Relationship Violence, Fear, and Exposure to Youth Violence Among Adolescents in New York City.

518433 research-article2014

JIVXXX10.1177/0886260513518433Journal of Interpersonal ViolenceDuPont et al.

Article

Relationship Violence, Fear, and Exposure to Youth Violence Among Adolescents in New York City

Journal of Interpersonal Violence 2014, Vol. 29(12) 2325–2350 © The Author(s) 2014 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/0886260513518433 jiv.sagepub.com

Melissa J. DuPont-Reyes,1 Deborah Fry,2 Vaughn I. Rickert,3 David L. Bell,1,4 Niki Palmetto,5 and Leslie L. Davidson1

Abstract Previous research has shown that there is an overlap between experiences of youth violence and adolescent relationship violence. Yet, little research exists which investigates the sex differences in the associations between specific types of youth violence and relationship violence while controlling for potential confounders. This study addresses this gap in the literature by exploring the associations between experiences of youth violence and receiving and delivering relationship violence in an urban adolescent sample. From 2006 to 2007, 1,454 adolescents aged 13 to 21 years in New York City completed an anonymous survey that included the validated Conflict in Adolescent Relationships Inventory that estimates experiences of relationship violence in the previous year as well as the prevalence of various exposures to youth violence. Bivariate and multivariate analyses assessed the overlap between experiencing other types of youth violence and delivering and 1Columbia

University, New York, NY, USA of Edinburgh/NSPCC Child Protection Research Centre, Scotland 3Indiana University School of Medicine, Indianapolis, USA 4New York–Presbyterian Hospital, NY, USA 5Pfizer, Inc., New York, NY, USA 2University

Corresponding Author: Melissa J. DuPont-Reyes, Mailman School of Public Health, Columbia University, 722 West 168th Street, Room 1601, New York, NY 10032, USA. Email: [email protected]

Downloaded from jiv.sagepub.com at NORTH DAKOTA STATE UNIV LIB on June 9, 2015

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receiving physical relationship violence and sexual coercion. Compared with youth in nonviolent relationships, we found a significant association between delivering and receiving relationship physical violence and sexual coercion with participating in a fight, missing school due to fear, being threatened/ injured with a weapon, gang membership, and carrying a weapon among both males and females. We also identified the sex differences between these specific associations of youth and relationship violence. Service providers working with adolescents experiencing relationship violence should be aware that they face a higher concurrent risk of experiencing or participating in other forms of youth violence. Likewise, providers working in the area of youth violence intervention and prevention should consider the possibility of concurrent relationship violence. Based on these findings, further research should explore whether interventions targeting relationship violence can also impact participation in youth violence and vice versa. Keywords relationship violence, adolescents, youth violence, sexual coercion

Introduction Youth violence, also known as community or peer violence, is a broad term that encompasses gang violence, bullying, slapping, hitting, robbery, and assault with or without the use of a weapon. In addition to youth violence, adolescents can also experience relationship violence, which often overlaps with the construct of youth violence. Relationship violence is usually defined as physical, sexual, or emotional violence within the context of a current or prior romantic or dating relationship (Centers for Disease Control and Prevention [CDC], 2012). Relationship violence is highly prevalent among adolescents who report participating in a range of physically violent behaviors as well as sexually violent or coercive behaviors (Foshee, Linder, MacDougall, & Bangdiwala, 2001; Jezl, Molidor, & Wright, 1996). Social learning theory (Bandura, 1977) has been used extensively to explain mutual violence within romantic relationships (Foo & Margolin, 1995; Gwartney-Gibbs, Stockard, & Brohmer, 1987; Lewis, Travea, & Fremouw, 2002). The theoretical framework posits that an individual learns behaviors through his or her social interactions, including in romantic relationships. For example, victims of relationship violence may view perpetrators of relationship violence as experiencing positive consequences from their physical, psychological, or emotional aggression. Therefore, the victim may be more likely to use similar strategies in their current or future


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relationships (Gray & Foshee, 1997; Palmetto, Davidson, Breitbart, & Rickert, 2013). Similarly, exposures to youth violence may alter behaviors of romantic partners to utilize physical, psychological, or emotional aggression in their relationship. Investigators in this area of research commonly refer to reporters of relationship violence as either victims or perpetrators. However, given what is known about the mutuality of relationship violence among adolescents (Gray & Foshee, 1997; Magdol et al., 1997; Morse, 1995) and for the purpose of this study, we feel it is more accurate to refer to relationship violence victimization and perpetration as receiving and delivering relationship violence, respectively. Youth violence, and relationship violence, both physical and sexual have short-term and lifelong sequalae as well as the more obvious physical sign, which may include social, behavioral, and psychological consequences (Coker et al., 2001; Silverman, Raj, Mucci, & Hathaway, 2001). As in other types of youth violence, relationship violence can be extremely harmful if the violent behavior continues into young adulthood. For example, adolescents who reported physical relationship violence in the past year have a higher incidence of concurrent abuse of alcohol, suicide attempts, and physical fighting than adolescents who have not experienced physical relationship violence (CDC, 2012). More immediate consequences of relationship violence can include physical injury requiring treatment, and in the most extreme cases, death (Ackard & Neumark-Sztainer, 2002; Coker et al., 2000). Quantitative and qualitative data on relationship violence is difficult to obtain for several reasons (Hickman, Jaycox, & Aronoff, 2004). First, both male and female adolescents often do not report relationship violence in part because they do not identify themselves as “victims” or “perpetrators” of relationship violence (Zeitler et al., 2006). There may also be underreporting of relationship violence because of fear around the loss of confidentiality and possible consequences if their experiences of violence or past behaviors are revealed, especially to a parent. Likewise, if a teen does identify as a “victim” or “perpetrator” of relationship violence, he or she may be particularly hesitant to discuss or share this very sensitive information both in research and clinical care settings (O’Keefe, 1997). Last, there is widespread stigma surrounding relationship violence in the general population which encourages youth to not discuss or disclose their experiences (Ashley & Foshee, 2005; Covington, Dalton, Diehl, Wright, & Piner, 1997). Despite the challenge of obtaining data on adolescent relationship violence, many studies have documented the impact of receiving relationship violence. Asking about behaviors rather than a value-laden label such as abuse has proven to yield a higher rate of relationships characterized by violence or coercion. In addition, asking through an anonymous survey has


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similarly shown a higher prevalence rate than a confidential survey and far higher than extracting information from clinical records. However, even in these studies, the focus has been primarily on females, both adolescents and young adults (Miller et al., 2007; Rickert et al., 2009; Silverman, Raj, Mucci, & Clements, 2004; Silverman et al., 2001; Wekerle & Wolfe, 1999; Williams, Larsen, & McCloskey, 2008). Few studies have examined the impact of relationship violence on young men, either delivering or receiving (Coker et al., 2001; Gray & Foshee, 1997; Jezl et al., 1996). For example, examining a cross-sectional sample of only male adolescents from urban community health centers, Reed, Silverman, Raj, Decker, and Miller (2011) found that male youth who reported delivering relationship violence were three times more likely to report exposure to youth violence, which included participation in nonpartner fights and gang involvement in the past year (Reed et al., 2011). Furthermore, males who reported delivering relationship violence were more likely to believe that their friends also delivered relationship violence, supported traditional gender norms, and had a perception of greater youth violence in their neighborhood. These attitudes and beliefs surrounding gender roles and violence may provide insight into the context in which young males deliver relationship violence. Even fewer studies have investigated the specific association between receiving and/or delivering relationship violence, and exposure to youth violence. Findings are equivocal, but suggest some degree of association between relationship violence and other types of youth violence. For example, Swahn et al. (2008) sampled high-risk urban youth and found that receiving youth violence was the most common type of violence reported by these adolescents followed by receiving relationship violence, delivering youth violence, delivering relationship violence, and suicide attempts. In their sample, there was a pattern of adolescents experiencing both relationship violence and youth violence. While males and females experienced a different pattern of youth violence, both experienced youth violence at similar rates to relationship violence. In addition, youth who reported delivering relationship violence were more likely to report receiving and delivering youth violence. Of note, no sex differences in the overlap between contexts in which relationship violence and youth violence occurred were detected. A second study examining delivering relationship violence found two associations between relationship violence and youth violence and sex differences in the associations: both males and females who reported bringing a weapon to school and females involved in physical fighting with a another female peer were more likely to report delivering relationship violence (Foshee et al., 2001). Findings from a study by Malik, Sorenson, and Aneshensel (1997) that surveyed over 719 high school students from Los Angeles County


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demonstrated sex differences in the prevalence of receiving and delivering relationship violence but found few sex differences in the report of youth violence experiences. They postulated that exposure to weapons and violent injury in the community was a common predictor of youth violence as well as receiving and delivering relationship violence. In fact, these researchers concluded that there is an overlap of violence from each context and that the violence is often mutual. Finally, O’Keefe (1997) found that males are more likely to experience parent–child violence, youth violence, including physical aggression and fighting, when compared with female adolescents. She concluded that youth violence was less important in predicting the delivery of relationship violence for both males and females but contributed to the justification of the belief among young people that relationship violence is an acceptable solution to conflict in a romantic relationship. Due to the sampling techniques, it is difficult to determine if this was a causal association or simply a correlation between youth violence and relationship violence among this sample. This study, unlike others, measured the importance of the relationship with the adolescent as a key variable (O’Keefe, 1997). From this, males reported having longer relationships and with more dating partners, while females reported more conflict in the relationship and saw their relationships as more serious. From these studies, it is clear that males and females display different patterns of relationship violence and youth violence, and each sex regards relationships differently in terms of attachment, seriousness, and frequency. There is evidence supporting an association between delivering youth violence and delivering relationship violence, but a greater study is required to examine the overlap by specific exposures to youth violence and relationship violence. Moreover, research must assess specific sex differences in the overlap of violence while simultaneously controlling for potential confounders such as the level of fear in the relationship, relationship importance, and prior child maltreatment, including sexual assault. This study fills this void by using a large sample of (N = 910) adolescents from New York City (NYC) who reported on a battery of commonly used youth violence and relationship violence behaviors. We examined the association between overall and specific experiences related to youth violence, including being threatened or injured with a weapon, participating in a fight, missing school due to fear, gang membership, and carrying a weapon, with relationship violence relative to the occurrence of (a) delivering relationship physical violence and sexual coercion and (b) receiving relationship physical violence and sexual coercion. Differences in occurrences of relationship violence by sex were also explored. While both sexes experience relationship violence, they differ in the amount of harm inflicted by relationship violence. From a priori research,


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we know that biological sex plays a key part in assessing relationship violence experiences particularly as we assess both receiving and delivering relationship physical violence and sexual coercion. Based on the findings of previous studies, we hypothesized there would be an association between some of the behaviors common to youth violence with both delivering and receiving relationship violence in addition to sex differences in the specific overlaps. We hypothesized (a) males would experience significant associations in delivering youth violence and relationship violence and (b) females would experience significant associations in receiving youth violence and relationship violence.

Method Study Sample Drawn from a convenience sample of four public high schools in NYC, 1,454 adolescents aged 13 to 21 years in 2006 and 2007 completed an audio computer-assisted self-interviewing (ACASI) or a paper and pencil anonymous survey in either English or Spanish representing a response rate of 70% of the schools population. Owing to multiorganizational involvement, the protocol and consent for this study were reviewed and approved by three institutional review boards including that of the NYC Department of Education. Passive parental consent was obtained after mailing letters to the parents in English, Spanish and/or Chinese that contained study information and the opportunity to opt their child out of the study. Active assent of the student was also requested at the time of survey implementation. Students were offered a US$10 gift card to a bookstore for participating (for more detailed methods, see Fry, Davidson, Rickert, & Lessel, 2008). Two of the four schools completed an audio computer-assisted or ACASI version of the survey and, owing to a lack of computer availability, the other two schools completed paper and pencil versions. A total of 46 parents opted their child out of the study, and 52 youth opted themselves out. Of the 1,454 students who participated and answered at least one survey question, 142 were removed from analysis for extensive missing data required for this study. For current analyses, youth who did not have a relationship partner in the last year or had a same-sex relationship were excluded (excluding n = 341). Same-sex relationships were excluded due to small reported numbers. Thus, violence best reflects male to female and female to male relationship violence. Similarly, youth with incomplete data regarding biological sex, relationship status, same-sex relationship status, and youth violence measures were excluded (n = 203). There was no statistical difference between the


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included and excluded participants. The excluded participants had a similar racial/ethnic distribution and the same median age as the included participants. The final sample for these analyses included 910 participants.

Study Measures The survey drew questions from many sources including the CDC Behavioral Risk Factor Surveillance Survey (CDC, 2006), the NYC Youth Risk Behavior Survey (YRBS; NYC Department of Health and Mental Hygiene, Department of Education, & National Centers for Disease Control and Prevention), and the World Health Organization Multicountry Study (Garcia-Moreno, Jansen, Ellsberg, Heise, & Watts, 2005). The following measures were assessed: race/ethnicity, age, biological sex, nature and importance of the romantic relationship, lifetime and last 12-months occurrences of physical/verbal/sexual abuse within the romantic relationship, experiences of nonpartner sexual violence, and lifetime and last 12-months occurrences of youth violence including participating in a fight, missing school due to fear, being threatened/injured with a weapon, gang membership, and carrying a weapon. Estimates of relationship physical violence and sexual coercion, either received or delivered, in the previous year by a sexual or romantic partner were obtained using the Conflict in Adolescent Relationships Inventory (CADRI) subscales. The CADRI provides measures of the frequency of relationship physical violence and sexual coercion, but does not measure severity of experiences of relationship physical violence and sexual coercion. The CADRI has a kappa score of 0.85 and a Cronbach’s alpha score of 0.51 for sexual coercion and 0.83 for physical violence (Wolfe et al., 2001). The specific variables from the questionnaire used in these analyses are provided in the appendix. Five paired questions measured experiences of youth violence and were taken from the YRBS. Responses to questions 1 and 2 of the youth violence measures were coded as “0 days, 1 day, 2 or 3 days, 4 or 5 days, 6 or more days.” Responses to questions 3 and 4 of the youth violence measures were coded as “0 times, 1 time, 2 or 3 times, 4 or 5 times, 6 or 7 times, 8 or 9 times, 10 or 11 times, 12 or more times.” Question 5 asking about gang membership was coded as “yes/no.” Responses to the exposures to youth violence questions 1 to 4 were dichotomously categorized as “seldom or never” or “sometimes or often.” A dichotomous youth violence variable was created for whether a respondent had experienced any youth violence overall. The survey asked five paired questions to measure experiences of physical violence in the relationship in the past year and three paired questions to measure experiences of sexual coercion in the relationship in the past year, all taken from the CADRI. Responses to the experiences


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of relationship physical violence and sexual coercion were dichotomously categorized as “seldom or never” or “sometimes or often.” Other predictors used in this analysis include race/ethnicity, age, biological sex, the importance of the relationship, and nonpartner sexual abuse history. Fear within the context of the relationship was also included in the analysis. Two questions measured the respondent’s fear of the partner and the partner’s fear of the respondent. Responses to the fear question were coded as “not at all” or “a little to very afraid.”

Data Analysis We calculated the prevalence of exposures to youth violence and relationship violence, and examined associations between youth violence and relationship violence. Uncorrelated chi-square statistics were used for bivariate comparisons between the categorical variables of youth violence and relationship violence in addition to test for sex differences in the data. p values < .05 were considered statistically significant. Logistic regression was used to obtain odds ratios (ORs) and 95% confidence intervals (CIs) for the crude association between youth violence and relationship violence. To further understand the association between youth violence and relationship violence, potential confounders (race/ethnicity, age, biological sex, the importance of the relationship, nonpartner sexual abuse history, and level of fear in the relationship) were considered for inclusion in adjusted models. All data analyses were performed using SAS Version 9.2.

Results Table 1 summarizes the sample characteristics of youth who reported heterosexual relationships within the past year (N = 910) including race/ethnicity, mean age, importance of the relationship, nonpartner sexual abuse history, level of fear in the relationship, and incidences of relationship violence and exposure to youth violence in the total sample, and by sex. The total sample had slightly more female participants (56%) than male (44%). There were no sex differences in the sample by age, race, or ethnicity. The mean age of the sample was 16 years and most respondents identified themselves as Hispanic/ Latino (74%) with smaller percentages reporting as Black/African American (20%), and Other racial/ethnic group (6%). We detected a large difference in how females (78%) as compared with males (59%) rated the importance of their most recent romantic relationship (p < .01). Moreover, female respondents were more likely to report a history of nonpartner sex abuse (17%) when compared with males (4%). Race/ethnicity, age, importance of


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Table 1. Sample Characteristics by Sex Partners and Peers, New York City, 20062007. Total Sample (n = 910) Select demographics and nature of the romantic relationship Race/ethnicity (%) Hispanic/Latin American 73.8 Black/African American 20.0 Other 6.2 Mean age in years 16.0 How important is/was this relationship to you? % Important to very important 69.8 How much would you say you are afraid of him or her? % A little to very afraid 16.8 How much would you say your partner is afraid of you? % A little to very afraid 20.5 Presence of nonpartner sex abuse, % yes 11.1 Incidences of relationship violence by type in the past year Receipt of physical violence, % yes 29.8 Receipt of sexual coercion, % yes 16.0 Delivery of physical violence, % yes 32.5 Delivery of sexual coercion, % yes 11.5 Incidences of exposure to youth violence in the past year Missed school/felt unsafe, % yes 10.1 Carrying a weapon, % yes 14.3 Threatened/injured with a weapon, % yes 15.4 Participated in a fight, % yes 48.9 Gang membership, % yes 13.7

Females (n = 507)

Males (n = 403)

75.7 19.9 4.4 16.0

73.1 19.0 7.9 16.0

78.2**

40.9

20.04**

12.5

18.3 16.6**

23.34* 4.2

29.7 15.1 44.4** 9.4

30.0 17.0 17.0 14.32*

12.37* 7.3 10.6 45.0 7.6

7.2 23.47** 21.72** 54.05** 21.74**

*p < .05. **p < .01, chi-square tests were used to compare sexes.

the relationship, and history of nonpartner sex abuse were not statistically significant predictors of relationship violence in bivariate analyses and as a result, were not included in the multivariate analysis examining the relationship between youth violence and relationship violence. The level of fear in the relationship was a statistically significant predictor of relationship violence in bivariate analyses and was included in the multivariate analysis. However, the inclusion of the level of fear resulted in a little to no decrease in the point estimates. As such, in the interest of model parsimony and increased statistical power, the fear variables were not included as covariates in the final adjusted models examining the


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relationship between youth violence and relationship violence. Owing to significant differences in variables and measures of violence by sex in Table 1, all subsequent analyses were stratified by sex. Among females, delivering physical violence was the most common reported type of relationship violence (44%), followed by receiving physical violence (30%), receiving sexual coercion (15%), and delivering sexual coercion (9%). We found a slightly different pattern among males where the most common reported type of relationship violence was receiving physical violence (30%), followed by both delivering physical violence (17%) and receiving sexual coercion (17%), and last, delivering sexual coercion (14%). Among both males and females, the most frequently reported exposure to youth violence, excluding relationship violence, was participating in a fight (45% females and 54% males). The remaining forms of youth violence reported by females was missing school (12%), being threatened or injured with a weapon (11%), gang membership (8%), and carrying a weapon (7%) and by males, carrying a weapon (24%), followed by being threatened or injured with a weapon (22%) gang membership (22%), and missing school (7%). We detected significant relationships between exposure to youth violence and receiving relationship physical violence and sexual coercion among both males and females when compared with youth in nonviolent relationships (see Table 2). Relative to females who were in nonviolent relationships, females who were threatened or injured with a weapon, participated in a fight, and experienced any youth violence overall in the past year, were more likely to report receiving both relationship physical violence and sexual coercion. In addition, females who missed school for feeling unsafe were more likely to report receiving physical relationship violence, and females who reported carrying a weapon were more likely to report receiving relationship sexual coercion. Relative to males who were in nonviolent relationships, males who were threatened or injured with a weapon, carried a weapon, reported gang membership, and experienced any youth violence overall in the past year were more likely to report receiving both relationship physical violence and sexual coercion. Similar to receiving relationship violence, significant associations between exposures to youth violence and delivering relationship physical violence and sexual coercion were detected (see Table 3). Compared with females in nonviolent relationships, females who were threatened or injured with a weapon, participated in a fight, and experienced any youth violence overall in the past year were more likely to report delivering relationship physical violence. The only significant association between exposures to youth violence and relationship sexual coercion among females was those who reported carrying a weapon. Males who were reported carrying a weapon and



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n = 146 (30%)

n = 346 (70%)

Received Students in Nonviolent Physical Violence Relationships

Missed school/felt unsafe Yes n = 25 (17%)* n = 36 (11%) Carrying a weapon Yes n = 15 (10%) n = 21 (6%) Threatened/injured with a weapon Yes n = 25 (17%)** n = 27 (8%) Participated in a fight Yes n = 96 (68%)** n = 121 (36%) Gang membership Yes n = 12 (9%) n = 25 (7%) Any youth violence n = 107 (76%)** n = 155 (47%) Yes

Females

n = 10 (9%) n = 37 (34%)** n = 35 (32%)** n = 67 (62%) n = 30 (28%)* n = 84 (79%)**

1.79 [0.89, 3.57] 2.45 [1.37, 4.39] 3.74 [2.47, 5.67] 1.16 [0.56, 2.37] 3.61 [2.32, 5.62]

n = 112 (30%)

1.78 [1.03, 3.09]

OR (95% CI)

n = 160 (65%)

n = 46 (19%)

n = 127 (51%)

n = 46 (18%)

n = 48 (19%)

n = 16 (6%)

n = 262 (70%)

Received Students in Nonviolent Physical Violence Relationships

Males

(continued)

2.03 [1.18, 3.47]

1.73 [1.02, 2.93]

1.56 [0.98, 2.47]

2.14 [1.28, 3.58]

2.22 [1.34, 3.68]

1.49 [0.65, 3.40]

OR (95% CI)

Table 2. Received Relationship Physical Violence and Sexual Coercion by Exposure to Youth Violence in the Past Year: Partners and Peers, New York City, 2006-2007.

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n = 383 (85%) n = 7 (12%) n = 25 (44%)** n = 20 (35%)** n = 37 (65%) n = 18 (33%)** n = 48 (87%)**

2.37 [1.05, 5.34] 2.16 [1.06, 4.42] 2.23 [1.36, 4.10] 1.30 [0.51, 3.27] 1.94 [1.09, 3.45]

n = 61 (17%)

1.34 [0.64, 2.82]

OR (95% CI)

n = 182 (66%)

n = 50 (18%)

n = 144 (52%)

n = 57 (20%)

n = 54 (19%)

n = 17 (6%)

n = 297 (83%)

Received Sexual Students in Nonviolent Coercion Relationships

Males

3.54 [1.54, 8.13]

2.22 [1.17, 4.21]

1.73 [0.96, 3.14]

2.12 [1.15, 3.94]

3.30 [1.81, 6.02]

2.19 [0.86, 5.56]

OR (95% CI)

Note. OR = odds ratio; CI = confidence interval. Students in nonviolent relationships are the referent group. ORs and the 95% CIs for exposures to youth violence are given. *p < .05. **p < .01, for chi-square tests comparing students reporting violent versus nonviolent relationships.

Missed school/felt unsafe Yes n = 10 (16%) n = 47 (12%) Carrying a weapon Yes n = 9 (14%)* n = 25 (7%) Threatened/injured with a weapon Yes n = 12 (19%)* n = 37 (10%) Participated in a fight Yes n = 40 (63%)** n = 159 (42%) Gang membership Yes n = 6 (10%) n = 28 (8%) Any youth violence Yes n = 43 (69%)* n = 200 (54%)

n = 68 (15%)

Received Sexual Students in Nonviolent Coercion Relationships

Females

Table 2. (continued)


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n = 219 (44%)

n = 274 (56%)

Delivered Students in Nonviolent Physical Violence Relationships

Missed school/felt unsafe Yes n = 33 (15%) n = 28 (10%) Carrying a weapon Yes n = 21 (10%) n = 15 (6%) Threatened/injured with a weapon Yes n = 34 (16%)** n = 18 (7%) Participated in a fight n = 88 (33%) Yes n = 130 (61%)** Gang membership Yes n = 17 (8%) n = 20 (8%) Any youth violence n = 114 (44%) Yes n = 149 (70%)**

Females

n = 61 (20%) n = 158 (53%) n = 59 (20%) n = 198 (68%)

2.63 [1.44, 4.81] n = 20 (32%)* 3.15 [2.16, 4.58] n = 36 (59%) 1.06 [0.54, 2.08] n = 17 (28%) 3.02 [2.06, 4.43] n = 46 (77%)

n = 19 (6%)

n = 297 (83%)

n = 63 (21%)

n = 7 (11%)

n = 64 (17%)

1.86 [0.93, 3.70] n = 22 (35%)**

1.57 [0.92, 2.70]

OR (95% CI)

Delivered Students in Nonviolent Physical Violence Relationships

Males

(continued)

1.56 [0.82, 2.98]

1.58 [0.84, 2.96]

1.26 [0.72, 2.20]

1.85 [1.01, 3.38]

2.06 [1.14, 3.72]

1.88 [0.76, 4.69]

OR (95% CI)

Table 3. Delivered Relationship Physical Violence and Sexual Coercion by Exposure to Youth Violence in the Past Year: Partners and Peers, New York City, 2006-2007.

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n = 47 (9%)

n = 453 (91%)

Delivered Sexual Students in Nonviolent Coercion Relationships

Females

n = 66 (21%) n = 163 (53%) n = 60 (20%) n = 205 (68%)

2.08 [0.91, 4.77] n = 15 (28%) 1.61 [0.86, 3.02] n = 32 (62%) 1.27 [0.43, 3.76] n = 17 (33%)* 1.22 [0.64, 2.33] n = 41 (80%)

n = 19 (6%)

n = 329 (86%)

n = 66 (21%)

n = 7 (13%)

n = 55 (14%)

2.73 [1.12, 6.65] n = 20 (38%)**

2.02 [0.92, 4.45]

OR (95% CI)

Delivered Sexual Students in Nonviolent Coercion Relationships

Males

1.96 [0.94, 4.08]

2.04 [1.07, 3.89]

1.41 [0.77, 2.58]

1.45 [0.75, 2.80]

2.24 [1.21, 4.16]

2.34 [0.93, 5.87]

OR (95% CI)

Note. OR = odds ratio; CI = confidence interval. Students in nonviolent relationships are the referent group. ORs and the 95% CIs for exposures to youth violence are given. *p < .05. **p < .01, for chi-square tests comparing students reporting violent versus nonviolent relationships.

Missed school/felt unsafe Yes n = 9 (21%) n = 52 (12%) Carrying a weapon Yes n = 7 (16%)** n = 29 (6%) Threatened/injured with a weapon Yes n = 8 (19%) n = 44 (10%) Participated in a fight Yes n = 24 (56%) n = 195 (44%) Gang membership Yes n = 4 (9%) n = 33 (8%) Any youth violence Yes n = 25 (60%) n = 239 (55%)


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threatened or injured with a weapon were more likely to report delivering relationship physical violence. Males who reported carrying a weapon and gang membership were more likely to report delivering relationship sexual coercion when compared with males.We considered fear within the context of the relationship as an alternative measure of relationship violence to the other measures in the CADRI survey, and the association between fear of the partner and youth violence was also examined. About 20% of females and 12% of males responded that they were “a little to very afraid” of their partner, and about 18% of females and 23% of males responded that their partner was “a little to very afraid” of them. Table 4 addresses the relationship between fear within the context of the relationship and exposures to youth violence. Fear of partner and partner’s fear of respondent was associated with all specific types of relationship violence (p < .01 for χ2). We found that males who missed school or felt unsafe, carried a weapon, and were threatened or injured with a weapon had increased odds of reporting fear in the relationship between both partners. Females showed a less consistent pattern. Females who missed school or felt unsafe, participated in a fight, or reported experiencing any youth violence were more likely to report that they feared their partner. On the other hand, females who reported carrying a weapon and gang membership were more likely to report that their male partner fears them.

Discussion Our study findings confirm results or prior studies that have investigated the association between youth violence and relationship violence. We detected a striking association between exposures to youth violence and receiving and delivering relationship physical violence and sexual coercion. We found that this association applies to both males and females and that both sexes report similar rates of youth violence. Similar to previous research, we found an association between youth violence and delivering relationship physical violence, specifically in carrying a weapon and gang membership; however, we also found the association not just in delivering relationship violence but also in receiving, and not just in physical violence but also in sexual coercion in the relationship. Last, we identified important sex-specific patterns in youth violence and relationship violence among urban adolescents with noteworthy differences in effect sizes. In terms of receiving relationship violence, either physical violence or sexual coercion, we found strong associations among both sexes with the experiences of being threatened or injured with a weapon (females: OR = 2.45 for physical violence and OR = 2.16 for sexual coercion; males: OR = 2.14 for physical violence and OR = 2.12 for sexual coercion) and carrying a


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No Fear of My Partner

A Little to Very Afraid of My Partner

Missed school/felt unsafe Yes n = 42 (11%) n = 19 (19%)** Carrying a weapon Yes n = 26 (7%) n = 10 (10%) Threatened/injured with a weapon Yes n = 39 (10%) n = 13 (13%) Participated in a fight Yes n = 163 (42%) n = 54 (56%)* Gang membership n = 30 (8%) n = 7 (7%) Yes Any youth violence Yes n = 200 (76%) n = 62 (24%)*

Females

n = 61 (19%) n = 169 (54%) n = 70 (22%)

1.39 [0.71, 2.71] 1.77 [1.13, 2.77] 0.93 [0.40, 2.18]

n = 215 (6%)

n = 71 (22%)

1.59 [0.74, 3.41]

1.65 [1.04, 2.63]

n = 20 (6%)

No Fear of My Partner

1.99 [1.10, 3.61]

OR (95% CI)

n = 30 (13%)

n = 9 (20%)

n = 25 (56%)

n = 19 (42%)**

n = 16 (36%)*

n = 7 (16%)*

A Little to Very Afraid of My Partner

Males

(continued)

0.95 [0.48, 1.87]

0.89 [0.41, 1.95]

1.07 [0.57, 2.01]

3.07 [1.59, 5.90]

1.93 [0.99, 3.75]

2.75 [1.09, 6.94]

OR (95% CI)

Table 4. Level of Fear in the Romantic Relationship by Exposure to Youth Violence in the Past Year: Partners and Peers, New York City, 2006-2007.


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My Partner Is Not My Partner Is a Little Afraid of Me to Very Afraid of Me

Females

n = 16 (60%) n = 60 (21%) n = 53 (19%) n = 143 (52%) n = 60 (22%) n = 184 (68%)

2.39 [1.15, 4.99] 0.95 [0.44, 2.02] 1.47 [0.93, 2.33] 2.28 [1.10, 4.73] 1.34 [0.84, 2.15]

n = 60 (73%)

n = 19 (23%)

n = 51 (61%)

n = 26 (31%)*

n = 27 (33%)*

n = 11 (41%)*

My Partner Is My Partner Is a Little Not Afraid of Me to Very Afraid of Me

1.23 [0.64, 2.38]

OR (95% CI)

Males

1.29 [0.74, 2.24]

1.08 [0.60, 1.94]

1.47 [0.89, 2.43]

1.94 [1.12, 3.36]

1.77 [1.03, 3.04]

2.48 [1.10, 5.57]

OR (95% CI)

Note. OR = odds ratio; CI = confidence interval. Students reporting no fear in the relationship are the referent group. ORs and the 95% CIs for exposures to youth violence are given. *p < .05. **p < .01, for chi-square tests comparing students reporting fear versus no fear in the relationship.

Missed school/felt unsafe Yes n = 48 (12%) n = 13 (14%) Carrying a weapon Yes n = 24 (6%) n = 12 (13%)* Threatened/injured with a weapon Yes n = 42 (11%) n = 9 (10%) Participated in a fight Yes n = 170 (43%) n = 47 (53%) Gang membership Yes n = 25 (6%) n = 12 (13%)* Any youth violence Yes n = 207 (79%) n = 54 (21%)


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weapon (females: OR = 1.79 for physical violence and OR = 2.37 for sexual coercion; males: OR = 2.22 for physical violence and OR = 3.30 for sexual coercion). This would suggest that the exposure to a weapon, which can be due to various experiences such as carrying a weapon for the intention of hurting someone or feeling safe and protected, or being harmed by a weapon in the community, puts youth at greater risk of receiving relationship violence of either physical or sexual nature. Among males, we found that gang membership is also strongly associated with receiving both relationship physical violence (OR = 1.73) and sexual coercion (OR = 2.22), indicating a possible correlation between gang membership, carrying a weapon, and being harmed by a weapon. These three exposures to youth violence can put males at an increased risk of receiving physical violence and sexual coercion by a romantic partner. Among females, participating in a fight was also strongly associated with receiving relationship violence (OR = 3.74, for physical violence, and OR = 2.23 for sexual coercion), which would indicate a potential correlation between involvement in a fight and being harmed by a weapon. Overall, we conclude that there are significant associations between exposures to youth violence and receiving relationship violence. The specific associations between exposures to youth violence and delivering relationship violence were slightly different than receiving relationship violence. The increased risk of relationship violence due to an exposure to a weapon varies for delivering relationship violence. Being threatened or injured with a weapon was associated with delivering relationship physical violence but not sexual coercion (females: OR = 2.63 for physical violence; males: OR = 1.85 for physical violence). In addition, carrying a weapon is associated with delivering relationship physical violence and sexual coercion among males but only sexual coercion among females (females: OR = 2.73 for sexual coercion; males: OR = 2.06 for physical violence and OR = 2.24 for sexual coercion). We found that gang membership is also associated with delivering relationship sexual coercion among males (OR = 2.04), indicating that females who are in romantic relationships with male gang members are at a greater risk of receiving sexual coercion. Intuitively, among females only, participating in a fight was also strongly associated with delivering relationship physical violence but not sexual coercion (OR = 2.63 for physical violence). Implications from this finding and from previous research (Foshee et al., 2001; Swahn et al., 2008) is that females who are often getting in trouble at school or in the community for fighting may likely be concurrently delivering physical violence to their male partner. Overall, we conclude that there are significant associations between exposures to youth violence and delivering relationship violence among both sexes. The overall and sex-specific patterns in youth violence and relationship violence among urban adolescents


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have salient implications. Weapon exposure by way of carrying a weapon or being threatened or injured with a weapon increase risk of relationship physical violence and sexual coercion—delivering and receiving. Our findings among males were particularly noteworthy and different from other studies because males who are involved with gangs and report carrying weapons typically have not been required to report on both the receipt and delivery of relationship physical violence and sexual coercion but rather only on the delivery of relationship violence. Females are more often viewed as being receivers of relationship violence, but our study findings indicate that the males are just as likely to receive relationship violence as females, and that males receive both physical violence and sexual coercion as well. The difference between sexes exists mainly in delivering relationship physical violence and sexual coercion and the amount of harm inflicted by each type. Our study identified that fear in the context of the relationship is also associated with other types of youth violence but in a slightly different way when compared with relationship physical violence and sexual coercion. Missing school because of feeling unsafe was a significant association with fear between partners, particularly in males. This has strong implications for truant youth as we have found an association between missed school and fearing a partner. As we found a strong association between weapon exposure and relationship violence, we found a pattern between weapon exposure and fear in the context of the relationship. Females who reported carrying a weapon (OR = 2.39) and gang membership (OR = 2.28) were more likely to report that their male romantic partner fears them. Similarly, males who carried a weapon (fear of partner: OR = 1.93; partner fears me: OR = 1.77) and were threatened or injured with a weapon (fear of partner: OR = 3.07; partner fears me: OR = 1.94) had increased odds of reporting both that they feared their partner and that their partner was afraid of them. Youth service as well as health care providers who provide care to high-risk youth who have experienced this type of weapon exposure and gang membership should remember that their romantic relationships may also be compromised by feelings of fear and distrust, and therefore, not necessarily supportive and nurturing. Furthermore, providers can use this knowledge to help guide their intervention to prevent an escalation of violence in an adolescent relationship. There are several key limitations worth mentioning. First, this study was of cross-sectional nature, which does not allow for the assessment of temporality, and therefore causality in the associations we found. That is, it is unclear whether the reported exposure to youth violence occurred before or after the reported relationship violence incidents. The time frame of reported events of hitting or coercion was unknown. This prevents the assessment of directionality, and therefore inhibits the determination of causality. Second,


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although we were able to examine the association between youth violence and relationship violence, we could not determine which is the putative cause and effect. Exposure to youth violence might have caused one to experience either receiving or delivering relationship violence or it might have been the inverse causal relationship: relationship violence influences participation in youth violence. The directionality of the association between youth violence and relationship violence was unknown. In addition, the study sample oversampled Latino urban youth from NYC public schools; therefore, our results may not be applicable to the population of all youth in NYC public high schools, or of those in private schools, youth of other cultural and racial backgrounds, or youth living outside of NYC. Despite these limitations, the study provides insight into youth violence and relationship violence among urban youth and salient association that differs by sex. Research needs to explore these complex interrelationships to better intervene in reducing both youth violence and relationship violence. Longitudinal data would allow a better understanding of whether the exposure to youth violence leads to increased violence in romantic relationships or vice versa. The role of fear in general and in romantic relationships as a promotor of the use of weapons by youths or gang membership would also be a fruitful area for research. Results from our study may be used by researchers and youth service providers to further understand the predictors shaping youth violence and relationship physical violence and sexual coercion among urban youth. Youth service providers including medical providers, social workers, community providers of youth services and programming, and providers in school settings such as school counselors and nurses can benefit from our study’s findings to help guide their practice in assisting youth experiencing youth violence and/or relationship violence. Due to the overlap between both contexts of violence, youth providers who encounter a youth involved in one context must also screen that youth for violence in the other context. For example, a young male might disclose to a youth service provider that he is a member of a gang. Our data suggest that it is important for the provider to screen the young male for both receiving and delivering sexual coercion. Screening adolescents for violence must include both contexts of youth violence and relationship violence. Following screening for youth violence and relationship violence, interventions, such as youth services and programs, should attempt to address both types of violence concurrently. Finally, youth service providers can also gain information about the sexspecific associations between relationship violence and youth violence and address the needs of youth accordingly. Furthermore, it is important for


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providers to inquire not just about relationship length and satisfaction, but also about the presence of any fear. If a youth discloses fear within the context of the relationship, then the provider should consider screening for other types of youth violence among both adolescents involved in the particular relationship. By acknowledging the overlaps of the two contexts of relationship violence and other types of youth violence, violent behaviors overall can be addressed as they are disclosed to reduce youth and relationship violence among adolescents. Further knowledge in this area will guide intervention and prevention efforts to reduce violent behaviors among adolescents.

Appendix Exposures to Youth Violence (5 items) 1. During the past 30 days, on how many days did you not go to school because you felt you would be unsafe at school or on your way to or from school? (missed school) 2. During the past 30 days, on how many days did you carry a weapon such as a gun, knife, or club? (carrying a weapon) 3. During the past 12 months, how many times has someone threatened or injured you with a weapon such as a gun, knife, or club? (threatened/injured with a weapon) 4. During the past 12 months, how many times were you in a physical fight? (participated in a fight) 5. At any time during the past 12 months, have you been a member of a gang? (gang membership) Measures of Relationship Physical Violence (5 items: A items indicate delivered; B items indicate received) During a conflict or argument with my partner in the past year: 1. 2. 3. 4. 5.

A. I threw something at him or her. B. She or he threw something at me. A. I threatened to hurt him or her. B. She or he threatened to hurt me. A. I kicked, hit, or punched him or her. B. She or he kicked, hit, or punched me. A. I pushed, shoved, or shook him or her. B. She or he pushed, shoved, or shook me. A. I slapped him or her or pulled his or her hair. B. She or he slapped me or pulled my hair.


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Journal of Interpersonal Violence 29(12) Measures of Relationship Sexual Coercion (3 items: A items indicate delivered; B items indicate received).

During a conflict or argument with my partner in the past year: 1. 2. 3.

A. I touched him or her sexually when he or she didn’t want me to. B. She or he touched me sexually when I did not want him or her to. A. I forced him or her to have sex when she or he didn’t want to. B. She or he forced me to have sex when I didn’t want to. A. I threatened him or her in attempt to have sex with him or her. B. She or he threatened me in an attempt to have sex with me. Measures of Fear Within the Context of the Relationship (2 items)

Some people are afraid that their partner will hurt them if they argue or do something their partner doesn’t like. A. B.

How much would you say you are afraid of him/her? How much would you say your partner is afraid of you? Measures of Non-Partner Sexual Abuse History (5 items).

Many people experience sexual violence outside of dating relationships, both by people they know and by strangers. This section asks what types of violence you may have experienced in your life. When we ask about “sexual abuse,” we mean any sexual fondling, touching, oral sex, intercourse (penetration of the vagina or anus with a penis, fingers, or object). How often in your life has: A. B. C. D. E.

Your parent sexually abused you or forced you to have sex? A family member other than a parent sexually abused you or forced you to have sex? An older acquaintance (such as a family friend, teacher, minister, neighbor etc.) sexually abused you or forced you to have sex? Someone else your age who you knew but was not your partner sexually abused you or forced you to have sex? A stranger sexually abused you or forced you to have sex?

Authors’ Note The opinions expressed are the responsibility of the authors and not necessarily those of the Centers for Disease Control and Prevention.

Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.


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Funding The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This project was supported in part by the New York City Council. This research was also supported in part by the National Center for Injury Prevention and Control, Centers for Disease Control and Prevention (Grant R49 CE002096-01 and cooperative agreement U49CE000731).

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Author Biographies Melissa J. DuPont-Reyes, MPH was Program Coordinator for Columbia’s Center for Youth Violence Prevention and the Center for the Study of Social Inequalities and Health at Mailman School of Public Health, Columbia University. Ms. DuPont-Reyes is a PhD Candidate in the Department of Epidemiology at the Mailman School of Public Health. Deborah Fry, MA, MPH is a Research and Teaching Fellow at the University of Edinburgh/ NSPCC Child Protection Research Centre. At the Centre, Deborah undertakes primary research on the issues of child sexual abuse and youth violence and is involved in research exploring both interventions and effective prevention. Vaughn I. Rickert is the Donald P. Orr, MD, Professor of Adolescent Medicine within the Department of Pediatrics and is the director of the Section of Adolescent Medicine at Indiana University School of Medicine and Riley Hospital for Children. Dr. Rickert has authored and co-authored over 100 publications in adolescent health, and research interests focus on adolescent relationship violence and contraceptive use in this population. David L. Bell, MD, MPH. Since 1999, Dr. Bell has been Medical Director of the Young Men’s Clinic, a unique adjunct to New York Presbyterian Hospital’s Family Planning Clinic, where he delivers primary care to adolescent and young adult males with a focus on sexual and reproductive health. Dr. Bell has authored articles on adolescent male sexual and reproductive health and trends in reproductive health care delivery for adolescent males and his research includes studies on adolescent


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male relationship development and male knowledge and attitudes of emergency contraception. Niki Palmetto is currently an Associate Director in the Epidemiology division of Pfizer, Inc. Dr. Palmetto received her PhD in Epidemiology at Columbia University Mailman School of Public Health, New York, NY in 2011 during which her main research focus focused on measurement issues surrounding adult suicide attempts in large epidemiologic studies and in the area of intimate partner violence within young dating relationships. Leslie L. Davidson is Professor of Clinical Epidemiology and Clinical Pediatrics at the Mailman School of Public Health at Columbia University and a senior member of the Center for Injury Epidemiology and Prevention at Columbia. Her primary research interests are screening, and epidemiology focusing on the prevention of accidents and violence, particularly intimate partner violence, most recently involving adolescents and young adults.


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