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Adolescents’ experiences of dating and intimate partner violence: “once is not enough”
CLINICAL ROUNDS Adolescents’ Experiences of Dating and Intimate Partner Violence: “Once Is Not Enough” Lisa Scheiman, CNM, MS, and April M. Zeoli, MPH Pregnant and parenting adolescents represent a significant proportion of the individuals directly affected by intimate partner violence. Although screening tools are useful, it is important to ask very specific questions to open lines of communication with adolescents. This article presents a clinical case that highlights the challenges of screening adolescents for intimate partner violence and offers suggestions for health care providers. Specific examples of screening questions are offered. J Midwifery Womens Health 2003;48: 226 –228 © 2003 by the American College of Nurse-Midwives. keywords: intimate partner violence, adolescent health
Ms. C.B. is a 17-year-old G3P2012 who presents in clinic 2 weeks’ postpartum for an emergency visit to discuss her concerns about returning to work. She lives with her boyfriend of 3 years, their two children, and his mother. Her boyfriend did not want the new second child and does not participate in his care. C.B. feels exhausted and unsupported. She finds it intolerable to stay at home with them any longer and wants to return to work as soon as possible. Depression and intermittent high blood pressure complicated C.B.’s pregnancies. She was ambivalent about psychiatric care and antidepressant medication throughout both pregnancies. At times, C.B. expressed interest in receiving treatment for her depression. Many referrals were made, but C.B never kept her appointments, claiming she had car trouble or was sick. Instead, she called her midwife to talk about what was troubling her on that particular day. C.B. assured her midwife that she wasn’t planning suicide although she did think about it generally at times. During her first pregnancy, she filled a prescription for an antidepressant but threw out the medication when her boyfriend’s aunt threatened to take custody of the child at birth because C.B. was “crazy.” The majority of the stress C.B. felt was centered on money and relationship issues. She had a minimum wage job that was the sole source of income for her and her family. Her boyfriend’s mother allowed them to live with her but did not support them financially in any other way. C.B. owned a car but her boyfriend controlled use of it. According to C.B., her boyfriend was demeaning, controlling, and often not home. Throughout both of C.B.’s pregnancies, she was screened for interpersonal violence. C.B. readily discussed emotional and verbal abuse from her boyfriend but denied
Address correspondence to Lisa Scheiman, CNM, MS, Nurse-Midwifery Service, University of Michigan, 1500 East Medical Center Drive F4835, Ann Arbor, MI 48109.
226 © 2003 by the American College of Nurse-Midwives Issued by Elsevier Inc.
physical abuse of any sort. Her midwife initiated discussions about physical abuse many times during her pregnancies by using techniques such as standardized and openended questions, but C.B. consistently denied any occurrence. During the course of C.B.’s 2-week postpartum visit, a discussion ensued about her desire to return to work so quickly after her baby’s birth to fulfill her desire to get out of the house. C.B. again described verbal abuse from her boyfriend but denied any physical contact. After a 20minute discussion, the midwife said, “C.B., I think he is hurting you physically.” At that point, C.B. began sobbing and disclosed physical abuse that had been occurring since her first pregnancy. Her explanation for not disclosing earlier was fear because her boyfriend threatened that he would take her oldest son away if she told anyone. BACKGROUND Intimate partner violence is a pattern of coercive behaviors used by adults and/or adolescents to control their partners. It often includes a physical assault or threat of a physical assault, sexual abuse, domination, humiliation, intimidation, possessiveness, and minimization of feelings, and blaming.1 Intimate partner violence is a problem of epidemic proportions. The Commonwealth Fund’s 1998 Survey of Women’s Health found that 39% of respondents had experienced physical abuse, sexual assault, or domestic violence.2 According to the Bureau of Justice Statistics, the rate of victimization by an intimate partner is greatest between the ages of 16 and 24.3 Furthermore, a recent study by Silverman et al.4found that one in five high school females experienced physical and/or sexual abuse at the hands of a dating partner. This growing body of research reveals that intimate partner violence among adolescents is more prevalent than previously assumed. Females who experience dating violence are more likely to engage in adverse health behaviors and to have more Volume 48, No. 3, May/June 2003 1526-9523/03/$30.00 • doi:10.1016/S1526-9523(03)00072-2
long-term health consequences. Substance abuse, unhealthy weight control behaviors, sexual risk behaviors, pregnancy, and suicide are all more common in women who experience violence.4 Other behaviors associated with dating violence are first intercourse before age 15, not using a condom at last intercourse, equal to or greater than three sex partners in the past 3 months, substance use before last intercourse, and intercourse without contraception use.5,6 Although causality is uncertain, it is likely that these elements contribute to the higher pregnancy rate associated with adolescents who experience violence. Pregnant teens experience abuse an estimated 16 to 37% of the time.7,8 This is higher than the estimated rate for pregnant adults, suggesting that pregnant adolescents are more vulnerable to victimization than pregnant adult women. During pregnancy, adolescents have the added developmental issues of overvaluing peer influence and desire for emancipation from parental figures. The desire for the baby to be born into a nonviolent home may increase the adolescent’s ability to break off the relationship. Conversely, the adolescent’s desire for her child to be born into a family unit may conflict with her desire for safety. Unfortunately, violence during pregnancy often continues into the postpartum period. Although older adolescents report more dating violence overall,3,5 younger adolescent mothers are more likely to report violence during the early postpartum period. In a study from the University of Texas evaluating all women 18 years of age and younger who gave birth in a 2-year time span, the overall rate of violence during a 24-month postpartum period was 41%, with the highest prevalence occurring during the first 3 months.9 This study highlights the necessity of continuing to screen for violence after birth. In fact, in this study three of four adolescents reporting violence during the postpartum period did not report violence during pregnancy.10 SCREENING FOR DATING AND INTERPERSONAL VIOLENCE A study by Parsons et al.11 on the screening practices of obstetricians/gynecologists revealed that the majority do not screen for interpersonal violence. This was also true in an exploratory study of staff nurses in Texas where only 30% routinely screened.12 Interviews with midwives in Sweden reported a low client disclosure rate of interpersonal violence, which the authors attributed to the lack of specific screening recommendations, even though the midwives supported screening all pregnant women for the
Lisa Scheiman, CNM, MS, is a graduate of the University of Michigan and the University of Illinois at Chicago. She is a nurse-midwife in full-scope clinical practice and director of the sexual assault nurse examiner program at the University of Michigan. April Zeoli, MPH, is a doctoral student at Johns Hopkins Bloomberg School of Public Health. She is currently studying injury and violence prevention, with a focus on intimate partner violence
Journal of Midwifery & Women’s Health • www.jmwh.org
occurrence of violence.13 Furthermore, a study of primary care physicians, including obstetrician/gynecologists, by Rodriguez et al.14 revealed that, although 79% of physicians surveyed screened for abuse when a woman presented with an injury, screening under other circumstances was rare. Physicians and nurses identify lack of training and education as a key barrier that prevents initiation of screening for violence.11,12,14 –16 Another common barrier noted in studies of physician responses is the belief that screening is not effective in stopping violence.11,15 Education and training for all clinicians who care for adolescents and women may resolve some of these barriers.
HOW WELL DOES SCREENING IDENTIFY WOMEN AT RISK FOR IPV? Even the most effective screening tools for dating violence do not guarantee that an adolescent will disclose whether she is in a violent relationship. Some will continue to deny the violence in their lives regardless of how the health care provider approaches the issue. However, providers should continue to screen, because although some adolescents will disclose after the first screening effort, it may take repeated questioning over time for others to feel comfortable to disclose. Literature supports the need to ask questions that are specific and direct. For example, asking “are you being abused” may get a negative response as adolescents, like adults, are reticent to disclose that they are being abused, or they may not define their experience as “abuse.” However, more specific and direct questions, such as “Are you frightened by your boyfriend’s temper?” “Does your boyfriend call you names?” or “Has your boyfriend ever hurt you or threatened to hurt you?” have been shown to improve disclosure in adolescents.17 Because adolescents have limited life experiences, many girls will struggle with defining what they experience as abuse despite being hit, threatened, or constrained by their partner.17 Therefore, health care providers should be alert to red flags of dating violence, such as substance abuse, disordered eating, anorexia, bulimia, sexual risk behaviors, and their consequences (i.e., frequent STDs and pregnancies), and suicidal ideation and attempts. By familiarizing adolescents with the available community resources for interpersonal violence, health care providers can help them overcome some of the barriers to ending an abusive relationship. Providers can make resource materials available to all of their clients, regardless of suspected or known abuse status. In addition, by creating an environment in which the adolescent feels safe and believed if she reveals her abuse status, providers themselves become a resource that they can access. The goal of screening for interpersonal violence should be reframed, defining success as simply showing the client that a caring and supportive environment exists and that she is not alone in her situation. 227
DISCUSSION As presented in our case, helping adolescents experiencing interpersonal violence requires patience and empathy. The added impact of the developmental stage involved makes the health care provider’s job more complex. C.B. was offered shelter and babysitting by her noncustodial father and stepmother, but she didn’t avail herself of their offer because she would have to follow their rules. At that particular time, her emancipation from her father was more important to her than being free from physical harm. Her difficulties with authority figures also made it difficult for her to confide in her midwife even though she knew and trusted her for 3 years. In accordance with the ACNM position statement on violence against women,18 C.B.’s midwife made the appropriate assessments for violence, intervened, and made referrals for her client. It was only after many attempts at screening, varied approaches with questioning, did C.B. feel safe enough to disclose her true situation. Although the midwife in this case made the appropriate assessments, it took direct and concrete statements to finally break through C.B.’s denials. Well-designed evaluations of interpersonal violence education programs are necessary to determine what is effective in altering provider behavior so that adolescents such as C.B. have the opportunity to finally reach out and receive the services they need related to the experience of interpersonal violence.
Partner violence among adolescents in opposite-sex romantic relationships: findings from the National Longitudinal Study of Adolescent Health. Am J Public Health 2001;91:1679 –85. 6. Wilson KM, Klein JD. Opportunities for appropriate care: Health care and contraceptive use among adolescents reporting unwanted sexual intercourse. Arch Pediatr Adolesc Med 2002;156: 341–4. 7. Covington DL, Justason BM, Wright LN. Severity, manifestations, and consequences of violence among pregnant adolescents. J Adolesc Health 2001;28:55–61. 8. Curry MA, Doyle BA, Gilhooley J. Abuse among pregnant adolescents: Differences by developmental age. Am J Matern Child Nurs 1998;23:144 –50. 9. Parker B, McFarlane J, Soeken K, Torres S, Campbell D. Physical and emotional abuse in pregnancy: A comparison of adult and teenage women. Nurs Res 1993;42:173–8. 10. Harrykissoon SD, Rickert VI, Wiemann CM. Prevalence and patterns of intimate partner violence among adolescent mothers during the postpartum period. Arch Pediatr Adolesc Med 2002;156:325– 30. 11. Parsons LH, Zaccaro D, Wells B, Stovall TG. Methods of and attitudes toward screening obstetrics and gynecology patients for domestic violence. Am J Obstet Gynecol 1995;173:381–6. 12. Glaister JA, Kesling G. A survey of practicing nurses’ perspectives on interpersonal violence screening and intervention. Nurs Outlook 2002;50:137–43.
REFERENCES
13. Edin KE, Hogberg U. Violence against pregnant women will remain hidden as long as no direct questions are asked. Midwifery 2002;18:268 –78.
1. Nebraska Domestic Violence Sexual Assault Coalition. Reaching, teaching teens to stop violence power and control in dating relationships. Lincoln (NE): Nebraska Domestic Violence Sexual Assault Coalition, 1996.
14. Rodriguez MA, Bauer HM, McLoughlin E, Grumbach K. Screening and intervention for intimate partner abuse: practices and attitudes of primary care physicians. J Am Med Assoc 1999;282: 468 –74.
2. Collins KS, Schoen C, Joseph S, Duchon L, Simantov E, Yellowitz M. Health concerns across a woman’s lifespan: The Commonwealth Fund 1998 Survey of Women’s Health [Internet]. Commonwealth Fund May 1999 [cited February 5, 2002] Available from http://www.cmwf.org/programs/women/ksc.
15. Gerbert B, Caspers N, Bronstone AM, Moe J, Abercrombie P. A qualitative analysis of how physicians with expertise in domestic violence approach the identification of victims. Ann Intern Med 1999;131:578 –84.
3. Intimate partner violence. Washington (DC): Bureau of Justice Statistics Special Report. NCJ 178-247 May 2000. 4. Silverman JG, Raj A, Mucci LA, Hathaway JE. Dating violence against adolescent girls and associated substance use, unhealthy weight control, sexual risk behavior, pregnancy, and suicidality. J Am Med Assoc 2001;286:572–9. 5. Halpern CT, Oslak SG, Young ML, Martin SL, Kupper LL.
228
16. Cole TB. Case management for domestic violence. J Am Med Assoc 1999;282:513–4. 17. Givens C, Chesler J, Share D. Adolescent health issues: Assessments, approaches, and interventions in a community based teen health center. Battle Creek (MI): Kellogg Foundation, 1994. 18. American College of Nurse-Midwives. Position statement on violence against women 2001. Washington (DC): American College of Nurse-Midwives, 2001.
Volume 48, No. 3, May/June 2003
Ms. C.B. is a 17-year-old G3P2012 who presents in clinic 2 weeks’ postpartum for an emergency visit to discuss her concerns about returning to work. She lives with her boyfriend of 3 years, their two children, and his mother. Her boyfriend did not want the new second child and does not participate in his care. C.B. feels exhausted and unsupported. She finds it intolerable to stay at home with them any longer and wants to return to work as soon as possible. Depression and intermittent high blood pressure complicated C.B.’s pregnancies. She was ambivalent about psychiatric care and antidepressant medication throughout both pregnancies. At times, C.B. expressed interest in receiving treatment for her depression. Many referrals were made, but C.B never kept her appointments, claiming she had car trouble or was sick. Instead, she called her midwife to talk about what was troubling her on that particular day. C.B. assured her midwife that she wasn’t planning suicide although she did think about it generally at times. During her first pregnancy, she filled a prescription for an antidepressant but threw out the medication when her boyfriend’s aunt threatened to take custody of the child at birth because C.B. was “crazy.” The majority of the stress C.B. felt was centered on money and relationship issues. She had a minimum wage job that was the sole source of income for her and her family. Her boyfriend’s mother allowed them to live with her but did not support them financially in any other way. C.B. owned a car but her boyfriend controlled use of it. According to C.B., her boyfriend was demeaning, controlling, and often not home. Throughout both of C.B.’s pregnancies, she was screened for interpersonal violence. C.B. readily discussed emotional and verbal abuse from her boyfriend but denied
Address correspondence to Lisa Scheiman, CNM, MS, Nurse-Midwifery Service, University of Michigan, 1500 East Medical Center Drive F4835, Ann Arbor, MI 48109.
226 © 2003 by the American College of Nurse-Midwives Issued by Elsevier Inc.
physical abuse of any sort. Her midwife initiated discussions about physical abuse many times during her pregnancies by using techniques such as standardized and openended questions, but C.B. consistently denied any occurrence. During the course of C.B.’s 2-week postpartum visit, a discussion ensued about her desire to return to work so quickly after her baby’s birth to fulfill her desire to get out of the house. C.B. again described verbal abuse from her boyfriend but denied any physical contact. After a 20minute discussion, the midwife said, “C.B., I think he is hurting you physically.” At that point, C.B. began sobbing and disclosed physical abuse that had been occurring since her first pregnancy. Her explanation for not disclosing earlier was fear because her boyfriend threatened that he would take her oldest son away if she told anyone. BACKGROUND Intimate partner violence is a pattern of coercive behaviors used by adults and/or adolescents to control their partners. It often includes a physical assault or threat of a physical assault, sexual abuse, domination, humiliation, intimidation, possessiveness, and minimization of feelings, and blaming.1 Intimate partner violence is a problem of epidemic proportions. The Commonwealth Fund’s 1998 Survey of Women’s Health found that 39% of respondents had experienced physical abuse, sexual assault, or domestic violence.2 According to the Bureau of Justice Statistics, the rate of victimization by an intimate partner is greatest between the ages of 16 and 24.3 Furthermore, a recent study by Silverman et al.4found that one in five high school females experienced physical and/or sexual abuse at the hands of a dating partner. This growing body of research reveals that intimate partner violence among adolescents is more prevalent than previously assumed. Females who experience dating violence are more likely to engage in adverse health behaviors and to have more Volume 48, No. 3, May/June 2003 1526-9523/03/$30.00 • doi:10.1016/S1526-9523(03)00072-2
long-term health consequences. Substance abuse, unhealthy weight control behaviors, sexual risk behaviors, pregnancy, and suicide are all more common in women who experience violence.4 Other behaviors associated with dating violence are first intercourse before age 15, not using a condom at last intercourse, equal to or greater than three sex partners in the past 3 months, substance use before last intercourse, and intercourse without contraception use.5,6 Although causality is uncertain, it is likely that these elements contribute to the higher pregnancy rate associated with adolescents who experience violence. Pregnant teens experience abuse an estimated 16 to 37% of the time.7,8 This is higher than the estimated rate for pregnant adults, suggesting that pregnant adolescents are more vulnerable to victimization than pregnant adult women. During pregnancy, adolescents have the added developmental issues of overvaluing peer influence and desire for emancipation from parental figures. The desire for the baby to be born into a nonviolent home may increase the adolescent’s ability to break off the relationship. Conversely, the adolescent’s desire for her child to be born into a family unit may conflict with her desire for safety. Unfortunately, violence during pregnancy often continues into the postpartum period. Although older adolescents report more dating violence overall,3,5 younger adolescent mothers are more likely to report violence during the early postpartum period. In a study from the University of Texas evaluating all women 18 years of age and younger who gave birth in a 2-year time span, the overall rate of violence during a 24-month postpartum period was 41%, with the highest prevalence occurring during the first 3 months.9 This study highlights the necessity of continuing to screen for violence after birth. In fact, in this study three of four adolescents reporting violence during the postpartum period did not report violence during pregnancy.10 SCREENING FOR DATING AND INTERPERSONAL VIOLENCE A study by Parsons et al.11 on the screening practices of obstetricians/gynecologists revealed that the majority do not screen for interpersonal violence. This was also true in an exploratory study of staff nurses in Texas where only 30% routinely screened.12 Interviews with midwives in Sweden reported a low client disclosure rate of interpersonal violence, which the authors attributed to the lack of specific screening recommendations, even though the midwives supported screening all pregnant women for the
Lisa Scheiman, CNM, MS, is a graduate of the University of Michigan and the University of Illinois at Chicago. She is a nurse-midwife in full-scope clinical practice and director of the sexual assault nurse examiner program at the University of Michigan. April Zeoli, MPH, is a doctoral student at Johns Hopkins Bloomberg School of Public Health. She is currently studying injury and violence prevention, with a focus on intimate partner violence
Journal of Midwifery & Women’s Health • www.jmwh.org
occurrence of violence.13 Furthermore, a study of primary care physicians, including obstetrician/gynecologists, by Rodriguez et al.14 revealed that, although 79% of physicians surveyed screened for abuse when a woman presented with an injury, screening under other circumstances was rare. Physicians and nurses identify lack of training and education as a key barrier that prevents initiation of screening for violence.11,12,14 –16 Another common barrier noted in studies of physician responses is the belief that screening is not effective in stopping violence.11,15 Education and training for all clinicians who care for adolescents and women may resolve some of these barriers.
HOW WELL DOES SCREENING IDENTIFY WOMEN AT RISK FOR IPV? Even the most effective screening tools for dating violence do not guarantee that an adolescent will disclose whether she is in a violent relationship. Some will continue to deny the violence in their lives regardless of how the health care provider approaches the issue. However, providers should continue to screen, because although some adolescents will disclose after the first screening effort, it may take repeated questioning over time for others to feel comfortable to disclose. Literature supports the need to ask questions that are specific and direct. For example, asking “are you being abused” may get a negative response as adolescents, like adults, are reticent to disclose that they are being abused, or they may not define their experience as “abuse.” However, more specific and direct questions, such as “Are you frightened by your boyfriend’s temper?” “Does your boyfriend call you names?” or “Has your boyfriend ever hurt you or threatened to hurt you?” have been shown to improve disclosure in adolescents.17 Because adolescents have limited life experiences, many girls will struggle with defining what they experience as abuse despite being hit, threatened, or constrained by their partner.17 Therefore, health care providers should be alert to red flags of dating violence, such as substance abuse, disordered eating, anorexia, bulimia, sexual risk behaviors, and their consequences (i.e., frequent STDs and pregnancies), and suicidal ideation and attempts. By familiarizing adolescents with the available community resources for interpersonal violence, health care providers can help them overcome some of the barriers to ending an abusive relationship. Providers can make resource materials available to all of their clients, regardless of suspected or known abuse status. In addition, by creating an environment in which the adolescent feels safe and believed if she reveals her abuse status, providers themselves become a resource that they can access. The goal of screening for interpersonal violence should be reframed, defining success as simply showing the client that a caring and supportive environment exists and that she is not alone in her situation. 227
DISCUSSION As presented in our case, helping adolescents experiencing interpersonal violence requires patience and empathy. The added impact of the developmental stage involved makes the health care provider’s job more complex. C.B. was offered shelter and babysitting by her noncustodial father and stepmother, but she didn’t avail herself of their offer because she would have to follow their rules. At that particular time, her emancipation from her father was more important to her than being free from physical harm. Her difficulties with authority figures also made it difficult for her to confide in her midwife even though she knew and trusted her for 3 years. In accordance with the ACNM position statement on violence against women,18 C.B.’s midwife made the appropriate assessments for violence, intervened, and made referrals for her client. It was only after many attempts at screening, varied approaches with questioning, did C.B. feel safe enough to disclose her true situation. Although the midwife in this case made the appropriate assessments, it took direct and concrete statements to finally break through C.B.’s denials. Well-designed evaluations of interpersonal violence education programs are necessary to determine what is effective in altering provider behavior so that adolescents such as C.B. have the opportunity to finally reach out and receive the services they need related to the experience of interpersonal violence.
Partner violence among adolescents in opposite-sex romantic relationships: findings from the National Longitudinal Study of Adolescent Health. Am J Public Health 2001;91:1679 –85. 6. Wilson KM, Klein JD. Opportunities for appropriate care: Health care and contraceptive use among adolescents reporting unwanted sexual intercourse. Arch Pediatr Adolesc Med 2002;156: 341–4. 7. Covington DL, Justason BM, Wright LN. Severity, manifestations, and consequences of violence among pregnant adolescents. J Adolesc Health 2001;28:55–61. 8. Curry MA, Doyle BA, Gilhooley J. Abuse among pregnant adolescents: Differences by developmental age. Am J Matern Child Nurs 1998;23:144 –50. 9. Parker B, McFarlane J, Soeken K, Torres S, Campbell D. Physical and emotional abuse in pregnancy: A comparison of adult and teenage women. Nurs Res 1993;42:173–8. 10. Harrykissoon SD, Rickert VI, Wiemann CM. Prevalence and patterns of intimate partner violence among adolescent mothers during the postpartum period. Arch Pediatr Adolesc Med 2002;156:325– 30. 11. Parsons LH, Zaccaro D, Wells B, Stovall TG. Methods of and attitudes toward screening obstetrics and gynecology patients for domestic violence. Am J Obstet Gynecol 1995;173:381–6. 12. Glaister JA, Kesling G. A survey of practicing nurses’ perspectives on interpersonal violence screening and intervention. Nurs Outlook 2002;50:137–43.
REFERENCES
13. Edin KE, Hogberg U. Violence against pregnant women will remain hidden as long as no direct questions are asked. Midwifery 2002;18:268 –78.
1. Nebraska Domestic Violence Sexual Assault Coalition. Reaching, teaching teens to stop violence power and control in dating relationships. Lincoln (NE): Nebraska Domestic Violence Sexual Assault Coalition, 1996.
14. Rodriguez MA, Bauer HM, McLoughlin E, Grumbach K. Screening and intervention for intimate partner abuse: practices and attitudes of primary care physicians. J Am Med Assoc 1999;282: 468 –74.
2. Collins KS, Schoen C, Joseph S, Duchon L, Simantov E, Yellowitz M. Health concerns across a woman’s lifespan: The Commonwealth Fund 1998 Survey of Women’s Health [Internet]. Commonwealth Fund May 1999 [cited February 5, 2002] Available from http://www.cmwf.org/programs/women/ksc.
15. Gerbert B, Caspers N, Bronstone AM, Moe J, Abercrombie P. A qualitative analysis of how physicians with expertise in domestic violence approach the identification of victims. Ann Intern Med 1999;131:578 –84.
3. Intimate partner violence. Washington (DC): Bureau of Justice Statistics Special Report. NCJ 178-247 May 2000. 4. Silverman JG, Raj A, Mucci LA, Hathaway JE. Dating violence against adolescent girls and associated substance use, unhealthy weight control, sexual risk behavior, pregnancy, and suicidality. J Am Med Assoc 2001;286:572–9. 5. Halpern CT, Oslak SG, Young ML, Martin SL, Kupper LL.
228
16. Cole TB. Case management for domestic violence. J Am Med Assoc 1999;282:513–4. 17. Givens C, Chesler J, Share D. Adolescent health issues: Assessments, approaches, and interventions in a community based teen health center. Battle Creek (MI): Kellogg Foundation, 1994. 18. American College of Nurse-Midwives. Position statement on violence against women 2001. Washington (DC): American College of Nurse-Midwives, 2001.
Volume 48, No. 3, May/June 2003