Acculturation, ethnic identity, and dating violence among Latino ninth-grade students

BACKGROUND: Studies of dating violence among Latino men and women have found that victims who are less acculturated have lower rates of dating violence. None of these studies have focused on adolescents. We assessed acculturation, ethnic identity, and dating violence victimization among Latino ninth-grade students. METHODS: Students from 13 high schools representing 24% of ninth-grade students in the Texas Lower Rio Grande Valley during 2000-2001 completed questionnaires. This analysis is restricted to students age 14 years or older who self-identified as Hispanic or Latino (n = 4,525). Logistic regression was performed to estimate the risk of dating violence associated with measures of acculturation and ethnic identity. RESULTS: Latino female adolescents were more likely to report dating violence victimization in the past 12 months (8.7%) than were males (6.4%). Parental birthplace outside of the United States was significantly associated with a reduced likelihood of dating violence victimization among females. Reporting a great deal of ethnic discrimination was strongly associated with increased dating violence victimization among females. CONCLUSIONS: These findings suggest that greater acculturation may be associated with greater prevalence of dating violence victimization among females. Understanding those aspects of Latino culture that may impact risk of dating violence could have important public health implications.     

Violence involvement, substance use, and sexual activity among Mexican-American and European-American adolescents

PURPOSE: This study examined longitudinal associations between violence involvement, substance use, and sexual activity. METHODS: A total of 302 urban Mexican-American and European-American adolescents were randomly selected and recruited from the membership lists of a large health maintenance organization. Data were obtained from interviews conducted when the mean ages of adolescents were 15, 18, and 19 years. RESULTS: Independent of age, gender, ethnicity, family socioeconomic status, and previous levels of health risk behavior, adolescents who had been victimized by violence at age 15 were more likely to use tobacco at age 19. Adolescents who had been victimized by or perpetrated violence at age 18 had a greater number of sexual partners and were more likely to use marijuana at age 19. In addition, adolescents who had perpetrated violence at age 18 engaged in greater alcohol use at age 19. A second set of analyses showed that independent of demographics and previous violence involvement, adolescents who had used marijuana at age 15 were more likely to report violence involvement at age 19. Adolescents who had used tobacco or who had a greater number of sexual partners at ages 15 or 18 were more likely to report violent victimization at age 19. CONCLUSIONS: Associations between violence involvement and other forms of health risk behavior are bidirectional. Adolescents involved with violence are at risk for increases in substance use and sexual behavior over time. Adolescents who engage in substance use and sexual behavior with multiple partners are also at risk for later violence involvement.     

Family and school socioeconomic disadvantage: Interactive influences on adolescent dating violence victimization

Although low socioeconomic status has been positively associated with adult partner violence, its relationship to adolescent dating violence remains unclear. Further, few studies have examined the relationship between contextual disadvantage and adolescent dating violence, or the interactive influences of family and contextual disadvantage. Guided by social disorganization theory, relative deprivation theory, and gendered resource theory, we analyzed data from the U.S. National Longitudinal Study of Adolescent Health (1994–1996) to explore how family and school disadvantage relate to dating violence victimization. Psychological and minor physical victimization were self-reported by adolescents in up to six heterosexual romantic or sexual relationships. Family and school disadvantage were based on a principal component analysis of soecioeconomic indicators reported by adolescents and parents. In weighted multilevel random effects models, between-school variability in dating violence victimization was proportionately small but substantive: 10% for male victimization and 5% for female victimization. In bivariate analyses, family disadvantage was positively related to victimization for both males and females; however, school disadvantage was only related to males' physical victimization. In models adjusted for race/ethnicity, relative age within the school, and mean school age, neither family nor school disadvantage remained related to males' victimization. For females, family disadvantage remained significantly positively associated with victimization, but was modified by school disadvantage: family disadvantage was more strongly associated with dating violence victimization in more advantaged schools. Findings support gendered resource theory, and suggest that status differentials between females and their school context may increase their vulnerability to dating violence victimization.     

Dating violence among gay, lesbian, and bisexual adolescents: results from a community survey

PURPOSE: To characterize the prevalence of dating violence experienced by gay, lesbian, bisexual (GLB), and heterosexual adolescents. METHODS: Self-report surveys were collected and analyzed from 521 adolescents at a GLB youth rally. Respondents were asked about dating violence, including types of abuse, threats of "outing," and gender of abuser. Multivariate logistic regression analyses were used to test group differences. RESULTS: Reports of dating violence were prevalent in all sexual orientation groups, and there were few statistically significant differences. Compared with heterosexuals and controlling for age, bisexual males had greater odds of reporting any type of abuse, and bisexual females had greater odds of experiencing sexual abuse. Controlling for age, lesbians had greater odds of being scared about their safety, compared with heterosexual females, and bisexuals were more likely to be threatened with outing, compared with gay males/lesbians. CONCLUSIONS: Overall, the prevalence of dating violence among GLB adolescents is similar to that of heterosexuals. Dating violence outreach and prevention efforts should be targeted to reach GLB adolescents.     

Longitudinal predictors of serious physical and sexual dating violence victimization during adolescence

BACKGROUND: This study identifies potentially modifiable risk factors for the onset of and chronic victimization from serious physical and sexual dating violence. METHODS: One thousand two hundred ninety-one 8th and 9th graders from a county in North Carolina were assessed annually for 5 and 4 years, respectively. RESULTS: For males, having been hit by an adult with the intention of harm, having low self-esteem, and having been in a physical fight with a peer predicted onset of serious physical dating violence victimization. Those variables, plus having a friend who has been a victim of dating violence, alcohol use, and being white, predicted chronic victimization for males. For females, onset of serious physical dating violence victimization was predicted by having been hit by an adult; that variable, plus living in a single-parent household, predicted chronic victimization from serious physical violence. Also for females, onset of sexual violence victimization was predicted by having a friend who has been the victim of dating violence and being depressed; those variables and gender stereotyping predicted chronic victimization from sexual dating violence. CONCLUSIONS: The findings identify high-risk groups and risk factors to target for intervention and have implications for approaches to delivering dating violence prevention programs.     

Prevalence of partner violence in same-sex romantic and sexual relationships in a national sample of adolescents.

PURPOSE: To present the first national prevalence estimates of psychological and physical intimate partner violence between adolescents in same-sex relationships. METHODS: Analyses focus on 117 adolescents aged 12-21 years (50% female) from Wave II of the National Longitudinal Study of Adolescent Health who reported exclusively same-sex romantic or sexual relationships in the 18 months before interview. Items from the Conflict Tactics Scale were used to measure partner violence victimization. Data analysis included computation of prevalence estimates and a logistic regression analysis to assess associations between sociodemographic characteristics and violence victimization. RESULTS: Almost one-quarter of adolescents with same-sex romantic or sexual partners reported some type of partner violence victimization; about 1 in 10 reported physical victimization. Significant sex differences were found (OR = .29, CI = 0.08, 1.00), with males being less likely than females to report "any violence." Of six other sociodemographic characteristics examined, importance of religion (OR = .27, CI = 0.07-1.07) and school size (OR = .32, CI = 0.09-1.11) were associated with victimization at the p < .10 level. Adolescents who reported that religion was important to them and adolescents who attended larger schools were at lower risk of "any violence." CONCLUSIONS: As with opposite-sex relationships, psychological and minor physical violence victimization is common among adolescents involved in same-sex intimate relationships. Males reporting exclusively same-sex relationships were less likely than females to report experiencing the violence behaviors examined.     

Relationship between number of sexual intercourse partners and selected health risk behaviors among public high school adolescents.

PURPOSE: To examine the relationship between number of sexual partners and selected health risk behaviors in a statewide sample of public high school students. METHODS: The Centers for Disease Control and Prevention Youth Risk Behavior Survey was used to secure usable sexual risk-taking, substance use, and violence/aggression data from 3805 respondents. Because simple polychotomous logistic regression analysis revealed a significant Race x Gender interaction, subsequent multivariate models were constructed separately for each race-gender group. Odds ratios and 95% confidence intervals was calculated from polychotomous logistic regression models for number of sexual intercourse partners and their potential risk behavior correlates. RESULTS: An increased number of sexual intercourse partners were correlated with a cluster of risk behaviors that place adolescents at risk for unintended pregnancy, human immunodeficiency virus/acquired immunodeficiency syndrome, and other sexually transmitted infections. For Black females, alcohol, tobacco, marijuana use, and dating violence behaviors were the strongest predictors of an increased number of sexual partners; white females had similar predictors with the addition of physical fighting. For white males, alcohol, tobacco, marijuana use, physical fighting, carrying weapons, and dating violence were the strongest predictors of an increased number of sexual intercourse partners. Black males had similar predictors with the addition of binge alcohol use. CONCLUSION: Prevention of adolescent sexual and other health risk behaviors calls for creative approaches in school and community settings and will require long-term intervention strategies focused on adolescent behavior changes and environmental modifications.     

Gender, Mature Appearance, Alcohol Use, and Dating as Correlates of Sexual Partner Accumulation from Ages 16–26 Years

PURPOSE: To determine growth in sexual partnering from age 16-26 years, and to test whether biological and social factors launched these growth patterns. METHODS: A prospective design was used. Participants were 176 young people (47% female) followed from birth to age 26 years. Sexual partnering was measured as the accumulated number of different sexual intercourse partners at ages 16, 19, 23, and 26 years. Physical appearance of maturity, alcohol use, and dating were measured at ages 13-16 via observations, interviews, and questionnaires. RESULTS: Mature appearance at age 13 years, use of alcohol more than monthly at age 16, and a history of a steady romantic partner before age 16 were each associated with a greater number of sexual intercourse partners by age 16. However a more mature appearance, more frequent alcohol use, and greater dating involvement did not foreshadow a steeper accumulation of sexual partners between ages 16 and 26. Only gender had such a "growth" influence, with males accruing sexual partners more rapidly from the ages of 16-26 years when compared with females. CONCLUSIONS: Adolescents had accumulated a higher number of sexual partners by age 16 years when they looked older, drank alcohol more frequently, and were more involved with dating in early to middle adolescence. Also male gender was associated with accumulation of sexual partners more rapidly between ages 16 and 26 years, and there was little indication that the accumulation of different sexual partners had begun to slow by age 26 for the average participant.     

Physical dating violence among high school students--United States, 2003

Dating violence is defined as physical, sexual, or psychological violence within a dating relationship. In a study of dating violence victimization among students in grades 7-12 during 1994-1995, the 18-month prevalence of victimization from physical and psychological dating violence was estimated at 12% and 20%, respectively. In addition to the risk for injury and death, victims of dating violence are more likely to engage in risky sexual behavior, unhealthy dieting behaviors, substance use, and suicidal ideation/attempts. Dating violence victimization can be a precursor for intimate partner violence (IPV) victimization in adulthood, most notably among women. Among adult women in the United States, an estimated 5.3 million IPV incidents occur each year, resulting in approximately 2 million injuries and 1,300 deaths. By using data from the 2003 Youth Risk Behavior Survey (YRBS), CDC analyzed the prevalence of physical dating violence (PDV) victimization among high school students and its association with five risk behaviors. The results indicated that 8.9% of students (8.9% of males and 8.8% of females) reported PDV victimization during the 12 months preceding the survey and that students reporting PDV victimization were more likely to engage in four of the five risk behaviors (i.e., sexual intercourse, attempted suicide, episodic heavy drinking, and physical fighting). Primary prevention programs are needed to educate high school students about healthy dating relationship behaviors, and secondary prevention programs should address risk behaviors associated with dating violence victimization.     

Prevalence and correlates of adolescent dating violence: baseline study of a cohort of 7,960 male and female Mexican public school students

INTRODUCTION: Factors correlated with adolescent dating violence have yet to be documented in most developing countries; this study assesses the prevalence and correlates of victimization with and perpetration of dating violence among Mexican youth. METHODS: This was the baseline measurement (1998-1999) of a cohort of 7960 public school students (11-24 years) developed to explore various health behaviors in Mexican youth. Multinomial logistic regression models were constructed with adolescent dating violence as the dependent variable. RESULTS: Prevalence of dating violence victimization was 9.37% (female) and 8.57% (male) for psychological violence; 9.88% (female) and 22.71% (male) for physical violence, and 8.63% (female) and 15.15% (male) for both psychological and physical violence. Prevalence of perpetration was 4.21% (female) and 4.33% (male) for psychological violence; 20.99% (female) and 19.54% (male) for physical violence; and 7.48% (female) and 5.51% (male) for both types of violence. Factors associated with dating violence victimization for both genders included: two or more lifetime sexual partners and intra-familial violence. Higher age, alcohol use and illegal drug use were significantly associated with victimization only among girls. The following were significantly associated with perpetration of dating violence in both genders: gang membership, illegal drug use, two or more lifetime sexual partners and intra-familial violence. Higher age and alcohol use were significantly associated with perpetration only among girls. High or middle socio-economic status was associated with perpetration only in boys. CONCLUSIONS: Future research on adolescent dating violence in Mexico should further explore severity and frequency of violent behaviors, include a focus on severe dating violence and take into account the context and meaning of dating violence. A longitudinal design that allows determination of causality will also be needed in order to develop prevention strategies.     

Dating violence victimization: associated drinking and sexual risk behaviors of Asian, Native Hawaiian, and Caucasian high school students in Hawaii

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.     

Associations Between Latent Classes of Interpersonal Polyvictimization and Polyperpetration and Sexual Risk Behaviors Among Young Pregnant Couples: A Dyadic Analysis

Interpersonal violence victimization and perpetration have been associated with sexual risk behaviors among adolescents and young adults, but research is lacking on: (1) how patterns of interpersonal polyvictimization and polyperpetration are associated with sexual risk among young pregnant couples, and (2) how individual and partner experiences of violence differentially impact sexual risk. The current analyses used baseline data from a longitudinal study that followed 296 pregnant young couples from pregnancy to 12 months postpartum. Couples were recruited at obstetrics and gynecology clinics, and an ultrasound clinic in the U.S. Latent class analysis identified subgroups based on polyvictimization and polyperpetration. Using the Actor–Partner Interdependence Model, path analyses assessed actor–partner effects of class membership on sexual risk. Three latent classes were used for women: Class 1: Polyvictim–Polyperpetrator; Class 2: Nonvictim–Nonperpetrator; and Class 3: Community and Prior IPV Victim. Four latent classes were used for men: Class 1: Community and Prior IPV Victim; Class 2: Polyvictim–Nonpartner Perpetrator; Class 3: Prior IPV and Peer Victim; and Class 4: Nonvictim–Nonperpetrator. Path analyses revealed that females in Class 2 and their male partners had higher condom use than females in Class 3. Males in Class 2 had more sexual partners than males in Class 1. Among nonmonogamous couples, males in Class 2 were less likely to be involved with a female partner reporting unprotected sex than males in Class 1. Among nonmonogamous couples, females in Class 2 had more acts of unprotected sex than females in Class 1. Males in Class 4 were less likely to have concurrent sexual partners compared to males in Class 1. Risk reduction interventions should address both victimization and perpetration. Additional research is needed to understand how mechanisms driving differential sexual risk by patterns of interpersonal polyvictimization and polyperpetration.     

Sexual intercourse precedes partner violence in adolescent romantic relationships

PurposeTo examine whether psychological or physical violence between adolescent romantic partners is associated with the sexual intercourse status of the couple.MethodsThis study used a nationally representative sample of 6548 adolescents 12 to 21 years old from the National Longitudinal Study of Adolescent Health (Add Health). Variables of interest include violence between partners, whether partners had sexual intercourse, and demographics such as respondent’s gender, race, and socioeconomic status. Bivariate comparisons of proportions and logistic regression models were used to analyze data.ResultsViolent victimization was more likely to occur in romantic relationships that included sexual intercourse: 37% of the respondents reporting sexual relationships experienced at least one form of verbal or physical violence victimization, compared with 19% of those reporting relationships with no sexual intercourse. In relationships characterized by both sexual intercourse and violence, sexual intercourse was significantly more likely to precede violence rather than the reverse, regardless of type of violent act.ConclusionsThe covariation of violent victimization and sexual intercourse in adolescent romantic relationships underscores the need for health and sex education programs to integrate instruction and guidance on multiple facets of romance and sexuality.     

Assessing the Effects of the Dating Violence Prevention Program “Safe Dates” Using Random CoefficientRegression Modeling

The Safe Dates Project is a randomized trial for evaluating a school-based adolescent dating violence prevention program. Five waves of data were used to examine the effects of Safe Dates over time including primary and secondary prevention effects, moderators, and mediators of program effects. Using random coefficients models, with multiple imputation of missing data, significant program effects were found at all four follow-up periods on psychological, moderate physical, and sexual dating violence perpetration and moderate physical dating violence victimization. Marginal effects were found on sexual victimization. Effects on severe physical perpetration at all four follow-up periods were moderated by prior involvement in that type of violence. Primary and secondary prevention effects were found and the program was equally effective for males and females and for whites and non-whites. Program effects were mediated by changes in dating violence norms, gender-role norms, and awareness of community services.     

A longitudinal perspective on dating violence among adolescent and college-age women

OBJECTIVES: We investigated physical assault in dating relationships and its co-occurrence with sexual assault from high school through college. METHODS: Two classes of university women (n = 1569) completed 5 surveys during their 4 years in college. RESULTS: Women who were physically assaulted as adolescents were at greater risk for revictimization during their freshman year (relative risk = 2.96); each subsequent year, women who have experienced violence remained at greater risk for revictimization than those who have not. Across all years, women who were physically assaulted in any year were significantly more likely to be sexually assaulted that same year. Adolescent victimization was a better predictor of college victimization than was childhood victimization. CONCLUSIONS: There is a need for dating violence prevention/intervention programs in high school and college and for research on factors that reduce revictimization.     

Intimate Partner Violence,Sexual Autonomy and Postpartum STD Prevention Among Young Couples: A Mediation Analysis

CONTEXT

The transition to parenthood is a stressful time for young couples and can put them at risk for acquiring STDs. Mechanisms underlying this risk—particularly, intimate partner violence (IPV) and sexual autonomy—have not been well studied.

METHODS

Between 2007 and 2011, a prospective cohort study of the relationships and health of pregnant adolescents and their male partners recruited 296 couples at four hospital‐based obstetrics and gynecology clinics in the U.S. Northeast; participants were followed up six and 12 months after the birth. Structural equation modeling identified associations among IPV at baseline and six months, sexual autonomy at six months and STD acquisition at 12 months. Mediating effects of sexual autonomy were tested via bootstrapping.

RESULTS

Females were aged 14–21, and male partners were 14 or older. For females, IPV victimization at baseline was positively associated with the likelihood of acquiring a postpartum STD (coefficient, 0.4); level of sexual autonomy was inversely associated with the likelihood of acquiring an STD and of having a male partner who acquired one by the 12‐month follow‐up (–0.4 for each). For males, IPV victimization at baseline was negatively correlated with a female partner's sexual autonomy (–0.3) and likelihood of acquiring an STD (–0.7); victimization at six months was positively related to a partner's sexual autonomy (0.2). Sexual autonomy did not mediate these relationships.

CONCLUSIONS

Females' sexual autonomy appears to protect against postpartum STDs for both partners. Future research should explore the efficacy of IPV‐informed approaches to improving women's sexual and reproductive health.     

An evaluation of Safe Dates, an adolescent dating violence prevention program.

OBJECTIVES: This study assessed the effects of the Safe Dates program on the primary and secondary prevention of adolescent dating violence. METHODS: Fourteen schools were randomly allocated to treatment conditions. Eighty percent (n=1886) of the eighth and ninth graders in a rural county completed baseline questionnaires, and 1700 (90%) completed follow-up questionnaires. RESULTS: Treatment and control groups were comparable at baseline. In the full sample at follow-up, less psychological abuse, sexual violence, and violence perpetrated against the current dating partner were reported in treatment than in control schools. In a subsample of adolescents reporting no dating violence at baseline (a primary prevention subsample), there was less initiation of psychological abuse in treatment than in control schools. In a subsample of adolescents reporting dating violence at baseline (a secondary prevention subsample), there was less psychological abuse and sexual violence perpetration reported at follow-up in treatment than in control schools. Most program effects were explained by changes in dating violence norms, gender stereotyping, and awareness of services. CONCLUSIONS: The Safe Dates program shows promise for preventing dating violence among adolescents.     

The Prevalence of Bisexual and Homosexual Orientation and Related Health Risks Among Adolescents in Northern Thailand

Homo- or bisexual (HB) adolescents may have greater and different health risks than the population of heterosexual adolescents. We assessed sexual orientation and health risk behaviors in 1,725 consenting 15- to 21-year-old vocational school students in northern Thailand. Data were collected using audio-computer-assisted self-interviewing. Nine percent of males and 11.2% of females identified themselves as homo- or bisexual. HB males had an earlier mean age at sexual debut (14.7 years) and a higher mean number of lifetime sexual partners (7.9) than did heterosexual males (16.8 years and 5.8 partners, respectively). HB males (25.9%) and females (32.2%) were sexually coerced more often than were heterosexual males (4.6%) and females (19.6%). Drug use was reported significantly more frequently by HB females and significantly less frequently by HB males than by their heterosexual counterparts. HB males showed more signs of social isolation and depression than did heterosexual males. We conclude that HB adolescents in northern Thailand are at greater and different health risks than are their heterosexual counterparts. Differential health education messages for HB and heterosexual youth are warranted.     

Peer Victimization and Unhealthy Weight Control Behaviors—the Role of Intersecting Identities among New York City Youth

We investigated the intersection of sexual minority, gender, and Hispanic identities, and their interaction with peer victimization in predicting unhealthy weight control behaviors (UWCB) among New York City (NYC) youths. Using logistic regression with data from the 2011 NYC Youth Risk Behavior Survey, we examined the association of sexual identity, gender, ethnicity, and peer victimization (dating violence, bullying at school, electronic bullying) in predicting UWCB. Sexual minority youths, dating violence victims, and youths bullied at school had 1.97, 3.32, and 1.74 times higher odds of UWCB than their counterparts, respectively (P < 0.001). The three-way interaction terms between (i) dating violence, gender, and sexual identity and (ii) electronic bullying, gender, and sexual identity were statistically significant. The effect of dating violence on unhealthy weight control practices was strongest among sexual minority males (OR = 4.9), and the effect of electronic bullying on unhealthy weight control practices was strongest among non-sexual minority males (OR = 2.9). Sexual minority and gender identities interact with peer victimization in predicting unhealthy weight control practices among NYC youths. To limit the prevalence and effect of dating violence and electronic bullying among youths, interventions should consider that an individual’s experiences are based on multiple identities that can be linked to more than one ground of discrimination.     

Assessing the long-term effects of the Safe Dates program and a booster in preventing and reducing adolescent dating violence victimization and perpetration

OBJECTIVES: This study determined 4-year postintervention effects of Safe Dates on dating violence, booster effects, and moderators of the program effects. METHODS: We gathered baseline data in 10 schools that were randomly allocated to a treatment condition. We collected follow-up data 1 month after the program and then yearly thereafter for 4 years. Between the 2- and 3-year follow-ups, a randomly selected half of treatment adolescents received a booster. RESULTS: Compared with controls, adolescents receiving Safe Dates reported significantly less physical, serious physical, and sexual dating violence perpetration and victimization 4 years after the program. The booster did not improve the effectiveness of Safe Dates. CONCLUSIONS: Safe Dates shows promise for preventing dating violence but the booster should not be used.