Causes and consequences of adolescent dating violence: a systematic review

Abstract: Background: Adolescent dating violence (ADV) is highly prevalent and can have serious health consequences, including homicides, and be a predictor of intimate partner violence in adulthood. This review aims to systematize the knowledge produced in recent empirical investigations in health that focus on the causes and consequences of ADV to subsidize new research and prevention programs. Methods: Review of studies published in PubMed over the last five years through MeSH Database: “Intimate Partner Violence” AND “Adolescent” NOT “prevention and control” NOT “Adult”. Results: We analyzed 35 papers, of which 71.4% were developed in the USA. Some studies have shown prevalence greater than 50% in both genders, both as victims and perpetrators, with more serious consequences for females. Three main thematic cores were identified in the studies: ADV-related vulnerabilities, circularity of violence and ADV-associated health problems. Data indicate that ADV is deep-seated in the patriarchal culture and is more frequent in connection with racism, heterosexism and poverty. It occurs in a circular way and is linked to other forms of violence in different contexts (family, school, community and social media). It is associated with health problems such as depression, anxiety, low self-esteem, alcohol and drugs abuse and unprotected sex. Conclusions: The knowledge produced in the studies reviewed reveals the urgency and importance of implementing early preventive actions in schools, involving families and the community. These should focus on the deconstruction of current cultural gender patterns, based on their historical origin, in order to support emancipatory and liberating pedagogical approaches.


Introduction
dolescent Dating Violence (ADV) is defined as any intentional, psychological/emotional, physical or sexual abuse that occurs between people involved in a romantic relationship. 1 It is a significant event in several parts of the world 2 and can have immediate and late health consequences, and women are the most serious and fre-quent injury victims. 3,4 ADV is often not perceived by those involved or valued by society, although it may culminate in murders, usually of women, as in abusive relationships in adulthood. 5 ADV is a predictor of marital violence in adulthood. 5 Femicide in adulthood has been addressed as an important public health problem and has been gaining prominence also concerning the health of adolescents. 6,7 Several population-based studies have shown health problems associated with ADV, including depression, anxiety, and alcohol and other drugs abuse. 8 Other authors point out the sexual risk behavior of STI/AIDS and the low academic performance as negative consequences of ADV 9 . In addition, there is evidence that violence in other settings, such as in the family and neighborhood may be related to ADV. 8 ADV is a health problem in different parts of the world and one of the main issues to be tackled. 7 Consequently, several policies and action programs have been implemented, especially in the school setting, the main arena for socialization and construction of adolescents' identity. 10,11 However, the issue is hardly discussed in developing countries, and knowledge about the subject is still incipient, hampering sensitization of people about the problem and policy formulation to address it. 12 This bibliographic review is being proposed considering the challenges faced in addressing situations of violence involving intimate adolescents and the recognition of the need to act early to prevent this type of violence. It aims to systematize the knowledge produced in empirical investigations in the field of health focused on the causes and consequences of ADV. This review intends to subsidize new research and prevention programs that contribute to curb violence in intimate adolescent relationships.

Methods
This is a review of studies published in PubMed, the most important database of health studies. This database was chosen because it is the one that gathers the largest number of bibliographical sources from around the world in the field of health and journals of recognized quality. In general, papers published in qualified journals from other databases are also found in PubMed.
The following search strategy was followed on June 28, 2017 through MeSH Database: "Intimate Partner Violence" AND "Adolescent" NOT "prevention and control" NOT "Adult" in the last five years. Most of the articles found with this search strategy predominantly use the terminology Dating Violence.
Fifty-nine papers were made available. Then, after reading abstracts, 13 papers were excluded from the established inclusion criteria -papers with full-text in English, derived from empirical research with adolescents on ADV: 9 because they were studies with children and 4 with adults. After further reading, eleven more papers were excluded: 6 because they were not on the subject of the study, 2 because the full-texts were not available, 2 because they were review papers and 1 because they were published in German. Thus, a total of 35 papers were analyzed, as can be seen in the chart below ( Figure 1).
The thematic analysis of papers was carried out. First, separately by each author. Subsequently, authors showed each other's analyses and reached the final categories through dialogue with literature. The following steps marked by Minayo 13 were followed: comprehension reading and rereading to familiarize with data; identification of themes of analysis considering the objectives of the study; classification of themes and comparative dialogue with literature; and elaboration of interpretative synthesis.
In addition to papers of this review shown in Tables 1, 2 and 3 in the results, other 19 papers included in the introduction to the text and in data discussion were read.

Results and Discussion
Most of the studies used a quantitative method, of which 25 (71.4%) were cross-sectional studies and nine (25.7%) were longitudinal cohort studies. Only one (2.8%) of the studies used a qualitative method using focal groups and participant observation. As for the location, 26 were conducted in North America (25 in the U.S. and one in Canada); four in Africa (1 in Egypt, 2 in South Africa and 1 in several countries -Egypt, South Africa, Liberia, Kenya, Malawi, Rwanda and Zambia); 4 in Europe (1 UK, 2 Spain and 1 Sweden); and 1 in Asia (Japan).
ADV prevalence rates were variable, with the highest one found at 70.7%, in a study carried out in Egypt with 400 adolescents of both genders, referring to any type of ADV, whether psychological, physical or sexual. 14 The second highest rate was 70%, shown in a research developed in the U.S. with 399 adolescents. 15 A study conducted in seven African capitals evidenced ADV prevalence ranging from 26.5% to 48%. 16 In other studies with a higher number of adolescents, rates were lower: 33.4% in a study of 14,190 secondary school students in the U.S. 17 and 27.7% in a sample of 6,390 American adolescents. 18 It is worth noting that there are different types of dating-related abuse and that, according to Reidy's study, 19 few adolescents engage in multiple forms of violence and most young people are not perpetrators.
Considering the aim of this review to highlight the causes and consequences of ADV, three main thematic cores were identified in the studies: I-ADV-related vulnerabilities; II-circularity of violence; and III-ADVassociated health problems. We sorted papers in three tables, in a didactic way according to the main thematic core that originated them, although papers identified drew characteristics of more than one thematic core or all, as de scribed and analyzed below. Tables 1, 2 and  3 show the study design, location, thematic categories, objectives, sample studied and results/conclusions. They are shown at the end of each category.      Traditional and cyber abuse were positively associated. Cyber abuse perpetration in the previous year predicted cyber abuse perpetration 1 year later. * TDV: Teen Dating Violence; ** IPV: Intimate Partner Violence; *** RR: Relative Risk

I -ADV-related vulnerabi lities
The concept of vulnerability applied to health emerged and gained momentum in the 1990s in the face of the HIV/AIDS epidemic. 20 It refers to a set of aspects, not only individual, but also collective and social that lead to greater susceptibility to illness. In the analysis of papers in this bibliographic review, we observed that certain vulnerabilities, similar to those observed in the HIV/AIDS epidemic, are identified as ADV-related, including gender inequality, low age, racial discrimination, homophobia and poverty.
Among these factors, what stands out the most in the reviewed works is gender inequality. This feature underpins the patriarchal culture, in which the social roles played by men and women are assigned different powers. Men are domineering and women dominated, which makes men naturally aggressive and strong, and women, in turn, fragile and helpless. Oftentimes, this domination relationship that justifies violence in certain situations is not perceived even in cases of physical abuse that are sometimes considered normal in a dating relationship. 3 The patriarchal culture favors the boys' perpetration of violence, because when they feel their virilities threatened, they try to impose themselves by violent means and consider this violence of lesser importance. 21 Thus, gender inequality is a risk factor for violence against women in this age group. 22,23 The revised papers reveal that both boys and girls are ADV victims and perpetrators, with prevalence varying according to the stage of adolescence. In some phases of adolescence, women are more perpetrators of physical and psychological violence than men, 24,25 differing from the characteristics of intimate partner   26 However, as for sexual violence, they are the main victims. Although reciprocal involvement in violence is pointed out as the most common pattern of ADV, the consequences are always worse for girls. 14,27,28 Gender violence, such as early marriage, abusive sexual behavior, deprivation of work and inheritance and the impediment of family visits 29 is trivialized or unrecognized in certain cultures. On the other hand, in cultures where this is recognized, ADV is less frequent, just as adolescents have more conservative sexual behavior and more egalitarian relationships. 30 Racial discrimination, poverty and heterosexism are vulnerabilities found in the studies analyzed that were associated to ADV. The World Conference Against Racism held in Durban in 2001 31 stresses the importance articulating between gender discrimination, racism, homophobia and class exploitation, common oppressions in the international globalization context. Alleyne-Green et al 32 observed that ADV is particularly more likely in non-white girls.
A higher prevalence of ADV among non-whites was also found by Earnest et al 33 in a study with 75,590 students. Some papers have shown that ADV is more prevalent in poverty contexts, especially in African Americans and among couples of sexual minority. 17,34,35 The higher rate of violence in same-gender couples in some studies leads to a reflection on the weight of heterosexism and homophobia in the context of social vulnerability for the occurrence of ADV. 18,36,37

II -Circularity of Violence
Violence in other contexts, such as in the family and in the neighborhood seems to be related to ADV, 15,38,39 corroborating with the idea of circularity of violence brought by some authors. 40,41 It is observed that structural violence of society that denies citizenship to some social groups is also related to community, intrafamily and interpersonal violence. It occurs in circular fashion in the diverse environments of adolescents' socialization, dating relationships, family and friends. 2 Patterns of social interaction learned throughout life may predict future violent behavior in intimate relationships. However, not all who are exposed to violence become aggressive adolescents. 19 Cultural factors influence the emergence of ADV. A study conducted in United Kingdom and Spain revealed similar ADV rates in both countries. However, severe forms are more common in Spain, since in this country, milder expressions of violence are widely accepted as a normal event. 42 Part of the studies of this review evidences an association between hostile treatment, anger and aggressive responses and ADV. 24 Other studies have shown corporal punishment in the family and at school as ADVassociated factors. 14 ADV-bullying was a frequent finding. 17,18 The history of ill-treatment in childhood, witnessing intrafamily violence, poor care provided by parents and feeling insecure at school are found in several studies as strongly associated with ADV. 16,[32][33][34] Psychological distress may be the causal role in the relationship between domestic violence and victimization in adolescence dating. 43 In addition, ADV can create a relationship pattern that persists in adulthood. 44 The ADV rate is high among adolescents, estimated at 70% in a study with 299 mothers who were victims of domestic violence and their adolescent children. Adolescents reported perpetrating at least one of three dating abuse types. 15 On the other hand, adolescents with a good family relationship, in which both parents are present, engage less in ADV and are less likely to tolerate or perpetrate some kind of violence in intimate relationships. 27,45 ADV perpetration is also lower when adolescents have more propositional peer networks and neighborhood social control 41 .The quality of the neighborhood is itself a contextual factor that can influence the emotional well-being of individuals. The bad neighborhood objective conditions, including poverty and instability of residence cause emotional distress that can increase the probability of ADV. 38 Another context associated to ADV identified in papers was that of virtual violence. 46 The popularity of using text messages, social media and Internet among adolescents can create opportunities for dating violence through virtual media. It includes attitudes such as monitoring, control, harassment or verbal and emotional abuse of a partner through technology, cell phones, threatening text or voice messages, or online publications of insulting content.
The consequences of ADV observed in the studies analyzed were low self-esteem, depressive symptoms, psychiatric disorders, drug abuse, risky sexual behavior and low academic performance. 18,32,50 The more intense the violence, the greater the prevalence of severe psychiatric disorders common in adolescents. The association between psychiatric disorders and ADV varies with age, and the strength of the association decreased in magnitude with age. 51 The acceptance of psychological abuse seems to mediate the association between ADV and psychiatric disorders such as depression, anxiety and hostility. 44 The heavy consumption of alcoholic beverages and other drugs is associated with an increased perpetration of physical violence in dating. 41 Copp 38 identified that symptoms of anger and depression are found in cases of intimate partner violence associated with the disadvantageous neighborhood.
ADV is related to the use of chemical substances. 52 This association is found when both partners are drug users, when only one is a drug user and with different types of drugs (alcoholic beverages, marijuana). 53 In some studies, there was an intersection between ADV and substance use as a means of dealing with the disruption of the love relationship. 54

Final Considerations
This review evidences that the phenomenon of ADV is complex since it involves multiple causes of an individual, social and cultural nature that require intersectoral actions to address it. The revised studies further clarify the potential health impairments resulting from ADV. However, it is worth highlighting the lack of research on homicides of adolescent and young women that could reveal other relevant angles of the problem to public health. The main recommendation of this review is the urgent and essential need of preventive actions that focus on the deconstruction of current cultural patterns of gender based on the revival of its history, in order to support emancipatory and liberating pedagogical approaches to be implemented early in schools, involving families and the community.