CSIRO PUBLISHING
Sexual Health, 2014, 11, 561–567 http://dx.doi.org/10.1071/SH14020
Body mass index, self-esteem and weight contentment from adolescence to young adulthood and women’s risk for sexually transmitted disease Michael J. Merten A,C and Amanda L. Williams B A
Department of Human Development and Family Science, Oklahoma State University, 1111 Main Hall, 700 N. Greenwood Avenue, Tulsa, OK 74106, USA. B Department of Child and Family Studies, University of Southern Mississippi, 118 College Drive #5035, Hattiesburg, MS 39406, USA. C Corresponding author. Email: [email protected]
Abstract. Background: Women’s risk for sexually transmitted diseases (STDs) were examined in terms of adolescent and young adult weight status, self-esteem trajectories and weight contentment using two waves of a nationally representative dataset. Methods: Using Waves 1 and 3 of the National Longitudinal Study of Adolescent Health, body mass index (BMI), self-esteem and weight contentment were examined during adolescence and young adulthood to assess the likelihood of STDs among 4000 young adult single women. Results: Change in BMI, specifically weight loss between adolescence and young adulthood, significantly increased women’s risk for STDs. Continuously low self-esteem during adolescence and young adulthood significantly increased women’s risk for STDs. When women’s contentment with their weight decreased from adolescence to young adulthood, women’s risk for STDs was greater. Regardless of other variables, Black women were more likely to have an STD. Conclusions: Results suggest that women’s selfperception is important in reducing sexual risk; specifically, patterns of self-esteem, BMI and weight contentment across developmental periods should be a critical focus of research and practice related to adolescent and young adult sexual health. There are many known benefits to fostering self-esteem during adolescence and findings from this study add STD prevention among young women to this list. Results emphasise the needed prevention during adolescence to address selfperspective and self-esteem for the long-term sexual well-being of young women. Additional keywords: obesity, weight perception. Received 19 January 2014, accepted 12 September 2014, published online 1 December 2014
Introduction High-risk sexual encounters are an important public health issue as they are associated with a variety of adverse physical, emotional and psychosocial outcomes.1,2 These outcomes are particularly relevant for young adult single women as the majority are sexually active, have multiple sex partners (more so than their married or cohabitating peers) and often use ineffective or inconsistent methods of avoiding unintended pregnancy and sexually transmitted diseases (STD).1 These findings are pronounced for African Americans as well as young women who are overweight or obese.3–5 Although young adults comprise ~25% of the population, they account for half of all reported STDs.2,6,7 This prevalence of STDs among young adults, combined with the high STD risk of single women, suggests a need for further research with this age group; however, researchers note a general societal taboo regarding research on sexual issues, especially those concerning women and obese individuals.8,9 Journal compilation CSIRO 2014
Women’s sexual risk is important to study from the context of bodyweight as obese women’s sexual behaviours might present a greater health risk than behaviours of non-obese women. Several studies have associated body mass index (BMI) with high-risk sexual encounters; however, those studies were isolated to a single developmental period (adolescence or young adulthood5,10–12) and were assessed using cross-sectional data.3 Bajos et al.3 linked obesity in females under the age of 30 years with ineffective contraceptive methods, unsafe sexual practises and unintended/unwanted pregnancies3,13 compared with overweight and normal weight women. Obese women in this same study were also most likely to meet a sexual partner online and were more likely to view pornography. The findings by Bajos et al. suggest that women experiencing obesity may be engaging in riskier sexual encounters than non-obese women with potentially deleterious sexual health outcomes.3 The longitudinal implications of women’s weight for decisions to engage in high-risk sexual activity are virtually unexplored in www.publish.csiro.au/journals/sh
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empirical research. It is unknown whether weight change (i.e. BMI continuity and change) is related to these behaviours, particularly when simultaneously considering women’s perceptions of themselves including self-esteem and contentment with body size. It is of interest in the present study to determine whether an association exists between adolescent and young adult BMI and young adult risky sexual behaviours, specifically women’s reports of STDs, as such reports suggest a variety of risky sexual scenarios including infrequent condom use and multiple sexual partners.14 When evaluating associations between weight status and psychosocial or behavioural outcomes, the role of selfperception must be considered. Individuals’ perceptions of their body, regardless of actual weight status, have been found to be biased15 and can influence self-esteem, psychological well-being, high-risk behaviours and status attainment.16–18 Women of recommended weight often perceive themselves as overweight and this perception may be influenced by personal characteristics including race/ ethnicity.15 Previous research suggests heavier weight is only linked with sexual risk among White women.13 Obesity and overweight, as well as how women feel about their weight, have implications for internalising disorders,19,20 which have also been linked with increased sexual risk-taking.21 Goodson et al.22 questioned the value of self-esteem as a predictor of adolescent sexual behaviour; however, in their extensive review of 189 studies examining the link between self-esteem and sexual behaviours, only eight were longitudinal in nature, they used relatively small samples sizes, results were rarely generalisable, and they did not follow adolescents into adulthood. By using a large national dataset, the present study extends this line of research beyond individual psychosocial well-being at a single developmental period to explore the relationship between global self-esteem changes over time and emerging adult sexual behaviours. Other studies have emphasised the continuity or change in mental health well-being over time and the effects of that trajectory on health or health behaviours (e.g. depression23). In the present study, and in tandem with weight continuity and change, self-esteem trajectories and patterns of weight contentment from adolescence to young adulthood will be explored for any relationship with women’s reports of sexually transmitted disease. Life course theory provides a framework for studying links between human development during key developmental periods and risks experienced across the lifespan.24 The present study approach is consistent with the life course principle of timing or sequence of life transitions/events.24 Our focus is on when BMI and self-perception is high versus low and how the timing/ sequence of these experiences relate to STD. The goal is to identify potential ‘developmental turning points’24 or sensitive developmental periods during adolescence or young adulthood when actual and perceived weight might have the most influence on risky sexual behaviours. In summary, the focus of this study is on the association between adolescent and young adult weight status (BMI), changes in self-esteem and weight contentment, and young adult STDs. It is important to study correlates and predictors of young adult sexual risk to improve timely education,
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prevention and intervention efforts aimed at reducing prevalence of sex-related health conditions, as well as eliminating the taboo surrounding discussions of sexual health. Previous evidence independently linking study variables to high-risk sexual behaviours lack the developmental context the longitudinal data in the present study can provide. The following main hypotheses are proposed: (1) Women with a higher BMI during adolescence and young adulthood will be more likely to report young adult STDs than women with a lower BMI during either period. (2) Women with consistently high, increasing or decreasing self-esteem from adolescence to young adulthood will be less likely to report young adult STDs than women reporting low self-esteem during both reporting periods. (3) Women content with their weight during adolescence and/or young adulthood will be less likely to report young adult STDs than women who were never content with their weight during either reporting period. Because the present study is focussed on women, self-esteem trajectories will not be confounded by gender as they have been in previous studies.25 Analyses in the present study are limited to single, never-married women as they represent a higher risk cohort for contracting STDs. Any observed associations between weight, self-esteem and STDs are expected to vary by race/ethnicity as BMI and assessments of ‘appropriate’ weight status differ between Black and White women.13,26 Methods Survey design Data for this study came from a nationally representative sample of adolescents participating in the National Longitudinal Study of Adolescent Health.27 The present study uses data from Wave 1 (1995) and Wave 3 (2001) at which times adolescents and their parents were interviewed at home regarding a variety of health and lifestyle topics. The Adolescent Health Survey comprises data collected from a representative sample of high school students using a complex cluster-sampling frame. Through stratified sampling, 134 middle and high schools were selected resulting in a total sample size of 20 745 youths. The sample was diversified by region, urbanicity, school type (public vs private), racial composition and size of the school. Sample weights ensured representativeness of the sample. Institutional review board approval was obtained for data analysis and dissemination of findings. During Wave 1, adolescent participants ranged in age from 12 to 19 years; during Wave 3, the same respondents were aged 18–26 years. In addition to questions that remained unchanged, the Wave 3 questionnaire was designed to examine issues relevant to young adulthood. A total of 9496 male and female participants provided complete data on measures of interest in our study in Wave 1 and Wave 3. Of that number, 4907 were Black, Hispanic or White females. We then limited the sample to never married females, thus giving us a total sample size of 4000 females; Black (n = 1117), Hispanic (619) and White (n = 2264). The mean age of the participants in this study during adolescence and young adulthood was 14.69 years and 21.68 years, respectively.
BMI, self-esteem and STDs
Study variables BMI status Participant height and weight was measured at Wave 1 (adolescence) and Wave 3 (young adulthood) to compute individual body mass index (i.e. weight in kilograms divided by height in meters squared (kg/m2)). BMI status depends on age and gender with reference percentile curves published by the Centers for Disease Control and Prevention,28 which indicated that adolescents with a BMI in the 95th percentile and adults with a BMI of 30 or greater are considered obese. Self-esteem Four items measuring self-esteem similar to Rosenberg’s self-esteem scale29 were asked of participants during both Waves 1 and 3. Participants reported their level of agreement (0 = strongly disagree to 5 = strongly agree) to the following questions: ‘You have a lot of good qualities; You like yourself just the way you are; You have a lot to be proud of; and You feel like you are doing everything just about right’ (For similar use of these items, see 30). Various versions of the Rosenberg scale have been tested for reliability and validity in many languages and have been found to be effective.31,32 The Cronbach’s a for this measure in Wave 1 and Wave 3 was 0.80 and 0.78, respectively. Weight contentment Contentment with weight was assessed during both Waves 1 and 3 via a single item, ‘How do you think of yourself in terms of weight?’ Possible responses to this question were 1 = very underweight; 2 = underweight; 3 = about the right weight; 4 = overweight; 5 = very overweight. This item was recoded as 1 = about the right weight (content) or 0 = otherwise (discontent). The following four categories captured reported weight contentment over time: (1) discontent in both adolescence and young adulthood; (2) content in adolescence only; (3) content in young adulthood only; and (4) content in both adolescence and young adulthood. Young adult sexually transmitted disease The following item measured the presence of STDs in young adulthood: ‘In the past 12 months, have you been told by a doctor or nurse that you had the following sexually transmitted diseases?’ The possible sexually transmitted diseases were: chlamydia, gonorrhea, trichomoniasis, syphilis, genital herpes, genital warts, human papilloma virus, bacterial vaginosis, pelvic inflammatory disease, cervicitis, urethritis, vaginitis, HIV/AIDS, or other. Women’s responses were 0 (no) or 1 (yes). Race/ethnicity Dichotomous variables were created to assess Black, Hispanic, and White racial/ethnic statuses. The dichotomous variables for each of the minority statuses were included as independent variables in the logistic regression analyses and those regression coefficients are interpreted in comparison to the reference group, which is Whites.
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Statistical analysis We created four BMI trajectory groups: (1) consistently high (adolescent BMI is above 22.94, which was the mean BMI of study participants in adolescence and change in BMI from adolescence to young adulthood is one-half standard deviation of the change score); (2) consistently low (adolescent BMI is below 22.94 and the BMI change from adolescence to young adulthood is one-half a standard deviation of the change score); (3) increasing (increase in BMI from adolescence to young adulthood of more than half a standard deviation of the change score); and (4) decreasing (decrease in BMI of more than half a standard deviation of the change score). For example, an individual with a BMI of 23 in adolescence and a BMI of 27 in young adulthood would be in the ‘increasing’ trajectory group because their BMI increased by more than half a standard deviation (2.25 units) from adolescence to young adulthood. Based on participants’ responses to self-esteem items during adolescence and young adulthood, we created four self-esteem trajectory groups: (1) consistently high (initial self-esteem score is above 16, which was the mean self-esteem score in adolescence and change in self-esteem from adolescence to young adulthood is one-half standard deviation of the change score); (2) consistently low (initial self-esteem score is below 16 and the self-esteem change from adolescence to young adulthood is one-half a standard deviation of the change score); (3) increasing (increase in self-esteem of more than half a standard deviation of the change score); and (4) decreasing (decrease in self-esteem of more than half a standard deviation of the change score). A similar strategy was used to create depressive symptom trajectory groups in a previous study, which examined the relationship between depressive symptom trajectory groups and physical health problems.23 All analyses were conducted using SAS version 9.3 software (SAS Institute, Cary, NC, USA). Binary logistic regression was used to investigate the relationship between weight status, selfperception and presence of an STD among young adult women. First, dummy-coded weight status variables were entered into Model 1 to determine the relationship between weight status and STDs. Next, self-esteem trajectories and weight contentment were added in Model 2 to determine whether these variables are significantly related to young adult STDs. In addition, it allowed us to determine whether weight status was related to STDs even after controlling for self-esteem and weight contentment. Odds ratios (OR) and 95% confidence intervals (CI) were calculated. Results Fifteen per cent of the sample reported having an STD in the previous 12 months. In terms of weight, BMI increased from adolescence to young adulthood for 60% of the sample while only 3% reported a decreased BMI over the same period; 24% of the sample had a consistently low BMI and 11.5% had a consistently high BMI. These trends varied somewhat by race/ ethnicity (Table 1). The consistently high BMI group had mean BMI values in adolescence and young adulthood of 24.79 and 23.46 respectively. The consistently low BMI group had mean values of 20.33 in adolescence and 22.77 in young adulthood.
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Among the increasing BMI group, 25.20 and 31.96 were the respective values in adolescence and young adulthood. The decreasing group reported a mean BMI value of 19.62 in adolescence and 19.69 in young adulthood. The consistently high self-esteem group had mean selfesteem values in adolescence and young adulthood of 18.45 and 18.21, respectively. The consistently low self-esteem group had mean self-esteem values of 14.94 in adolescence and 15.49 in young adulthood. The increasing self-esteem group reported mean self-esteem values of 13.68 and 18.00 in adolescence and young adulthood respectively. Participants in the decreasing self-esteem trajectory reported a mean self-esteem of 18.44 in adolescence and 14.33 in young adulthood. Weight contentment was consistently low among 37% of the sample. Table 1 shows the percentages across the BMI, self-esteem and weight contentment groups. Table 2 presents participants’ reports of having an STD, as well as continuity or change in self-esteem and weightperception by BMI category. A greater proportion of women who reported a lower BMI in young adulthood than adolescence (i.e. decreasing BMI trend) reported having an STD compared with women who reported an increased or stable BMI. The majority of women in each BMI category reported consistently low self-esteem from adolescence to young adulthood, with the exception of the decreased BMI group, which had a similar proportion of women reporting consistently low and increasing self-esteem. Weight contentment followed a similar pattern, with the majority of women reporting low weight contentment during adolescence and young adulthood, except for the decreased BMI group who had a similar number of women reporting consistently low and increasing weight contentment. In Model 1, women reporting any change in BMI from adolescence to young adulthood (i.e. BMI increase or Table 1.
Women’s reports of an STD, BMI, self-esteem and weight contentment by race Note: Data are from Wave 1 and Wave 3 of the National Longitudinal Study of Adolescent Health. STD, sexually transmitted disease; BMI, body mass index. Results are presented as percentages Variable
Race/ethnicity Total Hispanic (n = 4000) (n = 619)
Table 2. Percentage of women’s reports of STD, self-esteem and weight perception by BMI group STD, sexually transmitted disease; BMI, body mass index. Results are presented as percentages Decreased (n = 116)
Black (n = 1117)
White (n = 2264)
15.04
12.28
21.93
10.91
BMI Low High Increased Decreased
24.07 11.51 61.34 3.07
23.26 14.70 59.45 2.58
20.41 10.65 64.55 4.39
28.53 9.19 60.03 2.25
32.33 29.21 26.39 12.07
36.03 23.91 28.92 11.15
25.25 37.24 24.35 13.16
35.72 26.48 25.91 11.89
Weight contentment Low 37.73 High 29.77 Increased 13.79 Decreased 18.70
42.30 25.77 12.80 19.12
35.64 29.44 14.99 19.93
35.26 34.11 13.57 17.06
BMI group Increased (n = 2448)
High (n = 418)
Low (n = 1018)
STD
17.24
14.05
15.31
13.75
Self-esteem group Low High Increased Decreased
31.90 25.00 31.90 11.21
33.51 30.49 23.66 12.34
33.25 26.32 30.62 9.81
31.17 27.34 28.81 12.68
Weight contentment Low 40.52 High 13.79 Increased 38.79 Decreased 6.90
44.11 23.61 8.80 23.49
53.85 14.66 23.08 8.41
10.51 59.43 19.35 10.71
Table 3. Unstandardised regression coefficients for the associations between women’s reports of STD and BMI, self-esteem, weight contentment groups and race/ethnicity Note: The two models were adjusted for number of lifetime sexual partners and adolescent and young adulthood socioeconomic status. STD, sexually transmitted disease; BMI, body mass index; B, unstandardised regression coefficient; OR, Odds ratio; CI, confidence interval B
STD
Self-esteem group Low High Increased Decreased
decrease of more than half a standard deviation of the change score) were at increased risk for STDs [increasing BMI OR = 1.29 (95% CI: 1.09–1.54); decreasing BMI OR = 1.48 (95% CI: 1.15–1.90)] compared with women with consistently low BMIs (Table 3). However, when self-esteem and weight contentment were entered into Model 2, only decreasing BMI increased women’s risk for STDs [OR = 1.48 (95% CI: 1.15–1.90)]. Having a significantly low self-esteem uniquely predicted greater STD risk [OR = 1.23 (95% CI: 1.02–1.49)] as did decreasing weight contentment from
BMI groupA High Increased Decreased
0.26 0.26 0.39
Model 1 OR 95% CI 1.30 1.29 1.48
0.95–1.79 1.09–1.54** 1.15–1.90**
B
Model 2 OR 95% CI
0.15 0.08 0.39
1.16 1.08 1.48
0.84–1.61 0.88–1.33 1.15–1.90**
Self-esteem groupB Low Increased Decreased
0.21 0.16 0.06
1.23 1.17 1.06
1.02–1.49* 0.96–1.45 0.82–1.39
Weight contentmentC Low Increased Decreased
0.13 0.22 0.27
1.14 1.25 1.31
0.90–1.43 0.98–1.59 1.03–1.66*
Black Hispanic
0.59 0.11
1.80 1.12
1.52–2.13*** 0.89–1.42
*P < 0.05, **P < 0.01, ***P < 0.001. A Reference group is made up of those with a low BMI. B Reference group is made up of those with a high self-esteem. C Reference group is made up of those with a high weight contentment.
BMI, self-esteem and STDs
adolescence to young adulthood [OR = 1.31 (95% CI: 1.03–1.66)] compared with women with consistently high self-esteem and weight contentment. Black participants were more likely than White participants to report having an STD [OR = 1.80 (95% CI: 1.52–2.13)]. All possible two- and three-way interactions among study variables were examined; however, all of these were not statistically significant. Discussion By using a nationally representative sample, this study examined the longitudinal associations between adolescent and young adult BMI, self-esteem and weight contentment in terms of women’s STDs. After accounting for self-perception and race/ethnicity, decreasing BMI trends were significantly related to women’s reports of STDs. It was hypothesised that having a consistently high BMI in adolescence and young adulthood would increase STD risk; however, results indicate that any change in BMI (particularly a decrease) increases risk. Having persistently low self-esteem during adolescence and young adulthood also increased young women’s STD incidence, independent of BMI. Previous studies suggest positive self-perception has an empowering effect, increasing women’s confidence in their ability to insist on safe sex practises such as condom use.33 The present study suggests this empowerment might play a formative role during adolescence when sexual identity, esteem and habits begin developing, which then endures into adulthood.34 Taken together, and consistent with the life course approach used in this study, these findings portray adolescence as a key developmental period in the life course24 for the development of positive body image and healthy weight. A recent study by DeMaria et al.35 found no link between BMI and STDs; however, results from the present work emphasise the importance of developmental timing and sequence24 of obesity and that continuity and change in obesity, low selfesteem and weight contentment is more important than current weight status in understanding the link between physical size, self-perception and sexual health. Continuously low selfesteem emerged as a key risk factor for STDs, regardless of women’s current or previous weight status. Previous research indicates that sexual function improves following weight loss;36 however, when obesity is experienced during adolescence, the damage to self-esteem may persist even when individuals are no longer obese, which can have an impact on sexual decision-making and safer sex behaviours. Poor self-esteem is closely linked with sexual risk;37 it tends to decline during adolescence and does not always rebound with age.25 Independent of self-esteem or whether women gained or lost weight between adolescence and young adulthood, decreased contentment with their weight increased women’s risk for STDs. Happiness or satisfaction with one’s body is reflective of body image, and decreasing contentment with body shape or size might also be associated with diminished sexual selfesteem.38 Although the construct of sexual self-esteem is beyond the scope of the present study, it seems intuitive that when women transition from contentment to discontentment, it
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would have implications for their overall self-perception and confidence. Revisiting the study by Auslander et al.,33 women who feel better about themselves report a greater likelihood of insisting a sexual partner use condoms, which reduces the risk of STDs. Women who feel discontent with their bodies during young adulthood may lack confidence in such ability. Women reporting both satisfaction and dissatisfaction with their body images have been linked with high-risk sexual activity;39 however, the present study suggests it is the change from contentment to discontentment across developmental periods that has important implications for STDs and associated behaviours. Bodyweight dissatisfaction can be a motivating factor towards healthier lifestyle choices and weight loss, particularly for women.40 However, the present study findings also associate dissatisfaction with sexual risk. Nutrition and weight-loss efforts that capitalise on body dissatisfaction to motivate women towards change should also consider risk behaviours linked with women’s previous and current weight discontentment. Race emerged as a significant risk factor for STDs independent of weight status, self-esteem or weight contentment, as Black women were consistently more likely to report having an STD than were White women. Other studies have also found that Black young adults, specifically women, are at greater risk for contracting HIV and other sexually transmitted diseases;41 present study results re-emphasise a need for prevention efforts targeted to this demographic of women. Study limitations The outcome variable in this study was based on self-report, in that participants reported whether they had ever been diagnosed with a specific STD in the past 12 months. Therefore, all respondents who answered ‘yes’ had been tested for and diagnosed with the condition by a medical professional during the Wave 3 assessment period. Thus, outcomes are based on the diagnosis and not actual presence of a disease or health condition. This means that participants who responded ‘no’ to the outcome variable may actually have an undiagnosed occurrence of the condition. Biospecimen STD data was collected from participants during Wave 3; however, only tests for chlamydia, gonorrhea and trichomoniasis were administered, thus limiting the scope and utility of such a measure. Conclusions and implications The purpose of this study was to examine the association between BMI continuity and change and young adult STDs. Decreasing BMI was linked with greater sexual risk; however, it was not just women’s weight status, but also selfperception, that increased their risk for STDs. While a negative change in weight contentment from adolescence to young adulthood was related to incidence of STD, low self-esteem posed enduring harm by increasing women’s risk for STDs. Although Goodson et al. found little support for a link between self-esteem and sexual risk behaviours in their meta-analysis of mostly cross-sectional studies,22 the present study highlights the importance of a life-course24 perspective to understand the longitudinal importance of how a woman perceives herself and
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her body during the transition from adolescence to young adulthood, with a large, nationally representative sample of women. Adolescence is a critical time in the life course for development of several protective assets42 and there are many known benefits to fostering adolescent self-esteem. Findings from this study add long-term STD prevention to this list. Therefore, self-esteem should be a core concept in sex education efforts (independent from, as well as integrated with, discussions of actual sex behaviours) as high selfesteem may moderate how adolescents and young adults perceive and implement information gained in such programs in their sexual practises. Additional research is needed to determine whether a preventative focus on general and sexual self-esteem during adolescence provides current and long-term protection from STDs (i.e. adolescence as developmental life course turning point; 24) or if self-esteem should be a sustained focus across the life course, particularly among individuals who are/have been obese and who grow less discontent with their bodies over time. While body dissatisfaction can motivate women to engage in healthier lifestyle behaviours, there is a fine line between dissatisfaction and shame, with the latter actually harming women’s overall health.43 It is critical that prevention programs aimed at youth and young adults appropriately balance physical health promotion with promotion of positive self-perception. The use of STDs as a sexual risk outcome likely underrepresents the prevalence of participants’ engagement in risky sexual behaviours; broadening the scope of the dependent variable in future studies would likely strengthen observed relationships. The longitudinal nature of this study highlights the developmental significance of adolescent self-esteem for young adult health behaviours as well as the importance of assessing multiple constructs as they develop over time. Based on a life course framework24 and building on the results from the present study, future efforts to understand and promote positive sexual experiences and sexual health should not limit the focus to adults’ current weight status and self-perception, but also address individuals’ developmental history in terms of obesity, self-esteem and weight contentment. Acknowledgements This research uses data from Add Health, a program project directed by Kathleen Mullan Harris and designed by J. Richard Udry, Peter S. Bearman, and Kathleen Mullan Harris at the University of North Carolina at Chapel Hill, and funded by grant P01-HD31921 from the Eunice Kennedy Shriver National Institute of Child Health and Human Development, with cooperative funding from 23 other federal agencies and foundations. Special acknowledgement is due to Ronald R. Rindfuss and Barbara Entwisle for assistance in the original design. Information on how to obtain the Add Health data files is available on the Add Health website (http://www.cpc.unc.edu/addhealth). No direct support was received from grant P01-HD31921 for this analysis.
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adolescent females: inter-relationships and temporal effects. J Adolesc Health 2006; 38: 268–74. doi:10.1016/j.jadohealth.2004. 12.010 Goodson P, Buhi E, Dunsmore S. Self-esteem and adolescent sexual behaviors, attitudes, and intentions: a systematic review. J Adolesc Health 2006; 38: 310–9. doi:10.1016/j.jadohealth.2005.05.026 Wickrama KAS, Wickrama T, Lott R. Heterogeneity in youth depressive symptom trajectories: social stratification and implications for young adult physical health. J Adolesc Health 2009; 45: 335–43. doi:10.1016/j.jadohealth.2009.04.018 Elder G. The life course as developmental theory. Child Dev 1998; 69: 1–12. doi:10.1111/j.1467-8624.1998.tb06128.x Robins RW, Trzesniewski KH, Tracy JL, Gosling S, Potter J. Global self-esteem across the lifespan. Psychol Aging 2002; 17: 423–34. doi:10.1037/0882-7974.17.3.423 Paeratakul S, White MA, Williamson DA, Ryan DH, Bray GA. Sex, race/ethnicity, socioeconomic status, and BMI in relation to selfperception of overweight. Obes Res 2002; 10: 345–50. doi:10.1038/ oby.2002.48 Harris KM, Halpern CT, Whitsel E, Hussey J, Tabor J, Entzel P, Udry JR. The national longitudinal study of adolescent health: Research design. 2009. Available online at: http://www.cpc.unc.edu/projects/ addhealth/design [verified 30 November 2014]. Centers for Disease Control and Prevention. CDC growth charts: United States, 2000. Atlanta, GA, 2000. Available online at: http:// www.cdc.gov/growthcharts [verified 9 February 2010]. Rosenberg M. Society and the adolescent self-image. Princeton, NJ: Princeton University Press; 1965. Russell ST, Crockett LJ, Shen Y, Lee S. Cross-ethnic invariance of self-esteem and depression measures for Chinese, Filipino, and European American Adolescents. J Youth Adolesc 2008; 37: 50–61. doi:10.1007/s10964-007-9231-1 Beeber LB, Seeherunwong A, Schwartz T, Funk SG, Vongsirimas N. Validity of the Rosenberg self-esteem scale in young women from Thailand and the USA. Thai J Nurs Res 2007; 11: 240–50. Pullmann H, Allik J. The Rosenberg self-esteem scale: its dimensionality, stability and personality correlates in Estonian. Pers Individ Dif 2000; 28: 701–15. doi:10.1016/S0191-8869(99) 00132-4
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33 Auslander B, Baker J, Short M. Perceptions of appearance, weight satisfaction, and attractiveness: their relationship to perceptions of sexual assertiveness in young women. J Adolesc Health 2010; 46: S40. doi:10.1016/j.jadohealth.2009.11.094 34 Graber JA, Brooks-Gunn J, Galen BR. Betwixt and between: sexuality in the context of adolescent transitions. In Jessor R, editor. New perspectives on adolescent risk behavior. Cambridge: Cambridge University Press; 1998. pp. 270–316. 35 DeMaria AL, Lugo JM, Rahman M, Pyles RB, Berenson AB. Association between body mass index, sexually transmitted infections, and contraceptive compliance. J Women’s Health 2013; 22: 1062–8. doi:10.1089/jwh.2012.4116 36 Werlinger K, King T, Clark M, Pera V, Wincze J. Perceived changes in sexual functioning and body image following weight loss in an obese female population: a pilot study. Sex Marital Ther 1997; 23: 74–8. doi:10.1080/00926239708404419 37 Ethier K, Kershaw T, Lewis J, Milan S, Niccolai L, Ickovics J. Selfesteem, emotional distress and sexual behavior among adolescent females: inter-relationships and temporal effects. J Adolesc Health 2006; 38: 268–74. doi:10.1016/j.jadohealth.2004.12.010 38 Wang F, Wild TC, Kipp W, Kuhle S, Veugelers PJ. The influence of childhood obesity on the development of self-esteem. Health Rep 2009; 20: 21–7. 39 Gillen MM, Lefkowitz ES, Shearer CL. Does body image play a role in risky sexual behavior and attitudes? J Youth Adolesc 2006; 35: 230–42. doi:10.1007/s10964-005-9005-6 40 Millstein RA, Carlson SA, Fulton JE, Galuska DA, Zhang J, Blanck HM, Ainsworth BE. Relationships between body size satisfaction and weight control practices among U.S. adults. Medscape J Med 2008; 10: 119. 41 Fergus S, Zimmerman MA, Caldwell CH. Growth trajectories of sexual risk behavior in adolescence and young adulthood. Am J Public Health 2007; 97: 1096–101. doi:10.2105/AJPH.2005.074609 42 Viner R, Ozer E, Denny S, Marmot M, Resnick M, Fatusi A, Currie C. Adolescence and the social determinants of health. Lancet 2012; 379: 1641–52. doi:10.1016/S0140-6736(12)60149-4 43 Sinclair S, Myers J. The relationship between objectified body consciousness and wellness in a group of college women. J Coll Couns 2004; 7: 150–61. doi:10.1002/j.2161-1882.2004.tb00246.x
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Sexual Health, 2014, 11, 561–567 http://dx.doi.org/10.1071/SH14020
Body mass index, self-esteem and weight contentment from adolescence to young adulthood and women’s risk for sexually transmitted disease Michael J. Merten A,C and Amanda L. Williams B A
Department of Human Development and Family Science, Oklahoma State University, 1111 Main Hall, 700 N. Greenwood Avenue, Tulsa, OK 74106, USA. B Department of Child and Family Studies, University of Southern Mississippi, 118 College Drive #5035, Hattiesburg, MS 39406, USA. C Corresponding author. Email: [email protected]
Abstract. Background: Women’s risk for sexually transmitted diseases (STDs) were examined in terms of adolescent and young adult weight status, self-esteem trajectories and weight contentment using two waves of a nationally representative dataset. Methods: Using Waves 1 and 3 of the National Longitudinal Study of Adolescent Health, body mass index (BMI), self-esteem and weight contentment were examined during adolescence and young adulthood to assess the likelihood of STDs among 4000 young adult single women. Results: Change in BMI, specifically weight loss between adolescence and young adulthood, significantly increased women’s risk for STDs. Continuously low self-esteem during adolescence and young adulthood significantly increased women’s risk for STDs. When women’s contentment with their weight decreased from adolescence to young adulthood, women’s risk for STDs was greater. Regardless of other variables, Black women were more likely to have an STD. Conclusions: Results suggest that women’s selfperception is important in reducing sexual risk; specifically, patterns of self-esteem, BMI and weight contentment across developmental periods should be a critical focus of research and practice related to adolescent and young adult sexual health. There are many known benefits to fostering self-esteem during adolescence and findings from this study add STD prevention among young women to this list. Results emphasise the needed prevention during adolescence to address selfperspective and self-esteem for the long-term sexual well-being of young women. Additional keywords: obesity, weight perception. Received 19 January 2014, accepted 12 September 2014, published online 1 December 2014
Introduction High-risk sexual encounters are an important public health issue as they are associated with a variety of adverse physical, emotional and psychosocial outcomes.1,2 These outcomes are particularly relevant for young adult single women as the majority are sexually active, have multiple sex partners (more so than their married or cohabitating peers) and often use ineffective or inconsistent methods of avoiding unintended pregnancy and sexually transmitted diseases (STD).1 These findings are pronounced for African Americans as well as young women who are overweight or obese.3–5 Although young adults comprise ~25% of the population, they account for half of all reported STDs.2,6,7 This prevalence of STDs among young adults, combined with the high STD risk of single women, suggests a need for further research with this age group; however, researchers note a general societal taboo regarding research on sexual issues, especially those concerning women and obese individuals.8,9 Journal compilation CSIRO 2014
Women’s sexual risk is important to study from the context of bodyweight as obese women’s sexual behaviours might present a greater health risk than behaviours of non-obese women. Several studies have associated body mass index (BMI) with high-risk sexual encounters; however, those studies were isolated to a single developmental period (adolescence or young adulthood5,10–12) and were assessed using cross-sectional data.3 Bajos et al.3 linked obesity in females under the age of 30 years with ineffective contraceptive methods, unsafe sexual practises and unintended/unwanted pregnancies3,13 compared with overweight and normal weight women. Obese women in this same study were also most likely to meet a sexual partner online and were more likely to view pornography. The findings by Bajos et al. suggest that women experiencing obesity may be engaging in riskier sexual encounters than non-obese women with potentially deleterious sexual health outcomes.3 The longitudinal implications of women’s weight for decisions to engage in high-risk sexual activity are virtually unexplored in www.publish.csiro.au/journals/sh
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empirical research. It is unknown whether weight change (i.e. BMI continuity and change) is related to these behaviours, particularly when simultaneously considering women’s perceptions of themselves including self-esteem and contentment with body size. It is of interest in the present study to determine whether an association exists between adolescent and young adult BMI and young adult risky sexual behaviours, specifically women’s reports of STDs, as such reports suggest a variety of risky sexual scenarios including infrequent condom use and multiple sexual partners.14 When evaluating associations between weight status and psychosocial or behavioural outcomes, the role of selfperception must be considered. Individuals’ perceptions of their body, regardless of actual weight status, have been found to be biased15 and can influence self-esteem, psychological well-being, high-risk behaviours and status attainment.16–18 Women of recommended weight often perceive themselves as overweight and this perception may be influenced by personal characteristics including race/ ethnicity.15 Previous research suggests heavier weight is only linked with sexual risk among White women.13 Obesity and overweight, as well as how women feel about their weight, have implications for internalising disorders,19,20 which have also been linked with increased sexual risk-taking.21 Goodson et al.22 questioned the value of self-esteem as a predictor of adolescent sexual behaviour; however, in their extensive review of 189 studies examining the link between self-esteem and sexual behaviours, only eight were longitudinal in nature, they used relatively small samples sizes, results were rarely generalisable, and they did not follow adolescents into adulthood. By using a large national dataset, the present study extends this line of research beyond individual psychosocial well-being at a single developmental period to explore the relationship between global self-esteem changes over time and emerging adult sexual behaviours. Other studies have emphasised the continuity or change in mental health well-being over time and the effects of that trajectory on health or health behaviours (e.g. depression23). In the present study, and in tandem with weight continuity and change, self-esteem trajectories and patterns of weight contentment from adolescence to young adulthood will be explored for any relationship with women’s reports of sexually transmitted disease. Life course theory provides a framework for studying links between human development during key developmental periods and risks experienced across the lifespan.24 The present study approach is consistent with the life course principle of timing or sequence of life transitions/events.24 Our focus is on when BMI and self-perception is high versus low and how the timing/ sequence of these experiences relate to STD. The goal is to identify potential ‘developmental turning points’24 or sensitive developmental periods during adolescence or young adulthood when actual and perceived weight might have the most influence on risky sexual behaviours. In summary, the focus of this study is on the association between adolescent and young adult weight status (BMI), changes in self-esteem and weight contentment, and young adult STDs. It is important to study correlates and predictors of young adult sexual risk to improve timely education,
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prevention and intervention efforts aimed at reducing prevalence of sex-related health conditions, as well as eliminating the taboo surrounding discussions of sexual health. Previous evidence independently linking study variables to high-risk sexual behaviours lack the developmental context the longitudinal data in the present study can provide. The following main hypotheses are proposed: (1) Women with a higher BMI during adolescence and young adulthood will be more likely to report young adult STDs than women with a lower BMI during either period. (2) Women with consistently high, increasing or decreasing self-esteem from adolescence to young adulthood will be less likely to report young adult STDs than women reporting low self-esteem during both reporting periods. (3) Women content with their weight during adolescence and/or young adulthood will be less likely to report young adult STDs than women who were never content with their weight during either reporting period. Because the present study is focussed on women, self-esteem trajectories will not be confounded by gender as they have been in previous studies.25 Analyses in the present study are limited to single, never-married women as they represent a higher risk cohort for contracting STDs. Any observed associations between weight, self-esteem and STDs are expected to vary by race/ethnicity as BMI and assessments of ‘appropriate’ weight status differ between Black and White women.13,26 Methods Survey design Data for this study came from a nationally representative sample of adolescents participating in the National Longitudinal Study of Adolescent Health.27 The present study uses data from Wave 1 (1995) and Wave 3 (2001) at which times adolescents and their parents were interviewed at home regarding a variety of health and lifestyle topics. The Adolescent Health Survey comprises data collected from a representative sample of high school students using a complex cluster-sampling frame. Through stratified sampling, 134 middle and high schools were selected resulting in a total sample size of 20 745 youths. The sample was diversified by region, urbanicity, school type (public vs private), racial composition and size of the school. Sample weights ensured representativeness of the sample. Institutional review board approval was obtained for data analysis and dissemination of findings. During Wave 1, adolescent participants ranged in age from 12 to 19 years; during Wave 3, the same respondents were aged 18–26 years. In addition to questions that remained unchanged, the Wave 3 questionnaire was designed to examine issues relevant to young adulthood. A total of 9496 male and female participants provided complete data on measures of interest in our study in Wave 1 and Wave 3. Of that number, 4907 were Black, Hispanic or White females. We then limited the sample to never married females, thus giving us a total sample size of 4000 females; Black (n = 1117), Hispanic (619) and White (n = 2264). The mean age of the participants in this study during adolescence and young adulthood was 14.69 years and 21.68 years, respectively.
BMI, self-esteem and STDs
Study variables BMI status Participant height and weight was measured at Wave 1 (adolescence) and Wave 3 (young adulthood) to compute individual body mass index (i.e. weight in kilograms divided by height in meters squared (kg/m2)). BMI status depends on age and gender with reference percentile curves published by the Centers for Disease Control and Prevention,28 which indicated that adolescents with a BMI in the 95th percentile and adults with a BMI of 30 or greater are considered obese. Self-esteem Four items measuring self-esteem similar to Rosenberg’s self-esteem scale29 were asked of participants during both Waves 1 and 3. Participants reported their level of agreement (0 = strongly disagree to 5 = strongly agree) to the following questions: ‘You have a lot of good qualities; You like yourself just the way you are; You have a lot to be proud of; and You feel like you are doing everything just about right’ (For similar use of these items, see 30). Various versions of the Rosenberg scale have been tested for reliability and validity in many languages and have been found to be effective.31,32 The Cronbach’s a for this measure in Wave 1 and Wave 3 was 0.80 and 0.78, respectively. Weight contentment Contentment with weight was assessed during both Waves 1 and 3 via a single item, ‘How do you think of yourself in terms of weight?’ Possible responses to this question were 1 = very underweight; 2 = underweight; 3 = about the right weight; 4 = overweight; 5 = very overweight. This item was recoded as 1 = about the right weight (content) or 0 = otherwise (discontent). The following four categories captured reported weight contentment over time: (1) discontent in both adolescence and young adulthood; (2) content in adolescence only; (3) content in young adulthood only; and (4) content in both adolescence and young adulthood. Young adult sexually transmitted disease The following item measured the presence of STDs in young adulthood: ‘In the past 12 months, have you been told by a doctor or nurse that you had the following sexually transmitted diseases?’ The possible sexually transmitted diseases were: chlamydia, gonorrhea, trichomoniasis, syphilis, genital herpes, genital warts, human papilloma virus, bacterial vaginosis, pelvic inflammatory disease, cervicitis, urethritis, vaginitis, HIV/AIDS, or other. Women’s responses were 0 (no) or 1 (yes). Race/ethnicity Dichotomous variables were created to assess Black, Hispanic, and White racial/ethnic statuses. The dichotomous variables for each of the minority statuses were included as independent variables in the logistic regression analyses and those regression coefficients are interpreted in comparison to the reference group, which is Whites.
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Statistical analysis We created four BMI trajectory groups: (1) consistently high (adolescent BMI is above 22.94, which was the mean BMI of study participants in adolescence and change in BMI from adolescence to young adulthood is one-half standard deviation of the change score); (2) consistently low (adolescent BMI is below 22.94 and the BMI change from adolescence to young adulthood is one-half a standard deviation of the change score); (3) increasing (increase in BMI from adolescence to young adulthood of more than half a standard deviation of the change score); and (4) decreasing (decrease in BMI of more than half a standard deviation of the change score). For example, an individual with a BMI of 23 in adolescence and a BMI of 27 in young adulthood would be in the ‘increasing’ trajectory group because their BMI increased by more than half a standard deviation (2.25 units) from adolescence to young adulthood. Based on participants’ responses to self-esteem items during adolescence and young adulthood, we created four self-esteem trajectory groups: (1) consistently high (initial self-esteem score is above 16, which was the mean self-esteem score in adolescence and change in self-esteem from adolescence to young adulthood is one-half standard deviation of the change score); (2) consistently low (initial self-esteem score is below 16 and the self-esteem change from adolescence to young adulthood is one-half a standard deviation of the change score); (3) increasing (increase in self-esteem of more than half a standard deviation of the change score); and (4) decreasing (decrease in self-esteem of more than half a standard deviation of the change score). A similar strategy was used to create depressive symptom trajectory groups in a previous study, which examined the relationship between depressive symptom trajectory groups and physical health problems.23 All analyses were conducted using SAS version 9.3 software (SAS Institute, Cary, NC, USA). Binary logistic regression was used to investigate the relationship between weight status, selfperception and presence of an STD among young adult women. First, dummy-coded weight status variables were entered into Model 1 to determine the relationship between weight status and STDs. Next, self-esteem trajectories and weight contentment were added in Model 2 to determine whether these variables are significantly related to young adult STDs. In addition, it allowed us to determine whether weight status was related to STDs even after controlling for self-esteem and weight contentment. Odds ratios (OR) and 95% confidence intervals (CI) were calculated. Results Fifteen per cent of the sample reported having an STD in the previous 12 months. In terms of weight, BMI increased from adolescence to young adulthood for 60% of the sample while only 3% reported a decreased BMI over the same period; 24% of the sample had a consistently low BMI and 11.5% had a consistently high BMI. These trends varied somewhat by race/ ethnicity (Table 1). The consistently high BMI group had mean BMI values in adolescence and young adulthood of 24.79 and 23.46 respectively. The consistently low BMI group had mean values of 20.33 in adolescence and 22.77 in young adulthood.
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Among the increasing BMI group, 25.20 and 31.96 were the respective values in adolescence and young adulthood. The decreasing group reported a mean BMI value of 19.62 in adolescence and 19.69 in young adulthood. The consistently high self-esteem group had mean selfesteem values in adolescence and young adulthood of 18.45 and 18.21, respectively. The consistently low self-esteem group had mean self-esteem values of 14.94 in adolescence and 15.49 in young adulthood. The increasing self-esteem group reported mean self-esteem values of 13.68 and 18.00 in adolescence and young adulthood respectively. Participants in the decreasing self-esteem trajectory reported a mean self-esteem of 18.44 in adolescence and 14.33 in young adulthood. Weight contentment was consistently low among 37% of the sample. Table 1 shows the percentages across the BMI, self-esteem and weight contentment groups. Table 2 presents participants’ reports of having an STD, as well as continuity or change in self-esteem and weightperception by BMI category. A greater proportion of women who reported a lower BMI in young adulthood than adolescence (i.e. decreasing BMI trend) reported having an STD compared with women who reported an increased or stable BMI. The majority of women in each BMI category reported consistently low self-esteem from adolescence to young adulthood, with the exception of the decreased BMI group, which had a similar proportion of women reporting consistently low and increasing self-esteem. Weight contentment followed a similar pattern, with the majority of women reporting low weight contentment during adolescence and young adulthood, except for the decreased BMI group who had a similar number of women reporting consistently low and increasing weight contentment. In Model 1, women reporting any change in BMI from adolescence to young adulthood (i.e. BMI increase or Table 1.
Women’s reports of an STD, BMI, self-esteem and weight contentment by race Note: Data are from Wave 1 and Wave 3 of the National Longitudinal Study of Adolescent Health. STD, sexually transmitted disease; BMI, body mass index. Results are presented as percentages Variable
Race/ethnicity Total Hispanic (n = 4000) (n = 619)
Table 2. Percentage of women’s reports of STD, self-esteem and weight perception by BMI group STD, sexually transmitted disease; BMI, body mass index. Results are presented as percentages Decreased (n = 116)
Black (n = 1117)
White (n = 2264)
15.04
12.28
21.93
10.91
BMI Low High Increased Decreased
24.07 11.51 61.34 3.07
23.26 14.70 59.45 2.58
20.41 10.65 64.55 4.39
28.53 9.19 60.03 2.25
32.33 29.21 26.39 12.07
36.03 23.91 28.92 11.15
25.25 37.24 24.35 13.16
35.72 26.48 25.91 11.89
Weight contentment Low 37.73 High 29.77 Increased 13.79 Decreased 18.70
42.30 25.77 12.80 19.12
35.64 29.44 14.99 19.93
35.26 34.11 13.57 17.06
BMI group Increased (n = 2448)
High (n = 418)
Low (n = 1018)
STD
17.24
14.05
15.31
13.75
Self-esteem group Low High Increased Decreased
31.90 25.00 31.90 11.21
33.51 30.49 23.66 12.34
33.25 26.32 30.62 9.81
31.17 27.34 28.81 12.68
Weight contentment Low 40.52 High 13.79 Increased 38.79 Decreased 6.90
44.11 23.61 8.80 23.49
53.85 14.66 23.08 8.41
10.51 59.43 19.35 10.71
Table 3. Unstandardised regression coefficients for the associations between women’s reports of STD and BMI, self-esteem, weight contentment groups and race/ethnicity Note: The two models were adjusted for number of lifetime sexual partners and adolescent and young adulthood socioeconomic status. STD, sexually transmitted disease; BMI, body mass index; B, unstandardised regression coefficient; OR, Odds ratio; CI, confidence interval B
STD
Self-esteem group Low High Increased Decreased
decrease of more than half a standard deviation of the change score) were at increased risk for STDs [increasing BMI OR = 1.29 (95% CI: 1.09–1.54); decreasing BMI OR = 1.48 (95% CI: 1.15–1.90)] compared with women with consistently low BMIs (Table 3). However, when self-esteem and weight contentment were entered into Model 2, only decreasing BMI increased women’s risk for STDs [OR = 1.48 (95% CI: 1.15–1.90)]. Having a significantly low self-esteem uniquely predicted greater STD risk [OR = 1.23 (95% CI: 1.02–1.49)] as did decreasing weight contentment from
BMI groupA High Increased Decreased
0.26 0.26 0.39
Model 1 OR 95% CI 1.30 1.29 1.48
0.95–1.79 1.09–1.54** 1.15–1.90**
B
Model 2 OR 95% CI
0.15 0.08 0.39
1.16 1.08 1.48
0.84–1.61 0.88–1.33 1.15–1.90**
Self-esteem groupB Low Increased Decreased
0.21 0.16 0.06
1.23 1.17 1.06
1.02–1.49* 0.96–1.45 0.82–1.39
Weight contentmentC Low Increased Decreased
0.13 0.22 0.27
1.14 1.25 1.31
0.90–1.43 0.98–1.59 1.03–1.66*
Black Hispanic
0.59 0.11
1.80 1.12
1.52–2.13*** 0.89–1.42
*P < 0.05, **P < 0.01, ***P < 0.001. A Reference group is made up of those with a low BMI. B Reference group is made up of those with a high self-esteem. C Reference group is made up of those with a high weight contentment.
BMI, self-esteem and STDs
adolescence to young adulthood [OR = 1.31 (95% CI: 1.03–1.66)] compared with women with consistently high self-esteem and weight contentment. Black participants were more likely than White participants to report having an STD [OR = 1.80 (95% CI: 1.52–2.13)]. All possible two- and three-way interactions among study variables were examined; however, all of these were not statistically significant. Discussion By using a nationally representative sample, this study examined the longitudinal associations between adolescent and young adult BMI, self-esteem and weight contentment in terms of women’s STDs. After accounting for self-perception and race/ethnicity, decreasing BMI trends were significantly related to women’s reports of STDs. It was hypothesised that having a consistently high BMI in adolescence and young adulthood would increase STD risk; however, results indicate that any change in BMI (particularly a decrease) increases risk. Having persistently low self-esteem during adolescence and young adulthood also increased young women’s STD incidence, independent of BMI. Previous studies suggest positive self-perception has an empowering effect, increasing women’s confidence in their ability to insist on safe sex practises such as condom use.33 The present study suggests this empowerment might play a formative role during adolescence when sexual identity, esteem and habits begin developing, which then endures into adulthood.34 Taken together, and consistent with the life course approach used in this study, these findings portray adolescence as a key developmental period in the life course24 for the development of positive body image and healthy weight. A recent study by DeMaria et al.35 found no link between BMI and STDs; however, results from the present work emphasise the importance of developmental timing and sequence24 of obesity and that continuity and change in obesity, low selfesteem and weight contentment is more important than current weight status in understanding the link between physical size, self-perception and sexual health. Continuously low selfesteem emerged as a key risk factor for STDs, regardless of women’s current or previous weight status. Previous research indicates that sexual function improves following weight loss;36 however, when obesity is experienced during adolescence, the damage to self-esteem may persist even when individuals are no longer obese, which can have an impact on sexual decision-making and safer sex behaviours. Poor self-esteem is closely linked with sexual risk;37 it tends to decline during adolescence and does not always rebound with age.25 Independent of self-esteem or whether women gained or lost weight between adolescence and young adulthood, decreased contentment with their weight increased women’s risk for STDs. Happiness or satisfaction with one’s body is reflective of body image, and decreasing contentment with body shape or size might also be associated with diminished sexual selfesteem.38 Although the construct of sexual self-esteem is beyond the scope of the present study, it seems intuitive that when women transition from contentment to discontentment, it
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would have implications for their overall self-perception and confidence. Revisiting the study by Auslander et al.,33 women who feel better about themselves report a greater likelihood of insisting a sexual partner use condoms, which reduces the risk of STDs. Women who feel discontent with their bodies during young adulthood may lack confidence in such ability. Women reporting both satisfaction and dissatisfaction with their body images have been linked with high-risk sexual activity;39 however, the present study suggests it is the change from contentment to discontentment across developmental periods that has important implications for STDs and associated behaviours. Bodyweight dissatisfaction can be a motivating factor towards healthier lifestyle choices and weight loss, particularly for women.40 However, the present study findings also associate dissatisfaction with sexual risk. Nutrition and weight-loss efforts that capitalise on body dissatisfaction to motivate women towards change should also consider risk behaviours linked with women’s previous and current weight discontentment. Race emerged as a significant risk factor for STDs independent of weight status, self-esteem or weight contentment, as Black women were consistently more likely to report having an STD than were White women. Other studies have also found that Black young adults, specifically women, are at greater risk for contracting HIV and other sexually transmitted diseases;41 present study results re-emphasise a need for prevention efforts targeted to this demographic of women. Study limitations The outcome variable in this study was based on self-report, in that participants reported whether they had ever been diagnosed with a specific STD in the past 12 months. Therefore, all respondents who answered ‘yes’ had been tested for and diagnosed with the condition by a medical professional during the Wave 3 assessment period. Thus, outcomes are based on the diagnosis and not actual presence of a disease or health condition. This means that participants who responded ‘no’ to the outcome variable may actually have an undiagnosed occurrence of the condition. Biospecimen STD data was collected from participants during Wave 3; however, only tests for chlamydia, gonorrhea and trichomoniasis were administered, thus limiting the scope and utility of such a measure. Conclusions and implications The purpose of this study was to examine the association between BMI continuity and change and young adult STDs. Decreasing BMI was linked with greater sexual risk; however, it was not just women’s weight status, but also selfperception, that increased their risk for STDs. While a negative change in weight contentment from adolescence to young adulthood was related to incidence of STD, low self-esteem posed enduring harm by increasing women’s risk for STDs. Although Goodson et al. found little support for a link between self-esteem and sexual risk behaviours in their meta-analysis of mostly cross-sectional studies,22 the present study highlights the importance of a life-course24 perspective to understand the longitudinal importance of how a woman perceives herself and
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her body during the transition from adolescence to young adulthood, with a large, nationally representative sample of women. Adolescence is a critical time in the life course for development of several protective assets42 and there are many known benefits to fostering adolescent self-esteem. Findings from this study add long-term STD prevention to this list. Therefore, self-esteem should be a core concept in sex education efforts (independent from, as well as integrated with, discussions of actual sex behaviours) as high selfesteem may moderate how adolescents and young adults perceive and implement information gained in such programs in their sexual practises. Additional research is needed to determine whether a preventative focus on general and sexual self-esteem during adolescence provides current and long-term protection from STDs (i.e. adolescence as developmental life course turning point; 24) or if self-esteem should be a sustained focus across the life course, particularly among individuals who are/have been obese and who grow less discontent with their bodies over time. While body dissatisfaction can motivate women to engage in healthier lifestyle behaviours, there is a fine line between dissatisfaction and shame, with the latter actually harming women’s overall health.43 It is critical that prevention programs aimed at youth and young adults appropriately balance physical health promotion with promotion of positive self-perception. The use of STDs as a sexual risk outcome likely underrepresents the prevalence of participants’ engagement in risky sexual behaviours; broadening the scope of the dependent variable in future studies would likely strengthen observed relationships. The longitudinal nature of this study highlights the developmental significance of adolescent self-esteem for young adult health behaviours as well as the importance of assessing multiple constructs as they develop over time. Based on a life course framework24 and building on the results from the present study, future efforts to understand and promote positive sexual experiences and sexual health should not limit the focus to adults’ current weight status and self-perception, but also address individuals’ developmental history in terms of obesity, self-esteem and weight contentment. Acknowledgements This research uses data from Add Health, a program project directed by Kathleen Mullan Harris and designed by J. Richard Udry, Peter S. Bearman, and Kathleen Mullan Harris at the University of North Carolina at Chapel Hill, and funded by grant P01-HD31921 from the Eunice Kennedy Shriver National Institute of Child Health and Human Development, with cooperative funding from 23 other federal agencies and foundations. Special acknowledgement is due to Ronald R. Rindfuss and Barbara Entwisle for assistance in the original design. Information on how to obtain the Add Health data files is available on the Add Health website (http://www.cpc.unc.edu/addhealth). No direct support was received from grant P01-HD31921 for this analysis.
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