Issues in Mental Health Nursing, 36:217–221, 2015 Copyright © 2015 Informa Healthcare USA, Inc. ISSN: 0161-2840 print / 1096-4673 online DOI: 10.3109/01612840.2014.963902
Factors Influencing Adolescent Girls’ Sexual Behavior: A Secondary Analysis of the 2011 Youth Risk Behavior Survey Katharine Anatale, BS, RN Rutgers, The State University of New Jersey, New Brunswick, New Jersey, USA
Sarah Kelly, PhD, RN
Issues Ment Health Nurs Downloaded from informahealthcare.com by Kainan University on 04/27/15 For personal use only.
Rutgers, The State University of New Jersey, Newark, New Jersey, USA
Adolescence is a tumultuous and challenging time period in life. Sexual risk behavior among adolescents is a widespread topic of interest in the current literature. Two common factors that influence increased sexual risk behavior are symptoms of depression and negative body image. The purpose of this study was to investigate the effect of body image and symptoms of depression upon sexual risk-taking in an adolescent female population. A secondary data analysis of the 2011 Youth Risk Behavior Survey (YRBS) was used to explore girls’ sexual activity, body image, and mental health. There were 7,708 high-school girls who participated in this study. Three questions were used to represent the constructs under investigation. There were significant correlations between sexual activity, body image, and symptoms of depression; only symptoms of depression were significant predictors of both sexual activity and condom usage. Body image was a predictor of sexual activity, but not condom use. Our findings support previous studies that suggested that people with depressive symptoms were more likely to engage in risky sexual behaviors. Our study also supports the idea that a negative body image decreases sexual activity; however, other researchers have reported that negative body image leads to an increase in sexual activity.
Adolescence is a tumultuous and challenging time period in life. While adolescents undergo the normal physiologic changes that accompany puberty, they are also faced with many intense social issues revolving around relationships with others, independence from parents, and burgeoning sexuality (Cleveland Clinic Foundation, 2009). Although these issues encompass adolescents of both genders, girls are more at risk for social and emotional problems: specifically symptoms of depression, negative body image, and sexual risk behavior (U.S. Department of Health and Human Services, 2010). Adolescent girls are three times more likely to experience major depressive episodes than boys (U.S. Department of Health and Human Services 2010). In terms of satisfaction with appearance, between the ages 10 Address correspondence to Sarah Kelly, Rutgers, The State University of New Jersey, 366 Ackerson Hall, 180 University Ave, Newark, NJ 07102, USA. E-mail: [email protected]
and 14, girls’ satisfaction has been shown to decrease (Barker & Bernstein, 2010). According to the Centers for Disease Control and Prevention (CDC), in 2011, 45.6% of high-school girls were sexually active. Furthermore, those girls were less likely to have participated in sex with boys who used condoms during intercourse (CDC, 2012). It is important to clarify the contributing factors to girls’ high levels of depression symptoms, negative body image, and sexual risk-taking. With the knowledge of why girls are more likely to engage in risky behaviors, it is possible for those in the social and healthcare fields to intervene in a crucial way. Body image and symptoms of depression are two key elements that influence risky sexual behaviors; therefore, the purpose of this study was to investigate the effects of body image and symptoms of depression upon sexual activity in an adolescent female population. BACKGROUND Sexual risk behavior among adolescents is a widespread topic of interest in the current literature (Pearson, Kholodkov, & Henson, 2012; Seth et al., 2011). Sexual risk behavior can result in unplanned pregnancy or increased sexually transmitted infections (National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Division of Adolescent and School Health, 2013). These activities include inconsistent condom use, increased number of sexual partners, or early coital debut (Lehrer, Shrier, Gortmaker, & Buka 2006; Pearson et al., 2012; Seth et al., 2011). Two common factors that influence increased sexual risk behavior among teen girls are depressive symptoms and negative body image (Pearson et al., 2012; Seth et al., 2011). To date, no research was found that directly investigated the relationships among body image, depression symptoms, and sexual risk-taking together, using a female sample. Instead, most studies focused on either depression symptoms or body image and how these factors separately influenced sexual risk behavior. This study is attempting to view the complex relationship between the three elements of body image, symptoms of
217
218
K. ANATALE AND S. KELLY
Issues Ment Health Nurs Downloaded from informahealthcare.com by Kainan University on 04/27/15 For personal use only.
depression, and sexual risk behavior together, in order to glean a fuller picture of the components that may influence adolescent girls’ behaviors. Body Image and Sexual Risk Behaviors One important factor contributing to girls’ risky sexual behaviors is body image. The relationship between negative body image and increased sexual risk-taking behaviors has been explored in a variety of populations and settings, many of which surround adolescent and young adult girls ((Littleton, Breitkopf, & Berenson, 2005; Seth et al., 2011). Researchers have found that one of the most notable factors contributing to early sexual activity, inconsistent condom usage, and an increase in sexual partners among women, is negative body image (Littleton et al., 2005; Pearson et al., 2012; Valle, Roysamb, Sundby, & Klepp, 2009). The correlation between negative body image and increased sexual risk-taking was supported in a study of 522 African-American female adolescents (Wingood, Di Clemente, Harrington, & Davies, 2002) and in a study from Norway, which investigated factors such as body image, parental involvement, and psychosocial determinants, as they relate to first sexual encounters among 15- and 16-year-old girls and boys (Valle et al., 2009). Contrary to previous studies, Gillen, Lefkowitz, and Shearer (2006) focused on the relationship between positive body image and sexual risk behavior among both male and female teens. They discovered that, for girls, a positive body image was associated with increased sexual behavior, yet, also resulted in more consistent condom usage (Gillen et al., 2006). Gillian et al. (2006) suggested that, for girls, an increase in confidence in personal appearance led to an increased confidence in sexual situations, including insistence on condom usage. In light of these results, it appears that body image and sexual activity have a complex interaction. Depressive Symptoms and Sexual Risk Behaviors Another common factor contributing to increased sexual risk is depression symptoms. Higher levels of depression symptoms have been shown to relate to increased sexual risk behaviors among 403 US girls between the ages of 14 and 25 (Mazzaferro et al., 2006), and among 415 African-American female adolescents (Brown et al., 2006). Using The National Longitudinal Study of Adolescent Health (ADD Health), it was discovered that moderate and high levels of depression symptoms in adolescents of both genders related to risky behaviors, such as decreased condom usage and increased number of partners (Khan et al., 2009). This same ADD health data produced similar results of increased sexual risk behavior correlating to symptoms of depression with a sample of adolescent girls only (Lehrer et al., 2006). A study in Uganda of both male and female university students found that depression symptoms were associated with an increased number of sexual partners (Agardh, CantorGraae, & Ostergren, 2012). The ADD health data also revealed
a relationship between depressive symptoms and earlier sexual onset (Longmore, Manning, Giordano, & Rudolph, 2004). Although there is a wealth of information relating to adolescent girls’ sexual risk-taking behavior, it is important to clarify the factors leading to increased sexual risk behaviors. Clarifying the risk factors will enable healthcare providers to counsel those with a higher probability for sexual risk behaviors. It is also important to view the three constructs of body image, depression symptoms, and sexual risk-taking activity together, in order to tease out the relationships among these three concepts.
METHOD A secondary analysis of data was completed using the 2011 Youth Risk Behavior Survey (YRBS). The YRBS is a national survey conducted by the CDC biennially and given to youth in grades 9–12. It focuses on six main areas of interest: (1) behaviors that contribute to unintentional injuries and violence; (2) sexual behaviors that contribute to HIV infection, other STDs, and unintended pregnancy; (3) tobacco use; (4) alcohol and other drug use; (5) unhealthy dietary behaviors; and (6) physical inactivity (CDC, 2013). The YRBS utilizes a sampling procedure that produces estimates of the population that are accurate within ± 5% at a 95% confidence interval (CDC, 2013). Their sampling procedure is a three-step process. First, the CDC categorizes geographic areas into primary sampling units or PSUs. Second, the CDC selects schools from within the PSUs, which include both public and private institutions. Finally, one or two classes are randomly selected to participate from each school and from each of the grades 9–12 (CDC, 2013). Parental consent is required in order for students to participate in the YRBS, either actively or passively. In active consent, the parent must return a form in order for the student to take the survey. Passive consent is where the parent only needs to return a form if they do not give permission for participation. Each student can choose whether they would like to participate in the survey. Four questions from the YRBS were selected to represent the three constructs under investigation: depression symptoms, sexual risk behavior, and body image. 1. Depression symptoms: ‘During the past 12 months, did you ever feel so sad or hopeless almost every day for two weeks or more in a row that you stopped doing some usual activities?’ (Answer options are ‘yes’ or ‘no’) 2. Sexual risk behavior: ‘Have you ever had sexual intercourse?’ (Answer options are ‘yes’ and ‘no’) and ‘The last time you had sexual intercourse did you or your partner use a condom?’ (Answer options are ‘I have never had sexual intercourse’, ‘yes’, and ‘no’) 3. Body image: ‘How do you describe your weight?’ (Answer options are ‘very underweight’, ‘slightly underweight’,
219
FACTORS INFLUENCING ADOLESCENT GIRLS’ SEXUAL BEHAVIOR
TABLE 1 Sample Characteristics of Female Population
Issues Ment Health Nurs Downloaded from informahealthcare.com by Kainan University on 04/27/15 For personal use only.
Characteristics Age (mean ± SD) Gender (Female) Educational level 9th Grade 10th Grade 11th Grade 12th Grade Ethnicity Caucasian African-American Hispanic
n 16 ± 1.2 7,708 1,873 1,884 2,064 1,859 3,022 1,432 1,121
‘about the right weight’, ‘slightly overweight’, and ‘very overweight’). Data Analysis Summary statistics were used to summarize the study variables. Descriptive statistics were used to characterize the participants’ demographics and to quantify their self-reported body image, depression symptoms, and sexual activity experiences. In addition, bivariate correlational and logistic regression analyses were used to describe the relationship(s) among the three variables (body image, depression symptoms, and sexual activity). The IBM Statistical Package for Social Sciences (SPSS) version 21 program was used for data analysis (New York, NY). RESULTS There were 7,708 (50.2%) high-school girls who participated in this study. The participants’ grade in school was evenly distributed among the 9th to 12th grades, with slightly more girls in the 11th grade (n = 2,064) (Table 1). The main ethnicities of the participants were Caucasian (n = 3,022), African-American (n = 1,432), and Hispanic/Latino (n = 1,238). The majority (n = 4,817; 63%) of girls were not depressed and reported that they were at the right weight (n = 4,078; 53.7%). Slightly over 2,000 girls (30%) self- reported being overweight. In terms of sexual activity, about half of the girls had reported engaging in sex (n = 3,408; 48%). Of those who had sex, 57% (n = 1,953) reported use of a condom or their partner’s use of a condom during intercourse (Table 2). The relationship among body image, depression symptoms, and sexual behavior was examined using correlations. There was a positive relationship between depression symptoms and selfperceived body image as slightly or very overweight (r = 0.08, p < 0.01). There was a positive relationship between feelings of depression and ever having had sex (r = 0.15, p < 0.01). However, there was a negative relationship between body image and ever having had sex (r = –0.03, p < 0.01). Although all
TABLE 2 Sample Female Characteristics of Depression Symptoms, Sexual Activity, and Body Image Characteristics Depression symptoms Yes No Sexual activity Yes Used condom Did not use condom No Body image (mean ± SD) Very underweight Slightly underweight About the right weight Slightly overweight Very overweight
n
(%)
2,823 4,817
37 63
3,408 1,953 1,455 3,811
48 57 43 52
129 718 4, 078 2, 280 389
± ± ± ± ±
1.7 9.5 53.7 30 5.1
these correlations were statistically significant, there were weak coefficients. Logistical regression was used to determine the likelihood of sexual activity and condom usage among girls who are depressed and have a negative body image. Depression symptoms were the strongest variable in each model. In the first model, depression symptoms and body image were regressed onto sexual activity (Table 3). The odds ratio (OR) suggests that girls who are depressed were 1.9 times more likely to have had sex, controlling for all other variables in the model. The OR for body image was
Factors Influencing Adolescent Girls’ Sexual Behavior: A Secondary Analysis of the 2011 Youth Risk Behavior Survey Katharine Anatale, BS, RN Rutgers, The State University of New Jersey, New Brunswick, New Jersey, USA
Sarah Kelly, PhD, RN
Issues Ment Health Nurs Downloaded from informahealthcare.com by Kainan University on 04/27/15 For personal use only.
Rutgers, The State University of New Jersey, Newark, New Jersey, USA
Adolescence is a tumultuous and challenging time period in life. Sexual risk behavior among adolescents is a widespread topic of interest in the current literature. Two common factors that influence increased sexual risk behavior are symptoms of depression and negative body image. The purpose of this study was to investigate the effect of body image and symptoms of depression upon sexual risk-taking in an adolescent female population. A secondary data analysis of the 2011 Youth Risk Behavior Survey (YRBS) was used to explore girls’ sexual activity, body image, and mental health. There were 7,708 high-school girls who participated in this study. Three questions were used to represent the constructs under investigation. There were significant correlations between sexual activity, body image, and symptoms of depression; only symptoms of depression were significant predictors of both sexual activity and condom usage. Body image was a predictor of sexual activity, but not condom use. Our findings support previous studies that suggested that people with depressive symptoms were more likely to engage in risky sexual behaviors. Our study also supports the idea that a negative body image decreases sexual activity; however, other researchers have reported that negative body image leads to an increase in sexual activity.
Adolescence is a tumultuous and challenging time period in life. While adolescents undergo the normal physiologic changes that accompany puberty, they are also faced with many intense social issues revolving around relationships with others, independence from parents, and burgeoning sexuality (Cleveland Clinic Foundation, 2009). Although these issues encompass adolescents of both genders, girls are more at risk for social and emotional problems: specifically symptoms of depression, negative body image, and sexual risk behavior (U.S. Department of Health and Human Services, 2010). Adolescent girls are three times more likely to experience major depressive episodes than boys (U.S. Department of Health and Human Services 2010). In terms of satisfaction with appearance, between the ages 10 Address correspondence to Sarah Kelly, Rutgers, The State University of New Jersey, 366 Ackerson Hall, 180 University Ave, Newark, NJ 07102, USA. E-mail: [email protected]
and 14, girls’ satisfaction has been shown to decrease (Barker & Bernstein, 2010). According to the Centers for Disease Control and Prevention (CDC), in 2011, 45.6% of high-school girls were sexually active. Furthermore, those girls were less likely to have participated in sex with boys who used condoms during intercourse (CDC, 2012). It is important to clarify the contributing factors to girls’ high levels of depression symptoms, negative body image, and sexual risk-taking. With the knowledge of why girls are more likely to engage in risky behaviors, it is possible for those in the social and healthcare fields to intervene in a crucial way. Body image and symptoms of depression are two key elements that influence risky sexual behaviors; therefore, the purpose of this study was to investigate the effects of body image and symptoms of depression upon sexual activity in an adolescent female population. BACKGROUND Sexual risk behavior among adolescents is a widespread topic of interest in the current literature (Pearson, Kholodkov, & Henson, 2012; Seth et al., 2011). Sexual risk behavior can result in unplanned pregnancy or increased sexually transmitted infections (National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Division of Adolescent and School Health, 2013). These activities include inconsistent condom use, increased number of sexual partners, or early coital debut (Lehrer, Shrier, Gortmaker, & Buka 2006; Pearson et al., 2012; Seth et al., 2011). Two common factors that influence increased sexual risk behavior among teen girls are depressive symptoms and negative body image (Pearson et al., 2012; Seth et al., 2011). To date, no research was found that directly investigated the relationships among body image, depression symptoms, and sexual risk-taking together, using a female sample. Instead, most studies focused on either depression symptoms or body image and how these factors separately influenced sexual risk behavior. This study is attempting to view the complex relationship between the three elements of body image, symptoms of
217
218
K. ANATALE AND S. KELLY
Issues Ment Health Nurs Downloaded from informahealthcare.com by Kainan University on 04/27/15 For personal use only.
depression, and sexual risk behavior together, in order to glean a fuller picture of the components that may influence adolescent girls’ behaviors. Body Image and Sexual Risk Behaviors One important factor contributing to girls’ risky sexual behaviors is body image. The relationship between negative body image and increased sexual risk-taking behaviors has been explored in a variety of populations and settings, many of which surround adolescent and young adult girls ((Littleton, Breitkopf, & Berenson, 2005; Seth et al., 2011). Researchers have found that one of the most notable factors contributing to early sexual activity, inconsistent condom usage, and an increase in sexual partners among women, is negative body image (Littleton et al., 2005; Pearson et al., 2012; Valle, Roysamb, Sundby, & Klepp, 2009). The correlation between negative body image and increased sexual risk-taking was supported in a study of 522 African-American female adolescents (Wingood, Di Clemente, Harrington, & Davies, 2002) and in a study from Norway, which investigated factors such as body image, parental involvement, and psychosocial determinants, as they relate to first sexual encounters among 15- and 16-year-old girls and boys (Valle et al., 2009). Contrary to previous studies, Gillen, Lefkowitz, and Shearer (2006) focused on the relationship between positive body image and sexual risk behavior among both male and female teens. They discovered that, for girls, a positive body image was associated with increased sexual behavior, yet, also resulted in more consistent condom usage (Gillen et al., 2006). Gillian et al. (2006) suggested that, for girls, an increase in confidence in personal appearance led to an increased confidence in sexual situations, including insistence on condom usage. In light of these results, it appears that body image and sexual activity have a complex interaction. Depressive Symptoms and Sexual Risk Behaviors Another common factor contributing to increased sexual risk is depression symptoms. Higher levels of depression symptoms have been shown to relate to increased sexual risk behaviors among 403 US girls between the ages of 14 and 25 (Mazzaferro et al., 2006), and among 415 African-American female adolescents (Brown et al., 2006). Using The National Longitudinal Study of Adolescent Health (ADD Health), it was discovered that moderate and high levels of depression symptoms in adolescents of both genders related to risky behaviors, such as decreased condom usage and increased number of partners (Khan et al., 2009). This same ADD health data produced similar results of increased sexual risk behavior correlating to symptoms of depression with a sample of adolescent girls only (Lehrer et al., 2006). A study in Uganda of both male and female university students found that depression symptoms were associated with an increased number of sexual partners (Agardh, CantorGraae, & Ostergren, 2012). The ADD health data also revealed
a relationship between depressive symptoms and earlier sexual onset (Longmore, Manning, Giordano, & Rudolph, 2004). Although there is a wealth of information relating to adolescent girls’ sexual risk-taking behavior, it is important to clarify the factors leading to increased sexual risk behaviors. Clarifying the risk factors will enable healthcare providers to counsel those with a higher probability for sexual risk behaviors. It is also important to view the three constructs of body image, depression symptoms, and sexual risk-taking activity together, in order to tease out the relationships among these three concepts.
METHOD A secondary analysis of data was completed using the 2011 Youth Risk Behavior Survey (YRBS). The YRBS is a national survey conducted by the CDC biennially and given to youth in grades 9–12. It focuses on six main areas of interest: (1) behaviors that contribute to unintentional injuries and violence; (2) sexual behaviors that contribute to HIV infection, other STDs, and unintended pregnancy; (3) tobacco use; (4) alcohol and other drug use; (5) unhealthy dietary behaviors; and (6) physical inactivity (CDC, 2013). The YRBS utilizes a sampling procedure that produces estimates of the population that are accurate within ± 5% at a 95% confidence interval (CDC, 2013). Their sampling procedure is a three-step process. First, the CDC categorizes geographic areas into primary sampling units or PSUs. Second, the CDC selects schools from within the PSUs, which include both public and private institutions. Finally, one or two classes are randomly selected to participate from each school and from each of the grades 9–12 (CDC, 2013). Parental consent is required in order for students to participate in the YRBS, either actively or passively. In active consent, the parent must return a form in order for the student to take the survey. Passive consent is where the parent only needs to return a form if they do not give permission for participation. Each student can choose whether they would like to participate in the survey. Four questions from the YRBS were selected to represent the three constructs under investigation: depression symptoms, sexual risk behavior, and body image. 1. Depression symptoms: ‘During the past 12 months, did you ever feel so sad or hopeless almost every day for two weeks or more in a row that you stopped doing some usual activities?’ (Answer options are ‘yes’ or ‘no’) 2. Sexual risk behavior: ‘Have you ever had sexual intercourse?’ (Answer options are ‘yes’ and ‘no’) and ‘The last time you had sexual intercourse did you or your partner use a condom?’ (Answer options are ‘I have never had sexual intercourse’, ‘yes’, and ‘no’) 3. Body image: ‘How do you describe your weight?’ (Answer options are ‘very underweight’, ‘slightly underweight’,
219
FACTORS INFLUENCING ADOLESCENT GIRLS’ SEXUAL BEHAVIOR
TABLE 1 Sample Characteristics of Female Population
Issues Ment Health Nurs Downloaded from informahealthcare.com by Kainan University on 04/27/15 For personal use only.
Characteristics Age (mean ± SD) Gender (Female) Educational level 9th Grade 10th Grade 11th Grade 12th Grade Ethnicity Caucasian African-American Hispanic
n 16 ± 1.2 7,708 1,873 1,884 2,064 1,859 3,022 1,432 1,121
‘about the right weight’, ‘slightly overweight’, and ‘very overweight’). Data Analysis Summary statistics were used to summarize the study variables. Descriptive statistics were used to characterize the participants’ demographics and to quantify their self-reported body image, depression symptoms, and sexual activity experiences. In addition, bivariate correlational and logistic regression analyses were used to describe the relationship(s) among the three variables (body image, depression symptoms, and sexual activity). The IBM Statistical Package for Social Sciences (SPSS) version 21 program was used for data analysis (New York, NY). RESULTS There were 7,708 (50.2%) high-school girls who participated in this study. The participants’ grade in school was evenly distributed among the 9th to 12th grades, with slightly more girls in the 11th grade (n = 2,064) (Table 1). The main ethnicities of the participants were Caucasian (n = 3,022), African-American (n = 1,432), and Hispanic/Latino (n = 1,238). The majority (n = 4,817; 63%) of girls were not depressed and reported that they were at the right weight (n = 4,078; 53.7%). Slightly over 2,000 girls (30%) self- reported being overweight. In terms of sexual activity, about half of the girls had reported engaging in sex (n = 3,408; 48%). Of those who had sex, 57% (n = 1,953) reported use of a condom or their partner’s use of a condom during intercourse (Table 2). The relationship among body image, depression symptoms, and sexual behavior was examined using correlations. There was a positive relationship between depression symptoms and selfperceived body image as slightly or very overweight (r = 0.08, p < 0.01). There was a positive relationship between feelings of depression and ever having had sex (r = 0.15, p < 0.01). However, there was a negative relationship between body image and ever having had sex (r = –0.03, p < 0.01). Although all
TABLE 2 Sample Female Characteristics of Depression Symptoms, Sexual Activity, and Body Image Characteristics Depression symptoms Yes No Sexual activity Yes Used condom Did not use condom No Body image (mean ± SD) Very underweight Slightly underweight About the right weight Slightly overweight Very overweight
n
(%)
2,823 4,817
37 63
3,408 1,953 1,455 3,811
48 57 43 52
129 718 4, 078 2, 280 389
± ± ± ± ±
1.7 9.5 53.7 30 5.1
these correlations were statistically significant, there were weak coefficients. Logistical regression was used to determine the likelihood of sexual activity and condom usage among girls who are depressed and have a negative body image. Depression symptoms were the strongest variable in each model. In the first model, depression symptoms and body image were regressed onto sexual activity (Table 3). The odds ratio (OR) suggests that girls who are depressed were 1.9 times more likely to have had sex, controlling for all other variables in the model. The OR for body image was
