Journal of Health Communication, 16:112–123, 2011
Copyright # 2011 Guttmacher Institute
ISSN: 1081-0730 print=1087-0415 online
DOI: 10.1080/10810730.2010.535112
112
At the same time that there was a decline in comprehensive school-based sex
education, adolescents’ use of the Internet became nearly universal. This study
explores adolescents’ use and evaluation of the Internet for sexual health information,
with a focus on the issues of contraception and abstinence. The authors conducted 58
in-depth interviews with juniors and seniors in 3 public high schools in New York City
and Indiana. Most of the adolescents used the Internet on a daily basis, but few considered
it a main source of information about contraception or abstinence. Students
were more likely to rely on and had greater trust in traditional sexuality education
sources such as school, family members, and friends. Most of the adolescents the
authors interviewed were wary of sexual health information on the Internet, and
the authors describe strategies adolescents used to sort through the abundance of
sex-related material. Formal and informal efforts to provide sexuality education to
adolescents should include specific age- and content-appropriate Web sites because
many teens are not actively searching on their own, and they express reservations
about relying on the Internet as a source of sexual health information.
Funding for abstinence-only-until-marriage programs has increased substantially, and
research has suggested that fewer adolescents are getting comprehensive information
about contraception at school (Santelli et al., 2006). For example, the percentage of
15–19-year-olds receiving any formal instruction about birth control declined from
81% of male adolescents and 87% of female adolescents in 1995 to 66% of male adolescents
and 70% of female adolescents in 2002 (Lindberg, Santelli, & Singh, 2006).
During this same time period, teens’ exposure to other potential sources of
information about sexuality also changed. The majority of teens (93%) are users
Ann E. Biddlecom was formerly a Senior Research Associate at the Guttmacher Institute.
The views expressed herein are those of the author and do not necessarily reflect the views of
the United Nations.
This work was supported by a grant from the Ford Foundation.
The authors thank Luciana Hebert and Ruth Milne for their substantive contributions to
the project, and Heather Boonstra, Lawrence B. Finer, Laura D. Lindberg, and Susheela
Singh for providing feedback on the article. The authors are also grateful to several school
staff members (names purposely excluded to protect the identities of the schools) for their
invaluable guidance and help with recruitment activities.
Sexuality education in the United States has changed significantly over the past decade.
Funding for abstinence-only-until-marriage programs has increased substantially, and
research has suggested that fewer adolescents are getting comprehensive information
about contraception at school (Santelli et al., 2006). For example, the percentage of
15–19-year-olds receiving any formal instruction about birth control declined from
81% of male adolescents and 87% of female adolescents in 1995 to 66% of male adolescents
and 70% of female adolescents in 2002 (Lindberg, Santelli, & Singh, 2006).
During this same time period, teens’ exposure to other potential sources of
information about sexuality also changed. The majority of teens (93%) are users of the Internet, including
approximately three quarters who have a high-speed connection
at home (Zhao, 2009). Data from 2006 show that more than one in four
teens looked for health, dieting, or physical fitness information online (Lenhart,
Madden, Macgill, & Smith, 2007). A study of teens and young adults (18–29 years
old) showed similarly high levels of Internet use and of those using the Internet,
72% had gone online for health or medical information (Fox & Jones, 2009).
There are substantial and growing efforts to provide teens with sexual health information
on the Internet. Web sites such as sexetc.org, iwannaknow.org, and scarleteen.
com are intended to provide factual and real-world information about a range of sexual
health issues as well as a forum for adolescents to (anonymously) submit questions and
participate in discussions. Two small-scale and somewhat dated studies found that
approximately one in four young adults used the Internet to find information about sex
(Borzekowski & Rickert, 2001a; Rideout, 2001). A study of 412 10th graders in 2000
found that the Internet was teens’ most common source of information about birth control
and sex, although friends and parents were identified as more valuable sources
(Borzekowski & Rickert, 2001b). Yet, despite the rapid growth in teens’ use of the Internet,
recent evidence has lagged about the ways that teens use, view, and trust the Internet
as a sexual health information source, particularly in relation to more traditional sources
such as family, friends, and school. To address this gap, we conducted an exploratory
studywith 58 high school students to find out how they used the Internet for sexual health
information, particularly contraception and abstinence. We focused especially on how
these teens discerned whether information or Web sites were trustworthy and discuss
opportunities for improving links between accurate teen sexual healthWebsites and teens.
Methods
Our analysis is based on interviews conducted April to June 2008 with 58 high school
juniors and seniors recruited from three sites: a large public high school (approximately
3,700 students) and a small public high school (approximately 400 students), both in
New York City, and a large public high school (approximately 1,800 students) in a
mid-sized city in Indiana. After obtaining administrative approval, we worked with
a health teacher or key contact at each school to develop recruitment strategies. At
the Indiana school, a short description of the study was read during the morning
announcements for three weeks, a brief video clip about the study aired each morning
during the schools’ in-house television programming for 1 week and a health teacher
introduced the study in health classes. At the small public school, the director of special
programs briefed teachers on the project. Teachers then explained the study to all junior
and senior classes using a short study description 3–4 weeks before the interviews
took place. At our third site, the large public school in New York City, we worked with
the vice principal of health education once we had obtained study approval from the
New York City Department of Education. Several days before the interviews, we went
to junior and senior gym classes and briefly explained the study.
Information packets were made available to all interested students and included
a short study description, a parental consent form (available in Spanish and English,
as well as Chinese and Korean at the large New York City school), a form collecting
students’ age, gender, grade, and race=ethnicity and an envelope for returning the
forms confidentially. Packets were returned to designated staff members, and all
students had to submit signed parental consent forms to be eligible for selection.
We obtained signed consent from all students before starting the interviews.
Internet and Sexual Health Information for Teens 113
Students were selected for interviews at each site on the basis of our study goal
of racial and ethnic diversity as well as students’ availability during the school day.
We interviewed a total of 26 students at the Indiana school, 9 students at the small
New York City public school, and 23 students at the large New York City public
school. Students ranged in age from 16 to 19 years. Table 1 indicates the distribution
of respondents by gender, race=ethnicity, state, and grade.
To ensure a diversity of perspectives, we aimed to interview seven students in each
gender by race=ethnicity category of Table 1. We fell short of that goal by one interview
for Asian male students and two interviews each for Black and Hispanic male
students. The two coauthors who conducted the interviews are White, non-Hispanic,
middle-aged women, which may have presented more of a barrier to participation for
teenage males, particularly those of a different racial=ethnic background.
Interviews were digitally recorded and 40 minutes long, on average. Every participant
received a $25 gift certificate as a token of appreciation. The project was
reviewed and approved by the Guttmacher Institute’s institutional review board.
Although this article focuses on information about contraception and abstinence
obtained online, the interviews covered an array of potential sources: school, friends,
boyfriends=girlfriends, family, mass media, doctors=nurses, and religious groups. We
asked similar questions about each source, namely what the teenager had learned
(probing on the specific topics of abstinence and contraception=safe sex) and how
much they trusted the source for this kind of information. Similarly, although we outlined
the questions to be asked during the interviews (see the Appendix for the interview
guidelines) we were flexible about question order and language. For example,
during the interviews, we generally tried to avoid using the term contraception because
it was not understood by some teens. We determined during pretesting that the term
birth control was sometimes interpreted to mean (only) the pill (or, occasionally, other
hormonal methods). We also found that some teens used the term safe sex as shorthand
for using contraception (usually condoms) to prevent sexually transmitted
diseases and=or pregnancy. Thus, during the interviews we typically used the terminology
birth control, condoms, or safe sex as in ‘‘Tell me about any discussions you’ve
had with family members about birth control, condoms, or safe sex.’’ For brevity, in
Table 1. Demographic characteristics of in-depth interview respondents
Female Male Total
Race=ethnicity
White 9 9 18
Black 8 5 13
Hispanic 9 5 14
Asian 7 6 13
State
Indiana 16 10 26
New York 17 15 32
Class
Junior 20 14 34
Senior 13 11 24
Total 33 25 58
114 R. K. Jones and A. E. Biddlecom
our analysis we often used the term contraception in reference to all three issues but
distinguished among birth control, condoms, and safe sex when appropriate.
The Internet can also be a source of sexually explicit material or pornography
for teens (Wolak, Mitchell, & Finkelhor, 2007; Ybarra & Mitchell, 2005). We
attempted to increase respondents’ willingness to share these experiences with the
following statement, read before the series of questions about online sexual health
information: ‘‘I know that there’s a lot of information out there on this topic, some
of it sexually explicit. My questions refer to all the different types of information.’’
We developed a scheme of approximately 20 codes based on the guidelines to capture
the main issues discussed and coded the 58 transcripts using QSR NVivo (Version
8.0) qualitative software. Each coauthor read through text searches for specific codes
and prepared a matrix of the substantive themes on the topic for each study participant.
Results are based on the common themes arising from these matrices. Quotes
from the interviews are identified by geographic place, gender, race=ethnicity, age
and whether the respondent was a daily or less frequent Internet user.
Results
Sexual Health Information on the Internet
All of the respondents reported exposure to, and familiarity with, the Internet. Most
teens (n¼43) used the Internet on a daily basis, ranging from 30 min to several
hours. There was substantial variation in Internet use among the remaining 15 teens;
some reported using it every other day whereas others reported less frequent use.
E-mail, instant messaging, and social networking (MySpace and Facebook) were
the most common Internet activities, and almost all of the teens used the Internet
for these purposes. Although less common, homework=research, music, shopping,
and gaming (mostly limited to male respondents) were other Internet activities.
A minority of teens (n¼21) were exposed to contraceptive information online.
Most of these teens had actively accessed this information in response to school
assignments and less often because of a personal situation or because they had
stumbled upon it in the course of other searches. In a few cases, teens talked about
going online to confirm or double-check contraceptive information they heard or
learned from other sources. Although these adolescents technically had obtained sexual
health information from the Internet, their limited exposure to this information
suggests that it was not a primary source of sex education.
Well I haven’t really seen a lot on birth control, but only when I have to do
a project, I found some very like good information, because we had to do
like a health project and stuff and we had to have some good information
and stuff like that. But like when I am searching the Internet, like pop-ups
I never see anything about that.
(New York, Black female, 16 years old, less frequent Internet user)
Like, I, this one time I had a question, you know? I didn’t really feel
comfortable asking like my mom, ‘cause she was the only one around.
You know, I was like, I went on the Internet and I was like, ‘‘Can a girl
get pregnant during her period?’’
(Indiana, Hispanic male, 17 years old, daily Internet user)
Internet and Sexual Health Information for Teens 115
Teens who used the Internet regularly and proactively to educate themselves about
contraception and safe sex were the exceptions rather than the rule.
Like this one Web site, I have gone to, like when I have personal
problems dealing with periods and stuff, they have like a search forum
where you can look up anything that has to deal with sex and health
and it tells you about birth control and it tells you about condoms, it tells
you about different things that could be, like, going on with you. It’s
really informational and it’s, like, teen comfortable.
(Indiana, White female, 18 years old, less frequent Internet user)
Most teens reported no exposure to contraceptive information on the Internet. In
some cases, they related that they knew the information was there if they needed
it, but they were not motivated to look it up or click on it. Others related that they
would go to other sources, such as school, friends, and family, or that they had the
information already. Some teens had not been exposed to contraceptive information
per se, although they could recall seeing online advertisements (e.g., pop-ups or sidebar
ads). However, few teens suggested that Internet ads provided them with new or
substantive information, and most seemed to regard them as increasing brand name
awareness or something to be ignored.
A minority of teens (n¼14) recalled exposure to abstinence information on the
Internet. This information was related in varied formats, including articles or discussions
about ‘‘how to decide when to have sex,’’ in the context of their religious
groups=Web sites, for a school assignment, by chance, and via advertisements to delay
sex. Overall, the online abstinence information described by teens was superficial and
lacked depth; relative to contraception, even fewer teens described actively seeking out
abstinence information on the web. Several teens who could not recall seeing abstinence
information online expected that they could find it if they needed it. The more common
sentiment was that the Internet was an unlikely place for abstinence information.
I think maybe once and I might have gotten to a Web site that talks about
abstinence and safe sex. And that was just like probably by chance, that I
got to that web site, I know there is definitely a lot of information out there.
(Indiana, White male, 17 years old, daily Internet user)
I really don’t think they have that [abstinence], I mean, I think they more
try to pressure you to have sex earlier than trying to prevent you from
doing it.
(New York, White female, 18 years old, daily Internet user)
Female participants were more likely than male participants to report exposure to
information about contraceptives. However, apart from this pattern, the information
teens reported receiving from the Internet about contraception and abstinence
did not differ substantially by gender or ethnicity.
Although we were most interested in online information about contraception and
abstinence, teens also related that they had sought out, or were exposed to, information
about sexually transmitted diseases (including HIV), pregnancy, pornography,
sexual anatomy, abortion, sexual pleasure, sexual terminology, and
reproductive cancers. Almost as many teens volunteered that they had been exposed
116 R. K. Jones and A. E. Biddlecom
to online information on sexually transmitted diseases (n¼15) as had been exposed to
contraceptive information. Information on sexually transmitted diseases was accessed
out of curiosity, concern or for a class assignment, and the online pictures that often
accompanied the information made an impression on a number of teens. Although we
did not consider it a type of sexual health information, it is worth noting that almost
all of these teens recalled involuntary exposure to advertisements (pop-ups, spam, or
sidebar ads) for pornography or sexually explicit photos or pictures.
Savvy and Wary Internet Users
Overall, only 5 of the teens we interviewed mentioned the Internet as one of their
most trusted sources of sexual health information. Teens were more likely to trust
(in order) family members (usually parents), school, medical professionals, and
friends for sexual health information. The majority of these teens indicated wariness
of online sexual health information, regardless of whether they had actually sought it
out or been exposed to it. Among the remaining teens, most described outright distrust
and only a few indicated trust in the Web. There was no pattern in the degree of
trust in the Internet by gender, race=ethnicity, or actual Internet use; heavy Internet
users (several hours per day), daily but not heavy users, as well as less frequent users
were included in the groups of teens who qualified their trust or categorically
distrusted the Internet.
Some teens described ways they evaluated sexual health information online.
Most commonly, their trust depended on whether the Web site was a reputable or
known source. News Web sites and those associated with general health or medical
sources (e.g., WebMD or public health departments) were considered trustworthy,
and a few teens indicated that sites with the suffixes.gov, .org, and .edu were more
likely than.com Web sites to contain accurate information.
[I]t depends on the Web site. Wikipedia would be like 60%. But like on
[Web]MD, I would be like 90% because those are like information from
doctors and stuff, yeah.
(New York, Hispanic male, 17 years old, daily Internet user)
I guess it just depends on where you go. I guess if I went to like to an actual
Web site that I got from like the doctor’s office or something, I think I
would trust it. Yeah I would probably trust everything they say because
it’s from the doctor. And if I went to like a Web site I had heard from . . .
students or something like that, I probably would believe half the stuff.
(Indiana, Black female, 17 years old, daily Internet user)
Some teens related that trust in an Internet source was qualified by whether the
information corresponded with what they had learned from other sources. In the
other direction, some teens (n¼8) talked about purposefully using the Internet to
cross-check or validate information from other sources, including friends, school,
magazines, and other Web sites.
I trust it as long as it’s from a source that I know adds up to everything
else I have heard.
(Indiana, White female, 16 years old, daily Internet user)
Internet and Sexual Health Information for Teens 117
I can’t say that I’ve got too much information from them [his friends], but
depending on what it was, I might like look it up on the Internet and see
if I can trust them about it or not.
(Indiana, White male, 17 years old, daily Internet user)
Teens were aware that a lot of information on the Internet was user-generated
(‘‘Anyone can make a Web site’’) and this was another reason teens did not
unquestioningly consume or seek out sexual health information from this source.
Some teens expressed concern that information about sexual health issues may have
been generated by someone who was not an expert in the area and could, therefore,
be incorrect. The Web site Wikipedia was a common example of user-generated
information that may not be definitive.
Like the Internet, you see these things like Wikipedia and stuff like that;
and you know people can edit out information and stuff like that. So like
mainly, I just go to friends and stuff. Like I don’t really look online
because like those sources I can’t really trust. Because some of them could
be lying, some of them could be fake.
(Indiana, Hispanic female, 18 years old, daily Internet user)
You know sometimes you can identify, like you know, in my own personal
experience like .com, anyone can make up a Web site but .org is
more like an organization, it’s more reliable, but that doesn’t mean that
I will fully trust it.
(New York, Asian male, 18 years old, daily Internet user)
Last, the seemingly ubiquitous nature of sexually explicit or sexually oriented
material on the Internet made some adolescents reluctant to trust it for factual information
about sex. Moreover, sex and sexual imagery being used to sell or market products
(‘‘sex sells’’) made some teens skeptical of the factual information being provided.
Like the Internet, it’s pretty much just like giant billboard for sex. It’s
really, it’s not a good place to go if you are young, because being on
Internet, because all the pop ups and things you could type in kind of
makes you want to have sex. So it really doesn’t enforce the abstinence
rule and birth control, safe sex anything.
(Indiana, White male, 17 years old, less frequent user)
Well it’s really difficult because people, like, when you search for like
birth control options, like they ‘‘Oh, here, you wanna buy some condoms?’’
you know and stuff like that, instead of giving me information
on it, they want to like sell it to you.
(New York, Black female, 16 years old, less frequent user)
The fact that there are so many different Web sites and that different Web sites
will often give different answers to the same question contributed to some teens’
wariness. Adolescents also related that using relevant sexual health search terms
often meant having to sort through a lot of unrelated material or evaluate different
answers to the same question.
118 R. K. Jones and A. E. Biddlecom
I have done it once and they usually send you around the loop, like you are
just on like a massive hunt for information. Yeah, I usually just give up . . . .
when it comes to like things like sexuality, usually Web sites are like, either
they are for it or they are against it. And there is no real information
about it.
(New York, Hispanic male, 17 years old, daily Internet user)
Discussion and Conclusion
School-based comprehensive sex education has declined over the past decade, but
the dramatic rise in teens’ use of the Internet raised the possibility that it could fill
the sexual health information gap. However, the results from this exploratory study
suggest that a number of teens do not frequently use the Internet to obtain
educational information about sexual health, at least not as it pertains to contraception
and abstinence. Although most of these teens were online daily, few of them had
proactively searched, apart from school assignments, for substantive information
about these issues. These teens were also wary and discerning consumers: They were
aware of the abundance of online sexual health information but had criteria to help
evaluate the trustworthiness of information. The interactivity of the Internet that
makes it popular for social networking, its platform for advertising and the openness
that allows so many people to create and upload content of a wide-ranging nature
are the same characteristics that made these teens generally wary. These findings
suggest that the Internet reflects more potential than reality as a substantive source
of sexual health information for teens.
These findings must be interpreted with the several study limitations in mind.
First, the extent to which this study reflects these adolescents’ actual experiences is
only as accurate as the respondents’ memories. It is possible that some teens did
not recall, or failed to relate, exposure to substantive online information about contraception
and abstinence. Second, the study focus and recruitment materials may
have deterred sexually experienced teens from participating. Although the recruitment
materials indicated that the interviews would focus on where students’
obtained information about sexual health issues, several respondents related that
they had expected us to question them about their sexual behavior. Moreover, more
than half of the teenagers we interviewed related in an unprompted way that they
had not had sex. While this proportion seems reasonable, especially given that there
were more juniors than seniors in the sample, we still speculate that sexually experienced
teenagers may have been more uncomfortable or embarrassed talking to strangers
about these issues. Alternately, sexually experienced teens may have worried
that simply asking parents to sign the consent form would result in questions about
their own sexual behavior. This latter situation also raises the related limitation that
the requirement of written parental consent may have prevented some high school
students from participating because of parental refusal (real or anticipated) for other
reasons. Last, as we previously note, the gender, age, and race=ethnicity of the two
interviewers may have deterred male and youth of color from participating.
Although our study suggests the Internet is not filling a gap in sexual health education
for a number of adolescents, the medium shows much promise. There are many
teen-friendly Web sites that provide comprehensive information about these issues,
and some of these sites get tens of thousands of unique visitors per day and are
connected to popular social networkingWeb sites. Even though it is useful to examine
Internet and Sexual Health Information for Teens 119
the traffic to these sites and the kinds of questions submitted, there are many more
teens who, while Internet savvy, never make it to the sites or may do so but without
being certain if they can trust the information (Gilbert, Temby, & Rogers, 2005; Harvey,
Brown, Crawford, Macfarlane, & McPherson, 2007; Suzuki & Calzo, 2004). The
potential is great for the Internet to link teens to accurate sexual health information
and to build their trust and confidence in the information they get, but doing so only
through Internet-based approaches may not be completely effective.
Given that schools and family members still play an important role in providing
information about sex and are generally trusted by teens, it may be particularly effective
to capitalize on these information sources to link teens to reliable and comprehensive
sexual health information on the Web. Possible strategies for schools include
class assignments that require online research on sexual health topics, training students
how to conduct basic and effective searches for sexual health information,
and ensuring that students receive a list of comprehensive sexual health Web sites
for later reference. Organizations and individuals that work with adolescents, particularly
around issues of health, should provide teens with lists of Web sites they can
access for factual information about a range of sexual health issues. Connecting
teens to credible Web sites by way of parents or other family members is more challenging,
but often parents are as eager for reliable health information sources as are
their children. Professional organizations such as the Society for Adolescent Medicine,
the National Parent Teacher Association, and youth-serving organizations such
as the Boys and Girls Club of America should consider compiling lists of Internet
resources that can be used by parents and adolescents.
References: Jones, R. K., & Biddlecom, A. E. (2011). Is the Internet Filling the Sexual
Health Information Gap for Teens? An Exploratory Study. Journal Of Health
Communication, 16(2), 112-123. doi:10.1080/10810730.2010.535112
Attitudes, Experience, and Anticipation of Sex Among
5th Graders in an Urban Setting: Does Gender Matter?
Karen M. Anderson • Helen P. Koo •
Rene´e R. Jenkins • Leslie R. Walker •
Maurice Davis • Qing Yao • M. Nabil El-Khorazaty
Published online: 14 September 2011
_ Springer Science+Business Media, LLC 2011
Abstract To identify gender differences in correlates of
anticipation and initiation of sexual activity in the baseline
survey of 562 African-American 5th grade students prior to
initiation of a school-based pregnancy prevention intervention
curriculum. Students from 16 elementary schools
were administered the baseline questionnaire during classroom
periods. Using these data, binary and ordered logistic
regression models were used to analyze the factors affecting
virginity and anticipation of sexual activity separately by
gender, and tests of interaction between each factor and
gender were conducted on the combined sample. More boys
than girls had already had sex (18% vs. 5%) and anticipated
having sexual intercourse in the next 12 months (56% vs.
22%). Boys and girls also differed in the factors that affected
these outcomes. The perception that their neighborhood was
safe reduced the odds that boys anticipated sexual activity
but was not associated with this outcome among girls.
Pubertal knowledge increased the odds of anticipation, but
only among boys. Attitudes favoring abstinence decreased
anticipation of sex among both genders, but slightly more
among girls than boys. Having more frequent parent–child
communication about sex was associated with increased
anticipation among girls but decreased anticipation among
boys. Curriculum based approaches to adolescent pregnancy
prevention are appropriate for 5th grade elementary students
who may already be anticipating sexual activity in communities
with disproportionate rates of teen pregnancy. The
design of the interventions should consider the differences
in motivating factors by gender.
Keywords Pre-adolescents _ Sexuality _ Gender
differences _ Sexual activity _ Virginity _ Risk behaviors _
Adolescent pregnancy prevention
Introduction
Adolescents in the United States initiate sexual intercourse
at alarmingly young ages. Youth Risk Surveillance data
indicate that 5.9% of high school students initiated sex
before age 13. For Black male students the rate reaches
24.9% [1]. Yet, relatively few comprehensive sex education
programs are offered in elementary school settings. Only
27.5% of all schools sampled in the United States have a
policy that teaches about pregnancy prevention in elementary
schools and only 49% require human sexuality education.
Of those that teach pregnancy prevention or sexuality,
1.3 classroom hours are required and 10% provide any
classroom activity opportunities for the students to practice
skills [2]. In contrast, Mueller et al. [3] showed evidence that
school sex education can reduce adolescent sexual risk
behaviors when provided before sexual initiation, particularly
in youth at high risk for early sexual debut. The literature
suggests that having sex education for elementary
school aged children is very limited but may help delay early
sexual debut, especially in high risk populations.
While information on what is taught in schools can be
elicited from national surveillance studies, there is less
information available about the association between preadolescent
sexual attitudes, experiences and anticipation of
sexual behavior. The information could provide evidence
for increasing elementary school prevention programs
aimed at decreasing early sexual debut.
Research also shows that gender plays a role in attitudes
toward sexual intercourse in young adolescents. One study
of 4th and 5th graders found that twice as many males as
females anticipated having sex within the next year [4];
however, the study excluded already sexually active children.
In addition, research has consistently shown a gender
disparity in age of reported sexual debut, particularly in
black youth [4, 5] and in attitudes toward sex [6, 7].
This paper describes the attitudes toward sexual activity,
anticipation and experience of sexual intercourse among a
sample of 5th graders. In particular, it examines differences
between boys and girls in these factors. Thus, it provides
relatively rare data for a young age group, and could be
used in the promotion and design of interventions to delay
sexual debut among elementary students taking gender
differences into account.
The data were obtained from 5th grade students enrolled
in a pregnancy prevention school-based program, Building
Futures for Youth (BFY), prior to the beginning of the
intervention. The program was delivered over a 3-year
period and involved the parents of the students. In an earlier
study by several of the present authors only 44% of 7th grade
male students in the same school district reported being
virgins and consequently limited the program’s ability to
intervene prior to sex debut [8]. Consequently the new BFY
program targeted 5th graders and their parents with the
intent of intervening prior to initiating sex. The significant
gender differences in the proportion of boys versus girls
reporting sexual activity in the prior study also prompted the
investigators to consider tailoring some curriculum modules
to be more gender specific and hold same-sex sessions.
The content of the BFY intervention was based on a
conceptual framework for risk and resilient behavior. The
Social Cognitive Theory [9] informed the framework
because it takes into account individual, environmental and
peer factors in explaining human interpersonal behavior.
To guide the development of the intervention and its
evaluation, we developed a logic model considering these
factors based on the research literature on specific variables
influencing sexual attitudes and behavior of adolescents
and pre-adolescents. Figure 1 represents the variables
chosen for inclusion in the logic model. These are also the
variables included in the present article. A report of the
evaluation of the intervention has been published [10].
Methods
Study Design
The BFY intervention to delay sexual initiation was
implemented and evaluated, starting with 5th graders in 16
Washington, DC, schools during the 2001–2002 school
year. Eight schools each were randomly assigned to the
intervention and control conditions. The students were
followed longitudinally into the 6th and 7th grades. This
paper uses baseline data from the children at all 16 schools
prior to intervention activities, to examine baseline associations
among various sociodemographic factors and the
boys’ and girls’ psychosocial attributes, attitudinal and
knowledge characteristics related to sexuality, and their
sexual experience and anticipation of sexual activity.
Sample
The 5th grade students attending these 16 schools were
considered eligible for the study if they were able to
complete the survey in English. Students in special education
classes were excluded because the survey was selfadministered.
Fig. 1 Factors associated with sexual experience and anticipated
sexual activity
Matern Child Health J (2011) 15:S54–S64 S55
123
Parents of all eligible students signed consent forms for
their children to participate in the study. Of 793 eligible
students, 620 (89.5%) received parental consent. Of these,
562 (90.6%) completed the students’ baseline survey.
Analysis of the sociodemographic characteristics of these
students showed that they are representative of the students
at the study schools in being mostly African American
(99% vs. 97% in the 16 schools), more female (54% female
vs. 52% female in the 16 schools), and low income, as
represented by receipt of free or reduced priced school
lunch (75% vs. 76%).
Students were administered the baseline questionnaire
during classroom periods. Students marked a hard-copy
version of the 70-item questionnaire while listening to an
audiotape of the questions and answer choices using
audiocassette players with earphones. Pretesting found that
the use of audiocassette players decreased student interactions
and distraction and provided more privacy while
completing the questionnaire.
Survey Instrument
The baseline questionnaire measured background and risk
factors related to early sexual debut and adolescent pregnancy,
as well as outcomes targeted by the intervention
(Fig. 1). Intermediate outcomes included knowledge and
attitudinal factors that are relevant to delaying sexual initiation
and reducing pregnancy. We developed two genderspecific
questionnaires to tailor the wording to boys versus
girls. We included new questions and questions from previously
validated survey instruments, including the
National Longitudinal Study of Adolescent Health [11], the
Teen Activities and Attitudes Study [12], and the questionnaires
used in a predecessor study [8, 13]. The instrument
was tested and revised twice using cognitive
interviews and pilot tests. The institutional review boards
of the contributing institutions and the National Institute of
Child Health and Human Development (NICHD) approved
the final questionnaires and all study procedures.
Measures
Dependent Variables
Experience of Sexual Intercourse This was a dichotomous
variable (‘‘yes’’ and ‘‘no’’) based on responses to the
question, ‘‘Have you ever had sex?’’ (The questionnaire
stated that ‘‘having sex means the male’s penis is inside the
female’s vagina’’).
Anticipated Level of Sexual Activity in the Next
12 Months This variable was based on three questions
asking whether the students thought they would, in the next
12 months, kiss or touch under the clothes if they were
going out with someone they like a lot, and have sex. We
classified students who did not expect to engage in any of
these behaviors as having ‘‘low risk’’ anticipation, those
who reported that they might kiss or touch under the
clothes (answered ‘‘yes’’ or ‘‘don’t know’’) as having
‘‘moderate risk’’ anticipation, and those who responded
that they might have sexual intercourse (‘‘yes’’ or ‘‘don’t
know’’) as having ‘‘high risk’’ anticipation.
Independent Variables
Background Characteristics We identified six background
factors as independent variables: age; mother
works; free or reduced-price lunch (as a measure of poverty);
frequency of student attendance at religious services;
student feels their neighborhood is safe; and status of the
child’s pubertal development. The girls were asked: ‘‘Have
you started growing breasts or body hair?’’ and the boys
were asked: ‘‘Have you started growing body hair or has
your voice started to change?’’ Boys or girls answering
‘‘yes’’ to their question were classified as having experienced
pubertal signs. (Details on the puberty variables can
be found in another publication) [14].
School and Self Variables The ‘‘self confidence’’ variable
was based on responses to two statements: ‘‘Other kids my
age like me a lot’’ and ‘‘My parents are very proud of me.’’
The two numbers were summed to give a ‘‘self confidence’’
score. The ‘‘liking school’’ variable was similarly constructed,
summing responses to three statements: ‘‘I
get along with most of the students at my school;’’ ‘‘I like
most of the teachers at my school;’’ and ‘‘I like going to my
school.’’ The ‘‘extracurricular activities’’ variable represents
the number of activities that students indicated they
had participated in. We constructed three categories of
‘‘educational aspiration’’ from responses to two questions
about plans to finish high school and seek education
beyond high school.
Attitudinal and Knowledge Variables Three variables,
attitude toward sexual abstinence, attitude toward resisting
pressure to have sex, and parent–child communications
about sexual topics, were scales created through factor
analysis of groups of questions intended to measure these
constructs. Higher scores on these scales represented
greater favorability toward abstinence and refusal of sex,
and more frequent parent–child communication about
sexual topics. See Rose et al. [15] for details regarding the
development and psychometric properties of these scales.
We based the variable, whether parent would be upset if
the student were having sex and the parent found out, on a
direct question. The ‘‘knowledge of puberty’’ variable was
S56 Matern Child Health J (2011) 15:S54–S64
123
based on the number of pubertal signs that students
answered in two questions about the changes occurring
during puberty in boys and to girls.
Statistical Analyses
Because the level of sexual activity experienced and
anticipated, sexual attitudes, and relationships among some
factors were expected to differ between boys and girls, we
conducted analyses separately by gender. We first examined
for each gender the bivariate relationships of background,
school/self, and attitudinal characteristics of
students with the two dependent variables. For categorical
independent variables, we used cross-tabulations and chisquare
tests of significance. For cross-tabulations containing
small expected numbers of cases, we performed the
Fisher’s exact test. For continuous independent variables
(various scales), we computed their means for each category
of the dependent variables and tested the significance
of differences between means. We then included any
independent variable that was significantly related (at
P\0.10) to either dependent variable, for either gender, in
the subsequent multivariable analysis, so that the set of
independent variables would be comparable across the set
of multivariable models. (We included age in the multivariable
models, even though it was not significantly
related to the dependent variables in the bivariate analysis,
to distinguish the effects of age from puberty.) Out of the
562 students who completed the survey, 63 were dropped
from the analyses because they did not respond to all
questions that were used in multivariable analyses.
In the multivariable analysis of experience of sexual
intercourse, we used binary logistic regression to model the
likelihood of having had sex (vs. not having had sex). For
the three-level variable, anticipated sexual activity, we
estimated ordered logistic regression models. We modeled
the likelihood of being in the higher risk groups over being
in the lower risk groups (highest vs. moderate and low; and
highest/moderate vs. low). For each dependent variable, we
used all three sets of independent variables to assess which
background, school/self, and attitudinal factors had independent
associations with each dependent variable when all
three sets were taken into account.
These regression models were estimated separately by
gender. To test whether results differed by gender, we
estimated the models for the two genders combined, and
tested, one at a time, the interaction between gender and
each independent variable. A significant interaction (at
P\0.10) indicated that the different results observed in
the separate regressions for the two genders were statistically
significant.1
In the multivariable models, we re-scaled the three
attitudinal variables from the actual scores to standard
deviation units by dividing each individual’s score by the
standard deviation of the variable for that gender. The
effect of a change of one point in the score could not be
expected to be sizeable, given that the scales ranged
approximately from 0 to 100. In contrast, a change of one
standard deviation can be expected to have a meaningful
effect in the outcome.
Results
Sample Characteristics by Gender
Boys were significantly older than girls; 42% of the boys
were aged 11 or older, compared with 29% of the girls
(Table 1). (Ninety percent of students were either age 10 or
11.) Approximately three quarters of the mothers worked,
three quarters of the students received free or reduced-price
lunch, over half attended religious services ‘‘sometimes,’’
and nearly 70% felt their neighborhoods were safe. Significantly
more girls (79%) than boys (57%) reported
having experienced signs of puberty.
Girls had significantly higher self-confidence scores,
more extracurricular activities, and higher educational
aspirations than boys. The majority of both boys (68%) and
girls (78%), thought they would finish high school and
continue to some form of higher education. Boys and girls
liked their schools equally.
Boys and girls differed in all five attitudinal/knowledge
variables. Girls had more favorable attitudes toward
abstinence and toward resisting having sex, as well as
reporting more frequent communication with a parent
about sexual topics. Significantly more girls than boys
reported that their parents would be upset if they found out
that the youths were having sex (83% vs. 66%). Girls had
better knowledge about pubertal changes. Finally, more
boys (18%) than girls (5%) reported having had sex, and
more boys (56%) than girls (22%) anticipated having sex in
the next 12 months.
Bivariate Relationships
Among boys, pubertal development was significantly
related to having had sex (P = 0.011) and with anticipating
sexual activity (P = 0.051) (Table 2). Perceiving one’s
neighborhood as unsafe was associated with being at higher
risk of anticipating sexual activity (P = 0.037). Liking
school less was associated with having sex (P = 0.007)
1 We
use the significance level of P\0.10 throughout the paper, to
provide information on results that nearly reach the more conventional
level of P\0.05. By noting the variables with P values
between 0.05 and 0.10, we succinctly point out results that may be
fruitfully considered for further exploration in other studies.
Matern Child Health J (2011) 15:S54–S64 S57
and anticipating sexual activity (P = 0.030). Having lower
educational aspirations was related to higher levels of
anticipated sexual activity (P = 0.048). Having less
favorable attitudes toward abstinence and refusing sexual
activity and not thinking that parents would be upset about
their having sex were associated with higher probabilities
of having had sex and anticipating sexual activity
(P\0.01). Having fewer communications about sexuallyrelated
topics also was associated with anticipating sex
(P = 0.006). Having greater knowledge about puberty was
also significantly related to having had sex (P = 0.012)
and anticipating sexual activity (P = 0.089)
Girls who received a free or reduced-price school lunch
and those who had experienced pubertal changes were
more likely to anticipate having sex (P\0.05, Table 3).
Liking school less was related to sexual experience
(P = 0.068) and to anticipating sexual activity
(P = 0.018). Girls who did not expect to finish high school
were more likely to have had sex (P = 0.011). Girls with
more favorable attitudes toward abstinence and refusing
sex were less likely to have had sex (P\0.05) and less
likely to anticipate sexual activity (P\0.01). Girls with
more knowledge of puberty were more likely to anticipate
sexual activity (P = 0.042).
Multivariable Models
In the multivariable models (Table 4), boys with more
favorable attitudes toward abstinence had lower odds of
having had sex (OR = 0.38 for a standard deviation
change in the score), and those who thought their parents
would be upset about their having sex were less likely to
have had sex than boys who thought otherwise (OR =
0.38). The factors that were significantly related to virginity
differed for girls. Girls who were more favorable
toward refusing sex had reduced odds of having had sex
(OR = .62 for one standard deviation change in scores).
Tests of interactions of the various factors with gender in
the combined sample did not show any of the interactions
to be significant, even when the main effects of gender and
each variable, and the interaction term were included in the
regression. There were only 12 girls who have had sex. It is
likely that this is too small a number to support the
detection of significant interaction effects in the models.
Boys who felt their neighborhood was safe were less
likely to anticipate sexual activity (OR = 0.46) (Table 4).
Boys who had experienced signs of puberty had 2.7 times
the odds of anticipating sexual activity than boys without
pubertal signs. Boys favorable toward abstinence were less
likely to anticipate sexual activity (OR = 0.38 for one
standard deviation change in score), and those with more
communication with their parents about sexual topics were
also less likely to anticipate sexual activity (OR = 0.70 for
one standard deviation change in score). Boys who thought
their parents would be upset about their having sex also had
reduced odds of anticipating sexual activity (OR = 0.55).
The factors significantly related to sexual anticipation
differed in some respects for girls (Table 4). The more girls
liked their school, the less likely they were to anticipate
sexual activity (OR = 0.85). Girls who were more favorable
toward abstinence were also less likely to anticipate
sexual activity (OR = 0.37 for one standard deviation
change in score). Girls with more frequent communication
with their parents about sexual subjects were more likely to
anticipate sexual activity than those with less communication
(OR = 1.39 for one standard deviation change in
score). Girls with better knowledge about puberty had
higher odds of anticipating sexual activity than those with
less knowledge (OR = 1.05).
Some of the observed differences for anticipating sexual
activity between boys and girls were found not to be significant
in the tests of interactions of the various variables
with gender in the combined sample (Table 4). Four factors
differed significantly by tests of interaction in their relationships
to anticipation of sexual activity between boys
and girls. For boys safe neighborhoods related to less
anticipation of sexual activity, and the interaction test
showed this to be significant (P = 0.028). Attitude toward
abstinence was significantly related to sexual anticipation
for both boys and girls. The effect for girls was larger than
for boys (OR of 0.37 for girls, 0.38 for boys). The interaction
test showed this difference was significant (P =
0.075). For girls, more frequent parent–child communication
about sexual topics was positively associated with
anticipation of sexual activity, whereas for boys, the
association was negative. The interaction of gender with
communication was significant (P = 0.0006). Knowledge
about puberty was positively related to anticipation of
sexual activity among girls, but was not significantly
associated for boys. This difference was significant in the
interaction test (P = 0.044).
Discussion
This study demonstrates that some preadolescents in upper
elementary school have had sexual intercourse and anticipate
having sexual intercourse in the near future. The levels
of sexual activity are consistent with those found by the DC
Middle School Youth Risk Behavior Survey, in which
17.8% of males reported experiencing intercourse by age
11 or younger [16].
The factors associated with sexual experience and
anticipation of sexual activity were markedly different in
boys and girls in the multivariable analysis. For boys, the
only variables significantly related to virginity were a more
Matern Child Health J (2011) 15:S54–S64 S59
123
favorable attitude toward abstinence and thinking their
parents would be upset if they found their child was having
sex. For girls, the only (marginally) significant association
with virginity was a favorable attitude toward refusing sex.
The genders also differed in the ways factors were
related to anticipation of sexual activity. Among both boys
and girls, a more favorable attitude toward abstinence was
associated with less anticipation of sexual activity, but the
Table 2 Bivariate relationships of background, school, and attitudinal/knowledge variables to experience of sexual intercourse and
anticipated
sexual activity among male students
Variable Ever had sex Anticipated sexual activity
No Yes P-value Low risk Medium risk High risk P-value
Background characteristics
Age
11 years old and older 77 (80.2%) 19 (19.8%) 0.447 11 (11.5%) 27 (28.1%) 58 (60.4%) 0.252
10 years old and younger 111 (84.1%) 21 (15.9%) 12 (8.9%) 52 (38.5%) 71 (52.6%)
Mother works
No 43 (81.1%) 10 (18.9%) 0.736 5 (9.4%) 17 (32.1%) 31 (58.5%) 0.891
Yes 143 (83.1%) 29 (16.9%) 17 (9.7%) 62 (35.4%) 96 (54.9%)
Free/reduced-price lunch
No 42 (76.4%) 13 (23.6%) 0.173 5 (8.9%) 15 (26.8%) 36 (64.3%) 0.331
Yes 146 (84.4%) 27 (15.6%) 18 (10.3%) 64 (36.6%) 93 (53.1%)
Frequency of religious attendance
Never 42 (80.8%) 10 (19.2%) 0.458 8 (15.4%) 19 (36.5%) 25 (48.1%) 0.407
Sometimes, but not every week 97 (85.1%) 17 (14.9%) 11 (9.5%) 38 (32.8%) 67 (57.8%)
Once a week or more 45 (77.6%) 13 (22.4%) 3 (5.1%) 22 (37.3%) 34 (57.6%)
Safe neighborhood
No 55 (78.6%) 15 (21.4%) 0.305 5 (7.1%) 17 (24.3%) 48 (68.6%) 0.037*
Yes 133 (84.2%) 25 (15.8%) 18 (11.2%) 62 (38.5%) 81 (50.3%)
Pubertal development
No changes 88 (89.8%) 10 (10.2%) 0.011* 15 (15.3%) 34 (34.7%) 49 (50.0%) 0.051 #
Breasts/body hair or voice change/
body hair
100 (76.9%) 30 (23.1%) 8 (6.0%) 45 (33.8%) 80 (60.2%)
School and self variables
Self confidence–mean (SD) 1.3 (1.0) 1.4 (0.9) 0.516 1.2 (1.0) 1.5 (0.9) 1.2 (1.0) 0.208
Liking school–mean (SD) 1.8 (1.6) 1.1 (1.9) 0.007** 2.2 (1.2) 2.0 (1.5) 1.5 (1.8) 0.030*
Extracurricular activities–mean (SD) 2.4 (1.5) 2.8 (1.3) 0.116 2.0 (0.8) 2.7 (1.6) 2.4 (1.4) 0.138
Educational aspirations
Not finish high school 25 (75.8%) 8 (24.2%) 0.463 3 (9.4%) 7 (21.9%) 22 (68.8%) 0.048*a
Finish high school 33 (80.5%) 8 (19.5%) 5 (12.2%) 8 (19.5%) 28 (68.3%)
Beyond high school 130 (84.4%) 24 (15.6%) 15 (9.5%) 64 (40.5%) 79 (50.0%)
Attitudinal and knowledge variables
Attitude toward abstinence–mean (SD) 73.0 (22.9) 46.7 (23.7) 0.000*** 88.9 (12.6) 76.4 (20.5) 59.3 (25.6) 0.000***
Attitude toward refusing sex–mean
(SD)
69.7 (26.4) 49.4 (26.5) 0.000*** 75.7 (24.2) 75.1 (24.8) 59.5 (27.6) 0.000***
Parent–child communication–mean
(SD)
45.5 (30.4) 45.2 (27.1) 0.960 58.9 (30.8) 49.2 (28.8) 40.1 (29.2) 0.006**
Parents upset if found child had sex?
No 54 (71.1%) 22 (28.9%) 0.001** 5 (6.5%) 17 (22.1%) 55 (71.4%) 0.003**
Yes 134 (88.2%) 18 (11.8%) 18 (11.7%) 62 (40.3%) 74 (48.1%)
Knowledge of both genders puberty–
mean (SD)
6.8 (5.1) 9.0 (5.0) 0.012* 5.1 (4.7) 7.8 (5.3) 7.2 (5.1) 0.089 #
a Due to small expected cell counts, results from Fisher’s exact test are shown instead of chi-square test
# P\0.10, * P\0.05, ** P\0.01, *** P\0.001
S60 Matern Child Health J (2011) 15:S54–S64
123
effect was larger for girls than boys. Thus, it appears
important to get these pre-teens to accept the abstinence
message. Consistent and clear messaging, whether with
respect to abstinence or contraception, is one of the
characteristics of effective teen pregnancy prevention
programs [17]. However, it is also important to consider
that the context of remaining abstinent may differ by
gender and address different underlying motivations. A
Table 3 Bivariate relationships of background, school, and attitudinal/knowledge variables to experience of sexual intercourse and
anticipated
sexual activity among female students
Variable Ever had sex Anticipated sexual activity
No Yes P-value Low risk Medium risk High risk P-value
Background characteristics
Age
11 years old and older 76 (97.4%) 2 (2.6%) 0.518a 28 (35.9%) 37 (47.4%) 13 (16.7%) 0.389
10 years old and younger 177 (94.7%) 10 (5.3%) 62 (32.8%) 81 (42.9%) 46 (24.3%)
Mother works
No 58 (92.1%) 5 (7.9%) 0.169a 26 (41.3%) 27 (42.9%) 10 (15.9%) 0.209
Yes 191 (96.5%) 7 (3.5%) 62 (31.0%) 89 (44.5%) 49 (24.5%)
Free/reduced-price lunch
No 62 (98.4%) 1 (1.6%) 0.304a 18 (28.1%) 37 (57.8%) 9 (14.1%) 0.034*
Yes 191 (94.6%) 11 (5.4%) 72 (35.5%) 81 (39.9%) 50 (24.6%)
Frequency of religious attendance
Never 40 (95.2%) 2 (4.8%) 0.208a 16 (38.1%) 14 (33.3%) 12 (28.6%) 0.110
Sometimes, but not every week 148 (97.4%) 4 (2.6%) 55 (35.9%) 63 (41.2%) 35 (22.9%)
Once a week or more 62 (92.5%) 5 (7.5%) 17 (25.0%) 39 (57.4%) 12 (17.6%)
Safe neighborhood
No 82 (94.3%) 5 (5.7%) 0.537a 28 (32.2%) 40 (46.0%) 19 (21.8%) 0.911
Yes 171 (96.1%) 7 (3.9%) 62 (34.4%) 78 (43.3%) 40 (22.2%)
Pubertal development
No changes 55 (98.2%) 1 (1.8%) 0.470a 28 (50.0%) 20 (35.7%) 8 (14.3%) 0.013*
Breasts/body hair or voice change/
body hair
198 (94.7%) 11 (5.3%) 62 (29.4%) 98 (46.4%) 51 (24.2%)
School and self variables
Self confidence–mean (SD) 1.5 (0.8) 1.2 (1.2) 0.197 1.4 (0.8) 1.4 (0.9) 1.6 (0.7) 0.483
Liking school–mean (SD) 1.9 (1.5) 1.1 (1.6) 0.068# 2.2 (1.3) 1.7 (1.6) 1.6 (1.5) 0.018*
Extracurricular activities–mean (SD) 3.2 (2.0) 3.0 (1.8) 0.677 3.3 (2.2) 3.3 (1.9) 3.0 (1.8) 0.505
Educational aspirations
Not finish high school 25 (83.3%) 5 (16.7%) 0.011*a 9 (29.0%) 13 (41.9%) 9 (29.0%) 0.864
Finish high school 25 (100.0%) 0 (0%) 9 (36.0%) 10 (40.0%) 6 (24.0%)
Beyond high school 203 (96.7%) 7 (3.3%) 72 (34.1%) 95 (45.0%) 44 (20.9%)
Attitudinal and knowledge variables
Attitude toward abstinence–mean (SD) 84.3 (16.5) 71.6 (20.2) 0.010* 92.1 (9.6) 84.1 (14.8) 70.2 (20.5) 0.000***
Attitude toward refusing sex–mean
(SD)
87.5 (17.6) 70.8 (24.6) 0.002** 88.2 (16.5) 89.0 (15.1) 79.9 (24.4) 0.005**
Parent–child communication–mean
(SD)
60.6 (31.4) 57.8 (27.8) 0.761 58.6 (32.3) 62.2 (29.4) 59.8 (32.7) 0.700
Parents upset if found child had sex?
No 44 (95.7%) 2 (4.3%) 1.00a 12 (26.1%) 22 (47.8%) 12 (26.1%) 0.467
Yes 209 (95.4%) 10 (4.6%) 78 (35.3%) 96 (43.4%) 47 (21.3%)
Knowledge of both genders puberty–
mean (SD)
8.7 (5.1) 10.4 (6.0) 0.267 7.7 (5.0) 9.4 (5.1) 9.5 (5.4) 0.042*
a Due to small expected cell counts, results from Fisher’s exact test are shown instead of chi-square test
# P\0.10, * P\0.05, ** P\0.01, *** P\0.001
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study of predominantly white 8th graders supports this
possibility, finding that boys initiate sexual activity in the
context of seeking status with their peers, whereas girls
initiate sex primarily in the context of a boyfriend/girlfriend
relationship [18].
In national studies, non-virgin teens are somewhat more
likely to talk to their parents about sex than virgin teens,
with girls being more likely to have conversations about
how to say no to sex [19]. The differences we observed
with girls who anticipate sex reporting more parental
communication in contrast to boys suggest that younger
boys delay communication. Girls had significantly more
knowledge about puberty than boys, however, for boys
more knowledge about puberty was not associated with
anticipating sex, but for girls, it was positively related to
anticipating sexual activity. These results suggest that girls
may use knowledge about puberty in relation to their personal
plans differently than boys, or, alternatively, that girls
accumulate pubertal knowledge differently as they gain
sexual interest or experience.
We anticipated an association between school connectedness
and delaying sexual activity because of studies in
older adolescents [20]. In our study, the liking school
variable was associated with a lower likelihood of
Table 4 Results of binary logistic regressions of sexual experience and ordered logistic regressions of anticipated sexual activity by
gender
Variables Ever had sex Anticipated sexual activity
Males OR (95% CI) Females OR (95% CI) Males OR (95% CI) Females OR (95% CI)
Background characteristics
Age
11 years old or older 1.10 (0.49–2.48) 0.49 (0.10–2.48) 0.96 (0.54–1.70) 0.88 (0.52–1.49)
10 years old or younger 1.00 1.00 1.00 1.00
Free/reduced-price lunch
No 1.00 1.00 1.00 1.00
Yes 0.73 (0.30–1.78) 3.17 (0.36–27.90) 0.81 (0.41–1.59) 0.97 (0.55–1.72)
Safe neighborhood
No 1.00 1.00 1.00 1.00
Yes 0.84 (0.35–2.06) 1.05 (0.26–4.23) 0.46 (0.24–0.89)*b 1.22 (0.71–2.08)b
Pubertal development
No pubertal signs 1.00 1.00 1.00 1.00
Breasts/body hair or voice change/body hair 1.76 (0.66–4.68) 2.41 (0.27–21.78) 2.68 (1.40–5.12)** 1.49 (0.80–2.78)
School variables
Liking school 0.88 (0.70–1.12) 0.81 (0.54–1.21) 0.88 (0.73–1.06) 0.85 (0.71–1.00)#
Educational aspirations
Not finish high school 1.00 1.00a 1.00 1.00
Finish high school 0.82 (0.22–3.04) 0.98 (0.33–2.89) 0.69 (0.24–2.00)
Beyond high school 0.86 (0.29–2.49) 0.47 (0.12–1.88)a 0.67 (0.28–1.60) 0.92 (0.42–2.02)
Attitudinal and knowledge variables
Attitude toward abstinence (SD units) 0.38 (0.23–0.62)*** 0.75 (0.41–1.35) 0.38 (0.26–0.57)***b 0.37 (0.27–0.49)***b
Attitude toward refusing sex (SD units) 1.00 (0.61–1.65) 0.62 (0.38–1.03)# 1.07 (0.76–1.52) 0.89 (0.68–1.16)
Parent–child communication (SD units) 1.27 (0.83–1.92) 1.26 (0.64–2.48) 0.70 (0.53–0.93)*b 1.39 (1.07–1.81)*b
Parents upset if found child had sex?
No/not sure 1.00 1.00 1.00 1.00
Yes 0.38 (0.16–0.89)* 0.91 (0.17–4.81) 0.55 (0.28–1.06)# 0.64 (0.32–1.27)
Knowledge of both gender’s puberty 1.06 (0.97–1.17) 1.04 (0.91–1.19) 0.96 (0.90–1.02)b 1.05 (1.00–1.11)*b
Results in the ‘‘Ever Had Sex’’ columns are the odds of having had sex relative to the odds of not having had sex. Results in the
‘‘Anticipated
Sexual Activity’’ columns are the odds of being in the higher risk groups: high-risk group versus moderate/no-risk group and odds of
being in the
high/moderate-risk group versus no-risk group
# P\0.10, * P\0.05, ** P\0.01, *** P\0.001
a In the ‘‘Ever had sex’’ model, for girls, the categories for ‘‘Not finish high school’’ and ‘‘Finish high school’’ were collapsed
b The test of interaction of gender with this variable was significant: with safe neighborhood, P = 0.028; with attitude toward abstinence,
P = 0.075; with parent–child communication, P = 0.0006; with pubertal knowledge, P = 0.044
S62 Matern Child Health J (2011) 15:S54–S64
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anticipating sexual activity in girls only. For both genders,
neither liking school nor educational aspiration was significantly
associated with virginity. These differences from
the other studies could reflect differences in the samples
and measurement, but also possibly the differences in the
ages of the subjects. The association of neighborhood
safety with anticipation of sex in boys is similar to Add
Health data on older teens noting a modest association of
neighborhood context to sexual initiation in boys [21]. Our
study suggests the neighborhood variable should be further
studied and may be especially relevant for males.
Our findings are limited to fifth graders in selected areas
of Washington, DC, so they might not be generalizable to
all fifth graders. Our data are based on self-reports and
actively consented students, raising the possibility of bias.
We do not know the context of the reported sexual
experiences.
Conclusions
Although other researchers have studied the factors we
investigated in older adolescents, the present data are
unique in their focus on preadolescents. The gender differences
we found in fifth graders’ prior and anticipated
sexual experiences are similar to those that others have
found in older teenagers. The findings suggest that some
aspects of interventions to delay sexual activity should be
tailored to differing underlying attitudes and needs of pre and
early adolescent males and females and that young
males are especially important targets of interventions to
delay sexual debut. Our findings also support the development
of interventions to prevent teenage pregnancy or delay
sexual debut prior to the middle school years, particularly in
communities with high levels of teenage pregnancy.
Acknowledgments The authors would like to thank the members of
the Building Futures for Youth research team of the NIH-DC Initiative
to Reduce Infant Mortality for their roles in supporting this
research. The authors would also like to thank Allison Rose and
Deborah Schwartz for providing valuable comments on earlier drafts
of this manuscript. Funding was provided by grants from the Eunice
Kennedy Shriver National Institute of Child Health and Human
Development (NICHD) Grants 3U18HD030445, 3U18HD030447,
5U18 HD31206, 3U18HD031919, and 5U18HD036104 and the
National Center on Minority Health and Health Disparities
(NCMHHD). Participating institutions include Howard University,
Georgetown University, RTI International, and NICHD.
References
Anderson, K., Koo, H., Jenkins, R., Walker, L., Davis, M., Yao, Q., & Nabil El-Khorazaty, M.
M. (2011). Attitudes, Experience, and Anticipation of Sex Among 5th Graders in an Urban
Setting: Does Gender Matter?. Maternal & Child Health Journal, 15(S1), 54-64.
doi:10.1007/s10995-011-0879-5
Correlates of Sexual Risk Behaviors Among High School Students
in Colorado: Analysis and Implications for School-based
HIV/AIDS Programs
Stephen Nkansah-Amankra • Abdoulaye Diedhiou •
Harry L. K. Agbanu • Curtis Harrod •
Ashish Dhawan
Published online: 16 July 2010
_ Springer Science+Business Media, LLC 2010
Abstract Objectives of this study are to examine correlates
of antecedent sexual risk exposures associated with
HIV/AIDS infection among adolescents participating in the
2005 Colorado Youth Behavioral Risk Survey (CYBRS),
and to determine gender differences associated with these
exposures since previous studies have produced mixed
findings. Variables assessing these relationships were
drawn from CYBRS, 2005. We used v2 to assess bivariate
relationships and multinomial logistic regression to evaluate
associations among dependent variables (sexual risk
behaviors, age at first sex, and number of sexual partners in
the past 3 months) and independent variables (in-school
HIV/AIDS education, use of illegal substances, physically
forced sex, and alcohol use). We found no significant effect
of having received in-school HIV/AIDS education on all
outcome measures. Compared with females, males were
more likely to initiate sex at a relatively younger age,
report unprotected sex with multiple partners, and drink
alcohol before sexual intercourse. Among females, using 2
illegal substances increased the odds of early sexual debut
by 12 times, while using C3 substances increased the same
odds to 44-fold. Likewise, binge drinking was also associated
with higher odds of having multiple partners. Hispanic
ethnicity and physically forced sex variables were
consistently associated with high risk sexual behaviors,
early sexual initiation, and increased number of sexual
partners. Efforts to control the HIV/AIDS epidemic among
adolescents may need to focus on targeted interventions
aimed at addressing gender- and racial/ethnic-specific risk
exposures among this population group, including risk
behaviors linked with lifetime physically forced sex. The
need to re-examine the role of in-school HIV prevention
programs to build adequate competencies among students,
parents and community leaders to reduce risk exposures
associated with HIV/AIDS infection among youth is
emphasized.
Keywords HIV/AIDS _ Risk behaviors _ Adolescents _
Sexuality education
Introduction
The population of persons infected with HIV/AIDS in the
United States is the highest among industrialized countries,
and this trend is set to continue in the next decades [1].
Recent surveillance data reveals that more than one million
people were infected with the virus in the country, and
almost 14,000 related deaths occurred in 2007 [2].
Although the overall mortality has declined in the last few
S. Nkansah-Amankra (&)
Community Health Program, School of Human Sciences,
University of Northern Colorado, 501-20th Street,
Campus Box 93, Greeley, CO 80639, USA
e-mail: [email protected]
A. Diedhiou
South Carolina Public Health Consortium, University of South
Carolina, Columbia, SC 29208, USA
e-mail: [email protected]
H. L. K. Agbanu
Department for the Study of Religions, University of Ghana,
Legon-Accra, Ghana
e-mail: [email protected]
C. Harrod
School of Human Sciences, University of Northern Colorado,
501-20th Street, Campus Box 93, Greeley, CO 80639, USA
A. Dhawan
Monmouth Medical Center, Long Branch, NJ, USA
123
Matern Child Health J (2011) 15:730–741
DOI 10.1007/s10995-010-0634-3
decades, there are widening racial and age disparities in
new infections and deaths [3]. Minorities and adolescent
populations are more likely to be infected, or to die from
the infection [4]. Alarmingly, while the reported number of
cases in the country is comparable to some developing
nations, the estimated mortality is the highest among the
industrialized countries [2]. However, besides racial/ethnic
variations, the startling numbers may also reflect a more
insidious problem, a situation in which all population
groups are equally affected to some extent [5]. Research to
understand the patterns and roles of sexual risk behaviors
in emerging HIV/AIDS disparities among adolescents may
have an impact on the country’s efforts to address health
inequities [6].
Despite successful public health programs in the past
decades, there are indications that antecedent HIV risk
behaviors are still present for continued transmission of
HIV infections in the country [7]. Common sexual risk
behaviors that place young people at a potential likelihood
of HIV infections, sexually transmitted diseases (STD’s)
and other reproductive ill-health sequelae include unprotected
vaginal, anal and oral sexual intercourse [8]. The
most important of these predictors include racial disparities
in early sexual debut and number of sexual partners, and
rising ‘teen births’ after years of decline, with the highest
increases reported among non-Hispanic blacks [7, 9]. In
2005, more than 28% of black high-school students
reported having had sexual intercourse with four or more
persons, compared with 16% of Hispanic and 11% of white
students. In the same period, African-Americans accounted
for 69% of HIV/AIDS diagnoses among 13–19-year olds
[8]. The prevalence of sexually transmitted infections
(STIs) including Chlamydia, trichomonas, and gonorrhea
was three times higher among non-Hispanic black youth
and young adults compared to whites [10], reaching nearly
26% among girls ages 14–19 [7, 11]. Added to these risk
exposures is the gradual decline in overall support for
domestic HIV/AIDS programs, including those targeting
minorities and adolescents [12].
Significant patterns of risk reported at the national level
have also been documented among adolescents in Colorado
[13]. For example, while almost 12% of adolescents in
Colorado reported using an illicit substance in the past
month, almost 20% of males and approximately 22% of
females currently uses alcohol [14]. Although the AIDS
case rate among adults and adolescents in Colorado in 2007
was almost 9% compared with 15% nationwide, 1 in 4
adolescent females (14–19 years) was diagnosed with at
least 1 common STI [8]. In 2007, non-Hispanic black and
Latina adolescents had the highest teen birth rate and
specific STI’s were also highest among these racial groups
compared to the non-Hispanic white adolescent population
[15]. The observed disparities, nonetheless, raise serious
public health concerns, given that historically HIV infections
among Hispanics were lower than in other racial
groups [8]. Furthermore, growing media exposure to
explicit sexual portrayals among adolescents is suggested
as an additional risk for early sexual initiation and other
sexual risk behaviors, but these findings have been mixed
[16, 17]. Therefore, assessing antecedent risks for HIV
acquisition among adolescents across the state is critical in
designing targeted interventions to prevent primary infections
and other reproductive health sequelae.
It has often been suggested that at the root of racial
disparities in HIV infections, morbidity and mortality is
limited HIV/AIDS knowledge, particularly among minorities
and youth. One study reported almost 60% of Black
and other minorities did not receive prevention information
prior to their current HIV diagnosis [18]. For adolescents,
essential HIV/AIDS literacy facilitates appropriate attitudes
and skills needed to delay early sexual debut, reduce
the number of sex partners, and prevent illicit substance
use and STIs [19]. In-school HIV/AIDS education may also
contribute to reducing stigma, and boosting motivation for
students to learn their HIV status to prevent further infections
[20]. Colorado is one of the few states in the US that
mandates abstinence-only education for HIV/AIDS prevention
programs, and in general students’ participation in
sexuality education is voluntary, although a recent
amendment modifies the existing state statute on sexuality
education [13, 15]. Respective merits and limitations of
abstinence-only programs and adolescent sexuality education
have been reported by a number of studies [8, 9,
20–23]. Little is known about how adolescents translate
knowledge gained from school-based HIV/AIDS lessons
into reduced risks. Moreover, previous reviews of schoolbased
HIV/AIDS education programs in the US have been
mixed [24]. The purpose of the present study was to assess
relationships among adolescent sexual risk behaviors, HIV/
AIDS education, and other antecedent risk exposures
among respondents participating in the Colorado Youth
Behavioral Risk Surveys. In addition, we sought to determine
whether there were gender and ethnic differences in
these behavioral risk exposures.
Methods
Study Design and Data Source
We used cross-sectional data from the 2005 Colorado
Youth Risk Behavioral Survey (YRBS). Further details of
the survey design and psychometric properties of questionnaire
items are found elsewhere [25, 26]. Briefly, the
YRBS is a self-reported paper-based survey of high school
students conducted every 2 years by the Centers for
Matern Child Health J (2011) 15:730–741 731
123
Disease Control and Prevention (CDC) in collaboration
with Colorado local implementing partners. The survey
monitors risk behaviors and other characteristics associated
with mortality and morbidity among students in grades
9–12. In 2005, the survey was administered to a representative
sample of 1,498 students from 29 public high
schools throughout the state, and the overall response rate
was 60%. Surveyed schools and classes were selected
systematically with probability proportional to enrollment
based on grade levels. Parental permission was sought
before administration of the survey. Analytic sample
weights were included to account for differential sample
selection probabilities and non-responses across the racial
subgroups of high school students in the state.
Variable Definitions and Measures
Outcome Variables
Sexual Risk Behavior was a three-level summary variable
created from items suggested in previous studies [27], and
this summed variable was categorized as: High risk (had
sex with multiple partners, did not use condoms and/or
drank alcohol in the last sexual intercourse, and used no
method of contraception), Low risk (had sex with one
partner, used condom and did not drink alcohol in the last
sexual intercourse, and used a method of contraception)
and No risk (none of the above risk behaviors). Age at first
sexual intercourse was categorized based on respondents’
age at their first sexual intercourse as: no sexual intercourse
(participants reported as not having ever had sexual intercourse
at the time of survey), young adolescents (11–
14 years), and older adolescents (C15 years). Number of
current sexual partners was assessed based on the reported
number of sexual partners in the 3 months preceding the
survey and categorized as following: never had sexual
intercourse, had 1 partner, and had C2 sexual partners.
These variables were selected because of their known
association with transmission of HIV infections [28].
Covariates
HIV/AIDS education was dichotomized based on receipt or
not of in-class HIV/AIDS education. Substance use score
was constructed from the number of illegal psychoactive
substances (marijuana, cocaine, heroin, sniffing glue,
methamphetamines, ecstasy drugs and steroids without a
doctor’s prescription) used over the lifetime or in the
30 days prior to the survey, and categorized as following:
none (never used any illegal substances), low users (used
illegal drugs on 1 or 2 occasions), and high users (used C3
times any three of these substances). Physically forced sex
was a dichotomous variable based on whether or not the
student had been forced to have sex against his/her will.
Consistent with previous research [29], alcohol use was
categorized by the following: non-drinkers (no alcohol in
the past 30-day period), current light drinkers (C1 drink in
the past 30 days but\5 drinks in a row), and current binge
drinkers (C5 or more drinks in a row). Alcohol and other
drugs are considered antecedent risks of HIV/AIDS
because they indirectly increase the likelihood of engaging
in risky sexual behaviors through inhibition of positive
behaviors [30].
Potential confounding variables selected include age,
gender, number of hours watching TV, feeling sadness or
hopelessness, and cigarette smoking because of their documented
relationships with sexual risk behaviors [31, 32].
Statistical Analysis
Characteristics of respondents participating in the survey
were compared according to race and gender using RaoScott v2 tests for categorical variables. To further assess the
relationship between independent and outcome variables, all
independent variables that attained a statistical significance
of P B 0.25 in bivariate analyses [33] were entered into
multinomial logistic regression models in a manual stepwise
fashion, starting with those with the lowest P-value, to
identify factors associated independently with each of the
three outcome variables while controlling for potential
confounders. This method allows each outcome variable to
have more than two categories, thereby providing a single
estimate of odds ratio (OR) for the association between the
independent variables and each combination of the dependent
variables, while controlling for potential confounders.
Odds ratios (OR) were calculated and used as estimates of
risk ratios. The likelihood ratio test was used to compare
models to determine which variables were retained in multivariable
models at a significance level a = 0.05. Age and
grade level were not included in the same models because of
potential co-linearity. In addition, although research has
shown that risk behaviors and HIV/AIDS knowledge vary
among racial and gender groups, preliminary analyses by
race showed that not enough observations were available for
several racial groups. Therefore, we conducted stratified
multivariate analysis for gender only. All analyses were
performed with SAS 9.1.3 (SAS Institute, Cary, NC) and
accounted for the complex sampling design of the survey to
provide estimates representative of the high school student
population across the state.
Results
Respondents’ characteristics and the distribution of other
study variables are shown by race/ethnicity in Table 1.
732 Matern Child Health J (2011) 15:730–741
123
Table 1 Characteristics of participants in 2005 Colorado Youth Risk Behavioral Survey, by race/ethnicity
Variables Frequencya and weighted percentb P-valued
All respondents
(N = 1,474)c
Non-hispanic black
(n = 226)c
Non-hispanic white
(n = 999)c
Hispanic
(n = 249)c
Gender 0.00
Male 777 (50.86) 125 (59.73) 541 (52.95) 111 (40.32)
Female 697 (49.14) 101 (40.27) 458 (47.05) 138 (59.68)
Age (Years) 0.01
12–14 334 (18.03) 64 (24.60) 227 (18.82) 43 (12.50)
15–18 1145 (81.97) 163 (75.40) 777 (81.18) 205 (87.50)
Physically forced sex 0.20
Yes 74 (5.14) 12 (4.63) 53 (5.76) 9 (3.39)
No 1402 (94.86) 216 (95.37) 946 (94.24) 240 (96.61)
Sexual risk behaviors 0.01
No risk 943 (60.89) 133 (55.23) 681 (64.39) 129 (51.91)
Low risk 103 (6.78) 18 (6.91) 68 (6.84) 17 (6.54)
High risk 381 (32.33) 62 (37.86) 231 (28.77) 88 (41.55)
Substance use score 0.02
0 847 (54.85) 123 (53.62) 604 (57.85) 120 (45.97)
1 262 (18.75) 39 (21.20) 175 (17.90) 48 (20.31)
2 207 (15.70) 33 (10.18) 130 (15.50) 44 (18.87)
C3 135 (10.69) 27 (15.00) 76 (8.75) 32 (14.85)
Age at sexual debut 0.00
Never had sex 938 (60.89) 132 (54.50) 679 (64.35) 127 (52.10)
B14 250 (18.17) 57 (34.39) 130 (13.37) 63 (26.85)
C15 229 (20.94) 22 (10.60) 168 (22.28) 39 (21.05)
Number of current sexual partners 0.01
0 936 (60.83) 131 (54.42) 678 (64.40) 127 (51.78)
1 134 (9.70) 28 (12.29) 80 (8.90) 26 (11.20)
C2 345 (29.47) 51 (33.29) 217 (26.69) 77 (37.02)
TV watched (h) 0.00
0 152 (9.86) 16 (4.42) 121 (11.94) 15 (5.75)
1–2 571 (38.45) 75 (31.90) 428 (42.33) 68 (29.15)
C2 749 (51.69) 136 (63.69) 450 (45.73) 163 (65.10)
Sadness/hopelessness 0.00
Yes 369 (20.97) 66 (20.92) 221 (22.60) 82 (34.35)
No 1109 (75.03) 161 (79.08) 781 (77.40) 167 (64.65)
Alcohol use 0.25
Non-drinkers 806 (52.42) 131 (59.97) 552 (52.16) 123 (49.80)
Current light drinkers 233 (16.68) 31 (13.75) 168 (17.80) 34 (14.40)
Current binge drinkers 395 (30.90) 56 (26.27) 259 (30.04) 80 (35.80)
Cigarette smoking 0.25
Non-smokers 787 (70.36) 101 (66.22) 580 (71.39) 106 (68.44)
Quitters 47 (4.93) 8 (5.35) 28 (4.43) 11 (6.63)
Current smokers 240 (24.71) 38 (28.43) 162 (24.18) 40 (24.93)
HIV educatione 0.00
Yes 1256 (84.90) 186 (82.93) 876 (88.55) 184 (74.56)
No 146 (10.29) 24 (12.81) 78 (7.63) 41 (17.46)
Unsure 88 (4.81) 17 (4.26) 44 (3.82) 24 (7.98)
a Unweighted frequency describes the total number of respondents participating in the Colorado Youth Risk Behavioral Survey, 2005
b Percent distributions (in parenthesis) are weighted to reflect the total adolescent population across the state eligible to participate in the survey
c Numbers may not add up to the total due to missing values for a particular variable
d Rao-Scott v2 test of difference in proportions between non-Hispanic black, non-Hispanic white, and Hispanic
e Based on participation in a school-based HIV/AIDS education program and excludes all other HIV/AIDS or reproductive and sexual health knowledge
from other
sources
Matern Child Health J (2011) 15:730–741 733
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According to Table 1, nearly 64% of respondents were
non-Hispanic whites while Hispanics represented 24% and
black and other racial/ethnic groups 12%. These proportions
mirror the approximate distribution of racial groups
across the state. Both genders are equally represented in
this sample while older adolescents (ages 15–18 years) are
the predominant group. Nearly 85% of students reported
receiving in-school HIV/AIDS education.
Unadjusted Associations
Overall, with the exception of cigarette smoking, Hispanic
students reported higher risk exposures than their peers
from other racial/ethnic groups (Table 1). Bivariate associations
between respondents’ characteristics and gender
are presented in Table 2. Compared with females, male
participants had higher prevalence of high risk sexual
behaviors, and were more likely to initiate sex at a relatively
younger age. Although not statistically significant,
male adolescents were also more likely to report multiple
sexual partners in the 90-day period preceding the survey,
spending more hours watching television, being a current
smoker, and not receiving in-school HIV/AIDS education.
Conversely, females were more likely to report physically
forced sex, and feelings of sadness or hopelessness.
Adjusted Associations
In adjusted analyses (Table 3), predictors significantly
associated with high risk sexual behaviors included being
male, Hispanic, and having reported physically forced sex.
Likewise, light and binge drinking, smoking, and illegal
substance use showed significant effects on sexual risk
behaviors. The highest risk for early sexual debut was
observed among Blacks, and Hispanics. Similarly, there
was an eightfold increase in the odds of early sexual debut
among adolescents reporting physically forced sex. A
dose–response relationship was observed between illegal
substance use and age of sexual debut, with the strongest
effect among young adolescents. Likewise, current or past
smoking was associated with increased odds of early sexual
debut. Statistically significant correlates of having one or
more sexual partners included being Latino and a high user
of illegal substances, reporting forced sex, drinking alcohol,
and current smoking. Associations appeared more
marked between using two or more drugs and having C2
sexual partners.
Adjusted Gender Differences
Tables 4 and 5 provide gender-specific findings. For both
genders, race showed statistically significant effects on risk
behaviors. For example, being a Latino male or a black
female was associated with higher odds of early sexual
debut while Latino females were at increased risk of
engaging in high risk sexual behaviors. Likewise, females
reporting physically forced sex had increased odds of high
risk sexual behaviors and early sexual debut. Illegal drug
use showed strong dose–response relationships with sexual
risk behaviors, age at first sex, and number of sexual
partners in both genders. Among males, using C3 illegal
substances was associated with a ninefold increase in odds
of sexual risk behaviors, a 13-fold increase in odds of early
sexual debut, and a tenfold increase in odds of having one
or more sexual partners. For females, using 2 illegal substances
increased to almost 12 times the odds of early
sexual debut while using C3 substances increased the odds
to nearly 44-fold along with the odds of other outcomes. In
both genders, binge drinking was significantly associated
with higher odds of risky sexual behaviors. However,
among females, binge drinking was also associated with
higher odds of having C2 partners. Likewise, current
smoking was consistently associated with early sexual
debut, risky sexual behaviors, and having 1 or more current
sexual partners in both genders.
Discussion
Findings
Our findings suggest that behaviors that put adolescents at
increased risk of HIV/AIDS infections are present among
this population [4]. We found male gender, Hispanic ethnicity,
physically forced sex, and illegal substance use
variables to be significantly associated with high risk sexual
behaviors. Our observations are consistent with findings
from prior studies examining the relationships among
underlying risks for HIV infections in adolescent populations
[28, 30, 34–36]. Bensley and colleagues found a
sevenfold increase in HIV risk behaviors associated with
childhood physically forced sex among adults from
Washington State; in contrast their study did not find
excessive drinking to be related to HIV risk behaviors [30].
Similarly, a study by Mullings et al. reported associations
between childhood physically forced sex and risky adult
sexual behaviors; however, Hispanics were less likely than
non-Hispanic whites to report overall sexual risk behaviors
[28]. Discrepancies between our findings and previous
studies may be related to variations in populations studied,
and study power differences.
In contrast, television viewing, attendance at school
HIV/AIDS education, and feeling of hopelessness or sadness
were not associated with any risk behaviors. While we
734 Matern Child Health J (2011) 15:730–741
123
Table 2 Bivariate associations among gender and measures of sexual risk behaviors, and health risks among participants in 2005
Colorado
youth risk behavioral survey
Variables Frequencya and weighted percentb P-valued
All respondents
(N = 1,474)c
Male (n = 770)c Female (n = 694)c
Age (Years) 0.09
12–14 335 (18.13) 149 (16.45) 186 (19.87)
15–18 1149 (81.87) 636 (83.55) 513 (80.13)
Physically forced sex 0.00
Yes 75 (5.18) 16 (2.05) 59 (8.42)
No 1405 (94.82) 767 (97.95) 638 (91.58)
Sexual risk behaviors 0.15
No risk 946 (60.91) 477 (59.02) 469 (62.82)
Low risk 106 (6.90) 57 (6.16) 49 (7.65)
High risk 379 (32.20) 216 (34.82) 163 (29.53)
Substance use score 0.86
0 844 (54.59) 436 (54.45) 408 (54.64)
1 263 (18.97) 145 (19.76) 118 (18.01)
2 208 (15.75) 116 (15.25) 92 (16.49)
C3 134 (10.69) 70 (10.54) 64 (10.86)
Age at sexual debut 0.03
Never had sex 941 (60.90) 474 (58.88) 467 (62.97)
B14 251 (18.27) 154 (21.56) 97 (14.92)
C15 229 (20.82) 116 (19.56) 113 (22.12)
Current sexual partners 0.12
0 939 (60.84) 472 (59.91) 467 (62.80)
1 136 (9.81) 87 (11.70) 49 (7.89)
C2 344 (29.35) 182 (29.39) 162 (29.30)
TV watched (hours) 0.08
0 151 (9.69) 70 (8.77) 81 (10.64)
1–2 574 (39.56) 290 (36.33) 284 (40.88)
C2 751 (51.75) 423 (54.90) 328 (48.48)
Sadness/hopelessness 0.00
Yes 371 (25.17) 120 (14.39) 251 (36.40)
No 1111 (74.83) 666 (85.61) 445 (63.60)
Alcohol use 0.15
Non-drinkers 805 (52.13) 426 (53.95) 379 (50.27)
Current light drinkers 235 (16.82) 127 (17.73) 108 (15.89)
Current binge drinkers 398 (31.05) 204 (28.32) 194 (33.84)
Cigarette smoking 0.24
Non-smokers 784 (70.05) 397 (68.63) 387 (71.54)
Quitters 51 (5.12) 32 (5.88) 19 (4.34)
Current smokers 241 (24.82) 132 (25.50) 109 (24.12)
HIV educatione 0.25
Yes 1247 (84.98) 658 (85.14) 589 (84.82)
No 143 (10.15) 79 (10.60) 64 (9.70)
Unsure 88 (4.86) 44 (4.26) 44 (5.49)
a Unweighted frequency describes the total number of respondents participating in the Colorado Youth Risk Behavioral Survey, 2005
b Percent distributions (in parenthesis) are weighted to reflect the total adolescent population across the state eligible to participate in the
survey
c Numbers may not add up to the total due to missing values for a particular variable
d Rao-Scott v2 test of difference in proportions between males and females
e Based on participation in a school-based HIV/AIDS education program and excludes all other HIV/AIDS or reproductive and sexual
health
knowledge from other sources
Matern Child Health J (2011) 15:730–741 735
123
did not find any effects of television viewing, abundant
research has established the role of viewing television in
early sexual initiation, including reporting strong parental
disapproval of sex among adolescents [17, 37]. However, it
is unclear whether the association is related to parental
characteristics or to the content of the television exposure.
Our data did not allow exploring such effects. Therefore,
future studies examining different contextual characteristics
of parents and content analysis of television programs
are needed.
Table 3 Adjusted odds ratios for the associations among sexual risk behaviors, sexual debut, current partners and other predictors among
participants in 2005 Colorado youth risk behavioral survey
Predictors Sexual risk behaviors OR (95% CI) Sexual debut OR (95% CI) Number of current partners
OR (95% CI)
Low risk vs.
No risk
High risk vs.
No risk
11–14 Year
old vs. never
had sex
15–17 years
old vs. never
had sex
1 Sexual partner
vs. never had sex
C2 Sexual
partners vs.
never had sex
Gender
Female Referent Referent Referent Referent Referent Referent
Male 1.28 (0.67, 2.43) 1.68 (1.02, 2.76) 2.12 (1.21, 3.71) 1.34 (0.80, 2.24) 2.42 (1.29, 4.55) 1.35 (0.83, 2.19)
Race
White Referent Referent Referent Referent Referent Referent
Black and others 1.03 (0.27, 3.90) 1.86 (0.81, 4.27) 3.44 (1.47, 8.04) 0.63 (0.20, 1.92) 1.37 (0.52, 3.57) 1.72 (0.72, 4.11)
Latino 1.09 (0.38, 3.14) 2.71 (1.49, 4.93) 3.20 (1.70, 6.05) 1.69 (0.88, 3.26) 2.62 (1.22, 5.62) 2.07 (1.11, 3.88)
Physically forced sex
No Referent Referent Referent Referent Referent Referent
Yes 3.69 (0.57, 24.10) 5.97 (1.80, 19.78) 8.05 (2.26, 28.64) 2.74 (0.58, 12.88) 6.53 (1.78, 23.93) 4.93 (1.32, 18.44)
Substance use score
0 Referent Referent Referent Referent Referent Referent
1 2.80 (1.26, 6.22) 1.65 (0.83, 3.27) 2.02 (0.95, 4.30) 1.74 (0.85, 3.56) 2.50 (1.04, 6.03) 1.61 (0.84, 3.10)
2 3.19 (1.03, 9.87) 2.27 (1.08, 4.79) 3.77 (1.59, 8.91) 1.80 (0.78, 4.16) 1.84 (0.72, 4.71) 2.66 (1.23, 5.74)
C3 6.81 (1.84, 25.18) 9.55 (3.37, 27.08) 17.77 (5.81, 54.36) 4.95 (1.57, 15.60) 6.58 (2.02, 21.45) 10.63 (3.72, 30.40)
TV viewing (h)
0 Referent Referent Referent Referent Referent Referent
1–2 0.86 (0.30, 2.46) 0.72 (0.37, 1.38) 0.64 (0.27, 1.48) 0.83 (0.42, 1.64) 1.78 (0.61, 5.21) 0.56 (0.29, 1.08)
C2 0.86 (0.29, 2.55) 0.63 (0.33, 1.21) 0.80 (0.35, 1.79) 0.61 (0.30, 1.24) 0.89 (0.29, 2.75) 0.64 (0.33, 1.22)
Sadness/hopelessness
No Referent Referent Referent Referent Referent Referent
Yes 0.67 (0.31, 1.43) 0.99 (0.55, 1.77) 1.14 (0.60, 2.14) 0.80 (0.43, 1.49) 1.10 (0.54, 2.25) 0.85 (0.47, 1.55)
Alcohol use
Non-drinkers Referent Referent Referent Referent Referent Referent
Current light drinkers 1.91 (0.86, 4.24) 2.04 (1.08, 3.87) 0.99 (0.47, 2.11) 2.74 (1.39, 5.40) 1.70 (0.76, 3.78) 2.16 (1.15, 4.07)
Current binge drinkers 1.32 (0.49, 3.58) 3.64 (1.95, 6.80) 1.64 (0.82, 3.29) 4.15 (2.05, 8.39) 2.33 (0.96, 5.64) 3.23 (1.74, 6.00)
Cigarette smoking
Non-smokers Referent Referent Referent Referent Referent Referent
Quitters 0.28 (0.05, 1.76) 3.34 (0.93, 12.04) 4.99 (1.52, 16.41) 1.17 (0.19, 7.09) 2.19 (0.45, 10.80) 2.59 (0.68, 9.84)
Current smokers 1.42 (0.53, 3.79) 2.68 (1.43, 5.03) 2.77 (1.34, 5.72) 2.29 (1.12, 4.65) 3.23 (1.43, 7.33) 2.09 (1.09, 4.03)
HIV educationa
No Referent Referent Referent Referent Referent Referent
Yes 1.09 (0.36, 3.33) 1.26 (0.54, 2.93) 1.01 (0.36, 2.79) 1.41 (0.65, 3.08) 1.34 (0.53, 3.40) 1.16 (0.49, 2.71)
Unsure 0.26 (0.06, 1.27) 0.52 (0.21, 1.31) 0.51 (0.16, 1.64) 0.36 (0.10, 1.24) 0.26 (0.07, 1.06) 0.55 (0.23, 1.34)
OR odds ratio, adjusted for levels of other covariates, CI confidence interval
a Based on participation in a school-based HIV/AIDS education program and excludes all other HIV/AIDS or reproductive and sexual
health
knowledge from other sources
Note: Other significant associations were age 15–18 years and low risk sexual behaviors (OR: 4.51; 95% CI: 1.69, 12.05), and age 15–18
years
and having C2 sexual partners (OR: 4.54; 95% CI: 2.32, 8.91)
736 Matern Child Health J (2011) 15:730–741
123
With respect to HIV education, it is interesting to note
that even in an abstinence-only education state which
neither requires nor encourages in-school HIV prevention
education programs [13], nearly 9 in 10 students reported
receiving in-school HIV education. One explanation could
be the discrepancy between state-level policies, or lack of
consistency in policies across the board, and actual practices
in local districts and schools. For instance, a large
proportion of schools (62.3%) taught key HIV, STI, and
pregnancy prevention topics (including condom use and
how to access valid and reliable health information, products,
or services related to HIV, other STIs, and
pregnancy), in a required course for high school students
[38]. However, we found no significant association
between receiving in-school education and sexual risk
behaviors. A number of trajectories may explain this
observation.
First, given that school-based HIV/AIDS education in
the state is voluntary, many students may already have
been exposed before program attendance; thus schoolbased
lessons may not have adequately addressed those
established behaviors. Second, our findings may in part
reflect a limited variability in responses, due to the broadbased
nature of HIV/AIDS education programs offered in
Table 4 Adjusted odds ratios for the association between sexual risk behaviors, age at sexual debut, and number of current sexual
partners and
selected covariates among male respondents in 2005 Colorado youth risk behavioral survey
Predictors Sexual risk behaviors
OR (95% CI)
Sexual debut
OR (95% CI)
Number of current partners
OR (95% CI)
Low risk vs.
No risk
High risk vs.
No risk
11–14 Year
old vs. never
had sex
15–17 Years
old vs. never
had sex
1 Sexual
partner vs.
never had sex
C2 Sexual
partners vs.
never had sex
Race
White Referent Referent Referent Referent Referent Referent
Black and others 0.23 (0.04, 1.21) 1.98 (0.59, 6.64) 3.18 (0.99, 10.17) 0.34 (0.10, 1.11) 0.92 (0.22, 3.91) 1.62 (0.48, 5.44)
Latino 1.24 (0.43, 3.57) 2.13 (0.88, 5.18) 2.95 (1.32, 6.60) 1.30 (0.48, 3.53) 2.13 (0.79, 5.74) 1.76 (0.73, 4.25)
Physically forced sex
No Referent Referent Referent Referent Referent Referent
Yes 5.35 (0.30, 95.80) 2.39 (0.06,
100.31)
2.20 (0.05, 94.89) 3.60 (0.09,
145.52)
NA 4.83 (0.12,
190.65)
Substance use score
0 Referent Referent Referent Referent Referent Referent
1 0.96 (0.27, 3.45) 1.71 (0.66, 4.44) 1.37 (0.52, 3.60) 1.63 (0.55, 4.86) 2.43 (0.74, 8.03) 1.12 (0.44, 2.90)
2 5.46 (1.44, 20.73) 2.24 (0.76, 6.62) 2.38 (0.72, 7.86) 2.86 (0.92, 8.89) 2.75 (0.87, 8.67) 2.62 (0.85, 8.12)
C3 13.44 (2.09,
86.53)
9.63 (2.23, 41.53) 13.47 (2.75,
65.85)
8.32 (1.75, 39.50) 10.87 (2.11,
56.04)
10.01 (2.26,
44.29)
Alcohol use
Non-drinkers Referent Referent Referent Referent Referent Referent
Current light drinkers 2.51 (0.90, 6.98) 1.96 (0.81, 4.74) 1.59 (0.65, 3.92) 2.58 (1.02, 6.51) 2.62 (0.99, 6.94) 1.98 (0.80, 4.87)
Current binge
drinkers
0.36 (0.09, 1.40) 3.27 (1.36, 7.88) 2.00 (0.79, 5.05) 2.61 (0.97, 7.06) 2.31 (0.73, 7.33) 2.41 (1.00, 5.84)
Cigarette smoking
Non-smokers Referent Referent Referent Referent Referent Referent
Quitters 0.13 (0.01, 1.99) 4.50 (0.78, 25.97) 5.60 (1.21, 25.90) 1.79 (0.17, 18.31) 1.93 (0.38, 9.90) 3.93 (0.64, 24.05)
Current smokers 1.48 (0.44, 4.90) 2.90 (1.17, 7.23) 3.08 (1.14, 8.36) 2.20 (0.80, 6.07) 1.69 (0.60, 4.74) 2.87 (1.09, 7.57)
HIV educationa
No Referent Referent Referent Referent Referent Referent
Yes 0.55 (0.15, 2.10) 1.05 (0.36, 3.07) 0.93 (0.28, 3.14) 0.90 (0.32, 2.56) 0.72 (0.21, 2.47) 1.02 (0.36, 2.93)
Unsure 0.39 (0.06, 2.38) 0.85 (0.28, 2.55) 1.06 (0.35, 3.25) 0.47 (0.12, 1.81) 0.50 (0.12, 2.01) 0.84 (0.28, 2.55)
OR odds ratio, adjusted for levels of other covariates, CI confidence interval, NA not enough observations were available to generate
reliable
effect estimates
a Based on participation in a school-based HIV/AIDS education program and excludes all other HIV/AIDS or reproductive and sexual
health
knowledge from other sources
Note: Other significant associations were age and high sexual risk behaviors (OR: 3.64; 95% CI: 1.48, 8.95), and age and having C2
sexual
partners (OR: 4.16; 95% CI: 1.66, 10.40)
Matern Child Health J (2011) 15:730–741 737
123
schools. Targeted interventions are generally more effective
than broad-based programs, because the former recognizes
the unique age and developmental level-specific
needs of individuals as well as contexts that influence
behavior change. Finally, the observed relationship is also
consistent with conclusions from many studies that
knowledge alone is insufficient to affect changes in risk
behaviors or influence the antecedents of these behaviors
[34, 39]. The mediating role of ‘moral reasoning’ in
influencing behavior has been suggested [40] although
further research examining the relationship of the construct
with the perception of risk in HIV transmission among
adolescents is warranted.
We found alcohol drinking and current smoking to be
predictive of high risk sexual behaviors. Likewise, regardless
of gender, greater exposure to addictive substances
strongly and consistently correlated with higher likelihood
for HIV/AIDS-related risk behaviors, such as early sexual
initiation. These findings are consistent with other investigations
suggesting that alcohol, tobacco and other addictive
substances are associated with increased risk behaviors
related to HIV infections [34, 41]. Concerns for potential
increased risk among alcoholics are primarily due to greater
likelihood of co-occurring behavioral problems such as use
of injection drugs or other psychoactive substances resulting
in cognitive inhibition, poor behavioral judgment, and
Table 5 Adjusted odds ratios for the association between sexual risk behaviors, age at sexual debut, and number of current sexual
partners and
selected covariates among female respondents in 2005 Colorado youth risk behavioral survey
Predictors Sexual risk behaviors OR (95% CI) Sexual debut OR (95% CI) Number of current partners
OR (95% CI)
Low risk vs.
no risk
High risk vs.
no risk
11–14 Year
old vs. never
had sex
15–17 Years
old vs. never
had sex
1 Sexual
partner vs.
never had sex
C2 Sexual
partners vs.
never had sex
Race
White Referent Referent Referent Referent Referent Referent
Black and others 2.60 (0.47, 14.40) 1.24 (0.47, 3.31) 3.44 (1.13, 10.52) 0.95 (0.16, 5.73) 1.69 (0.42, 6.83 1.65 (0.48, 5.62)
Latino 0.93 (0.20, 4.26) 2.53 (1.17, 5.46) 2.35 (0.91, 6.08) 1.72 (0.76, 3.88) 2.61 (0.88, 7.73) 1.97 (0.89, 4.36)
Physically forced sex
No Referent Referent Referent Referent Referent Referent
Yes 3.37 (0.38, 29.84) 7.83 (3.15, 19.46) 12.07 (3.12, 46.77) 2.15 (0.41, 11.25) 2.40 (0.99, 5.82) 1.79 (0.42, 7.57)
Substance use score
0 Referent Referent Referent Referent Referent Referent
1 5.04 (1.79, 14.18) 1.56 (0.60, 4.06) 3.69 (1.04, 13.08) 1.60 (0.63, 4.02) 2.22 (0.55, 8.93) 1.96 (0.82, 4.69)
2 2.36 (0.34, 16.27) 2.54 (0.93, 6.94) 11.72 (3.44, 39.90) 1.16 (0.35, 3.88) 1.58 (0.32, 7.79) 2.82 (0.98, 8.15)
C3 5.08 (0.49, 52.64) 9.63 (2.23, 41.53) 43.82 (8.92, 215.43) 2.56 (0.43, 15.14) 5.45 (0.78, 33.92) 11.34 (2.17, 59.16)
Alcohol use
Non-drinkers Referent Referent Referent Referent Referent Referent
Current light drinkers 1.26 (0.35, 4.49) 2.18 (0.86, 5.56) 0.40 (0.09, 1.78) 3.24 (1.20, 8.73) 0.48 (0.07, 3.17) 2.59 (1.07, 6.26)
Current binge
drinkers
2.60 (0.75, 9.02) 3.50 (1.43, 8.53) 0.78 (0.25, 2.46) 6.61 (2.50, 17.44) 1.61 (0.36, 7.10) 4.21 (1.78, 9.98)
Cigarette smoking
Non-smokers Referent Referent Referent Referent Referent Referent
Quitters 0.28 (0.02, 4.63) 2.81 (0.56, 14.02) 5.83 (1.05, 32.31) 0.53 (0.05, 6.17) 2.49 (0.21, 30.11) 1.90 (0.37, 9.84)
Current smokers 1.11 (0.24, 5.09) 2.72 (1.18, 6.27) 3.08 (1.08, 8.77) 2.10 (0.83, 5.33) 7.20 (1.69, 30.76) 1.53 (0.64, 3.67)
HIV educationa
No Referent Referent Referent Referent Referent Referent
Yes 1.90 (0.34, 10.66) 2.18 (0.57, 8.42) 1.59 (0.25, 10.09) 2.87 (0.79, 10.35) 2.96 (0.71, 12.33) 1.68 (0.41, 6.95)
Unsure NAd 0.29 (0.03, 3.23) NAd 0.26 (0.02, 3.26) NAd 0.26 (0.02, 2.97)
OR Odds ratio, adjusted for levels of other covariates, CI Confidence interval, NA not enough observations were available to generate
reliable
effect estimates
a Based on participation in a school-based HIV/AIDS education program and excludes all other HIV/AIDS or reproductive and sexual
health
knowledge from other sources
Note: Other significant associations were age and low sexual risk behaviors (OR: 10.28; 95% CI: 1.44, 73.34), and age and high risk
sexual
behaviors (OR: 5.17; 95% CI: 1.88, 14.23)
738 Matern Child Health J (2011) 15:730–741
123
minimized risk perception [21, 30, 42]. We also found gender
and racial differences in risk exposures. While there are
documented racial disparities in sexual risk behaviors, these
are suggested to be due to socio-economic or other contextual
determinants such as drug availability in a particular
neighborhood rather than race per se [41].
Children forced to endure sexual intercourse are likely to
live with lifelong traumas, low self-esteem, and STIs [28].
Thus, major challenges for preventing HIV infections
include developing adequate competencies among the most
vulnerable populations, particularly adolescents and women.
But, it must also be recognized that HIV infections often
generate an intense societal stigma and a moral judgment
against affected individuals, and evoke much horrendous
societal condemnation [20, 39, 43]. Those societal attitudes,
in turn, generate denial, fear and discrimination; each of
which reinforces stereotypes and exacerbates existing disparities
[42], and may result in reluctance to seek information
on preventive measures or to use existing healthcare services
for an underlying STI [44]. Studies have also shown that
adolescent sexual risk behaviors usually co-occur with other
behaviors related to adverse developmental outcomes,
including delinquency [45]. In addition, most adolescents
often engage in short-termsexual relationships and over time
are likely to have multiple sexual partners, thus increasing
their vulnerability to HIV infections. Recent evidence suggests
that most individuals diagnosed with HIV in adulthood
were actually infected during adolescence [4].
Limitations
There are several limitations to this study. First, key control
variables such as socioeconomic status, parents and peerHIV/
AIDS literacy, and other contextual determinants of health
behaviors during adolescence were not available for inclusion
in our analysis. Second, self-reporting of adolescent sexual
and other risk behaviors may be subject to errors and social
desirability bias. This is likely to result in either exposure or
outcome misclassification. However, the reliability of the
YRBS items has been documented by other investigators [25,
26]. Lastly, the cross-sectional nature of the study makes it
impossible to infer causal relationships among variables. But,
other experimental and meta-analysis of prospective studies
suggest thatmany of the adolescent risk exposures eventually
become consequential for sexual risk behaviors, early sexual
debut, and multiple sexual partners [21]. However, observing
these factors longitudinally would be beneficial in delineating
the precise causal pathway.
Implications
In the light of our findings, the current focus of the HIV/
AIDS prevention research debate should not be whether
providing abstinence-only interventions is more costeffective
for delaying sexual debut or engaging students in
intensive school-based sexual health skill-building programs
that also target parents and community members.
Fundamentally, the differences in perspectives concerning
effectiveness or otherwise of abstinence-only programs
versus sexuality education programs in American society
today often reflect more of an ideological stance or a moral
view rather than science-based evidence. On one hand,
abstinence-only education mandates teaching adolescents
to completely abstain from sexual intercourse until marriage,
and such programs often provide neither a detailed
information on basic facts of human sexuality nor offer
different contraceptive options to choose when needed [22,
23]. The proponents of this program believe that is the only
way for reducing pregnancy, STI’s/STD’s and HIV infections.
On the other hand, sexuality education provides a
structured curriculum (based on relevant human behavioral
theories) on age appropriate information regarding human
sexuality, contraception [21, 23]. Thus, the discourse
should focus on exploring appropriate interventions that
address total adolescent development needs, including the
more insidious longstanding factors such as forced sexual
intercourse and other lifetime experiences associated with
risk behaviors. Extensive research has documented that
adolescent participation in targeted interventions generally
leads to reduced sexual and other behavioral risks [4].
Thus, future longitudinal studies of this population need to
explore the roles of different contexts in reducing HIV
transmission.
From a health promotion programming standpoint, there
is an urgent need to review current state school health
policies and to develop a comprehensive but gender- and
racial/ethnic-targeted programs that address both the individual
adolescent’s needs (risk behaviors) and the contextual
enabling factors (including peers, family and
community) in order to achieve greater benefits in
improving the health of this population. Achieving sustained
behavior change for this population may require
multi-level approaches involving individuals (parents,
caregivers, and peers), community leaders, and structural
policy and environmental changes. Such socio-ecological
interventions would also enable skill-based, age-appropriate
HIV and sexual health education programs to become
core components of any school-based programs.
Conclusion
We found gender and racial differences in key exposures
associated with HIV/AIDS risk behaviors among adolescents
in Colorado. However, there was no significant effect
of in-school HIV/AIDS education on risk behaviors,
Matern Child Health J (2011) 15:730–741 739
123
suggesting the urgency to review the current state school
health policies and to develop alternative programs that
comprehensively address the individual adolescent’s needs
along with underlying environmental exposures associated
with physically forced sexual intercourse. Until those factors
are addressed, efforts to control the HIV epidemic and
improve the health of this population are likely to be
unsuccessful.
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Issues in Comprehensive Pediatric Nursing, 33:82–100, 2010
Copyright © Informa UK Ltd.
ISSN: 0146-0862 print / 1521-043X online
DOI: 10.3109/01460861003663961
82
“IT DRIVES US TO DO IT”: PREGNANT ADOLESCENTS
I01Us15sC24uP16eN-s0 i48n36 C2Xomprehensive Pediatric Nursing, Vol. 33, No. 2, Feb 2009: pp. 0–0
IDENTIFY DRIVERS FOR SEXUAL RISK-TAKING
TD.rCiv. eKrsi nfgo rJ Sonexesual Activity
Tammy C. King Jones, PhD RNC-OB
University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
Background: Sexual risk-taking behaviors have a negative effect on the
heath and future of American adolescents. Aims and objectives: To gain
insight into these behaviors and preventative efforts, this study explored
the experiences and perceptions of 15 pregnant adolescents using a
qualitative feminist approach and in-depth interviews. Methods: As
participants discussed sex education, each identified influences on sexual
decision-making that often overpowered the information received.
Results: Content analysis and constant comparison of this data led to the
overarching theme “Drivers for Sexual Risk-taking.” Drivers were categorized
as internal and external and each demonstrated a significant
influence on adolescent sexual decision-making. Conclusion: Results of
this study can inform the development of educational efforts, reform of
social policy, and the focus of future research.
Keywords: Sexual risk-taking behaviors, Pregnant, Adolescent, Qualitative feminist
approach, Sex education
According to the Centers for Disease Control (CDC, 2009), adolescent
sexual risk-taking behaviors are a significant public health crisis. Whether
society condones it or not, a peaked interest in sex, self-exploration, and
sexual experimentation are a part of normal adolescent sexual development
(Hellerstedt & Radel, 2005; Katz, 2006; Monasterio, Hwang & Shafer,
2007; Walcott, Meyers & Landau, 2007). However, in the United States,
47.8% of ninth through twelfth grade students are doing much more than
experimenting and are engaging in sexual intercourse (CDC, 2009).
Received 14 November 2009; accepted 9 January 2010.
Address correspondence to Tammy C. King Jones, PhD, RNC-OB, University of Arkansas
for Medical Sciences, 4301 W. Markham St, Slot #526, Little Rock, Arkansas, 72205.
E-mail: [email protected]
Drivers for Sexual Activity 83
While some of these behaviors may be normal, there are risky sexual
behaviors that are cause for great concern. The 2007 Youth Risk
Behavior Surveillance data summarized in Table 1 outline some of these
behaviors and their prevalence by race/ethnicity, which include early
sexual debut, multiple sex partners, and unprotected sexual encounters
(CDC, 2007). These risky behaviors not only increase an adolescent’s
chance of becoming pregnant or acquiring a sexually transmitted infection
(STI), but also may have negative psychological effects (Brendgen,
Wanner, & Vitaro, 2007).
Research on adolescent risk-taking has largely focused on individual
or personal antecedents such as knowledge (Chia-Chen & Thompson,
2007). Taylor-Sheefer & Rew (2000) took a broader approach and
characterized the etiological contributors to adolescent sexual risk-taking
behaviors as environmental (family, friends, poverty), developmental
(cognitive, biologic) and personal (self-esteem, knowledge) factors. The
authors maintain that the interaction of these factors largely determines if
and/or when an adolescent will engage in sexual risk-taking behaviors.
Despite considerable efforts to understand and decrease these behaviors,
this phenomenon continues to perplex researchers, educators, and policymakers.
Insight into these behaviors from adolescents is needed in
order to develop effective interventions that address sexual risk-taking
and decrease the associated negative outcomes (unintended pregnancies and
STI acquisition) which have reached epidemic proportions (CDC, 2008).
Too often adult “experts” try to provide this insight, when in fact the
most valuable perspective may come from adolescents themselves
(DiCenso, Guyatt, Willan & Griffith, 2002). Researchers know that ideal
Table 1. 2007 youth risk behavior surveillance data
Sexual risk-taking behaviors
students 9–12 grades
Prevalence (%) by
race/ethnicity
Nationwide %
Early sexual debut (before age 13) 16.3—African American
8.2—Hispanic
4.4—Caucasian
7.1
*Multiple sex partners 27.7—African American
17.3—Hispanic
11.5—Caucasian
14.9
**Unprotected sexual encounters 32.7—African American
38.0—Hispanic
40.3—Caucasian
38.5
*Sexual intercourse with 4 or more people during their life.
**In students who had sex in the past 3 months, the percentage who did not use a condom at last
sexual intercourse.
84 T.C. King Jones
participants have “first hand experience” and knowledge of the research
problem (Rubin & Rubin, 1995, p. 65), and feel comfortable sharing their
experiences and perceptions. Unfortunately, forums for adolescent participation
in discussions about sexual risk-taking are rare, and when they are
included, establishing trust can be a challenge. Some researchers maintain
that issues of self-reporting and anonymity inhibit adolescents from
sharing their sexual experiences and openly voicing their questions and
concerns (Measor 2004; Yoo, Johnson, Rice & Manuel, 2004). This
reluctance often stems from fear of the consequences of teachers and
parents finding out about their previous and/or ongoing sexual activity
(Yoo et al., 2004). Seeking the perspective of pregnant adolescents on
sexual risk-taking can provide a retrospective and insider viewpoint without
the fear of disclosure felt by other adolescents, as pregnancy indicates
sexual activity. This stigmatized and often ignored population can
provide valuable information and knowledge related to the antecedents
for adolescent sexual risk-taking behaviors.
CONCEPTUAL FRAMEWORK
The theoretical underpinning for this study was Bandura’s (1986) model
of triadic reciprocal determinism. The research focus and interview guide
reflect the environmental, personal, and behavioral factors of the model.
Bandura (1986) purports that the triadic, reciprocal, and dynamic interplay
among these factors influences the actions and behaviors of humans.
Figure 1 represents the constructs of the model in relationship to this
research.
STUDY PURPOSE AND DESIGN
Studies designed to explore and recognize the perceptions of adolescents
contribute valuable insight into the life experiences of this population.
Qualitative research focusing on pregnant adolescents’ perceptions of sex
education and other sexual phenomena is limited, thus providing the
impetus for this study. Though the overall purpose of this research was to
explore pregnant adolescents’ perceptions of school-based sexuality
education (SBSE), rich data surrounding perceived influences on sexual
decision-making emerged from their stories.
To meet the study’s purpose, the researcher employed a qualitative
feminist research approach, which seeks to empower, raise social
awareness, and incite activism (Hesse-Biber & Leavy, 2007). Listening to
the voices of marginalized populations, such as pregnant adolescents, can
raise the consciousness of those who hear their stories and supports these
goals. Establishing a non-hierarchical relationship and commitment to
Drivers for Sexual Activity 85
minimal structure fostered trust and freedom of expression for the participants
and did not suppress their stories. Ultimately, this study yielded
thick descriptions of their realities related to SBSE as well as greater
insight into other dimensions of their sexual experiences, including the
drivers for sexual decision-making.
INSTRUMENTS
Demographics
Each participant completed a paper and pencil form by filling in the
blanks or circling the appropriate demographic responses that described
them. Characteristics such as age, ethnicity, educational preparation,
details of their SBSE, and age of sexual debut were included. Pilot
testing and refinement of the demographic instrument occurred prior to
the study.
Figure 1. Triadic reciprocal determinism and adolescent sexual
decision-making.
86 T.C. King Jones
Interview Guide
Consistent with feminist methodology (Hesse-Biber & Leavy, 2007), indepth
interviews mimicked conversation and had minimal structure. The
researcher developed grand tour, open-ended, and probe questions using
the conceptual framework and feminist research principles. After preliminary
work and collaboration with a qualitative researcher, these interview
questions were further refined. The researcher posed the grand tour
question, “Share with me what you remember about the sex education
you had in school.” Probe questions such as, “where did you learn about
sex” and “how are teenagers getting information about sex” fostered
further exploration of influences and sources of sexuality information and
education.
SAMPLE
The purposive sample included participants capable of offering expert
insight and reporting recent experiences with SBSE. The study’s inclusion
criteria ensured the selection of participants with first-hand knowledge of
SBSE. Participants were between the ages of 15 and 19 years, were
attending or had attended public school, had completed the 9th grade,
were pregnant or up to 8 weeks postpartum with first pregnancy or birth,
and reported participation in any type of SBSE class or program. Potential
participants who did not speak English were excluded.
Participants were recruited at a community women’s clinic that
provides care to women from urban and rural areas that are uninsured or
receive Medicaid benefits. This clinic designates one morning per week
to caring for pregnant adolescents and offers an environment that is nonthreatening
and supportive for these young women.
STUDY PROCEDURES
After receiving Institutional Review Board (IRB) approval, the researcher
spent time reviewing the study details with clinic nursing staff. Each
agreed to assist with recruitment of participants. Nurses reviewed patient
charts to determine if they met the age criteria, they then shared study
information with potential participants after the initial assessment to gain
permission for the researcher to talk with them about the study. Once
granted this permission, the researcher assessed for the presence of other
inclusion criteria, reviewed the details of the study, and if participants
agreed, began the informed consent process.
Before the interview, participants signed the appropriate study consent
and/or assents (if less than 18 years of age), a Health Insurance Portability
Drivers for Sexual Activity 87
and Accountability Act (HIPAA) consent, and completed the demographic
instrument. Details were reviewed making sure participants understood
that interviews were one-on-one, audiotaped, and that their commitment of
time would be 30 minutes to 1 hour. All interviews took place immediately
following the participants scheduled clinic appointment. Three participants
completed a 10–15 minute follow-up phone interview to expand
and clarify their previous accounts. At the end of the first interview,
participants received a 20-dollar gift card as a token of appreciation for
their time.
TRUSTWORTHINESS
Qualitative researchers employ methods to ensure the rigor, or trustworthiness,
of their work, which is similar to demonstrating reliability and
validity of quantitative studies. These methods foster the true and accurate
representation of the participants’ experiences and are demonstrated
by the credibility, dependability, confirmability, and transferability of the
findings (Lincoln & Guba, 1985). For this study, credibility was ensured
by verbatim transcription of audiotapes and member checking during
interviews and by second interviews. Investigator triangulation during the
sampling process, data collection, coding and data analysis further
supports the credibility of the findings. The researcher serving as the only
interviewer and an explicit audit trail support the dependability. The audit
trail contained details of each interview, transcript review, and all coding
and analytical decision-making. Researcher reflexive data and the audit
trail speak to the confirmability of findings by allowing for the examination
of researcher bias or assumptions (Hesse-Biber & Leavy, 2007).
Thick descriptions from the in-depth interview process serve to determine
the transferability of findings to similar situations.
ANALYSIS
Demographic data were analyzed and means calculated. Narrative data
were analyzed using content analysis and constant comparison. Content
analysis required total immersion in the data, as individual interviews
were searched line-by-line for patterns and codes (Burns & Grove, 2005).
The identification of differences and similarities among accounts was
accomplished through the iterative process of constant comparison
(Thorne, 2000).
Audiotaped interviews were professionally transcribed. To begin data
immersion, transcripts were read three times. First readings occurred
while listening to the audiotapes to ensure the accuracy of transcription.
The focus of second readings was to identify the need for clarification or
88 T.C. King Jones
confirmation and to determine if a second interview was necessary. All
transcripts were entered into the qualitative management software program,
Ethnograph (Seidel, 1998). This program enables the researcher to organize
data by numbering lines and categorizing multiple codes into data sets.
During the third and subsequent readings, the researcher searched line-byline
for patterns, codes, and themes (Rubin & Rubin, 2005). The data
collection and analysis processes occurred concurrently.
The development of a codebook began after the first three interviews
were entered in Ethnograph and initially analyzed. The researcher explicitly
identified and defined codes from the interviews to support recognition
and consistency. Sorting of interview data by codes facilitated the examination
of data across all interviews that referred to the same content (Rubin
& Rubin, 2005). The next phase entailed aggregating coded data into
similar categories and ultimately into six interrelated units of meaning or
factors. These factors were defined and similarities examined, leading to
the identification of the overarching theme. This decision-making process
is illustrated in Table 2.
FINDINGS
Eight African-American, 4 Caucasian, and 3 Hispanic pregnant adolescents
comprised the sample (N = 15). All participants were pregnant at the time
of their interviews. Their ages ranged from 15 to 19 years with a mean
age of 17 years. Each had varying degrees of educational preparation
(mean 11th grade) and most (n = 13) were currently residing with their
Table 2. Internal and external drivers for sexual decision-making (N = 15)
Theme Factor Raw Data
Drivers for sexual
risk-taking
Fitting-in (n = 8) “Sometimes it’s all in they head. Maybe nobody
says nothing, but girls be like if I do it [sex]
I’ll be popular.”
(Internal) Curiosity (n = 6) “Some people do it just to see how it feels, you
know, out of curiosity.”
Forbidden fruit(n = 6) “If you try to keep us from boys and don’t tell us
about stuff, it just going to drive us to want to
be with a boy.”
(External) Partner pressure (n = 11) “Their boyfriend said I’m going to leave you or
find someone else, so they did have it [sex].”
Peer pressure(n = 10) “If you say you a virgin, they be like you still a
virgin? And they call you square and make fun
of you.”
Media (n = 7) “TV has sex on it everywhere. You can find out
what you want to know there.”
Drivers for Sexual Activity 89
parents. Fourteen received SBSE solely in the U.S. public school system,
while one had SBSE instruction in Mexico as well as the U.S.
Participants reported age for first vaginal intercourse was 13 to 18
years with a mean of 15 years. Five of the participants reported that they
had engaged in oral sex, while three reported having anal sex. Data were
not collected in a manner that documented when these sexual behaviors
occurred in relation to one another. Further, participants were not asked
about their past/present history of sexually transmitted infections (STIs),
but a number (n = 5) of them disclosed this history during the interview
process.
When using a qualitative approach, the focus should be on the view of
reality that is important to the participant, rather than the researcher
(Speziale & Carpenter, 2003). While exploring pregnant adolescents’
perceptions of SBSE, they discussed drivers for sexual risk-taking as
more powerful than SBSE, thus resulting in pregnancy. Of the realities
they shared, the significance of what “drives” them and other adolescents
to participate in risky sexual behaviors is apparent in the theme that
emerged.
Drivers for Sexual Risk-Taking
The overarching theme that captured adolescents’ perceptions of significant
influences on sexual decision-making is “drivers for sexual risktaking.”
Participants described influences on sexual decision-making that
paralleled the constructs of Bandura’s model of triadic reciprocal determinism
(1986). These influences were delineated as internal or external
drivers. All (N = 15) participants discussed at least one of the six factors
(see Table 2).
Internal Drivers
Influences related to behavioral or personal factors were identified as
internal drivers. Participants described influences on sexual decisionmaking
that derived from their individual expectations, beliefs, cognition,
and developmental stage. In some cases, these drivers have environmental
contributors, but predominately originated from intrinsic factors.
Fitting-in. Many of the participants (n = 8) described the desire to “fit in”
as a strong internal driver. They discussed the lengths that adolescents
will take to be “a part of the crowd” or gain the attention of their friends.
One 16-year-old African American (AA) stated:
Some people if they unpopular or if they feel like it’s not a lot of people
notice them, they might start doing it. I’m not saying if you’re popular you
90 T.C. King Jones
don’t have to worry about it, but if you already known or don’t care what
people think about you, you won’t have to worry about it.
Another 18-year-old AA participant shared her thoughts on the difference
of wanting to be like friends and being pressured by those friends,
demonstrating important overlap between fitting-in and an external
driver, peer pressure.
I think a lot of girls, once they friend did it because you know after I lost
my virginity, eventually my best friend did too. It’s kind of like stuff she
wouldn’t do and then I end up doing it she’ll end up doing it. So it’s kind of
like you are not really being pressured per se, ‘cause they not really saying
anything to you, but it’s just in their actions.
Curiosity. Many participants (n = 6) talked about the impact of curiosity
related to the unknown as being a significant influence on their decisions
regarding sexual activity. An 18-year-old Hispanic participant, whose
sexual debut was at 16 years, shared how curiosity was a driver for her.
I was curious, and then there was a time I had sex, but I didn’t want to have
sex anymore. I was like now I know how it felt so I don’t have to have sex
with anyone else. Then I wasn’t curious anymore ‘cause I was like o.k., I
already know what to expect.
Forbidden fruit. Participants linked some of their curiosity to the
portrayal of sex as taboo or a forbidden act. For instance, some (n = 6)
described how the perception that adults were “keeping secrets” or hiding
information about sex stimulated their curiosity. According to one 15year-old, “my mom said don’t do it, but she wouldn’t tell me why not.
Like I can’t handle it.” Seven of the participants talked at length about
this influence. An African-American (AA) 16-year-old said, “You know,
when somebody tells you not to do something, it makes you want to go do
it.” Another AA participant elaborated,
If you have somebody that just breathe down your neck, don’t do it, don’t
do it, or don’t want to talk about it they done make you wonder what’s so
bad? Like me, I got a wondering mind if somebody keep telling me don’t
do it, eventually I’m gonna want to do it. I mean it kinda drives you to it.
The following account further demonstrates the significant effect of
forbidding sexual activity without adequate explanation or discussion.
This participant described how taking this approach could outweigh the
benefit of education.
Drivers for Sexual Activity 91
They [adults] can tell us what we supposed to know and all that, but that
don’t mean we won’t do it. If you tell me not to do something, it makes me
want to do it even more even if I know better.
External Drivers
Bandura (1986) asserts that social and physical structures within the
environment influence formation and initiation of behavior. Participants
shared stories about the significant influence of partners, peers, and media
on their sexual decision-making. These contributors were identified as
external drivers.
Partner pressure. The significance of pressure from boyfriends was
widely discussed (n = 11). Most often, the driver came in the form of
promises or ultimatums made by the boys. Some partners (n = 5) promised
love, commitment, or marriage in return for sex. One 15-year-old AA
participant describes her experience:
I feel like I wasn’t thinking at the time, I really didn’t want to do it at that
time, but it seemed like at that moment and it seem like he was pushing me
more into it even though I didn’t want to. The dumb thing that he told me was
to relax and he loved me and I think I actually gave into that dumb word.
One 16-year-old Caucasian adolescent reflects on her first time and what
she wants other girls to learn from her experience:
I’m really soft-hearted and honestly I think it is sort of my fault for like
what happened to me is because I gave in and I shouldn’t because he did,
he wore me down. And I think girls especially need to be talked to about
being soft-hearted. Don’t let a guy say, I love you, and we’ll be together
forever if we do this. It’s all talk, trust me. It can change within a blink of
an eye. They need to know that they need to toughen their heart up and
toughen it up quick ‘cause it will get them in trouble big time.
Pressures from peers. Though peer pressure and fitting-in overlap,
participants made the distinction between the two. They described how
peer pressure could be a driver for engaging in sexual activity. Ten of the
pregnant adolescents identified “making fun of virgins” and “building sex
up” as the most common ways this pressure manifests. A 15-year-old
Caucasian participant shares how these pressures influenced her decision
to have sex.
All of the girls was talking about it [sex] and how good it was and you
know, clowning because I was a virgin and how in everybody I hung
92 T.C. King Jones
around I was the only girl who was. It was just really a lot of peer pressure.
And I mean, I wish I, I regret that I did it.
This pressure from friends played a part in the decision-making for many
(n = 10) of these pregnant adolescents. One of the Hispanic adolescents
described the pressure she felt; “Well they were like, oh I’m already
having sex so you should do it too, it’s good. But I was like, um I want to
wait, but then I guess peer pressure got me.” The researcher followed her
statement with this probe question, “Do you think you would have made
the decision to go ahead and have sex with him if you hadn’t been getting
that pressure from your friends?” She replied, “I probably would have
waited.”
Participants expressed that many of their friends made sex sound
appealing. While most did not see the allure of sex after their first sexual
encounter, this portrayal by their peers did initially influence their sexual
decision-making. This Caucasian 16-year-old describes:
I had a couple of friends that started [having sex] in middle school and
they’ll tell you what it feels like and all this other stuff, you know, and how
good it is and how you get along so much better. They just asked why you
haven’t tried it yet or something like that and when you say you’re a virgin,
they’ll be like you still a virgin? And you know they call you a square. At
that point in time even the ones that don’t have sex, they’ll lie about it.
A 15-year-old AA participant described her girl friends as “persuasive”
and expressed her disappointment and ultimate regret for succumbing to
the pressure.
Most of the things start by peer pressure. And I don’t know why. It didn’t
feel like anything special, so losing your virginity is not the big rainbow of
the world. It’s like, you know, it didn’t seem worth it to me and most of the
people should think about it. If I could I would take it back, but it’s kind of
too late now.
Media influence. As the participants discussed influences and contributors
to sexual decision making, seven specifically discussed the inundation
and glamorization of sex in television, movies, Internet, and music
videos and lyrics. These venues were also described as a means of sex
education for adolescents. The researcher asked a 16 Caucasian year-old
participant where she thought kids “learn what sex is.” She responded:
I mean, you watch T.V. you see it on T.V. all the time. Your mom may be
in the other room. I mean my mom has come in there and she’s like what
Drivers for Sexual Activity 93
are you doing? And she [little sister] had porno up. I mean Internet, T.V.
changing the channels, you see it. They’re gonna know. You can’t hide it
from them, so just teach ‘em about it.
During an interview with a 17 year-old AA participant, she stated that
“everybody these days already knows about sex,” but that they are not
learning it from their parents or in school. When asked “where are they
learning about sex?” she replied, “On T.V. they show a lot of stuff about
sex. They’ve got a sex channel that shows you how to have sex.” One of
the Hispanic participants shared her thoughts on why kids have unrealistic
expectations regarding sex. She referred to this as “wrong sex.” When
asked to elaborate on what she meant by “wrong sex,” she described it as
sex that is portrayed as funny, casual, and without consequence.
The T.V. have programs that talk about like the wrong sex. ‘Cause like
Family Guy and all that stuff they talk about wrong sex. The guys like
thirteen, twelve and fourteen years old watch T.V. like Family Guy and
they go in with little girls and have sex. That’s why America have like the
guys have sex too young. I think it’s because the T.V. have the wrong sex.
Another participant talked at length about the importance of being honest
with adolescents on what to truly expect from sex. She described how
pornography depicts an unrealistic picture of sex.
I mean kids sneak porn and they see all this and think oh that’s neat. I’ll try
that with my girlfriend. It gets them all going. You know some of that stuff
hurts. Media has a lot of influence on kids I think. Especially T.V. and the
rap music you know.
DISCUSSION
While findings from this study are consistent with the literature, they also
contribute unique insight and add to the current body of knowledge. Of
particular interest is the perceived influence of media as a source of
education and the distinction between the concepts of peer pressure and
peer conformity. The identification of internal and external influences on
sexual decision-making provides a basis for future research and intervention
development.
Although only identified by seven participants, media (T.V., movies,
rap music, pornography) influence was described by them as a strong and
significant driver. Although media influence on adolescent sexual
decision-making is not replete in empirical literature (Chandra et al.,
2008), there are a number of studies that support current findings. Brown,
94 T.C. King Jones
Halpern & Engle (2005) identified television as the “sexual super peer”
and the exposure to sexual content on television has been linked to earlier
sexual debut (Collins et al., 2004). Findings from Burns & Porter (2007)
also linked the depiction of sex in the movies and novels to increased
curiosity about the “mysteries” of sexual relationships and as portraying
sexual inaccuracies. The participants in the current study consistently
described television, pornography, and the Internet as not only influences,
but perhaps, more importantly, as sources for education. This perception
that adolescents see various media venues as providing education about
sex, adds to the literature about its effects and influence. It is important
for parents, educators, and policymakers to consider these findings as
sexuality education and other preventative efforts for adolescent sexual
risk-taking are developed. Participants also shared that access to pornography
is not restrictive enough and validated that this exposure increases the
likelihood of adolescents engaging in risky sexual behaviors. Of further
interest, a cultural observation related to the sexual influence of media
was made by a Hispanic participant. This perspective from someone who
had attended school in both Mexico City, Mexico and El Paso, Texas that
“America” has a problem with media influence and adolescent sexual
risk-taking was both thought provoking and an implication for further
research.
Predominately, participants (n = 14) in the current study reported that
the sexual activity of peers influenced their own decision-making and that
of their friends. This comes as no surprise as, historically, peer pressure
has received the “blame” for the problem of adolescent sexual risk-taking.
Other researchers have studied influences or drivers for adolescent sexual
decision-making and this study supports many of their findings (Boyce,
Gallupe & Fergus, 2008; Morrissey & Higgs, 2006; Walcott et al., 2008).
When Sieving, Eisenburg, Pettingell & Skay (2006), examined the influence
of friends on adolescents’ sexual behaviors, they found that sexual
norms, values, and attitudes of friends played a role in determining the
timing of first sexual intercourse. Morrissey & Higgs (2006) explored
adolescent female sexual experiences and identified a number of influential
experiences related to first sexual intercourse that agreed with the current
study. Pressure to “fit in” and not be “left behind” represented a
significant influence in both.
The participants in this study clearly delineated what they perceived as
peer pressure and pressure they put on themselves to conform. The participants
perceive “making fun” of virgins and “building sex up” as pressure
from peers to engage in sexual activities. In contrast, curiosity and the
desire to “fit in” represented pressure they placed on themselves. While
the difference in the two was clear to the participants, Santor, Messervey
& Kusumakar (2000) identified common confusion between peer pressure
Drivers for Sexual Activity 95
and peer conformity and conducted research to examine and measure both
constructs. The distinction between peer pressure and conformity made
by the adolescent participants supports the findings of the Santor et al.
(2000) study. Those authors maintained that peer pressure is when
someone is “motivated to act and think in certain ways because they have
been urged, encouraged, or pressured by a peer to do so” as opposed to
wanting to be popular which “does not involve feeling pressure by a peer”
(p. 165).
Commonly, study participants cited that partners threatened to leave
and based their love on whether or not sex occurred. Adolescent desire for
acceptance and love makes this pressure a significant driver for engaging
in sexual behaviors. This external driver for sexual decision-making
(partner pressure) can be found throughout the literature (Boyce et al.,
2008; Hoggart, 2006; Morrison-Beedy et al., 2008). Similar to the findings
of the current study, the adolescent participants in the Hoggart (2006)
study described how boys use emotional “black mail” to get sex (p. 6). It
was apparent that for the study participants, the thought of losing or
disappointing their boyfriends was enough to sway some of them to have sex.
The effect of curiosity, or the intrigue of the unknown, was expressed
by the study participants (n = 6) as a being a driver for sexual activity.
This concept is not new to the literature. Adolescent female participants
in the Morrison-Beedy et al. (2008) study described how, although they
were currently abstinent, curiosity was something they had to overcome.
The teen mothers in the Burns & Porter (2007) study shared the desire to
engage in the unknown and satisfy their curiosity as influencing their
decision to have sex. This is consistent with the participants’ experiences
in the current study. Participants also described feeling that their parents
were keeping secrets from them about sex, which increased their desire to
uncover the information. This perception is supported by previous
research findings that demonstrate many American parents do not provide
their children with sufficient or accurate information about sex (Albert,
2007; Fields & Tolman, 2006; Hoff, Green & Davis, 2003). Evidence
shows that parents who are uncomfortable with sexual subject matter or
view sex as “taboo” are less likely to have discussions with their adolescents about sex (Aquilino &
Bragadottir, 2000; Chia-Chen & Thompson,
2007; DiCenso et al., 2001; Werner-Wilson & Fitzharris, 2001). Even
though participants did not describe why they thought adults did not talk
about sex, they seemed to believe what they were hiding (sex) had to
be something worth trying. The findings of the current study demonstrate
that this lack of disclosure by parents propagates the curiosity of
adolescents.
Six of the participants added to the evidence by going further with this
perception of sex as off limits, taboo, or forbidden, and the effect it has on
96 T.C. King Jones
their sexual decision-making. Being told what to do or not do represented
a struggle for autonomy and a powerful impetus for having sex. Participants
shared that their desire to engage in sexual activity peaked when adults
were autocratic and forbid them to do so. Understanding that taking a
negative approach when communicating with adolescents about sex can
“back-fire” is an important step in changing the way sexuality information
is presented and discussed with adolescents.
The participants in this study displayed no reluctance, spoke with ease,
and their accounts were candid. These participants did not have to worry
about their sexual activity being discovered and felt comfortable to
openly share their experiences and perceptions. The issue of adolescent
reluctance to discuss their sexuality is found throughout the literature
(Measor, 2004; Sieving et al., 2005). Many researchers detail the issues
surrounding this reluctance and how distrust often results in underreporting
and inhibited accounts (Aquinilo & Bragadottir, 2000; DiCenso et al.,
2001; Haglund, 2006; Reid & VanTeijlingen, 2006; Williams & Bonner,
2006). Selection of this population and utilization of the feminist approach
proved effective by minimizing this common barrier for adolescent
research.
LIMITATIONS
While the researcher made significant effort to ensure the trustworthiness
of the study and findings, there are limitations. The sample was derived
from one research setting and the socio-economic status of the participants
was not diverse as each received Medicaid benefits. Finally, the views of
postpartum participants might have varied from those expressed in this
study. Despite the limitations, parents, healthcare providers, educators,
and policymakers when developing preventative efforts for adolescent
sexual risk-taking should consider study findings. Further, results of this
study add to the body of knowledge because limited qualitative studies in
this area with this population have been conducted.
CONCLUSIONS
The need for continued research into the phenomena of adolescent sexual
risk-taking is apparent. While the findings from this study provide a
unique perspective, they also raise more questions. For instance, an
important comparison could be made by exploring the perceptions of
these drivers from adolescent females who have not participated in sexual
risk-taking behaviors (Table 1). Additionally, the presumed influence of
religion that comes from cultural traditions or living in the “Bible Belt”
did not emerge in this study. Only one participant discussed how being
Drivers for Sexual Activity 97
“raised up in church” meant she knew it was “wrong” to have sex before
she was married. Finally, even though this study included a small number
of participants, the sample was culturally diverse and no differences in
perceptions of influences on sexual decision-making were noted based on
race.
When considering preventative efforts for adolescent sexual risk-taking,
the drivers identified by pregnant adolescents must be considered.
Programs and initiatives need to move beyond a focus on knowledge
acquisition, and move toward addressing influential factors that are not
typically included in SBSE curricula. As noted in the findings, one participant
clearly contrasted knowledge and action. As illustrated in Figure 2, her
account demonstrates that drivers for sexual decision-making can outweigh
Figure 2. The imbalance of driving and inhibiting forces on adolescent
sexual risk-taking.
98 T.C. King Jones
the inhibiting benefit of SBSE. Identifying differences in the influence of
behavioral, personal, and environmental factors (Figure 1) on sexual
decision-making and revealing potential inhibiting forces could facilitate
the development of tailored behavioral interventions. Further, parents,
educators, healthcare professionals, and policymakers must realize that
continuing to regard sexual content as “off limits” for adolescents, can
only perpetuate adolescent sexual risk-taking.
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