 2014, Vol 104, No. 3
LETTERS
the emergence of gender-inequitable attitudes and how such attitudes are related to enacting proscribed gender roles and behaviors to inform the further refinement of these measures with the goal of elucidating how gender attitudes are associated with adolescent relationship abuse. We also appreciate Scheidell’s attention to adverse childhood experiences (ACES), including abuse, maltreatment, and witnessing domestic violence, which are important predictors of abuse perpetration and have been discussed in our previous work.7 Because the parent study was an evaluation of CBIM, a sexual violence prevention program that does not address ACES, and because participating school districts were involved in reviewing the program and associated survey tools, study measures did not include ACES assessment. We agree that examining the association of ACES with the emergence of gender attitudes and relationship abuse is needed. While selection bias is a potential concern, as noted in our article, the study did not purposefully exclude youths with histories of ACES, and the potential exclusion of this particularly high-risk group of youths from the study would result in an underestimation of the relationship between gender-equitable attitudes and recent relationship abuse perpetration. j
Resources Administration National Research Service Award for Primary Care (NRSA T32HP22240).
References 1. Pulerwitz J, Barker G. Measuring attitudes toward gender norms among young men in Brazil: development and pscyhometric evaluation of the GEM scale. Men Masculinities. 2007;10:322. 2. Das M, Ghosh S, Verma R, et al. Gender attitudes and violence among urban adolescent boys in India. Int J Adolesc Youth. 2012;Epub ahead of print. 3. Reed E, Silverman JG, Raj A, Decker MR, Miller E. Male perpetration of teen dating violence: associations with neighborhood violence involvement, gender attitudes, and perceived peer and neighborhood norms. J Urban Health. 2011;88(2):226---239. 4. Barker G, Ricardo C, Nascimento M. Engaging Men and Boys in Changing Gender-Based Inequity in Health: Evidence From Programme Interventions. Geneva, Switzerland: World Health Organization; 2007. 5. Christine AV. How Gender roles influence sexual and reproductive health among South African adolescents. Stud Fam Plann. 2003;34(3):160---172. 6. Dalal K, Lee MS, Gifford M. Male adolescents’ attitudes toward wife beating: a multi-country study in South Asia. J Adolesc Health. 2012;50(5):437---442. 7. Miller E, Breslau J, Chung W-JJ, Green JG, McLaughlin KA, Kessler RC. Adverse childhood experiences and risk of physical violence in adolescent dating relationships. J Epidemiol Community Health. 2011;65 (11):1006---1013.
Heather L. McCauley, ScD, MS Elizabeth Miller, MD, PhD
About the Authors The authors are with the Department of Pediatrics, University of Pittsburgh School of Medicine, and the Division of Adolescent Medicine, Children’s Hospital of Pittsburgh of UPMC, Pittsburgh, PA. Correspondence should be sent to Heather L. McCauley, ScD, MS, University of Pittsburgh School of Medicine, 3414 Fifth Avenue, CHOB 121, Pittsburgh, PA 15213 (e-mail: [email protected]). Reprints can be ordered at http://www.ajph.org by clicking the “Reprints” link. This letter was accepted November 10, 2013. doi:10.2105/AJPH.2013.301795
Contributors H. L. McCauley and E. Miller were both responsible for drafting and revising the letter.
Acknowledgments The parent study was funded by the Centers for Disease Control and Prevention (grant CE001561-01). H. L. McCauley is supported by a Health Services and
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