Dating Violence, Sexual Assault, and Suicide Attempts Among Urban
Teenagers
Elyse Olshen, MD, MPH; Katharine H. McVeigh,
PhD, MPH; Robin A. Wunsch-Hitzig, PhD; Vaughn I.
Rickert, PsyD
Arch Pediatr
Adolesc Med. 2007;161:539-545.
ABSTRACT
 |
|
Objective To
evaluate the relationship between dating violence, sexual assault,
and suicide attempts among urban adolescents.
Design Secondary analysis of the 2005 New York City Youth
Risk Behavior Survey.
Setting Eighty-seven New York City public high schools.
Participants Representative population-based sample of
8080 students, 14 years and older.
Main Exposures Dating violence in the past year and
lifetime history of sexual assault.
Outcome Measure One or more suicide attempts in the past
year.
Results Respondents were 50.0% female and primarily black
(36.0%) or Hispanic (40.1%). In the past year, 11.7% of females
and 7.2% of males reported 1 or more suicide attempts. Lifetime
history of sexual assault was reported by 9.6% of females and
5.4% of males. Dating violence in the past year was reported by
10.6% of females and 9.5% of males. In multivariate models,
controlling for persistent sadness, sexual orientation, and
significant risk behaviors, recent dating violence (odds ratio,
1.61; 95% confidence interval, 1.05-2.47) was associated with
suicide attempts in adolescent girls, while lifetime history of
sexual assault (odds ratio, 3.86; 95% confidence interval, 2.11-7.06)
was associated with suicide attempts in adolescent boys.
Conclusions In this population of urban youth, recent
dating violence among females and lifetime history of sexual
assault among males were significantly associated with suicide
attempts. Clinicians and educators should be trained to routinely
screen adolescents for violence victimization and should have a
low threshold for referring these at-risk teenagers for mental health
services.
INTRODUCTION
Suicide is the third
leading cause of death in adolescents.1
Although rates of adolescent suicide declined from 1991 to 2002,2
they remain unacceptably high. In 2003, 6.5 per 100 000 US
teenagers aged 14 to 19 years committed suicide. Completion rates in
this age group varied significantly by sex and race.3
Risk factors for adolescent suicide include prior suicide attempts,
depression, and substance abuse.4
Research to identify adolescents at risk for suicide attempts has
been specified, by the Institute of Medicine,5
as a priority for preventing adolescent suicide.
Data from the 2005 National Youth Risk Behavior Survey (YRBS)
suggest that suicide attempts are quite common among teenagers,
with 8.4% of high school students reporting 1 or more attempts
in the previous year.6
Using the 1993 Massachusetts YRBS, Woods et al7
demonstrated that adolescents who attempt suicide participate in
other risky behaviors, including physical fights, gun carrying, and
cigarette and other substance use. In addition, adolescent suicide
attempts have been linked to alcohol and other substance abuse,
violence perpetration, disordered eating, and nonheterosexual
identification.8-13
Finally, recent data14
suggest that adolescents who attempt suicide have increased rates of
depression and conduct disorder, which may predispose these youth to
engage in health-compromising behaviors.
Prior studies15-19
have demonstrated that a history of childhood or adolescent sexual
assault can predispose adolescents to future sexual assault and
dating violence victimization. Childhood sexual assault has been
clearly linked to adolescent depression, alcohol use, and violence
perpetration.20
Furthermore, as many as one third of female sexual assault survivors
are known to develop posttraumatic stress disorder.21
Therefore, sexual assault would seem to be a likely risk factor for a
suicide attempt. However, findings from prior research4,
22-24
on whether sexual assault is an independent risk for future suicidal
behavior have been mixed. Understanding the relationship between
sexual assault and suicidal behavior is important because data
from the 2005 National YRBS found 10.8% of adolescent girls and
7.5% of adolescent boys report a lifetime history of forced
sexual activity.6
Rates of adolescent dating violence vary widely, from 9% to
43%,6,
9,
16,
25
based on definitions used and populations surveyed. In the 2005
National YRBS, 9.3% of adolescent girls and 9.0% of adolescent boys
reported being hit, slapped, or hurt on purpose by a boyfriend or
girlfriend in the past year.6
Recent reports25-30
indicate there may be an independent association between dating
violence and suicidal thoughts and behaviors. However, dating
violence has also been shown to be associated with depressive
symptoms and multiple health-compromising behaviors.25,
28-30
Furthermore, rates of dating violence vary by sex and
race/ethnicity.6,
15-16
Thus, it is possible that the demonstrated association between dating
violence and suicide attempts is confounded by demographic
characteristics, coexisting depression, and other adolescent risk
behaviors. Most research25-30
on dating violence and suicidality in adolescents has been conducted
in nationally representative or largely white populations. Although
black and Hispanic adolescents report higher rates of dating
violence than their white peers,6,
15-16
to our knowledge, no study has evaluated the association between
dating violence victimization and suicide specific to minority
teenagers.
The purpose of the present study was to address gaps in the
literature by examining the independent relationships between
dating violence, sexual assault, and suicide attempts among
urban adolescents. We hypothesized that, after controlling for
factors identified in previous research4,
7-13
to be associated with suicide attempts, dating violence and sexual
assault would each be significantly associated with adolescent
suicide attempts in a population of predominantly black and Hispanic
urban teenagers.
METHODS
The YRBS is a biennial
survey of public high school students designed and supported by the
Centers for Disease Control and Prevention (CDC), conducted in states
and localities throughout the United States since 1991. The New York
City (NYC) YRBS was first conducted in 1993; by 1997, response rates
were high enough (>60%) to produce usable data. In 2005, the NYC
YRBS was jointly administered by the NYC Department of Health and
Mental Hygiene and Department of Education. The YRBS monitors
priority health risk behaviors that contribute to the leading
causes of mortality, morbidity, and social problems among youth.
A complete description of the YRBS survey methodology is
available.31
SAMPLE
The 2005 NYC YRBS used a stratified, 2-stage, cluster sample
design to produce a representative sample of students. The sample
was stratified by borough, with oversampling in 3 particularly
poor neighborhoods in which NYC Department of Health and Mental
Hygiene maintains District Public Health Offices, to permit
estimation of prevalence at the city, borough, and District
Public Health Office levels.
The first-stage sampling frame contained a specified number of
primary sampling units, consisting of schools, selected with
probability proportional to the school enrollment size. The
second sampling stage consisted of randomly selected classes
designated by period of the day (eg, second period) from grades
9 to 12 at each chosen school. All students in the selected
classes were eligible to participate in the survey. English as
a second language and special education classrooms were excluded.
The survey was conducted in the classroom and was self-administered,
with a data collector present. Survey procedures were designed
to protect the privacy of students by allowing for anonymous
and voluntary participation. Parents were informed of the survey
prior to data collection and could elect that their child not
participate. Study methods were approved by Department of Health
and Mental Hygiene and Department of Education institutional
review boards.
The 2005 YRBS initial sample included 91 schools; 2 were ineligible,
and 2 refused to participate. The final sample of 87 schools
resulted in a school response rate of 97.8% (of the 89 schools
eligible). Return visits were made to 50 schools to ensure an
adequate response rate. Of 11 710 eligible students, 8140
completed the questionnaire, for a student response rate of
69.5%. The overall response rate was 68.0%.
MEASURES
In 2005, the NYC YRBS questionnaire consisted of 99 items, the
maximum number allowed by the CDC YRBS protocol. Of these items,
86 were CDC core questions and 13 were chosen largely from the
CDC archive of optional YRBS questions. The self-administered
anonymous questionnaire measured different risk behaviors, including
tobacco, alcohol, and other drug use; unintentional injury and
violence; sexual behaviors; dietary behaviors; and physical
activity.
Primary
Dependent Variable
The primary dependent variable, suicide attempt, was a dichotomous
variable derived from the question, "During the past 12 months,
how many times did you actually attempt suicide?" Respondents
who indicated 0 times were coded as no, and respondents who
answered 1, 2 or 3, 4 or 5, or 6 or more times were coded as
yes. This question has been used in the YRBS since 1991. A study
of test-retest reliability32
in 1999 showed the item to have substantial reliability (
= 72.7%). This reliability estimate is believed
to be conservative because the correspondence between time 1 and time
2 estimates may be confounded by true changes in prevalence.32
Independent
Variables
Key independent variables included the following: (1) dating
violence ("During the past 12 months did your boyfriend or girlfriend
ever hit, slap, or physically hurt you on purpose?") ( = 53.6%32)
and (2) sexual assault ("Have you ever been physically forced
to have sexual intercourse when you did not want to?") ( = 65.8%33).
These reliability estimates may also be conservative.32
Other variables of interest, based on prior studies4,
7-13
showing an association with suicidal behavior, included items
related to alcohol (ever drink alcohol, first alcohol use before
the age of 13 years, alcohol use in the past 30 days, binge
drinking or 
5 drinks in a row in the past 30 days, and alcohol use at
school), tobacco use (ever smoked a cigarette, first cigarette
smoked before the age of 13 years, and smoked cigarettes daily
for the past 30 days), safety (in the past 30 days, have
you . . . rode in a car with a driver who had
been drinking alcohol, drove a car after drinking alcohol, carried a
weapon, carried a gun, or felt unsafe at school), violence (in the
past 12 months have you been . . . threatened at
school, involved in a physical fight, or injured in a physical
fight), and persistent sadness (feeling sad or hopeless for 2 weeks in a row
during the past 12 months). Respondents were recoded as having
disordered eating if they reported fasting for 24 hours; using diet
pills, powders, or liquids; vomiting; or using laxatives in the
past 30 days. Respondents were recoded as using "hard drugs" if
they reported any lifetime use of cocaine, heroin,
methamphetamines, ecstasy (3,4-methylenedioxymethamphetamine), or
inhalants. Respondents were recoded as using "any drugs" if they
reported lifetime use of hard drugs or marijuana. Sexual orientation
was also evaluated as an independent predictor for suicide
attempts. Respondents were recoded into 2 groups ("heterosexual
[straight]" and a combined category of "gay or lesbian," "bisexual,"
and "not sure"). These groupings were consistent with prior
research on sexual orientation and suicide, using the Massachusetts
YRBS.11
Self-reported race/ethnicity was recoded into 4 categories: white,
black, Hispanic, and Asian/other. Age was coded as 14, 15, 16, 17,
and 18 years or older, and grade as 9th, 10th, 11th, and 12th
grade.
STATISTICAL
ANALYSIS
Data were weighted to adjust for nonresponse and for varying
probabilities of selection. Weights were scaled so that (1) the
sum of the weights was equal to the total sample size and (2) the
weighted distribution of students matched the age, race, sex, and
geographic distribution of NYC public high school students. Analyses
were limited to respondents 14 years and older.
All prevalence, bivariate, and multivariate analyses were stratified
by sex. First, we examined the univariate prevalence of suicide
attempts, dating violence, sexual assault, sexual orientation,
demographic variables, and risk behaviors. Then, we conducted
bivariate analyses to examine the associations between hypothesized
independent predictors and suicide attempts, using 
2
testing. Finally, multivariate analyses were conducted using
logistic regression. The original models included main effects for
all variables significant (P<.05) on 2 testing.
The models were run iteratively with the least significant variable
removed at each step until only significant correlates remained.
Two potential confounders, age and race, that dropped out during
the modeling process were then reintroduced. These variables
were not significant and did not significantly affect other
variables and, thus, were not retained. In the female model,
lifetime history of sexual assault dropped out early in the
modeling process and was reintroduced. When added to the multivariate
model, the sexual assault variable was not significant and did
not change other predictors, so it was not retained in the final
female model. Similarly, dating violence dropped out early from
the male model and was then reintroduced. When added to the
multivariate model, the dating violence variable was not significant
and did not change other predictors, so it was not retained in
the final model. Interactions were tested for significant independent
predictors, including dating violence, sexual assault, and sexual
orientation. However, the sample size was too small for reliable
estimates to be calculated. Thus, interaction terms were not included
in the final models. All analyses were conducted using SAS
statistical software (SAS-Callable SUDAAN; SAS Institute Inc, Cary,
NC) to account for the complex survey design.
RESULTS
Of the original 8140
students surveyed, 60 were younger than 14 years and were excluded
from this study. Responses from 8080 adolescents 14 years and older,
who attended NYC public high schools, were included in the analyses.
The sample, which was weighted to be representative of the total NYC
public high school population, was 51.0% female and primarily
nonwhite (40.1% Hispanic, 36.0% black, 16.0% Asian/other, and 7.9%
white).
Table
1 presents the prevalence of persistent sadness, suicidal
behavior, and violence victimization among public high school
students in this major city. Persistent sadness (feeling sad or
hopeless daily for 2 weeks in a row during the past year) occurred in
40.2% of female students and 24.2% of male students; also, 19.9% of
females and 10.3% of males reported suicidal ideation or seriously
considering attempting suicide in the past year. Finally, 11.7% of
adolescent girls and 7.2% of adolescent boys attempted suicide 1 or
more times in the past year. A much smaller proportion of adolescent
girls and boys were injured or sought medical attention following a
suicide attempt. Lifetime history of sexual assault was experienced
by 9.6% of adolescent girls and 5.4% of adolescent boys. The
prevalence of dating violence in the past year was 10.6% among
adolescent girls and 9.5% among adolescent boys.
|
|
|
| Table 1.
Prevalence of Persistent Sadness, Suicidal Behavior, and
Violence Victimization in NYC Public High School Students,
2005
| | |
Bivariate analyses, stratified by sex, identified significant
associations (P<.05) between suicide attempts and each of
the following variables or domains: dating violence in the past
12 months; lifetime history of sexual assault; persistent sadness;
homosexual, bisexual, or unsure sexual orientation; and risky
behaviors related to alcohol, tobacco, other drugs, disordered
eating, violence, and safety. Unadjusted odds ratios for these
variables are shown in Table
2. We did not detect associations between suicide attempts and
age, grade, or race/ethnicity.
|
|
|
| Table 2.
Unadjusted Odds Ratios for 1 or More Suicide Attempts Among
Adolescent Males and Females by Significant Risk Behaviors*
| | |
Variables associated with suicide attempts were then entered into
multivariate models. For adolescent girls, dating violence in the
past 12 months was independently associated with suicide attempts.
Lifetime history of sexual assault was not associated with 1 or more
suicide attempts. Other significant correlates of suicide attempts in
adolescent girls included in the final model were sexual orientation,
persistent sadness, disordered eating, feeling unsafe at school,
engaging in a physical fight, and binge drinking (Table
3).
|
|
|
| Table 3. Final
Multiple Logistic Regression Models: Outcome Is 1 or More
Suicide Attempts in the Past 12 Months
| | |
Among male high school students, in multivariate analyses, lifetime
history of sexual assault was independently associated with
suicide attempts, but dating violence in the past 12 months was
not. Other correlates of suicide attempts among adolescent boys
included in the final model were sexual orientation, persistent
sadness, disordered eating, drug use, and gun possession (Table
3).
COMMENT
In this representative
citywide survey of 8080 public high school students, 11.7% of
adolescent girls and 7.2% of adolescent boys reported at least 1
suicide attempt in the prior year. In multivariate models,
controlling for persistent sadness, sexual orientation, and multiple
potentially confounding risk behaviors, dating violence was
associated with suicide attempts in adolescent girls, while history
of sexual assault was associated with suicide attempts in adolescent
boys.
We found that adolescent girls reporting recent dating violence
were 60% more likely to report 1 or more suicide attempts in
the past year. This association is similar in magnitude to that
reported among predominantly white adolescent girls from
Massachusetts25
and Vermont.27
Our findings differ from those of Borowsky et al,9
who found, in a national sample of teenagers, much stronger
associations between baseline violence victimization and suicide
attempts during a 1-year follow-up (odds ratio, 8.9 for black
girls, 7.7 for white girls, and 2.7 for Hispanic girls). However,
the increased odds ratios in their study may have been observed
because the authors did not distinguish between dating violence
and other types of violence reported by teenagers.
Unfortunately, our study was not designed to assess why dating
violence is associated with suicide attempts. Prior research30
suggests that teenagers who are depressed at baseline are more
likely to enter into violent relationships. Further studies
have found that teenagers who are victimized by dating partners
are more likely to develop posttraumatic stress disorder and
other mental health disorders.33
The co-occurrence of posttraumatic stress disorder and depression is
a strong risk for suicidal behaviors, including attempted
suicide.34
Thus, our findings are consistent with existing models of violence
victimization and mental health disorders.
Because other studies16-19
have identified history of sexual assault to be associated with
future victimization, we were interested in evaluating the role of
recent dating violence and lifetime history of sexual assault in a
single model of adolescent suicide attempts. One prior study28
found that 50% of teenagers reporting dating violence and date rape
also reported a suicide attempt. Other studies among adult
women23
and adolescent girls24
have also reported an association between sexual assault and suicide
attempts. These studies were conducted in largely white or adult
female cohorts. Among urban adolescent girls, we found that lifetime
history of sexual assault was not independently associated with
suicide attempts. Our findings may have differed from those of other
researchers because our model of risks for female suicide attempts
controlled for persistent sadness, sexual orientation, and other
potentially confounding risk behaviors. While our results should be
interpreted with caution, they may represent true null findings
regarding the association between sexual assault and suicide attempts
in this population.
For adolescent boys, we found that history of sexual assault was
associated with suicide attempts, whereas dating violence was not;
adding dating violence to the final model did not impact the
relationship between sexual assault and suicide attempts. These
marked differences between adolescent boys and girls are striking and
bear further investigation. Our measure of lifetime history of sexual
assault did not distinguish between childhood sexual abuse and
teenage sexual assault, 2 distinct entities. Therefore, it is not
clear whether the association between lifetime sexual assault and
suicide attempts we identified in adolescent boys reflects trauma
from a recent assault or trauma from childhood sexual abuse. While
many prior studies4,
19,
35-37
have demonstrated a relationship between childhood sexual abuse and
suicide, reports4,
22-24
on the association between adolescent sexual assault and suicide have
been mixed. Our findings may be consistent with 2 reports38-39
that indicate, compared with adolescent girls, adolescent boys
exhibit increased suicidal behaviors in the months following a sexual
assault. Furthermore, our findings are consistent with a recent study
using the 2001 National YRBS, which found lifetime history of sexual
assault to be associated with suicide attempts among males, but not
among females.40
Our study was unique in controlling for sexual orientation when
evaluating violence victimization and suicide attempts among
urban teenagers. Similar to prior studies,10-13
we found that adolescent boys and girls who identified as gay,
lesbian, bisexual, or unsure vs those who identified as heterosexual
were 3.4 and 2.5 times, respectively, as likely to report at least 1
suicide attempt in the past year. Unfortunately, we were unable to
conduct subgroup analyses because of the small number of teenagers
identifying as gay, bisexual, lesbian, or unsure. However, the
strength of the association that we detected suggests that sexual
orientation should be included as a covariate in future evaluations
of risks for adolescent suicide attempts. Future research is needed
to better evaluate subgroups and to determine whether there is
an interaction between violence victimization and sexual orientation.
One strength of this study was that we were able to examine the
relationship between violence victimization in a population at high
risk. Black and Hispanic teenagers are known to experience increased
rates of dating violence,6,
15-16
and Hispanic teenagers report higher rates of suicide attempts
compared with their white peers.6
However, our study, similar to at least 1 prior study,40
suggests there are no racial/ethnic differences in the associations
between dating violence, sexual assault, and suicide attempts.
Limitations of this research should be noted. First, as a
cross-sectional study, we were not able to assess the temporal
relationships between dating violence, sexual assault, and suicide
attempts. While our measures of suicide attempts and dating violence
were restricted to the prior 12 months, it is possible that some
or all of the suicide attempts reported preceded the episodes
of dating violence or sexual assault. Second, our analyses of
dating violence, sexual assault, and suicide attempts were all
based on single-item responses. While these variables have been
shown to have high test-retest reliability,32
teenagers may have had varying interpretations of the questions on
dating violence, sexual assault, and suicide attempts. In
particular, the association found between sexual assault and suicide
attempts in adolescent boys, but not in adolescent girls, may have
resulted from differences in how adolescent boys and girls define
sexual assault. Our accuracy would have been improved with
explicit definitions or multiple questions assessing each of the
key variables. A final limitation of this study was that we were
not able to assess the seriousness or lethality of the reported
suicide attempt. While the YRBS does evaluate whether students
were injured from a suicide attempt in the past year, rates
were too low (2.0% for females and 3.2% for males) to permit
logistic regression modeling for this outcome.
Our research provides further evidence of the association between
dating violence and suicide attempts among adolescent girls and
of the association between sexual assault and suicide attempts among
adolescent boys. Our study is unique in evaluating these
relationships in a population of predominantly minority urban
youth and in evaluating violence victimization, while controlling
for multiple potential confounding factors, in a single model.
While our study focused on public high school students in a
single urban area, our results are likely generalizable to urban
youth across the United States. Our findings are of concern
because dating violence and sexual assault are highly prevalent
among urban youth. Teenagers reporting violence victimization
are at increased risk for suicide attempts. Questions about
violence, depression, anxiety, substance abuse, and suicidality
are all extremely important and should be included as part of a
comprehensive health assessment of adolescents. Furthermore,
clinicians, educators, and other professionals working with
youth should be trained to routinely screen for violence
victimization and should have a low threshold for referring these
at-risk teenagers for mental health services.
AUTHOR INFORMATION
Correspondence:
Elyse Olshen, MD, MPH, 622 W 168th St, Room VC-402, New York, NY
10032 (eo85@columbia.edu
).
Accepted for Publication: November 14, 2006.
Author Contributions: Study concept and design: Olshen,
McVeigh, Wunsch-Hitzig, and Rickert. Analysis and interpretation
of data: Olshen, McVeigh, and Rickert. Drafting of the
manuscript: Olshen and McVeigh. Critical revision of the
manuscript for important intellectual content: Olshen, McVeigh,
Wunsch-Hitzig, and Rickert. Statistical analysis: Olshen,
McVeigh, and Rickert. Study supervision: McVeigh,
Wunsch-Hitzig, and Rickert.
Financial Disclosure: None reported.
Acknowledgment: We thank Bonnie Kerker, PhD, MPH, and Lorna
Thorpe, PhD, for their thoughtful and thorough review of the
manuscript.
Author Affiliations:
Division of General Pediatrics, Department of Pediatrics, Columbia University
Medical Center (Dr Olshen), Heilbrunn Department of Population and Family
Health, Mailman School of Public Health, Columbia University (Drs Olshen and
Rickert), and New York City Department of Health and Mental Hygiene (Drs McVeigh
and Wunsch-Hitzig), New York, NY.
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