Dating Violence Victimization: Associated Drinking and

Sexual Risk Behaviors of Asian, Native Hawaiian, and

Caucasian High School Students in Hawaii
Suhasini Ramisetty-Mikler, Deborah Goebert, Stephanie Nishimura, Raul Caetano

ABSTRACT: Ethnic minority groups such as Asian/Pacific Islanders (APIs) and native populations in Hawaii are seldom studied in
the area of intimate relationships. Using the 1999 Hawaii Youth Risk Behavior Survey, this study examined gender and ethnic
differences in experiencing physical dating violence and whether drinking (early initiation, binge drinking), unsafe sexual behaviors
(early initiation, multiple partners, use of alcohol and drugs with sex, history of sexual abuse), and suicidality constitute risk for
victimization among APIs, Native Hawaiian (NH), and Caucasian high school students in multiethnic state of Hawaii. The final
analysis included 559 boys and 683 girls. The overall rate of experiencing physical violence was 7.8% with both genders reporting
similar rates (boys 7.6%, girls 8.0%). Although not significantly different, NH students reported a higher rate (11.6%) than
Caucasians (7.3%) and APIs (6.5%). Significant bivariate associations were found between victimization and many of the risk factors.
Regression analyses indicated that students 16 years or older were nearly 3 times more at risk for experiencing dating violence. The
risk was 8-fold if youth were sexually active by age 13 compared to those who abstained. The risk is 3-fold for those who reported
prior sexual abuse. Early initiation of drinking (,12 years) and suicidality doubled the risk of being a victim. Clearly, the study
highlights the risk of experiencing dating violence when a teen engages in sex very early or uses alcohol. Schools must routinely
educate youth about various forms of dating violence, the effects of engaging in early sex, and drinking. Screening adolescents for
associated risk factors such as drinking and depression is crucial to identify victimization. Dating violence is an antecedent for adult
partner violence. Thus, by reducing youth dating violence, we may consequently reduce the incidence of adult partner violence. (J Sch
Health. 2006;76(8):423-429)

lescents has not received sufficient attention.6 Further,

D uring the last decade, there has been a continuous
growth of research on dating violence focusing on
high school and college students.1,2 There is no universal
consensus on the definition of dating violence. The US
Department of Justice defines dating violence as ‘‘the per-
petration or threat of an act of violence by at least 1 mem-
ber of an unmarried couple on the other member within the
context of dating or courtship.’’3 The Centers for Disease
Control and Prevention (CDC) defines dating violence as
encompassing ‘‘any form of sexual assault, physical vio-
lence, and verbal or emotional abuse’’ within the context of
dating.4 It occurs across all social-economic classes, and all
racial groups with most victims being young women who
are also at a higher risk for serious injury. Women aged
16-24 experience the highest rates of violence—nearly
20 per 1000 women.3,5 The terms ‘‘violence’’ and ‘‘dating
violence’’ are used interchangeably in this paper and ‘‘part-
ner violence’’ refers to violence between adult couples who
are either married or cohabiting.
Although society is becoming more aware of adult
couple violence, the issue of dating violence among ado-
Suhasini Ramisetty-Mikler, PhD, MPH, Faculty Associate (Susie.
Ramisetty-Mikler@UTSouthwestern.edu); and Raul Caetano, MD, PhD,
Professor and Dean (Raul.Caetano@UTSouthwestern.edu), University of
Texas Houston School of Public Health, Dallas Regional Campus, 6011
Harry Hines Blvd. V8.112, Dallas, TX 75390-9128; Deborah Goebert,
DrPH, Associate Professor of Psychiatry (GoebertD@dop.hawaii.edu);
and Stephanie Nishimura, MSW, Instructor (NishimuraS@do.hawaii.
edu), Department of Psychiatry, University of Hawaii, John A. Burns
School of Medicine, 1356 Lusitana Street, 4th Floor, Honolulu, HI 96813.
Work on this paper was supported by a contract (N01AA01015) from the
National Institute on Alcohol Abuse and Alcoholism (NIAAA), the National
Center for Minority Health and Health Disparities (NCMHD), and the
National Institutes of Health (NIH) to the University of Texas Houston
School of Public Health, Dallas Campus, Dallas, Texas. Dissemination is
supported by NIAAA and NCMHD Award (1 U01 AA014289-01).
fewer studies have addressed risk factors of dating violence
and the mechanism by which these factors operate. The
majority of adolescents tend to date steadily by 16, and
many experience an episode of violence as early as age 15,
suggesting that those who begin dating earlier are more
likely to become a victim.7 However, studies report varying
prevalence rates (lifetime or 12 month), for a wide range of
aggressive and coercive behaviors. Research indicates that
dating violence occurs at fairly high rates with the lower
bound around 8-9% when a specific type such as physical
violence that is most often and easily measured is consid-
ered. When several forms are considered, the rates are as
high as 96%. For example, the prevalence of dating vio-
lence including verbal, physical, and sexual among adoles-
cents ranges from 9% to 39%.6,8,9 Recent studies estimate
that 28-96% of adolescents are victims of dating violence
with some studies reporting rates as high as 60%.2,10,11
Gender differences exist in the type and rates of dating
violence experienced. Females are frequently victimized
as well as experience more severe dating violence perpe-
trated by their male partners. For example, female teens
perpetrate more or less minor acts of violence than do
male teens but are also likely to receive physical injuries
and are more likely to be sexually abused.11 Female teens
reported that male dates initiated abuse 70% of the time,
and males reported that their female dates initiated abuse
27% of the time.12 Approximately 1 in 5 high school girls
have reported being abused by a boyfriend,13 and approxi-
mately 1 out of every 3 high school and college students
have experienced sexual, physical, verbal, or emotional
violence while dating.1,14 A recent review reported that
physical violence victimization among girls range from 8%
to 57% and 6% to 38% among boys.15,16 Another study
found that 45% of female and 43% of male high school

Journal of School Health d October 2006, Vol. 76, No. 8 d ! 2006, American School Health Association d 423
students were victimized by their dating partners at least
once. Males report physical abuse (eg, being slapped and
hit with a fist or an object) more often than females, while
females report significantly more sexual abuse than males.
Both males and females report that males are frequently the
initiators of dating violence.17
The CDC reports 12-month prevalence of only physical
violence (hit, slap, or physically hurt) resulting in lower es-
timates as compared to the estimates reported above. Based
on the national Youth Risk Behavior Survey (YRBS) data,
dating violence victimization among high school students
remained constant (8.8%, 9.5%, and 8.9% in 1999, 2001,
and 2003 respectively), with apparent gender and ethnic
disparities. A higher proportion of females (12.5%) com-
pared to males (5.2%) and minority students (Black
11.6%, Hispanic 10.5% in 1999; Black 13.9%, Hispanic
9.3% in 2003) compared to White (6.7% in 1999; 7.0% in
2003) students experienced dating violence.4,18
Research on adolescent dating violence includes
Caucasian, Latino, and/or African American samples19-22
and ethnic minority groups reported the highest rates of vic-
timization.16 Data on other minority groups such as APIs and
native populations are very sparse. A recent study conducted
in Hawaii23 reported on verbal/psychological dating violence
victimization among adolescents in Asian American (Filipino
and Japanese) and 2 Pacific Islander (Native Hawaiian
[NH] and Samoan) groups. More than one half (58.3%) of
adolescents who were surveyed experienced psychological
or emotional dating violence including verbal abuse and
controlling behaviors. However, this study did not measure
physical abuse. The demographic profile of Hawaii pro-
vides an ideal setting to study minority groups including
Asians, NHs, and Pacific Islanders.24 The current study
used the 1999 Hawaii YRBS data to examine gender and
ethnic differences in experiencing physical dating violence
and whether drinking (early initiation, binge drinking),
unsafe sexual behaviors (early initiation, multiple partners,
use of alcohol and drugs with sex, history of sexual abuse),
and suicidality constitute risk for victimization.
Risk behaviors including early sexual initiation, multiple
partners, and drinking increase the chances of dating vio-
lence. Research has identified several risk factors of vic-
timization including maltreatment at home, mental health
factors, early sexual activity, and tobacco, alcohol, and
drug use causing interpersonal difficulties with peers and
dating partners.10,25,26 Adolescent girls who have experienced
dating violence may also demonstrate sequelae such as
unhealthy weight control behaviors, sexually transmitted dis-
eases, and suicidal ideation.13,22 In addition to a negative
impact on mental and emotional health, victimization may
result in poor health.17,27 Our prior work with this sample
indicated a strong association between drinking and sexual
risk behavior,28 and drinking and suicidal behavior.29 Thus,
suicidality, which is used as an indicator of mental health, is
included as a covariate in the multivariate analyses.
METHODS
Sample and Procedures
A 3-stage cluster sample design produced a representa-
tive sample of students in grades 9-12. Schools were
selected systematically with probability proportional to
enrollment in grades 9-12 using a random start. At class
424 d Journal of School Health d October 2006, Vol. 76, No. 8
level, all classes in a required subject were included in
the sampling frame. Systematic equal probability sam-
pling with a random start was used to select classes from
each school that participated in the survey. All students in
the selected classes were eligible to participate and only
those who obtained parental permission were surveyed.
The questionnaire contained 87 multiple-choice items in 6
categories of health risk behaviors among youth: behav-
iors that contribute to unintentional and intentional inju-
ries; tobacco, alcohol and other drug use; unsafe sexual
behaviors that contribute to unintended pregnancy and
sexually transmitted diseases; dietary behaviors; and
physical inactivity and individual information (gender,
age, grade, and ethnicity).
Measurements
Dating Physical Violence Victimization (Outcome Vari-
able). Students were asked if their dating partner ever hit,
slapped, or physically hurt them on purpose during the
past 12 months. Those who reported ‘‘yes’’ were identi-
fied as victims of physical abuse by dating partners.
Sexual Experiences. Age of sexual initiation: Students
were asked at what age they had their first sexual inter-
course. Multiple partners (lifetime): The students were
asked to indicate the number of people they had sex with in
their lifetime. Based on their responses, students were cate-
gorized into 2 groups—‘‘yes,’’ 2 or more partners; and
‘‘no,’’ multiple partners (those who never had sex or those
who had only 1 partner). Substance use before sex: Stu-
dents were asked about the use of alcohol or any drugs
(yes/no) in conjunction with the last intercourse. Ever been
forced to have sex: Students were asked whether they had
ever been forced to have sexual intercourse when they did
not want to.
Alcohol Use. Age of initiation: This is the age when
they first drank an alcoholic beverage including more than
a few sips. Drinking pattern (past 30 days): This variable
was constructed based on the standard measurement of epi-
sodic drinking in alcohol research.4,30,31 Two items based on
their alcohol use pattern during the past 30 days were used:
(a) On how many days did you have at least 1 drink of alco-
hol? Response categories included number of days: 0, 1, 2,
3-5, 6-9, 10-19, 20-29, and all 30 days; (b) On how many
days did you have 5 or more alcoholic drinks in a row, that
is, within a couple of hours? Response categories included
number of days: 0, 1, 2, 3-5, 6-9, 10-19, and 20 or more
days. These 2 items were cross-tabulated to determine stu-
dents drinking pattern and then placed into 1 of 3 catego-
ries: never drank (abstainer), drank 31 days but not 5 or
more drinks at any time within a 2-hour period (nonepiso-
dic), and episodic (drank 1 or more times 5 drinks or more
any time within a 2-hour period).
Suicidality (Past 12 Months). Suicidality measure used
3 questions that concern suicidal thoughts or attempts. Stu-
dents were asked if, during the past 12 months, they seri-
ously considered attempting suicide; whether they had made
plans about suicide; and how many times they actually at-
tempted committing suicide. Response choices for these
questions were either ‘‘yes’’ or ‘‘no.’’ A positive response to
any 1 of these 3 items was considered a risk for suicide.
Demographic Variables. Gender, age, grade (9th-12th),
and ethnicity: A 4-level categorical variable was derived
d ! 2006, American School Health Association
from 2 items that asked students to identify their ethnicity Predictors of Dating Violence Victimization
on the standard list and also whether or not they identify The results from the multivariate analyses (Table 3)
themselves as ‘‘Native Hawaiian’’ (yes/no). In the 1999 sur- indicate that 16-year-olds were nearly 3 times more at
vey, the NH category was added to the standard list and stu- risk for experiencing violence compared to 18-year-olds.
dents who chose NH from the standard list and those who Teens engaging in sexual activity, particularly at very
said ‘‘yes’’ that they were NHs were included under the NH young age 13 years or younger were at greatest risk
category. All others were coded based on ethnicity identi- (8-fold) compared to students abstaining from sex. Students
fied by students as ‘‘Asian/Pacific Islander,’’ ‘‘Caucasian’’ who reported prior experience of forced sex were also at
(reference group), and other/mixed or multiple races. risk of being abused. Drinking at younger age (,12
years) doubles the risk of being a victim compared to
Data Analysis those who never drank. Suicidal tendency, which repre-
Each student record was weighted to adjust for non- sents adolescents’ mental and emotional state, makes
response and for varying probabilities of sampling proce- them vulnerable for being victimized.
dures, and included a poststratification adjustment factor
calculated by gender within grade.4 The data were represen- DISCUSSION
tative of high school students in Hawaii public schools. Due The present study examined the prevalence of physical
to the multiclustered sampling design, analyses were con- dating violence victimization among high school students
ducted using SUDAAN software to adjust the standard er- in Hawaii. No significant differences were found for rates
rors.32 Cross-tabulations with chi-square statistic option were of dating victimization between male and female students.
performed to examine the bivariate associations between The overall 12-month rate of victimization is comparable
dating violence victimization and ethnicity, drinking practi- to the national victimization rate reported by the YRBS.
ces (early initiation, binge drinking), unsafe sexual behaviors Although not statistically significant, NH students re-
(early initiation, multiple partners, use of alcohol and drugs ported the highest rate (12%) that is 2 times higher than
with sex, history of sexual abuse), and suicidality. Results the rate reported by the majority group, API students
are reported in weighted percentages with their unweighted (6.5%).
sample size. For multivariate analyses, logistic regression
model was run for dating violence victimization as the depen-
dent variable with sexual experiences, episodic drinking pat-
tern, age at first drink, as independent variables controlling
Table 1
for covariate suicidality and demographic factors.
Demographic Characteristics of Students Who
Experienced Dating Violence Victimization
RESULTS
Demographics
Experienced
Respondents included 559 male and 683 female high Dating
school students, and the overall student response rate was Violence Statistic
63% (53% female and 47% male). Nearly one half were (Weighted Percent) v2 (df)
APIs (45.3%) and one fifth were NHs (17.3%), followed by
Caucasians (14%). The remaining students were from other Gender
ethnic backgrounds or of multiple backgrounds (23.4%). Male (n ¼ 555) 7.6 0.05 (1)
Female (n ¼ 680) 8.0
Dating Violence Experience Ethnicity
The overall prevalence of experiencing dating violence Asian/Pacific Islander 6.5 6.4 (3)
in this sample is 7.8% (n ¼ 101). As indicated in Table 1, (n ¼ 564)
similar rates of experience of dating violence were Native Hawaiian (n ¼ 200) 11.6
observed among both boys (7.6%) and girls (8.0%). Other/multiple/ 8.0
Although not significantly different from other ethnic American Indian/
groups, NH students reported experiencing violence at the Black/Hispanic (n ¼ 284)
highest rate and APIs at the lowest rate. Significant age White (n ¼ 170) 7.3
differences were observed in reporting violence with the Age (in years)***
highest rate around 16 years of age. No specific grade 13-14 (n ¼ 159) 5.5 38.2 (4)
differences were observed. 15 (n ¼ 317) 6.0
Experiencing dating violence is significantly associated 16 (n ¼ 328) 11.8
with all the risk factors under consideration (Table 2). Those 17 (n ¼ 294) 8.5
who never engaged in sex experienced the lowest rate of #18 (n ¼ 140) 4.3
violence, and those who initiated sexual activity very early, Grade
13 years or younger, experienced the highest. Those who 9th (n ¼ 341) 8.4 0.3 (3)
reported lifetime multiple partners, those who used alcohol 10th (n ¼ 324) 7.7
and drugs in conjunction with sex, and those who were vic- 11th (n ¼ 314) 7.4
tims of forced sex in their lifetime reported higher rates of 12th (n ¼ 258) 7.7
dating violence. Those who initiated drinking very early in
their life ("12 years), those who binge drink, and those *** p , .001.
with suicidal thoughts reported higher rates.

Journal of School Health d October 2006, Vol. 76, No. 8 d ! 2006, American School Health Association d 425
 In this sample, 16-year-olds, compared to 18 or older,
are nearly 3 times more at risk for experiencing violence.
As research suggests, many adolescents experience some
form of dating violence before they graduate from high
school,7 and as a dating relationship becomes more serious
the potential for and nature of violent behavior also esca-
lates.33 Several studies have shown that victims of violence
tend to be more absent from school and some drop out of
school prematurely,34 leading therefore to decrease in rates
assessed in the school settings over time. The study find-
ings clearly indicate that the risk of being victimized is
greater if teens begin to engage in sexual activity at a very
young age. Drinking at younger age (,12 years) doubles
the risk of being a victim compared to those who never
drank. Early sexual activity was also associated with the
risk of having multiple partners and alcohol use. Our prior
work with this sample indicated that the younger the age of
initiation, it is more likely that teens would have multiple
sexual partners. NHs and Caucasian students are more
likely to have multiple partners in their lifetime as they also
tend to initiate sex earlier. Findings also suggest that ado-
lescents who drink (episodic or nonepisodic) or use drugs
are more likely to be sexually active as well as engage in
unsafe behaviors such as sex with multiple partners.28
Victims of forced sex were also more likely to experi-
ence physical abuse in dating relationships. The violence

Table 3
Odds Ratios and 95% CI From Logistic Regression
Model Predicting Dating Violence
Table 2 Victimization (n ¼ 1035)
Drinking, Sexual Risk Behaviors, and Mental
Health Associated With Dating Violence
Victimization Adjusted
Predictor Odds Ratio 95% CI
Experienced
Dating Male (ref: female) 1.3 0.7-2.4
Violence Ethnicity (ref: white)
(Weighted Statistic Asian/Pacific Islander 1.0 0.6-1.8
Percent) v2 (df) Native Hawaiian 1.4 0.7-3.0
Other/multiple/ 0.8 0.3-2.6
Age of sexual initiation (in years)*** American Indian/
16 or older (n ¼ 126) 9.8 Black/Hispanic
14-15 (n ¼ 229) 13.0 68.3 (3) Age (ref: #18 years)
13 or younger (n ¼ 151) 21.8 13-14 2.3 0.7-7.5
Never had sex (n ¼ 700) 2.5 15 1.7 0.5-5.7
2 or more sexual partners 17.0 32.0 (1) 16 2.8* 1.1-7.0
(lifetime)*** (n ¼ 311) 17 2.3 0.9-6.0
One partner or never 4.3 Age of sexual initiation
had sex (n ¼ 895) (ref: never had sex)
Used alcohol or drug last 15.1 7.5 (1) 13 or younger 7.6*** 2.5-23.4
sexual activity** (n ¼ 126) 14-15 3.9** 1.5-10.0
Did not use or no sexual 6.8 16 or older 3.5*** 1.8-6.9
activity (n ¼ 1078) Multiple (2 or more) sexual 0.9 0.4-1.9
Ever been forced to 27.4 22.5 (1) partners (lifetime) (ref: 1
have sex*** (n ¼ 105) person or no sex)
Never been forced (n ¼ 1134) 6.2 Used alcohol or drug last 0.5* 0.3-0.9
Age of first drinking (in years)*** sexual activity (ref: no)
15 or older (n ¼ 223) 8.6 Ever been forced to have 3.1** 1.6-5.7
13-14 (n ¼ 274) 8.0 69.2 (3) sex (ref: no)
12 or younger (n ¼ 366) 13.1 Age of first drinking
Never drank (n ¼ 256) 3.0 (in years) (ref: never drank)
Drinking pattern (past 30 days)*** 12 or younger 2.2** 1.3-3.8
Binge drinking (n ¼ 326) 14.6 27.1 (2) 13-14 1.3 0.5-3.4
Drank, but no 8.3 15 or older 1.8 0.7-4.7
binging (n ¼ 204) Drinking pattern past
Never drank (n ¼ 664) 4.8 30 days (ref: never drank)
Suicidality (past 12 months)*** Binge drinking 1.2 0.5-2.5
Serious thoughts 15.5 21.6 (1) Drank, but no binging 1.0 0.4-2.6
about suicide, planned Suicidality (past 12 months) 1.9** 1.2-3.1
or attempted suicide (n ¼ 289) (ref: no)
Did not feel suicidal (n ¼ 938) 5.8 R2 ¼ 9.3%

** p , .01; *** p , .001. * p " .05; ** p " .01; *** p " .001.

426 d Journal of School Health d October 2006, Vol. 76, No. 8 d ! 2006, American School Health Association
literature provides concrete evidence that childhood expe-
riences of physical and sexual abuse are risk factors for
being a victim of domestic violence in adulthood30 as well
as alcohol abuse and problems.35,36 In this study, however,
it is not possible to explore at what age these adolescents
have been victims of forced sex and who the perpetrator
was. Studies37,38 note that children exposed to violence
exhibit elevated rates of many behavior problems including
externalizing and internalizing problems, substance abuse
problems, separation anxiety, social skill deficits, school
problems, attention deficits, posttraumatic stress disorder
and higher rates of aggression and violence in their own
behavior patterns. Evidence linking these predictors to vio-
lence is also based on Bandura’s social learning theory,
which suggests that conflict resolution through violence in
adult life can result from learned models of behavior dur-
ing childhood. Regrettably, these variables were not
included in the current study as they were not assessed in
the YRBS.
Findings suggest that suicidality, the state of emotional
and mental health, makes them vulnerable to being vic-
timized. Many adolescents experience intense emotional
states and depression, and in an effort to develop intimate
relationships, they may be tolerant of minor forms of vio-
lence to begin with. The rate of suicide among American
adolescents increased nearly 3-fold between the early
1960s and the late 1980s;39 however, there has been a gen-
eral decline in adolescent suicides since 1994.40 Nearly 3
million 12- to 17-year-old adolescents in the United States
contemplated suicide, and 37% of these adolescents at-
tempted suicide.41 Depression has been identified as one of
the risk factors for adolescent suicide behaviors40,42 along
with alcohol use.29 Previous local studies indicate that the
NH adolescents have higher rates of suicide attempts in
comparison to non-Hawaiian adolescents.43 NH adolescents
were found to have a risk for suicide attempts nearly 3
times higher than non-Hawaiian adolescents aged 10-14
and greater than 7 times higher than non-Hawaiian adoles-
cents aged 15-19.44 Although not significantly different,
NH students reported experiencing violence at a higher
rate. Our earlier studies using this sample indicated that
drinking was the best predictor for all suicide indicators.29
However, further studies might be helpful to understand the
mechanism of alcohol use coupled with depression and
early sexual activity in this ethnic group. Because of the
cross-sectional nature of the study, the temporality and the
mechanism cannot be addressed. For instance, a student
might be depressed and attempts to commit suicide as
a result of their current dating violence experiences or vice
versa. Further, a student might be drinking because of the
pressure from his or her dating partner. Dating partners
may not necessarily be their own classmates; they could be
outsiders and older college students.
Violence between 2 individuals in a relationship is
a complicated and multifaceted problem, and many varia-
bles including family environment, demographic region,
ethnicity, and substance use contribute to abusive relation-
ships. Findings of this study clearly recognize the role of
alcohol use and engaging in sexual activity at an earlier
age in increasing the risk of experiencing dating violence.
Adolescent’s experience of forced sex is also associated
with dating violence. According to Riggs and O’Leary,45
aggressive behaviors are set into motion by situational vari-
Journal of School Health d October 2006, Vol. 76, No. 8
ables such as a history of personal exposure to violence and
use of drugs and/or alcohol. However, adolescents being
young and highly impulsive and emotional, they may inter-
pret aggression as a legitimate response to conflict. In order
to have a meaningful change in the incidence of dating vio-
lence, a strategic plan at the school level must be imple-
mented to identify at-risk students and provide timely
intervention through education. The incidence of dating
violence among youth is substantial and predicts future
interpersonal risk for unhealthy, harmful relationships. Pre-
vention of domestic violence will require coordinated ef-
forts of local communities, schools, health care providers,
and all levels of government.46 All 50 states and the District
of Columbia have laws against dating violence including
sexual assault and stalking. However, the specific term
‘‘dating violence’’ is almost never used in these laws. Age
requirements and the language of the laws vary by state.3
School-based interventions such as Safe Dates are promis-
ing in preventing and reducing dating violence for as many
as 4 years after the program47 by positively changing cogni-
tive mediating variables.1 Implementing such cognitive and
behavioral-based programs in schools is necessary and cru-
cial in reducing dating violence.
There are several limitations to this study that need to
be acknowledged. These limitations include low student
response rate, underreporting of violence experiences due
to the content of the questionnaire, and reluctance to dis-
close sexual and substance use behavior. These data rep-
resent only public school students present on the day the
survey was administered and, therefore, do not represent
all persons in this age group. Extent of under- or over-
reporting of behaviors cannot be determined. The survey
questions demonstrated good test-retest reliability, but
several items need to be examined further.48 The cross-
sectional nature of the study does not allow the establish-
ment of a causal relationship and is limited in explaining
complex interactions among risk behaviors. For example,
sexual experience such as forced sex was a strong predictor
of victimization. However, the directionality is hard to
establish because of the cross-sectional nature of the data.
Further, because of the ambiguity of the question asked in
the survey by the CDC, the context in which the dating vio-
lence has occurred, frequency of occurrences, severity of
violence, and whether it is in retaliation from male to
female or female to male is unknown.
Regression models included only individual factors but
not family/parental factors (parental alcohol/drug use,
childhood experiences of violence) as they were not col-
lected in the survey. Nevertheless, the study findings sug-
gest that alcohol use and unhealthy sexual behaviors
rather than ethnicity significantly predicted victimization
among high school students in Hawaii. Finally, the study
is limited to the experiences of physical violence and
does not address other forms of violence such as sexual,
verbal, or psychological abuse that are perhaps widely
prevalent.
CONCLUSIONS
Dating violence is a public health concern as it is an
antecedent for partner violence in adulthood. Accurate
definition and scope of the problem must be determined
in order to plan future interventions. The study findings
d ! 2006, American School Health Association d 427
document that use of alcohol and early initiation of sex
increase the risk of violence victimization. Research
documents that behaviors such as drinking, one of the
most powerful predictors of risky sexual practices such as
having multiple sexual partners, depend directly on self-
control and life skills. The detrimental effect of alcohol
on sexual behavior is evident and supports previous
research based on problem-behavior theory signifying that
early age of onset for substance use is associated with
engaging in multiple health risk behaviors among adoles-
cents.49 These findings also underscore the importance of
abstinence, thus helping teens to delay sexual activity and
suggest a need for programs emphasizing abstinence from
alcohol and sex. Healthy ways of interacting must be inte-
grated into the health education curriculum to enhance
skills that promote nonviolent conflict resolution. Dating
violence, including minor acts such as a simple slap or
being pushed or shoved, must be addressed because they
are the precursors of partner violence in adult relationships.
Pediatricians and school health counselors must provide
routine guidance to increase awareness regarding various
forms of violence and how to identify early signs of abusive
relationships. Reducing adolescent dating violence may
consequently reduce the incidence of partner violence in
adulthood. j
References
1. Avery-Leaf S, Cascardi M, O’Leary KD, Cano A. Efficacy of a
dating violence prevention program on attitudes justifying aggression.
J Adolesc Health. 1997;21(1):11-17.
2. Halpern CT, Oslak SG, Young ML, Martin SL, Kupper LL. Partner
violence among adolescents in opposite-sex romantic relationships: find-
ings from the National Longitudinal Study of Adolescent Health. Am J
Public Health. 2001;91(10):1679-1685.
3. U.S. Bureau of Justice. The violence against women act of 2000.
Available at: http://www.ojp.usdoj.gov/vawo/laws/vawa_summary2.htm.
2001. Accessed July 15, 2005.
4. Centers for Disease Control and Prevention. Youth risk behavior
surveillance—United States, 1999. MMWR. 2000;49(SS-05):1-96.
5. Rennison CM, Welchans S. BJS Special Report: Intimate Partner
Violence. NCJ 178247, USDOJ-OJP; 2000.
6. Malik S, Sorenson SB, Aneshensel CS. Community and dating vio-
lence among adolescents: perpetration and victimization. J Adolesc
Health. 1997;21(5):291-302.
7. Henton J, Cate R, Koval J, Lloyd S, Christopher S. Romance and
violence in dating relationships. J Fam Issues. 1983;4:467-482.
8. Bergman L. Dating violence among high school students. Social
Work. 1992;37:21-27.
9. Smith JP, Williams JG. From abusive household to dating violence.
J Fam Violence. 1992;7:153-165.
10. Kreiter SR, Krowchuk DP, Woods CR, Sinal SH, Lawless MR,
DuRant RH. Gender differences in risk behaviors among adolescents who
experience date fighting. Pediatrics. 1999;104(6):1286-1292.
11. Cohall A, Cohall R, Bannister H, Northridge M. Love shouldn’t
hurt: strategies for health care providers to address adolescent dating vio-
lence. J Am Med Womens Assoc. 1999;54(3):144-148.
12. Molidor C, Tolman RM. Gender and contextual factors in adoles-
cent dating violence. Violence Against Women. 1998;4(2):180-194.
13. 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. JAMA.
2001;286:572-579.
14. Mitchell A. Teen dating violence. Protecting Sexually Active
Youth. 1996;4(1):1-5.
15. Hickman LJ, Jaycox LH, Aronoff J. Dating violence among ado-
lescents. Trauma Violence Abuse. 2004;5(2):23-142.
428 d Journal of School Health d October 2006, Vol. 76, No. 8
16. Howard DE, Wang MQ. Psychosocial factors associated with ado-
lescents boys’ reports of dating violence. Adolescence. 2003;38(151):519-
533.
17. O’Keefe M, Trester L. Victims of dating violence among high
school students. Violence Against Women. 1998;4(2):195-223.
18. Centers for Disease Control and Prevention. Youth risk behavior
surveillance—United States, 2003. MMWR. 2004;53(SS-02):1-96. Available
at: http://www.cdc.gov/mmwr/PDF/SS/SS5302.pdf. Accessed June 15, 2005.
19. Schwartz M, O’Leary SG, Kendziora KT. Dating aggression
among high school students. Violence Vict. 1997;12(4):295-305.
20. Howard DE, Wang MQ. Risk profiles of adolescent girls who were
victims of dating violence. Adolescence. 2003;38(149):1-14.
21. Valois RF, Oeltmann JE, Waller J, Hussey JR. Relationship
between number of sexual intercourse partners and selected health risk be-
haviors among public high school adolescents. J Adolesc Health.
1999;25(5):328-335.
22. Wingood GM, DiClemente RJ, McCree DH, Harrington K, Davies
SL. Dating violence and the sexual health of black adolescent females.
Pediatrics. 2001;107(5):E72.
23. Choi-Misailidis S, Mayeda DT, Hishinuma ES, Nishimura ST,
Chesney-Lind M. Dating violence victimization among Asian American
and Pacific Islander youth. Manuscript under review. 2006.
24. US Census Bureau. 2000 US Census Bureau. Available at: http://
quickfacts.census.gov/qfd/states/15000.html 2000. Accessed June 20, 2005.
25. Rogosch FA, Cicchetti D, Aber JL. The role of child maltreatment
in early deviations in cognitive and affective processing abilities and later
peer relationship problems. Dev Psychopathol. 1995;7(4):591-609.
26. Shields A, Cicchetti D. Parental maltreatment and emotion dysre-
gulation as risk factors for bullying and victimization in middle childhood.
J Clin Child Psychol. 2001;30(3):349-363.
27. Coker AL, McKeown RE, Sanderson M, Davis KE, Valois RF,
Huebner ES. Severe dating violence and quality of life among South Caro-
lina high school students. Am J Prev Med. 2000;19(4):220-227.
28. Ramisetty-Mikler S, Caetano R, Goebert D, Nishimura S. Ethnic
variation in drinking, drug use, and sexual behavior among adolescents in
Hawaii. J Sch Health. 2004;74(1):16-22.
29. Nishimura ST, Goebert DA, Ramisetty-Mikler S, Caetano R. Ado-
lescent alcohol use and suicide indicators. Cultur Divers Ethnic Minor
Psychol. 2005;11(4):309-320.
30. Caetano R, Cunradi C, Clark CL, Schafer J. Intimate partner vio-
lence and drinking patterns among White, Black, and Hispanic couples in
the US. J Subst Abuse. 2000;11(2):123-138.
31. Naimi TS, Brewer RD, Mokdad A, Denny C, Serdula MK, Marks
JS. Binge drinking among US adults. JAMA. 2003;289:70-75.
32. Research Triangle Institute. SUDAAN Software for the Statistical
Analysis of Correlated Data. Version 13.0. Research Triangle Park, NC:
Research Triangle Institute; 2005.
33. National Coalition Against Domestic Violence. Teen Dating Vio-
lence Resource Manual. Denver, Colo: Dating Violence Resource Center;
1997. Available at: www.ncvc.org/dvrc. Accessed June 15, 2005.
34. Dyregrov A. Educational consequences of loss and trauma. Educ
Child Psychol. 2004;21(3):77-84.
35. Ireland T, Widom CS. Childhood victimization and risk for alco-
hol and drug arrests. Int J Addict. 1994;29(20):235-274.
36. Miller BM. Investigating links between childhood victimization
and alcohol problems. In: Martin SE, ed. Alcohol and Interpersonal Vio-
lence: Fostering Multidisciplinary Perspectives (Vol. NIAAA Research
Monograph No. 24). Rockville, Md: NIAAA; 1993:315-323.
37. Barnett OW, Miller-Perrin CL, Perrin RD. Family Violence Across
the Lifespan. Thousand Oaks, Calif: Sage; 1997.
38. Bisson JI, Shepherd JP. Psychological reactions of victims of vio-
lent crime. Br J Psychiatry. 1995;167(6):718-720.
39. National Center for Health Statistics. Vital Statistics Mortality
Data, 1950-1995. Hyattsville, Md: Centers for Disease Control and Pre-
vention; 1997.
40. U.S. Public Health Service. The Surgeon General’s Call to Action
to Prevent Suicide. Washington, DC: U.S. Public Health Service; 1999.
41. Substance Abuse and Mental Health Services Administration. Sui-
cide, depression, and youth drinking. National Clearing House for Alcohol
and Drug Information Report. U.S. Department of Health and Human
Services. Prev Alert. 2002;5(17).
42. Johnson GR, Krug EG, Potter LB. Suicide among adolescents and
young adults: a cross-national comparison of 34 countries. Suicide Life
Threat Behav. 2000;30(1):74-82.
d ! 2006, American School Health Association
 43. Yuen NY, Nahulu LB, Hishinuma ES, Miyamoto RH. Cultural
identification and attempted suicide in Native Hawaiian adolescents. J Am
Acad Child Adolesc Psychiatry. 2000;39(3):360-367.
44. Goebert D, Birnie KK. Injury and disability among Native Hawai-
ians. Pac Health Dialog. 1998;5(2):253-259.
45. Riggs DS, O’Leary KD. A theoretical model of courtship aggres-
sion. In Pirog-Good MA, Stets JE, eds. Violence in Dating Relationships.
New York: Praeger; 1989:53-71.
46. Close SM. Dating violence prevention in middle school
and high school youth. J Child Adolesc Psychiatr Nurs. 2005;18(1):
2-9.
47. Foshee VA, Bauman KE, Ennett ST, Linder GF, Benefield T,
Suchindran C. Assessing the long-term effects of the Safe Dates program
and a booster in preventing and reducing adolescent dating violence
victimization and perpetration. Am J Public Health. 2004;94(4):619-624.
48. Brener ND, Kann L, McManus T, Kinchen SA, Sundberg EC,
Ross JG. Reliability of the 1999 Youth Risk Behavior Survey Question-
naire. J Adolesc Health. 2002;319(4):336-342.
49. DuRant RH, Smith JA, Kreiter SR, Krowchuk DP. The relation-
ship between early age of onset of initial substance use and engaging in
multiple health risk behaviors among young adolescents. Arch Pediatr
Adolesc Med. 1999;153(3):286-291.

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