White Book

Children and young people - Chapter 12

Dating violence and technology-facilitated abuse

      1. Dating violence and technology-facilitated abuse

‘I was so inexperienced, I didn’t know really what to think about it. And I was like, is this normal? Like, I didn’t know ... so, I knew that I really hated it and it was a horrible experience, but I think I, like, rationalised it in my head.’

Key messages

  • Dating violence is a serious, important and prevalent public health problem among Australian young people.1
  • A young person who is experiencing or using violence in their intimate relationships may present with physical health problems, mental health issues, risk-taking behaviour or other social and behavioural issues.2,3
  • While it is acknowledged that young women experience violence from male as well as female partners, there is evidence that dating violence is most likely to be perpetrated by a young man towards a young woman.1
  • Technology-facilitated abuse is an important form of abuse experienced by young as well as older women and can affect a victim/survivor’s access to social networks and seeking help.4
  • Victims/survivors can be supported through supportive counselling, education and addressing health concerns.

Dating violence

Dating violence is under-researched, particularly in Australia, with little known about its prevalence or the young people who use or experience dating violence in Australia. While it is acknowledged that dating can occur at all ages and stages of life, we will focus here on dating within young people’s relationships, typically in the age range of 16–25 years. Young people experiencing dating violence may be younger or older than this age group.

Similar to the definition of adult intimate partner abuse/violence (IPAV) described in Chapter 2: Intimate partner abuse and violence: Identification and initial response, dating violence is defined as any form of IPAV within young people’s relationships, excluding marriage or cohabitation.5 The abuse may be physical, emotional, sexual or coercive control.

Technology-facilitated abuse also commonly occurs within young people’s dating and casual relationships and is discussed in this chapter.

In Australia, the term ‘dating violence’ is not commonly used, and violence within young people’s relationships tends to be embedded within the definitions of IPAV and domestic violence.1,6,7 However, there are significant differences between adult IPAV and dating violence among young people.

Dating violence is unique because of the various developmental stages that young people are at and because dating partners do not usually have shared assets or children, although some couples may be cohabiting if they are in a committed stage of their relationship.8 As with adult IPV, dating violence is usually gendered within heterosexual relationships, with young women mostly being the victims/survivors and young men the perpetrators of violence.1

Dating violence is a serious, important and prevalent public health problem in Australia.1 It is estimated to affect around one in four young women, although figures could be higher due to under-recognition, underreporting9,10 and inconsistencies in defining and measuring it.11,12 Dating violence is important to identify and manage in the health system due to its associations with poor short- and long-term physical and mental health2,13 and risk-taking behaviours2,14 and sometimes even death.15,16 Further, there is a longitudinal risk of IPAV in future relationships13,17 with potential intergenerational impacts on the wellbeing of young children.18 Thus, appropriately addressing dating violence may have an impact in reducing violence in future relationships.

Those experiencing dating violence will present to general practice in a variety of ways. Most will present with mental health concerns such as depression, anxiety or risk-taking behaviours. Some may present with physical health concerns such as chronic headaches or other somatic symptoms. The role of the GP is to be aware of the possibility of dating violence in a young person and provide ongoing health advice, support and referrals.

Technology-facilitated abuse

Technology-facilitated dating abuse, or digital dating abuse, includes the use of digital media to ‘monitor, control, threaten, harass, pressure, or coerce a dating partner’,19 although definitions and measurement of this type of abuse are not clear or consistent.20,21

Australians are among the highest users of technology in the world,22 and technology is deeply embedded in the day-to-day lives of young people’s sexual and romantic relationships.23 It is used to find romantic partners, to get to know each other, to initiate relationships and end them.8,23

Within this context, ‘sexting’ is a popular way of sharing intimacy. Although the definition of sexting is not very clear, it involves dating partners sharing mutually consented sexual photographs or videos with each other.24 However, sexting often falls within the realm of technology-facilitated abuse.

A qualitative Australian study found that young people aged 15–20 years felt pressure to use sexting with their partners, with young women facing more pressure to send sexual images of themselves compared with young men.25 Another Australian study found young women experienced technology-facilitated sexual coercion as part of a pattern of abusive technology behaviours, more often than young men.26 These findings are mirrored in American studies, which also found that young women experienced more technology-facilitated abuse when compared with young men27 and also suffered more negative and serious consequences as a result.19 Recent Australian studies showed gendered differences in the way young women and young men experience, perpetrate and are impacted by technology-facilitated abuse.26,28

Technology-facilitated abuse is an important form of abuse to be aware of and understand, as it can occur even when the couple are not physically with each other,27 which affects prevention and management. Recent evidence shows that not only dating violence, but also domestic and family violence, are perpetrated using technology.4,29 In a Queensland study, adult women reported extensive use of technology by perpetrators, including the use of smartphones, social media accounts, computers, GPS devices and recording devices, to control, isolate, monitor and harass them.4 An Australian qualitative study of frontline IPAV practitioners described technology as a powerful tool for gaining control, engaging others in abuse and amplifying victim/survivors’ levels of fear.29

Therefore, health practitioners need to be aware that while young and older women find technology to be a useful and covert means of seeking help for IPAV,30,31 this may be hampered by technology-facilitated abuse. Perpetrators’ close monitoring of a woman’s use of the internet and sometimes even destroying her technological devices4 may get in the way of her seeking help and staying in touch with family and friends. This is important for the health practitioner to understand and take into consideration when suggesting avenues to young and older women to seek help and support for dating or family violence. Thus, apart from referring the woman to websites and apps for support and help, traditional methods of seeking help and support must also be offered.

The use of technology-facilitated abuse against children in the context of child pornography or otherwise is not included here but there is further guidance in Chapter 9: Child abuse and neglect.

Evidence-based information on managing dating violence in the Australian general practice setting is currently lacking. Therefore, the approaches to identifying and responding to dating violence are based on consensus of experts.

While it is acknowledged that young women experience violence from male as well as female partners, there is overwhelming evidence that the majority of IPAV among young people is perpetrated by young men against young women.1 The guidance here focuses on young women; however, it can be applied to young men experiencing dating violence too, whether perpetrated by male or female partners. Information regarding people in same-sex relationships is given in Chapter 19: LGBTIQA+ family abuse and violence.

Identification and case-finding

It is uncertain whether it is worth screening all young people for dating violence. It could be argued that dating violence should be routinely incorporated into the HEEADSSS assessment (Box 12.1) when asking about sex and relationships, as there is no published evidence of harm in doing this. However, the literature on adult IPAV recommends that we must not universally screen adult women for IPAV as this could cause more harm than benefit.32 Therefore, the GP needs to use their discretion.

As with adult women, we would usually recommend case-finding for dating violence, for example, when young women present with health concerns or risk-taking behaviours. Table 2.2 in Chapter 2 outlines a comprehensive list of possible physical, psychological and emotional presentations of IPAV in clinical practice.

There is plenty of evidence that dating violence is associated with:

  • mental health problems, including depression, anxiety, eating disorders and suicidal ideation13,33,34
  • risk-taking behaviours, including substance abuse and risky sexual behaviour13,33,35,36
  • physical health problems, including adverse reproductive outcomes (unwanted pregnancy, miscarriage, termination of pregnancy, sexually transmitted infections).3,37,38

Asking about dating violence

When inquiring about dating violence it is recommended that the young person is alone and not with their partner or others who could be condoning the violence, as outlined in Chapter 2: Intimate partner abuse and violence: Identification and initial response. Confidentiality and its exceptions need to be explained and the young person should be encouraged to discuss their concerns with a parent or other trusted adult.39

Begin with broad questions, such as asking if they feel afraid or unsafe in their relationship with their boyfriend/girlfriend or partner. Box 12.2 outlines some questions you could ask a young person about dating violence. These are similar to the questions asked to adult women about IPAV (refer to Box 2.1, Chapter 2).

Dating violence needs to be carefully asked about, as there is evidence that young women struggle to recognise it and will usually minimise and normalise dating violence experiences, due to societal norms.37,40

‘I was so inexperienced, I didn’t know really what to think about it. And I was like, is this normal? Like, I didn’t know ... so, I knew that I really hated it and it was a horrible experience, but I think I, like, rationalised it in my head.’

If dating violence is highly suspected, it is then worth asking about more specific experiences of abuse, as outlined in Box 2.1, Chapter 2).

A safety and risk assessment should be conducted in all suspected or confirmed dating violence cases. A risk assessment tool may be used to help assess risk. The Victorian Government’s Family Violence Multi-Agency Risk Assessment and Management Framework provides several guides and tools for risk identification, screening and assessment.

Box 12.1. The HEEADSSS psychosocial assessment41

  • Home environment
  • Education and employment
  • Eating and exercise
  • Peer-related Activities
  • Drugs, tobacco and alcohol
  • Sex and sexuality
  • Suicide, depression and other mental health issues
  • Safety from injury, violence and abuse, and safety precautions to reduce sun damage and vaccine-preventable infections

Box 2. Examples of questions to ask young people about their dating relationships

  • ‘How are things in your relationship with your partner (or say ‘boyfriend’ or ‘girlfriend’ as appropriate)?’
  • ‘Do you feel safe in your relationship? Have you ever felt unsafe in the past?’
  • ‘Are you afraid of your partner? Have you ever been afraid of any partner?’
  • ‘Has your partner physically threatened or hurt you?’
  • ‘Does your partner control what you wear? Who do you hang out with?’
  • ‘Does your partner check your phone or keep a tab on who you are texting or talking to?’
  • ‘Does your partner ever send you images you are not comfortable with or expect you to do the same?’
  • ‘Is there a lot of tension in your relationship? How do you resolve arguments?’
  • ‘Sometimes partners react strongly in arguments and use physical force. Is this happening to you?’
  • ‘Violence is very common in young people’s relationships. I ask a lot of patients about abuse because no-one should have to live in fear of their partners.’
  • ‘Do you have a trusted adult who you can go to for help if you feel unsafe?’

Telehealth

While telehealth can be a useful way to overcome certain barriers to consulting with young people, it also poses risks, as privacy (particularly from the perpetrator) cannot be guaranteed.42 While young people in Australia overwhelmingly welcome telehealth consultations, some also voiced concerns about privacy and safety;43 therefore, it is important to first check that the young person is alone and feeling safe to proceed with the telehealth consultation. It is recommended that we start with asking closed questions such as, ‘Are you alone?’ or ‘Is it safe for me to ask you how you are going?’.44 If concerns about the patient’s safety continue, it is worth making an excuse for the patient to come in for face-to-face assessment. During face-to-face appointments with the woman alone, it is worthwhile arranging ‘code words’ or other signals that might indicate to the GP that the patient is not feeling safe or to alert the GP to ring the police.44,45

Management

Due to the lack of evidence in managing dating violence in primary care, we recommend following the same advice as for adult women, but with a youth-friendly approach.39 Refer to Chapter 2: Intimate partner abuse and violence: Identification and initial response and Chapter 3: First-line response to intimate partner abuse and violence: Safety and risk assessment . Tips for working with young people experiencing dating violence are given in Box 12.3.

In the first instance we suggest using the LIVES framework5 as you would with adult women, along with the CARE approach.46 We recommend approaching the young person with a trauma- and violence-informed approach; this includes acknowledging the role of trauma and violence in the young person’s presentation and behaviours, allowing for extended consultation time, focusing on wellness and positive social and emotional connections and using a collaborative approach to care.47,48

Referral to a psychologist specialising in young people’s health would be ideal, importantly, someone trained in trauma- and violence-informed practice.47 If the young person experiencing dating violence attends school it may also be worthwhile connecting with the high school nurse or counsellor to support the young person, if this was deemed to be a safe approach for the young person and the young person feels comfortable with this approach. There is, however, limited evidence on the types of interventions that might work to address dating violence.

It is important to also ask young people under 18 years about the age of their dating partner, as there could be potential for child abuse, which requires mandatory notification. The legal requirement for mandatory notification varies from state to state and is detailed in Table 9.5.

Box 12.3. Tips for identifying and managing dating violence in general practice

  • Adopt a youth-friendly, developmentally appropriate approach to care. Explain confidentiality and the exceptions (see the adolescent health GP resource kit39 for in-depth guidance).
  • Adopt a trauma- and violence-informed approach to care.47,48
  • Establish a good rapport.
  • Adopt a non-judgemental approach.
  • Conduct a HEEADSSS assessment.
  • Ask open-ended questions.
  • Allow adequate time for consultations.
  • Encourage the young person to involve a trusted adult for support.
  • Use the LIVES framework and CARE approach to respond to dating violence.
  • Complement face-to-face appointments with telehealth to ensure continuity of care.

A 19-year-old young woman, Mia, attended her GP on multiple occasions for pelvic pain, abnormal bleeding and vaginal discharge. On multiple occasions she was found to have chlamydia and was treated appropriately and given advice on safe sex, contact tracing and mandatory notification.

Several months later she presented with chest pains and shortness of breath. All routine tests were normal and she was diagnosed with anxiety. The young woman declined to see a counsellor at this point and agreed to try lifestyle advice. She then returned two months later with her boyfriend, having missed her period. She was found to be pregnant and was referred for a termination. Following the termination Mia was lost to follow-up for several months.

Aged 21 years, Mia returned with symptoms of panic attacks and insomnia. She was referred to a psychologist. After several months of intermittent psychology sessions, Mia was returned to her GP, who took a detailed social history. It was revealed that Mia had been in two consecutive relationships involving dating violence. In the first relationship she experienced reproductive coercion where her boyfriend refused to wear a condom and disallowed Mia from using other methods of contraception. In the second relationship, Mia’s boyfriend controlled what she wore and who she saw and when she suggested they break up, her boyfriend threatened to share her nude images with his friends.

With support from her GP, psychologist and parents, Mia reported her boyfriend to the police and broke up with him. She needs ongoing psychological support and a good therapeutic relationship with her GP.

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