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Serious Injuries and Deaths of Adolescent Girls Resulting From Interpersonal Violence
Characteristics and Trends From the United States, 1989-1998
Harry Moskowitz, MD;
John L. Griffith, PhD;
Carla DiScala, PhD;
Robert D. Sege, MD, PhD
Arch Pediatr Adolesc Med. 2001;155:903-908.
ABSTRACT
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Background Little published data are available concerning the death and disability
of adolescent girls resulting from interpersonal violence (adolescents are defined as those aged 12-18 years in this study).
Objectives To determine whether there were sex differences in (a) the characteristics of those who were injured or died, (b) injury severity and outcomes, and (c) injury
mechanism; and to describe time trends in these differences.
Design Analysis of data concerning serious injuries due to assaults, recorded
in the National Pediatric Trauma Registry (from January 1, 1989, through December
31, 1998), and homicides, recorded in the Web-Based Injury Statistics and
Query Reporting System database (from January 1, 1990, through December 31,
1997).
Setting Patient data from participating pediatric trauma centers (National Pediatric
Trauma Registry) in 45 states and national death certificate data (Web-Based
Injury Statistics and Query Reporting System).
Patients Six hundred twelve adolescent girls who were seriously injured because
of an assault were compared with 2656 adolescent boys who were seriously injured
because of an assault. Three thousand four hundred eighty-seven adolescent
girls who died due to a homicide were compared with 17 292 adolescent
boys who died due to a homicide.
Results Assaulted adolescent girls were more likely to have preexisting cognitive
or psychosocial impairments than were adolescent boys (odds ratio, 1.68; 95%
confidence interval, 1.12-2.51). Adolescent girls trended toward more injury-related
impairments at discharge from the hospital (odds ratio, 1.16; 95% confidence
interval, 0.92-1.47). Adolescent girls were more likely to have been stabbed,
and less likely to have been shot. Also, adolescent girls were more likely
to have been injured at a home or a residence. Compared with all National
Pediatric Trauma Registry admissions, assaults declined at the same rate for
adolescent girls and boys. The proportion resulting from penetrating trauma
declined more slowly for adolescent girls.
Conclusions Interpersonal violence causes considerable morbidity and mortality for
young women. Research and interventions should be developed to respond to
adolescent girls who experience interpersonal violence.
INTRODUCTION
WOMEN in the United States experience violence from strangers and intimate
partners, with distinct medical and psychological sequelae.1
In contrast to adult-oriented research, research on youth violence has focused
mainly on boys.
One in three adolescents reports being in a physical fight in the past
year.2 Because of this high prevalence of adolescent
violence in the United States, the problem of violence as it affects adolescent
girls is a public health problem in its own right. Recent surveillance studies
conducted in the primary care3 and emergency
department4, 5, 6 settings,
for example, have shown that young women experience one third of nonlethal
violence-related injuries that require medical attention. Recent trends show
that the gap between male and female victimization rates is declining, and
that two thirds of the violence against women is not perpetrated by an intimate
partner.7
Previous studies8, 9 have
examined characteristics of the offenders of youth violence. These studies
revealed that the use of violent behaviors was associated with personal victimization,
depression, family conflict, number of sexual partners, and hopelessness.
This study was undertaken to better understand the pattern of severe
violence-related injuries among adolescent girls in the United States (adolescents are defined as those aged 12-18 years in this
study). Violence-related injuries included violence perpetrated by a stranger
and violence committed by an intimate partner. By analyzing data from the
National Pediatric Trauma Registry (NPTR) and the Centers for Disease Control
and Prevention's Web-Based Injury Statistics and Query Reporting System (WISQARS),
we were able to detect differences in demographics, injury characteristics,
and injury outcomes for adolescent boys and girls who were killed or seriously
injured by interpersonal violence. These differences will help to better tailor
violence prevention tactics more specifically to adolescent girls.
PATIENTS AND METHODS
The data analyzed in this study were obtained from 2 existing national
databases. Data concerning severe injuries to adolescents, including pregnant
adolescents, were obtained from the NPTR. Data concerning adolescents who
died due to a homicide were obtained from the Centers for Disease Control
and Prevention's WISQARS, which is a database compiled using data from the
National Center for Health Statistics data tapes.
INJURY DATA
The NPTR study population consists of persons assaulted, aged 12 to
18 years, and hospitalized in a participating institution during the 10-year
period ending December 31, 1998.
The NPTR database contains detailed information concerning pediatric
trauma patients, voluntarily submitted by participating pediatric trauma centers
and children's hospitals throughout the United States. At the time this study
was undertaken, 91 trauma centers from 45 states were participating.
At each NPTR site, a trained trauma nurse coordinator completes a data
collection form for each patient admitted for an injury in accordance with
NPTR guidelines. To guarantee uniformity across institutions, coding for natural
and external causes of injury, severity scoring, data management, analyses,
and reporting are performed centrally at the NPTR. There is a full-time staff
member at the registry who manually reviews each record for completeness.
This reviewer then enters data into specially designed computer programs,
which then automatically cross-check the data. If the reviewer finds missing
or illogical data, the submitting hospital is then asked to provide information
for correction or verification. These methods of data collection and quality
assurance have been described in detail elsewhere.10
Items from the NPTR data collection form, such as the intent of injury
and the determination of preexisting conditions, are established by asking
the patients, family members, physicians, and police officers.10
Assaults are coded according to International Classification
of Diseases, Ninth Revision (ICD-9), criteria and include all injuries
inflicted by another person with the intent to harm, including sexual abuse
and excluding child abuse.11
Patients in the NPTR database represent a severe subset of all injuries
seen in children because only injuries severe enough to require hospitalization
are included. Furthermore, since the NPTR's participating institutions are
hospitals specializing in the treatment of pediatric trauma, children treated
at NPTR sites are likely to be more severely injured than are children admitted
to other hospitals.12
DEATHS: VITAL STATISTICS DATA
The Centers for Disease Control and Prevention's National Center for
Health Statistics compiles the data in WISQARS, which contains mortality data
from January 1981 to December 1997. The information in this database comes
from death certificates and includes causes of death as determined by physicians,
medical examiners, and coroners. Population data come from the Bureau of Census.13
SUBJECTS
Of the 79 894 cases recorded in the NPTR for patients treated between
January 1, 1989, through December 31, 1998, we extracted all cases of assaults,
exclusive of child abuse, of patients aged 12 through 18 years. There were
3268 patients assaulted, 612 adolescent girls and 2656 adolescent boys. Injury
intent was assigned at the treating hospital. These assault cases represented
13.8% of all the NPTR cases in this age group.
From the WISQARS database, we extracted all cases of homicide of those
aged 12 to 18 years, except homicides due to legal intervention, that occurred
during the 8-year interval between January 1, 1990, and December 31, 1997.
This resulted in a total of 20 779 homicides, including 3487 adolescent
girls and 17 292 adolescent boys. The period for the WISQARS database
is different than for the NPTR database because customized age groups are
not available for data before 1990.
MEASURES
The analysis included the following variables from the NPTR and WISQARS:
sex, age, and mechanism of assault. Additional variables from the NPTR used
in the analyses included preinjury medical and psychosocial history, scene
of the injury (home, school, or public place), year of injury, season of injury,
injury severity, and outcomes. Preexisting medical conditions included mental
retardation and learning disabilities. Preexisting psychosocial problems included
problems with social interactions, such as violent or physically aggressive
behaviors.11
The severity of injury was measured by the Injury Severity Score.14 Outcomes included in-hospital death and functional
impairments at hospital discharge caused by the injury. Nine functional activities
were evaluated: feeding, vision, hearing, cognition, speech, bathing, dressing,
walking, and behavior. A clinician evaluated the patient's performance in
these domains using performance and neurological tests, and rated the patient
in each functional area as age appropriate, impaired, or unable. In this study,
impaired and unable were combined to reflect any degree of impairment at discharge
from the hospital.
DATA ANALYSIS
Data analysis was performed using Statistical Product and Service Solutions
for Windows, version 9.0.0,15 statistical software.
Bivariate analysis was accomplished with  2 tests and t tests. Because of the observational nature of the data,
multivariable models were used to adjust for potential confounders. Variables
found to be significant in previous studies or found to be significant in
bivariate analysis were included as candidates for the final logistic regression
models. Interaction terms were also examined and placed in these models. Models
were examined using stepwise likelihood ratios to determine significance.
Variables with P .05 were entered into the model.
Subsequently, variables with P .10 were removed
from the model.
The NPTR data set was found to have missing data, which were not evenly
distributed by sex. We, therefore, ran 2 separate analyses. One analysis consisted
of eliminating all cases with missing data. For the second analysis, data
were reanalyzed with the missing scene of injury being assigned as a public
place, as this was the most common scene. For cases missing preexisting cognitive
or psychosocial impairments, we took the conservative approach and assumed
that those patients missing data had no preexisting cognitive or psychosocial
impairments.
RESULTS
SEVERE INJURIES
Of the 79 894 patients in the NPTR, there were 3268 persons assaulted,
612 adolescent girls and 2656 adolescent boys. Table 1 shows patient characteristics before and after the assault.
Overall, 15% of the patients had data missing for the scene of injury and
12% had data missing for preexisting impairments. For children missing data
for the scene of injury, we used a public place as the scene of injury, as
this was the most common place for injury. We will report here the results
for the model that had missing data. For the patients who were missing data
for preexisting cognitive or psychosocial impairments, we took the conservative
approach and assumed those patients with missing data had no impairments.
This conservative approach reports a lower incidence of preexisting cognitive
or psychosocial impairments and, therefore, underestimates the odds ratio
(OR) to one that is lower than one might find if the data were complete. Assaulted
adolescent girls were slightly younger than adolescent boys and had a higher
incidence of preexisting cognitive or psychosocial impairments. Adolescent
girls sustained less severe injuries and had fewer impairments at discharge
from the hospital. More specifically, assaulted adolescent girls were 1.68
(95% confidence interval [CI], 1.12-2.51) times more likely to have a preexisting
cognitive or psychosocial impairment than were assaulted adolescent boys.
In bivariate analysis, adolescent girls were less likely (OR, 0.75; 95% CI,
0.61-0.92) to have impairments at discharge from the hospital due to an assault
than were adolescent boys. However, after adjusting for the age of the person
assaulted, the year of injury, the scene of injury, and any preexisting impairments,
adolescent girls had a trend toward more impairments at discharge from the
hospital than did adolescent boys (OR, 1.16; 95% CI, 0.92-1.47).
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Table 1. Patient Characteristics From the NPTR*
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When compared with injuries due to all causes in the NPTR, assaulted
adolescent girls accounted for 9.3% of all injured adolescent girls, while
assaulted adolescent boys accounted for 16.1% of all injured adolescent boys.
Thus, injured adolescent girls were only half as likely as injured adolescent
boys to be assaulted (OR, 0.53; 95% CI, 0.48-0.58).
The proportion of injuries caused by assaults declined for adolescent
girls and boys during the 10-year study period. In a linear regression model,
the percentage of injuries caused by assaults declined at a similar rate for
adolescent boys and girls, with injured adolescent girls continuing to be
assaulted at approximately half the rate of injured adolescent boys (P = .32) (Figure 1).
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Figure 1. Percentage of injuries from the
National Pediatric Trauma Registry caused by assaults.
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The sex-specific trends during the 10-year study period, however, diverged
for the subset of patients who sustained penetrating injuries (stab wounds
and gunshot wounds). The percentage of adolescent boys who were injured by
penetrating assaults declined almost 28% during the 10-year study period.
Penetrating assaults declined by only 6.8% in adolescent girls (Figure 2). The differences in decline between sexes during the 10-year
study period were statistically significant (P =
.04).
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Figure 2. Percentage of assaults from the
National Pediatric Trauma Registry in which penetrating weapons were used.
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Significant differences were found in the scene of injury for adolescent
girls and boys (P<.01). Adolescent girls were
more likely than adolescent boys to be injured in their home or another private
dwelling than a public place and were more likely than adolescent boys to
be injured in a school than a public place, with an unadjusted OR of 1.56
(95% CI, 1.09-2.24). After adjusting for preexisting conditions, age, and
the type of injury, adolescent girls were 2.27 (95% CI, 1.82-2.83) times more
likely to be injured in a home than a public place. Adolescent boys, by contrast,
were 1.75 (95% CI, 1.17-2.63) times more likely to be injured in school, and
2.27 (95% CI, 1.82-2.83) times more likely to be injured in a public place
than a home, after adjusting for the factors previously described.
Adolescents assaulted also differed markedly in the mechanism of their
injury. Adolescent girls were more likely than adolescent boys to have stab
wounds, while adolescent boys were more likely than adolescent girls to have
gunshot wounds (P<.001) (Table 2). Variables determined to be significant by bivariate analysis,
including preexisting conditions (P = .01), age (P<.01), and scene of injury (P<.01),
were then placed into a multivariable logistic regression model. After adjusting
for these same variables, adolescent girls were 2.15 times more likely to
be stabbed vs shot, and were 1.68 times more likely to have an injury due
to a stabbing vs a blunt injury (Table 3). Again, using a multivariable logistic regression model adjusting
for the same variables, adolescent boys were found to be 2.08 times more likely
to be shot than stabbed. In addition, adolescent boys were found to be 1.36
times more likely to have an injury due to a shooting vs a blunt injury.
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Table 2. Injury Characteristics From the NPTR
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Table 3. Crude and Adjusted ORs for Cause of Injury*
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DEATHS
The findings concerning the mechanism of injury were then compared with
homicide data available in the WISQARS database to determine if the data from
the NPTR would be consistent with population-based homicide data. After adjusting
for the age of the person killed and the year of the homicide, adolescent
girls from WISQARS were similarly found to be 2.50 times more likely to be
murdered by a stabbing than by a shooting. The situation for adolescent boys
was reversed, ie, they were less likely to be murdered by a stabbing than
by a shooting (Table 3). These
findings mirrored those from the NPTR concerning penetrating injuries.
During the 8-year period for which we have data from WISQARS, the homicide
rate declined for adolescent boys and girls. In 1990, the homicide rate for
adolescent boys was 16.21 per 100 000 and declined to a rate of 12.57
per 100 000 by 1997, for a decline of 22.5%. For adolescent girls, this
decline was less pronounced. The homicide rate for adolescent girls in 1990
was 3.81 per 100 000 and declined to a rate of 2.66 per 100 000
by 1997. This represents a decline of 30.2%. In a multivariable linear regression
model, we examined the interaction between sex and year of injury and found
that the differences in the decline between sexes trended toward significance
(P = .14). Similarly, there was a larger decline
in the rate of homicides due to penetrating weapons for adolescent boys (22.8%)
compared with that seen in adolescent girls (30.6%) (Figure 3), again trending toward significance (P = .14).
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Figure 3. Percentage of homicides from the
Web-Based Injury Statistics and Query Reporting System in which penetrating
weapons were used.
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COMMENT
Peer violence remains a common problem for adolescent girls and boys.
Because of their higher incidence of severe injury and death, most studies
of adolescent violence have focused on boys. However, violence is also a significant
problem for young women. This study indicates that there are specific differences
between adolescent girls and boys who are assaulted that are relevant to violence
prevention research and prevention strategies.
Although more adolescent boys than adolescent girls were treated by
the NPTR participants for assault-related injury, the actual number of assaulted
adolescent girls continues to be alarming, especially given the high injury
severity typical of patients included in the NPTR. Encouragingly, the NPTR
recorded an overall decline in the proportion of injuries caused by assault
for adolescent girls and boys. These findings are mirrored in other studies
and databases.2, 3, 16
An alarming number of adolescents continue to engage in behaviors that
contribute to intentional injuries. The Youth Risk Behavior Surveillance2 survey revealed that 17.3% of students nationwide
reported carrying a weapon in the 30 days before the survey. This same survey
also revealed that 35.7% of adolescents had been in at least 1 physical fight
in the preceding 12 months before the survey. The combination of these 2 factors
reveals that many adolescents are at risk for intentional injuries, such as
assaults carried out with a weapon.
In the NPTR, there was a significant difference in the decline of penetrating
assaults involving adolescent girls and boys during the 10 years included
in this study. Adolescent boys have experienced a decline of almost 28% in
the proportion of penetrating assaults. Adolescent girls, on the other hand,
have experienced a much slower decline, showing only a 6.8% reduction in the
proportion of penetrating assaults. In fact, the proportion of assaults in
which a penetrating weapon was used has switched from being higher in adolescent
boys in 1989 to being higher in adolescent girls since 1994. This slower decrease
for adolescent girls may reflect increasing violence among girls3
or an increase in the severity of dating violence or abuse. The WISQARS database
also revealed a slower decline in the rates of deaths caused by penetrating
weapons in adolescent girls. These 2 databases were compared to show that,
although the NPTR cannot be used to infer rates, the findings are similar
to a national database and, therefore, the NPTR findings are likely to be
more broadly generalizable. Taken in combination, these findings seem to represent
a failure of public health messages that focus mainly on violence risks among
adolescent boys rather than adolescent girls.
Assaulted adolescent girls were at an increased risk of having a preexisting
cognitive or psychosocial impairment when compared with assaulted adolescent
boys. Adolescent girls with preexisting psychosocial problems have been found
to be at an increased risk for being abusers of alcohol and other drugs, which
has also been shown to increase the risk of date rape.17, 18
Thus, adolescent girls with psychosocial problems are at increased risk for
adverse outcomes and there should be a focusing of violence prevention efforts
on these girls. Since 12% of patients had data missing on preexisting impairments,
with a higher percentage of adolescent girls missing data, we have probably
underestimated the number of adolescent girls with preexisting cognitive or
psychosocial impairments. This further underscores the risks for these girls.
While many recent articles19, 20, 21
have focused on handgun use in assaults and homicides, the results from this
study of injuries (NPTR data) and deaths (WISQARS data) show that adolescent
girls are more likely to be injured by piercing weapons, such as knives, than
by guns or other weapons. In general, adolescent girls are less likely to
own and use handguns than are adolescent boys. Recent efforts by handgun manufacturers
to market weapons to young women may trickle down to teenagers and reduce
this gap.
Much public and media attention is focused on violence in schools. Data
from the NPTR revealed, however, that adolescent girls were more likely to
be assaulted in their home or another private dwelling. This appears to indicate
that adolescent girls are likely to be intentionally injured by a friend,
acquaintance, or intimate partner who was with them in a residential location.
This may reflect the higher incidence of domestic violence and dating violence
seen in adolescent girls.3, 5, 22
However, because the NPTR does not include data on perpetrators, definitive
conclusions may not be drawn. Again, because of missing data from the NPTR,
we have probably underestimated the number of adolescent girls who have been
injured in a home and, therefore, we need to improve our violence prevention
programs to protect this vulnerable population.
Since hospitalization for assaults only represents a small fraction
of all assaults involving adolescents,23 several
limitations should be kept in mind. Patients in the NPTR represent only those
who were admitted to trauma centers and, therefore, represent only the most
severe forms of assault. In addition, because the NPTR is essentially a large
case series collected by voluntary participants and is not a representative
sample of the country, incidence rates and national estimates cannot be inferred
from NPTR data. Although this study included data on patients up to the age
of 18 years, some older adolescents may have been treated in adult trauma
centers and, therefore, would not be recorded in the NPTR. This would result
in an underestimation of the overall number of assaults. Data collected from
the WISQARS database are limited by the lack of outside confirmation of the
cause of death or the mechanism of injury, which could result in an inaccurate
estimate of the number of homicides.
CONCLUSIONS
Violence affects many teenaged girls in the United States. We found
marked differences between adolescent girls and boys who experienced assaults
and homicides. From the point of view of prevention, 2 important differences
became apparent. First, adolescent girls with preexisting psychosocial or
medical conditions appeared particularly vulnerable to serious injury. Second,
the dramatic decline in weapons-related injury among adolescent boys in the
1990s was only weakly mirrored among adolescent girls.
This study demonstrates the need to further refine violence prevention
strategies to account for these differences. We may need different prevention
strategies for adolescent girls than for adolescent boys. Violence prevention
programs geared specifically toward adolescent girls should focus on preventing
attacks from occurring in the girl's or a friend's home. Other studies are
needed to better understand the antecedents of adolescent violence and its
long-term physical and emotional consequences.
AUTHOR INFORMATION
Accepted for publication March 18, 2001.
This study was supported by National Research Service Award training
grant T32-HS00060 from the Agency for Healthcare Research and Quality, Rockville,
Md; grant H133B950006 from the National Institute on Disability and Research,
Washington, DC; the Maternal and Child Health Bureau of the Health Resources
and Services Administration, Rockville; and grant R49/CCR115279-03 from the
Centers for Disease Control and Prevention, Atlanta, Ga, and the Harvard Injury
Control Research Center, Boston, Mass.
Presented at the annual meeting of the Ambulatory Pediatrics Association,
Boston, Mass, May 16, 2000.
From the Division of Clinical Care Research (Drs Moskowitz, Griffith,
and Sege) and the Department of Pediatrics (Drs Moskowitz, DiScala, and Sege),
The Floating Hospital for Children, New England Medical Center, Boston, Mass.
Dr Moskowitz is now with the Department of Pediatrics, Mount Sinai School
of Medicine, New York, NY.
Corresponding author and reprints: Harry Moskowitz, MD, Department
of Pediatrics, Mount Sinai School of Medicine, Box 1198, One Gustave Levy
Place, New York, NY 10029.
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