Journal of Adolescent Health 56 (2015) 367e369
www.jahonline.org Editorial
Improving Research Methodology in Adolescent Sexual Health Research
Adolescent self-reports and retrospective accounts of sexual behavior can be unreliable because of reporting errors, recall bias, social desirability bias, ambiguous or inadequate survey terminology, researcher misclassification of responses, and other factors [1e4]. Recent technological advances have enabled adolescent sexual health researchers to evaluate whether and how neural activity can affect sexual decisionmaking. By obtaining data directly from biological measures, researchers avoid sole reliance on self-reported and often retrospective data, and can identify the specific biological mechanisms that can be involved in adolescent sexual decisionmaking. In this issue of the Journal, Hensel et al. [5] report on the feasibility of augmenting self-reported data on adolescent women’s sexual decision-making with functional neuroimaging data. Adolescent sexual health researchers are increasingly aware that biological claims about how decision-making processes work at neurocognitive and affective levels must be substantiated by direct evidence of neurocognitive and affective processes, rather than by retrospective self-reports or behavioral observation, alone. Consequently, research by Hensel et al. sets a benchmark for evidence-based scholarship in the field of U.S.based adolescent health research. This research shares with other influential research on sexual health and decision-making a variety of assumptions about sexuality, gender, and human biological diversity. These assumptions can affect research processes. Along these lines, a number of methodological improvements can be made to adolescent sexual health research to ensure that research findings lead to optimal health care practice and public policy. Adolescent sexual health researchers can benefit from guidance on how to reduce the influence of problematic assumptions and ideology about sexuality, gender, and human biological diversity in their scientific research. Like most of their peers, Hensel et al. [5] did not ask participants how they would describe their sexuality or attractions. Instead, they asked participants to state their partner’s gender. They reported that most participants in this small sample of
young women had indicated “male” partners. This information was assumed to inform the researchers about participants’ sexual attractions. However, some participants may have a current partner of one gender while being attracted to or preferring a partner of another gender. Some participants may prefer relationship partners of one gender and sexual activity partners of another gender. Without asking directly about attraction, this information remains unknown. Attraction often differs from identity. For example, a nationally representative Australian sample found that women and men with same-gender attractions and/or experiences often do not self-identify using sexuality labels such as lesbian, bisexual, gay, or “homosexual” [6]. Same-gender-attracted people (who may or may not also be attracted to people of another gender) are often underrepresented because of the over-reliance on identity labels in sexual health research. Adolescent sexuality contains far more nuance than that is acknowledged by the ostensibly discrete categories of gay, lesbian, bisexual, and heterosexual. Adolescent self-descriptions of sexuality include omnisexual, pansexual, homoflexible, heteroflexible, woman-loving, man-loving, person-loving, queer, mostly straight, bi-curious, and many more [7]. In addition, the conflation of “male” with man and “female” with woman leads to the miscategorization or exclusion of people with intersex characteristics, women who were assigned as male, men who were assigned as female, and people with nonbinary genders [8,9]. Although people with nonbinary genders are typically ignored or excluded as “outliers” in sexual health research, a nationwide U.S. study of 6,450 “transgender and gender nonconforming people” found that 41% reported identifying as female or women, 26% were identified as male or men, 20% as living part time as one gender, part time as another, and 13% as “a gender not listed here” (GNL) [10]. Among participants who reported identifying as GNL, most of the 860 written responses were genderqueer, pangender, third gender, hybrid, and variations on genderqueer. Additional responses included transmasculine, transfeminine, twidget, birl, OtherWise, and
See Related Article p. 389
Conflicts of Interest: The author has no potential conflicts of interest of a real or perceived nature. 1054-139X/Ó 2015 Society for Adolescent Health and Medicine. All rights reserved. http://dx.doi.org/10.1016/j.jadohealth.2015.01.013
368
Editorial / Journal of Adolescent Health 56 (2015) 367e369
transgenderist. Respondents also used some of the many culturally specific gender categories such as Two-Spirit (First Nations), Mahuwahine (Hawaiian), and Aggressive (Black and/or African-American), further illustrating the ethnocentrism of the culturally restrictive gender categories typically used in adolescent sexual health research. Adolescents have diverse ways of classifying their relationships and sexual activity partners. Survey items and interviews that rely on concepts like “partner” or “relationship” are unlikely to capture the range of adolescent sexual and affectional engagements. Evidence suggests that most sexually active adolescents have engaged in sexual activity outside of relationships or “nonrelationship sex” [11]. Other common forms of adolescent sexual activity that occur outside of being “in a relationship” include “hooking up” and other colloquial language that does not fit readily into the research categories of “in a relationship”, “dating”, or “single” [12]. In one study, 60% of undergraduate university students reported having had “friends with benefits” situations, which the researchers defined as “when people who are ‘just friends’ have sex” [13]. Even seemingly concrete terms such as “dating” can be ambiguous. One study described four distinct ways in which university students use this term, including interactions that involve “loosely organized, undefined time together, without making their interest in one another explicit, unless they hook up, at which point dating and hooking up become the same thing” [14]. Adolescent sexual and romantic relationship configurations often transcend the dyadic conceptual limitations of the term “couple” [15]. Most sexual health researchers have yet to integrate an awareness of this diversity within romantic relationships and nonrelationship relating styles into study design. Researchers’ assumptions about what constitutes “having sex” can be misaligned with participants’ own understanding of their sexual behavior. Views of which behaviors constitute having “had sex” also vary widely between individuals, and definitions of sexual activity can be influenced by cultural factors [16e18]. In a study of 599 undergraduate university students in the Midwestern U.S., 59% of students classified oral-genital contact as not constituting having “had sex”; 19% stated that penile-anal intercourse did not count as having “had sex” [19]. The use of binaries such as “high risk” versus “low risk” and “heavy” versus “light” to describe sexual activity, combined with penetration-centric response options, may provide a far tidier impression of adolescent sexual behavior than is reflected by the evidence. For example, many women’s sexual activity with other women involves vaginal-vaginal contact that defies such categorization. Although decades of research have established the legitimate risk of HIV and STI transmission through vaginalvaginal contact, sexual health researchers continue to apply sexual activity categories that assume the presence of a penis and focus on “penetrative” sexual acts. The tendency to describe individuals who share particular sexuality, gender history or experience, or physical characteristics as a “community” may reduce the likelihood that researchers will seek representative samples beyond those with a visible public presence and a well-established social network of others who share these characteristics. Researchers have critiqued the oversampling of the “visible” sections of a hidden population, the limitations of retrospective reporting, and the difficulty with attempts to capture complex emotions in brief and often impersonal surveys [20].
This editorial has addressed only a few of the many ways that researchers’ assumptions and ideology about sexuality, gender, and human biological diversity can affect research methods, interpretations of findings, and “evidence-based” public health policy. Sexual health researchers can improve their research methodology by distinguishing between identity, behavior, experience, and attraction; by integrating an awareness of diverse adolescent relating styles and sexual behaviors into their study design; by moving beyond binary categories and forcedchoice, single option items; and by providing inclusive research design that acknowledges sexuality, gender, and physical diversity in “general” and “nationally representative” research and not only in research that studies a particular population such as lesbian adolescents or young women with intersex characteristics. Researchers can use culturally appropriate language that is ecologically valid and reflects adolescents’ diverse conceptual and linguistic frameworks. Researchers can avoid conflating individual experiences and identities with social networks and with publicly visible “communities” of people who share ostensibly similar experiences. Finally, researchers can appropriately contextualize their samples and avoid making overgeneralizations about their findings. Researchers can achieve these aims by acknowledging the limitations of their participant sampling (e.g., by adding language such as “a predominantly white, heterosexually identified urban U.S. sample” to their title and abstract); remembering that “the general population” includes people with a wide diversity of sexualities, relating styles, gender histories and experiences, gender identities, and physical characteristics; and incorporating the multidimensional and often overlapping permutations of these categories into study design. Acknowledgments The author thanks Israel Berger and Tucker Lieberman for editorial feedback. Funding Sources No funding was received for this publication. Y. Gavriel Ansara, M.Sc., Ph.D. Research & Policy Team National LGBTI Health Alliance Sydney, Australia
References [1] Clark LR, Brasseux C, Richmond D, et al. Are adolescents accurate in selfreport of frequencies of sexually transmitted diseases and pregnancies? J Adolesc Health 1997;21:91e6. [2] Gallo MF, Steiner MJ, Hobbs MM, et al. Biological markers of sexual activity: Tools for improving measurement in HIV/sexually transmitted infection prevention research. Sex Transm Dis 2013;40:447e52. [3] McCallum EB, Peterson ZD. Investigating the impact of inquiry mode on self-reported sexual behavior: Theoretical considerations and review of the literature. J Sex Res 2012;49:212e26. [4] Schroder KE, Carey MP, Vanable PA. Methodological challenges in research on sexual risk behavior: II. Accuracy of self-reports. Ann Behav Med 2003; 26:104e23. [5] Hensel DJ, Hummer TA, Acrurio LR, et al. Feasibility of functional neuroimaging to understand adolescent Women’s sexual decision making. J Adolesc Health 2015;56:389e95.
Editorial / Journal of Adolescent Health 56 (2015) 367e369 [6] Smith AM, Rissel CE, Richters J, et al. Sex in Australia: Sexual identity, sexual attraction and sexual experience among a representative sample of adults. Aust N Z J Public Health 2003;27:138e45. [7] Jacobson B, Donatone B. Homoflexibles, omnisexuals, and genderqueers: Group work with queer youth in cyberspace and face-to-face. Group Ther LGBT Pop 2009;33:223e34. [8] Ansara YG, Hegarty P. Methodologies of misgendering: Recommendations for reducing cisgenderism in psychological research. Feminism Psychol 2014;24:259e70. [9] Carrera MV, DePalma R, Lameiras M. Sex/gender identity: Moving beyond fixed and ‘natural’ categories. Sexualities 2012;15:995e1016. [10] Harrison J, Grant J, Herman JL. A gender not listed here: Genderqueers, gender rebels, and otherwise in the National Transgender Discrimination Survey. LGBTQ Public Policy J Harv Kennedy Sch 2012;2. Available at: http://escholarship.org/uc/item/2zj46213. Accessed January 27, 2015. [11] Manning WD, Giordano PC, Longmore MA. Hooking up: The relationship contexts of “nonrelationship” sex. J Adolesc Res 2006;21:459e83. [12] Calzo JP. Hookup sex versus romantic relationship sex in college: Why do we care and what do we do? J Adolesc Health 2013;52:515e6. [13] Bisson MA, Levine TR. Negotiating a friends with benefits relationship. Arch Sex Behav 2009;38:66e73.
369
[14] Glenn N, Marquardt, E. Hooking up, hanging out, and hoping for Mr. Right. College women on dating and mating today. In An Institute for American Values Report to the Independent Women’s Forum. New York: Institute for American Values. Available at: http://www.americanvalues.org/search/ item.php?id=18. [15] Matsick JL, Conley TD, Ziegler A, et al. Love and sex: Polyamorous relationships are perceived more favourably than swinging and open relationships. Psychol Sex 2014;5:339e48. [16] Carpenter LM. The ambiguity of “having sex”: The subjective experience of virginity loss in the United States. J Sex Res 2001;38:127e39. [17] Weiss E, Whelan D, Gupta GR. Gender, sexuality and HIV: Making a difference in the lives of young women in developing countries. Sex Relat Ther 2000;15:233e45. [18] Yon-Leau C, Muñoz-Laboy M. “I don’t like to say that I’m anything”: Sexuality politics and cultural critique among sexual-minority Latino youth. Sex Res Soc Pol 2010;7:105e17. [19] Sanders SA, Reinisch JM. Would you say you “had sex” if.? JAMA 1999; 281:275e7. [20] McDermott E, Roen K, Piela A. Hard-to-reach youth online: Methodological advances in self-harm research. Sex Res Soc Pol 2013;10: 125e34.
www.jahonline.org Editorial
Improving Research Methodology in Adolescent Sexual Health Research
Adolescent self-reports and retrospective accounts of sexual behavior can be unreliable because of reporting errors, recall bias, social desirability bias, ambiguous or inadequate survey terminology, researcher misclassification of responses, and other factors [1e4]. Recent technological advances have enabled adolescent sexual health researchers to evaluate whether and how neural activity can affect sexual decisionmaking. By obtaining data directly from biological measures, researchers avoid sole reliance on self-reported and often retrospective data, and can identify the specific biological mechanisms that can be involved in adolescent sexual decisionmaking. In this issue of the Journal, Hensel et al. [5] report on the feasibility of augmenting self-reported data on adolescent women’s sexual decision-making with functional neuroimaging data. Adolescent sexual health researchers are increasingly aware that biological claims about how decision-making processes work at neurocognitive and affective levels must be substantiated by direct evidence of neurocognitive and affective processes, rather than by retrospective self-reports or behavioral observation, alone. Consequently, research by Hensel et al. sets a benchmark for evidence-based scholarship in the field of U.S.based adolescent health research. This research shares with other influential research on sexual health and decision-making a variety of assumptions about sexuality, gender, and human biological diversity. These assumptions can affect research processes. Along these lines, a number of methodological improvements can be made to adolescent sexual health research to ensure that research findings lead to optimal health care practice and public policy. Adolescent sexual health researchers can benefit from guidance on how to reduce the influence of problematic assumptions and ideology about sexuality, gender, and human biological diversity in their scientific research. Like most of their peers, Hensel et al. [5] did not ask participants how they would describe their sexuality or attractions. Instead, they asked participants to state their partner’s gender. They reported that most participants in this small sample of
young women had indicated “male” partners. This information was assumed to inform the researchers about participants’ sexual attractions. However, some participants may have a current partner of one gender while being attracted to or preferring a partner of another gender. Some participants may prefer relationship partners of one gender and sexual activity partners of another gender. Without asking directly about attraction, this information remains unknown. Attraction often differs from identity. For example, a nationally representative Australian sample found that women and men with same-gender attractions and/or experiences often do not self-identify using sexuality labels such as lesbian, bisexual, gay, or “homosexual” [6]. Same-gender-attracted people (who may or may not also be attracted to people of another gender) are often underrepresented because of the over-reliance on identity labels in sexual health research. Adolescent sexuality contains far more nuance than that is acknowledged by the ostensibly discrete categories of gay, lesbian, bisexual, and heterosexual. Adolescent self-descriptions of sexuality include omnisexual, pansexual, homoflexible, heteroflexible, woman-loving, man-loving, person-loving, queer, mostly straight, bi-curious, and many more [7]. In addition, the conflation of “male” with man and “female” with woman leads to the miscategorization or exclusion of people with intersex characteristics, women who were assigned as male, men who were assigned as female, and people with nonbinary genders [8,9]. Although people with nonbinary genders are typically ignored or excluded as “outliers” in sexual health research, a nationwide U.S. study of 6,450 “transgender and gender nonconforming people” found that 41% reported identifying as female or women, 26% were identified as male or men, 20% as living part time as one gender, part time as another, and 13% as “a gender not listed here” (GNL) [10]. Among participants who reported identifying as GNL, most of the 860 written responses were genderqueer, pangender, third gender, hybrid, and variations on genderqueer. Additional responses included transmasculine, transfeminine, twidget, birl, OtherWise, and
See Related Article p. 389
Conflicts of Interest: The author has no potential conflicts of interest of a real or perceived nature. 1054-139X/Ó 2015 Society for Adolescent Health and Medicine. All rights reserved. http://dx.doi.org/10.1016/j.jadohealth.2015.01.013
368
Editorial / Journal of Adolescent Health 56 (2015) 367e369
transgenderist. Respondents also used some of the many culturally specific gender categories such as Two-Spirit (First Nations), Mahuwahine (Hawaiian), and Aggressive (Black and/or African-American), further illustrating the ethnocentrism of the culturally restrictive gender categories typically used in adolescent sexual health research. Adolescents have diverse ways of classifying their relationships and sexual activity partners. Survey items and interviews that rely on concepts like “partner” or “relationship” are unlikely to capture the range of adolescent sexual and affectional engagements. Evidence suggests that most sexually active adolescents have engaged in sexual activity outside of relationships or “nonrelationship sex” [11]. Other common forms of adolescent sexual activity that occur outside of being “in a relationship” include “hooking up” and other colloquial language that does not fit readily into the research categories of “in a relationship”, “dating”, or “single” [12]. In one study, 60% of undergraduate university students reported having had “friends with benefits” situations, which the researchers defined as “when people who are ‘just friends’ have sex” [13]. Even seemingly concrete terms such as “dating” can be ambiguous. One study described four distinct ways in which university students use this term, including interactions that involve “loosely organized, undefined time together, without making their interest in one another explicit, unless they hook up, at which point dating and hooking up become the same thing” [14]. Adolescent sexual and romantic relationship configurations often transcend the dyadic conceptual limitations of the term “couple” [15]. Most sexual health researchers have yet to integrate an awareness of this diversity within romantic relationships and nonrelationship relating styles into study design. Researchers’ assumptions about what constitutes “having sex” can be misaligned with participants’ own understanding of their sexual behavior. Views of which behaviors constitute having “had sex” also vary widely between individuals, and definitions of sexual activity can be influenced by cultural factors [16e18]. In a study of 599 undergraduate university students in the Midwestern U.S., 59% of students classified oral-genital contact as not constituting having “had sex”; 19% stated that penile-anal intercourse did not count as having “had sex” [19]. The use of binaries such as “high risk” versus “low risk” and “heavy” versus “light” to describe sexual activity, combined with penetration-centric response options, may provide a far tidier impression of adolescent sexual behavior than is reflected by the evidence. For example, many women’s sexual activity with other women involves vaginal-vaginal contact that defies such categorization. Although decades of research have established the legitimate risk of HIV and STI transmission through vaginalvaginal contact, sexual health researchers continue to apply sexual activity categories that assume the presence of a penis and focus on “penetrative” sexual acts. The tendency to describe individuals who share particular sexuality, gender history or experience, or physical characteristics as a “community” may reduce the likelihood that researchers will seek representative samples beyond those with a visible public presence and a well-established social network of others who share these characteristics. Researchers have critiqued the oversampling of the “visible” sections of a hidden population, the limitations of retrospective reporting, and the difficulty with attempts to capture complex emotions in brief and often impersonal surveys [20].
This editorial has addressed only a few of the many ways that researchers’ assumptions and ideology about sexuality, gender, and human biological diversity can affect research methods, interpretations of findings, and “evidence-based” public health policy. Sexual health researchers can improve their research methodology by distinguishing between identity, behavior, experience, and attraction; by integrating an awareness of diverse adolescent relating styles and sexual behaviors into their study design; by moving beyond binary categories and forcedchoice, single option items; and by providing inclusive research design that acknowledges sexuality, gender, and physical diversity in “general” and “nationally representative” research and not only in research that studies a particular population such as lesbian adolescents or young women with intersex characteristics. Researchers can use culturally appropriate language that is ecologically valid and reflects adolescents’ diverse conceptual and linguistic frameworks. Researchers can avoid conflating individual experiences and identities with social networks and with publicly visible “communities” of people who share ostensibly similar experiences. Finally, researchers can appropriately contextualize their samples and avoid making overgeneralizations about their findings. Researchers can achieve these aims by acknowledging the limitations of their participant sampling (e.g., by adding language such as “a predominantly white, heterosexually identified urban U.S. sample” to their title and abstract); remembering that “the general population” includes people with a wide diversity of sexualities, relating styles, gender histories and experiences, gender identities, and physical characteristics; and incorporating the multidimensional and often overlapping permutations of these categories into study design. Acknowledgments The author thanks Israel Berger and Tucker Lieberman for editorial feedback. Funding Sources No funding was received for this publication. Y. Gavriel Ansara, M.Sc., Ph.D. Research & Policy Team National LGBTI Health Alliance Sydney, Australia
References [1] Clark LR, Brasseux C, Richmond D, et al. Are adolescents accurate in selfreport of frequencies of sexually transmitted diseases and pregnancies? J Adolesc Health 1997;21:91e6. [2] Gallo MF, Steiner MJ, Hobbs MM, et al. Biological markers of sexual activity: Tools for improving measurement in HIV/sexually transmitted infection prevention research. Sex Transm Dis 2013;40:447e52. [3] McCallum EB, Peterson ZD. Investigating the impact of inquiry mode on self-reported sexual behavior: Theoretical considerations and review of the literature. J Sex Res 2012;49:212e26. [4] Schroder KE, Carey MP, Vanable PA. Methodological challenges in research on sexual risk behavior: II. Accuracy of self-reports. Ann Behav Med 2003; 26:104e23. [5] Hensel DJ, Hummer TA, Acrurio LR, et al. Feasibility of functional neuroimaging to understand adolescent Women’s sexual decision making. J Adolesc Health 2015;56:389e95.
Editorial / Journal of Adolescent Health 56 (2015) 367e369 [6] Smith AM, Rissel CE, Richters J, et al. Sex in Australia: Sexual identity, sexual attraction and sexual experience among a representative sample of adults. Aust N Z J Public Health 2003;27:138e45. [7] Jacobson B, Donatone B. Homoflexibles, omnisexuals, and genderqueers: Group work with queer youth in cyberspace and face-to-face. Group Ther LGBT Pop 2009;33:223e34. [8] Ansara YG, Hegarty P. Methodologies of misgendering: Recommendations for reducing cisgenderism in psychological research. Feminism Psychol 2014;24:259e70. [9] Carrera MV, DePalma R, Lameiras M. Sex/gender identity: Moving beyond fixed and ‘natural’ categories. Sexualities 2012;15:995e1016. [10] Harrison J, Grant J, Herman JL. A gender not listed here: Genderqueers, gender rebels, and otherwise in the National Transgender Discrimination Survey. LGBTQ Public Policy J Harv Kennedy Sch 2012;2. Available at: http://escholarship.org/uc/item/2zj46213. Accessed January 27, 2015. [11] Manning WD, Giordano PC, Longmore MA. Hooking up: The relationship contexts of “nonrelationship” sex. J Adolesc Res 2006;21:459e83. [12] Calzo JP. Hookup sex versus romantic relationship sex in college: Why do we care and what do we do? J Adolesc Health 2013;52:515e6. [13] Bisson MA, Levine TR. Negotiating a friends with benefits relationship. Arch Sex Behav 2009;38:66e73.
369
[14] Glenn N, Marquardt, E. Hooking up, hanging out, and hoping for Mr. Right. College women on dating and mating today. In An Institute for American Values Report to the Independent Women’s Forum. New York: Institute for American Values. Available at: http://www.americanvalues.org/search/ item.php?id=18. [15] Matsick JL, Conley TD, Ziegler A, et al. Love and sex: Polyamorous relationships are perceived more favourably than swinging and open relationships. Psychol Sex 2014;5:339e48. [16] Carpenter LM. The ambiguity of “having sex”: The subjective experience of virginity loss in the United States. J Sex Res 2001;38:127e39. [17] Weiss E, Whelan D, Gupta GR. Gender, sexuality and HIV: Making a difference in the lives of young women in developing countries. Sex Relat Ther 2000;15:233e45. [18] Yon-Leau C, Muñoz-Laboy M. “I don’t like to say that I’m anything”: Sexuality politics and cultural critique among sexual-minority Latino youth. Sex Res Soc Pol 2010;7:105e17. [19] Sanders SA, Reinisch JM. Would you say you “had sex” if.? JAMA 1999; 281:275e7. [20] McDermott E, Roen K, Piela A. Hard-to-reach youth online: Methodological advances in self-harm research. Sex Res Soc Pol 2013;10: 125e34.
