Background and Study Objectives

1. Contextualizing Sexual Risk in Abusive Dating Relationships: A Qualitative Study of Adolescent Male PerpetratorsAuthors: Jeanne Hathaway, MD, MPH; Elizabeth Miller, MD, Phd; Anita Raj, PhD; Michele Decker, MPH; Emily Rothman, ScD; Elizabeth Reed, MPH; Jay Silverman, PhDFunded by the Centers for Disease Control and Prevention, Division of Reproductive Health and the William T. Grant Foundation

2. Background and Study Objectives Background:An estimated 1 in 5 high school girls report experiencing dating violence. Girls in abusive relationships are at increased risk of unprotected sex, sexually transmitted infections (STIs) and pregnancy. While condom refusal, birth control sabotage and coerced sex by abusive male partners are known to increase sexual risk for women and girls, underlying factors for these abusive behaviors have not been well defined. Study objectives:We sought to identify contextual factors that may contribute to male sexual risk behaviors through interviews with male perpetrators of dating violence. This presentation focuses on male-reported individual and relationship-level factors.

3. Methods We conducted semi-structured interviews with 24 males aged 15-21 years who were self-identified or identified through five school and community-based intervention programs as perpetrators of dating violence. Intervention programs were all in New England. Interviews included questions on boys’ dating and sexual relationships, sexual behaviors, and perpetration of dating violence. Subjects also completed a paper and pencil survey about their demographics, dating violence perpetration, sexual behaviors and other health indicators. Interview transcripts were coded independently by two researchers with the assistance of Atlas.TI software. Final codes were agreed upon by consensus. Survey data was entered into Excel and analyzed descriptively.

4. Study Sample (n = 24) • Median age: 19 years old • 92% - Born in U.S. • 75% - English is primary language

5. Dating Violence Perpetration (Survey Results) Boys’ reported the following abusive behaviors toward their girlfriends in the past 12 months: • 75% shouted or yelled at a girlfriend • 46% destroyed something that belonged to a girlfriend • 38% called a girlfriend fat or ugly • 38% told a girlfriend not to call or see a friend of hers • 25% threatened to hit, throw something at, or otherwise hurt a girlfriend • 25% hit, slapped, punched, kicked, or choked or otherwise hurt a girlfriend • 21% twisted a girlfriend’s arm or pulled her hair • 21% girlfriend had a sprain, bruise, or other injury because of a fight with you

6. Sexual Behavior (Survey Results) Number Sex Partners Ever *Of the 18 boys who reported six or more sex partners, the median number of sex partners was 20 (range 6 - 200) • 55% of boys reported that they first had sexual intercourse at or before age 13

7. Pregnancy Involvement • 33% reported getting a girl pregnant • 27% reported that a girl they got pregnant had an abortion Condom Use in Past 3 Months Multiple Partnering • 58% reported having sex with another girl when they were supposed to only be having sex with one girl Coercive Sexual Tactics • 17% reported pressuring a girl to have sex when she didn’t want to • 17% reported threatening to have sex with someone else if a girl didn’t have sex with you

8. Interview Findings Qualitative analysis revealed multiple individual and relationship factors that may contribute to the risk of STIs and pregnancy/pregnancy involvement for both male and female adolescents involved in abusive relationships. Based on boys’ narratives, we propose a hypothetical model of how these factors may increase boys’ sexual risk behaviors. Quotes illustrating the main components of the model are taken from 14 of the 24 interviews. Other social and environmental factors that may contribute to boys’ sexual risk behaviors are discussed separately.1 In terms of individual and relationship factors, the model postulates that boys’ personal experiences, including victimization and early sexual experiences, contribute to attitudes that focus their attention on their own needs and desires, decrease respect for female sexual partners (despite their desire for these partners), and decrease the importance of responsibility and other social mores. Hypothetical Model of Dating Violence and Male Sexual Risk Behaviors

9. Boys’ Personal Experiences Boys’ Attitudes and Beliefs Boys’ Sexual Risk Behaviors Victimization experience Early sexual experience Focused on self I get what I want Assumptions about girls’ sexual behavior Social mores not so important Lack of respect for girls Deny responsibility Emotional attachment to girls Frequent sex Multiple partnering Condom non-use Condom refusal Birth control sabotage Coerced sex Other Social and Environmental Factors Family situation Peers/peer norms Community factors Social norms (see adjacent poster1) 1 Teen Dating Violence and the Social and Environmental Context of Boy Perpetrators: A Qualitative Study with Teen Boys in Programs for Perpetration (Reed E, et al.) Session 3182.0

10. Boys’ Personal Experiences Many boys in this study reported a history of victimization by a family member, acquaintance, or other person as a child or adolescent. Boys also reported having sex for the first time at an early age; over half (55%) reported that they first had sexual intercourse at or before age 13. This was often with an older girl or woman, which in some cases was experienced as a sexual assault. “I was about, like, nine, ten… It was just some lady that was 22 years old… And she’s like, “Do you want to have sex? Do you want to have sex?” I was like fuckin’ the girl and we had sex.” – 17 y.o. who reported “6 or more” sex partners When asked when he first started having sex, one boy said he was “exposed” to sex when he was six to eight years old. He did not reveal the details, but agreed it was “something that you wouldn’t want to have happen to your own son.” – 20 y.o. who reported 30 or more sex partners

11. Focused on Self Many boys we spoke to seemed to be focused primarily on themselves and their own desires, sometimes at the expense of their sexual partners. Evidence of this attitude included having frequent sex, multiple partnering, having sex early in relationships, and condom non-use. “I was a little horn ball. That’s all I wanted to do was get laid… I had “fk friends” where we’d just bang whenever we both wanted it. And there was times when I had girlfriends for like three, four months, and then, um… they’d just catch me playin’ them or somethin’? They’d break up with me and I’d be like, “Oh well, I’ll go get another girl. And then I’d go to the mall, and then like, I’d get a new girlfriend, and I’d go out with her for like three weeks and then I’d get laid.” – 19 y.o. who reported 16 sex partners Subject: “There’s been times I haven’t used a condom… ‘cause it takes away the feelin’ and like, how can I say it?… Sometimes I felt like with a condom, I couldn’t get into it. And if I don’t get into it, then like, I’ll… I’ll lose my … I don’t know how to say it.” Int: “So you’d lose your erection.” Subject: “Yeah” – 19 y.o. who reported 200 sex partners

12. Another aspect of focusing on themselves was that boys sometimes viewed a relationship as less serious than their female sexual partner. This could occur in both short (a few days) and long-term (year or more) relationships. Subject: “I was talkin’ to a girl and after like three days we had sex and then right AFTER that she said, “So now you’re my boyfriend…” Int: “Right, in that situation she had it on her mind, like, well this could be a relationship, but maybe you had it on your mind, no strings attached.” Subject: “Oh, I had no string attached on my mind.” – 15 y.o. who reported 15 sex partners This egocentric focus also resulted in boys’ tendency to use condoms to protect themselves from STIs, rather than for protecting their sexual partners from STIs or pregnancy. Thus, if a boy didn’t think his girlfriend was cheating on him, he might stop using condoms - whether or not his girlfriend was using birth control or he was cheating on her. “If I know the girl? Like if I’ve known her for like a while, while? And I’ve known who she’s been with and, you know, that she’s been tested or whatever… then I probably won’t use a condom…” – 21 y.o. who reported 10 - 15 sex partners and denied a pregnancy claim by one girlfriend

13. I Get What I Want Several boys made it clear that they “get what they want,” particularly when it comes to sex. Although no boys admitted to physically forcing a girl to have sex, many disclosed other coercive tactics, such as playing “mind games” with girls or threatening to have sex with another girl if she wouldn’t have sex. “If I want it (sex) that bad, I’m gonna get it… I don’t force her or anything, I just put it in her head, like, “You will do this…” I don’t grab her and just force her, but… I just basically play a little head logic, a little mind game.” – 20 y.o. who reported “6 or more” sex partners “I just got to, you know, like, started undressin’ her and um, she’s like, “No! I’m not havin’ sex wit’ you” and I was like, and I just kept on talkin’ shit, talkin’ shit… like “Please, you act like you don’t want me.” …and then she was like, “No I DON’T want you. You’re so conceited!” Da da da da, and I’ll be, “Bch!”… and then, um, I just started undressin’ her, and she’s like… “whatever, go ahead”… She really didn’t want to be havin’ sex with me, but like she just did it because she heard so much about me.” – 18 y.o. who reported three sex partners

14. Assumptions About Girls’ Sexual Behavior It was not uncommon for boys to say that they could tell certain things about a girl’s sexual behavior just by looking at her or talking to friends. This included assumptions about whether or not a girl was a “slut,” whether a girl or her prior sex partners had STIs, or if a girlfriend was cheating on him. “If she carries herself like a slut, then… like, of course I’m gonna use a condom. But… if she like a nice, pretty like, decent girl, then I’ll have second thoughts about it…” – 19 y.o. who reported 200 sex partners [Discussing 7-8 month relationship] “I didn’t really think there was a need for a condom, ‘cause she told me that she’s only done it twice. And I know the two people that she’s been with. So I wasn’t worried about it that much. I didn’t really put that much care into it.” – 15 y.o. who reported 15 sex partners

15. Social Mores Not So Important Many boys in this study reported multiple ways in which they had stepped outside the boundaries of social mores. This often included drug use, not attending school, gang involvement, and/or criminal activity. Some boys also had few future plans for college or a career. “The first time I’ve ever been arrested or anything… I was in anger management in high school. I was actually, uh, ‘cause of all the stuff that happened in my family? I was kind of like an asshole in high school, like a little punk? (chuckles) – 20 y.o. who reported 50 - 60 sex partners “I was out there, just outta control, fightin’ people, smokin’ weed, um, I was in a gang. So, you know, a lot of that brought attention to me too, with the women. Then DYS came, and that’s been like… from I was fourteen all the way till eighteen.” – 21 y.o. who reported “6 or more” sex partners Int: “Where do you see yourself in 5 years?” Subject: “Struggling… Well, I mean just doin’ the same thing … I mean that I’ve been doin’ since I was little, like hustlin’ work.” – 18 y.o. who reported 26 sex partners

16. Lack of Respect for Girls Boys lack of respect for girls was demonstrated in numerous ways, including beliefs in male sexual entitlement, lack of empathy for how their actions could negatively impact girls, and other abusive and controlling behavior. In its extreme form, girls were described as sex objects to be denigrated for boys’ personal benefit. “It’s all in the way you talk to that female. Like, if you talk to her, like “hey (talks in smooth manner), if you talk to her… and she don’t have that mind power to basically figure out that you’re playin’ her? She’ll go for it. Like, she’ll go for the bait, and after that, it’s basically, do whatever you want. Turn her out, whatever.” – 20 y.o. who reported “6 or more” sex partners “I would just be holdin’ her down on the bed and be yellin’ and screaming at her, in her face… and then, after a while, I’ll just kind of… calm her down – crying and everything, being scared – and then… we’d have sex afterwards. Just, I guess to kill the.. the anger in the air… But now that I think about it, it probably didn’t calm her down. It probably just scared her more.” – 20 y.o. who reported seven sex partners

17. Male sexual entitlement included such double standards as “It’s natural for guys to flirt with other girls, but my girlfriend better not talk to other guys” and “I can cheat on my girlfriend, but if she cheats on me she’ll be sorry.” “She bring up the.. the whole cheating thing and I would flip out. That’s the thing that would really kind of trigger [the violence]. And she eventually cheated on me once, so I don’t know. I felt it was wrong that she did it to me… and that it wasn’t so bad that I did it.” – 20 y.o. who reported seven sex partners

18. Boys in the study also frequently described how they couldn’t trust girls, because girls “lied” so much. They gave examples of girls lying about being pregnant, who they were with, cheating, and if they had an STI. “She lied and said she was [pregnant], to stay with me… she thought her, that was the only way, like, her mom would let her go with me. She figured if she was pregnant, or whatever. She lied to both of us.” – 19 y.o. who reported 100 sex partners [Referring to girl who lived with him in 8th grade] “It was all the lies. Like, every day she would lie to me… Like, “Oh, I’m here,” but she really wasn’t there, like, I wasn’t jealous, but at the same time, I was just like, “Why are you, why are you lyin’ to me all the time?” – 21 y.o. who reported “6 or more” sex partners

19. Deny Responsibility Boys in this study tended not to take responsibility for protecting their female sex partners from STIs or pregnancy. This was sometimes attributed to “being young” or forgetting to use a condom “in the heat of the moment.” “I haven’t used a condom before, but… it’s like, ‘cause I never really put that thought in my head. ‘Cause we’re such a young age, we don’t really put as much stress towards these problems as adults would.” – 15 y.o. who reported 15 sex partners Int: “Which one of you made the decisions about birth control?...” Subject: “I don’t know. Nobody made no decision about that!” (yawns) – 21 y.o. who reported 50 or more sex partners Having been drunk or high was also used as an excuse for having had sex or not using a condom. “Like, oh man, I didn’t use a rubber! I was drunk last night, you know what I mean?” - 19 y.o. who reported 15 sex partners

20. Several boys also denied responsibility for pregnancies claimed by their girlfriends. “She’s like, “Oh, I’m pregnant.” I’m like, “Oh, really?” She’s like, “Yeah, …I’m two months pregnant. I’m like “Well, oh I don’t know if it could be mine… ‘cause I don’t know what you’ve been doin’.” And she freaked out, like she started yellin’ and screamin’. …She’s like,“Fk you! Fk you.” – 20 y.o. who reported 50 – 60 sex partners

21. Emotional Attachment to Girls At the same time that boys described disrespectful behavior towards girls, a few also spoke of strong emotional attachments to their girlfriends. These attachments were not necessarily protective, however, as these “beloved” girlfriends could be severely abused as well. “Well, I really cared about her. I loved her. I love the girl with all my heart, so I don’t want to lose her. So, I mean, she’s been there for me since day one.” [referring to same girlfriend about whom he had said:] “I never hit her. I would never hit a woman… [I] just like kind of choke her to make her stop… if I don’t think twice, I’d probably kill her…” – 17 y.o. who reported “6 or more” sex partners “It’s just that there was so much love (hits table for emphasis), and so much hate between me and my baby’s mother, it was just why I can’t control it… You’re thinkin’, like “My god, I just wanna kill you right now” and, but I don’t want to hit you, and I love you… I used to just scream on my BM (baby’s mother) like, “I just want to hold you right now, so tight, and just kiss you and just, you know? But you’re just so stupid dog!” and I just… BANG! Punched a wall or somethin’ like that… Basically, it’s hate and love.” – 21 y.o. who reported “6 or more” sex partners

22. Summary of Findings Findings from this study suggest various individual and relationship factors that may help to explain the association between dating violence and sexual health risks. We propose a hypothetical model whereby boys’ personal experiences, along with other social and environmental factors, influence boys’ attitudes about girls and sex, and that these attitudes contribute to behaviors that increase both boys’ and girls’ risk of STIs and pregnancy.

23. Limitations This qualitative study explored contextual factors that may influence the sexual risk behaviors of male dating violence perpetrators. Because we used a convenience sample, these findings are not representative of all adolescent males involved in dating violence. In summary, the primary limitations of this study are: • Convenience sample from dating violence intervention programs • Subjects were mainly from low-income, urban population • Small sample size • Based on self-report data • Interviewers were White women

24. Future Research • Population-based studies are needed to test the hypothetical model of dating violence and sexual risk behaviors proposed based on findings from this qualitative study. • Additional studies in this area should include populations not included in the current sample, including boys not attending dating violence intervention programs, boys from suburban and rural areas, and first generation immigrants. • It will also be important to incorporate the perspectives of girls who have experienced dating violence into the proposed model of dating violence and sexual risk behaviors.