Risk factors for adolescent sexual behavior, fertility, and sexually transmitted diseases.

Risk Factors for Adolescent Sexual Behavior, Fertility, and Sexually Transmitted Diseases John S. Santelli, Peter Beilenson

ABSTRACT: Current understanding of the risk factors related to adolescent initiation of sexual activity, use of contraception, pregnancy, and STDs is examined. From recent research on adolescent fertility, findings that have particular relevance to school health or reflect new understandings of adolescent sexuality are summarized. In selected cases, prevention programs that build directly on an understanding of these risk factors are cited. (J Sch Health. 1 W2;62(7):271-279)

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nderstanding the risk factors related to adolescent sexual behavior, pregnancy, and sexually transmitted diseases (STDs) is essential for early identification and care of “at risk” teens and for the design of primary and secondary prevention programs for schools and communities. Early identification of sexually active teens based on risk factors can facilitate timely entry into health counseling and use of contraceptive services. Early identification of pregnancy can allow adolescents to explore pregnancy options or can improve birth outcomes by facilitating entry into prenatal care. Knowledge of risk factors will inform the work of school nurses,health educators, and other school health personnel concerned with “children having children.” School nurses may be involved in early identification and counseling of sexually active or pregnant students. Health educators are involved in early identification and, through classroom education, are essential to primary and secondary prevention. All school professionals can be involved by ensuring that comprehensive, schol-based prevention programs are firmly grounded in an understanding of young people’s fertility-related behavior. Much was learned in the 1970s and 1980s about the factors that encourage and limit teen-age sexual activity, the use of contraception, and the decision to continue or terminate a pregnan~y.’-~ Studies of adolescent female fertility have grown increasingly sophisticated with the use of multiple regression techniques that allow one to assess the relative importance of multiple factors simultaneously.* However, much remains to be understood about the relative importance of individual risk factors. In this review, the current understanding of the risk factors for adolescent initiation of sexual activity, use of contraception, pregnancy, and STDs is examined. From the enormous volume of recent research on adolescent fertility, findings that have particular relevance to school health or reflect new understandings of adolescent sexuality are summarized. In selected cases prevention programs that build directly on an understanding of these risk factors are cited. More indepth analysis of risk factors is contained el~ewhere.l.*.~ John S. Santelli. MD, MPH. Medical Epidemiologist, Behavioral and Prevention Research Branch, Division of STD/HIV Prevention, National Centerfor Prevention Services, Centersfor Disease Control, IMX) Clifton Road (E-44), Atlanta, GA 30333. Peter Beilenson, MD, MPH, Director, School and Adolescent Health Services, Baltimore City Health Dept., 303 E. Fayette St., 2nd Floor, Baltimore, MD 21202.

INTERMEDIATE DETERMINANTS OF FERTILITY While cultural and certain biological factors have an enormous influence on adolescent fertility, numerous biopsychosocial factors (Figure 1) affect the sequence of fertility only through intermediate factors: intercourse, conception, and pregnancy outcome. Davis and Blake’ first described this analytic framework. Hofferthl elaborated on this model focusing on the interactions among psychosocial and biological variables in explaining the initiation of intercourse. While the biological reality of this framework seems self-evident, it often is ignored in discussions about teen-age pregnancy prevention that focus on general strategies such as raising selfesteem. Given this framework for fertility among all women, among teen-agers, childbearing is most influenced by 1) age at first intercourse, 2) use of contraception, and 3) pregnancy termination. Frequency of intercourse also is important though less is known about frequency than age at initiation of intercourse.6 Biopsychosocial risk factors that are most influential at one step in the sequence of adolescent fertility-related behaviors may not be as influential at other steps. Based on the 1988 National Survey of Family Growth,7S8race has declined in importance as a predictor of sexual activity initiation for older teens. However, race continues to have a sizeable influence on the likelihood of using contraception. Sexual experience, ever having had coitus, and sexual frequency show different demographic patterm6 In a similar way, research9-11suggests that family communication has little or no influence on an adolescent’s “decision” to engage in sexual activity. Family communication may have a greater influence on the adolescent’s use of contraception4J2 and access to abortion.I3J4 For STDs, a similar set of intermediate factors are operative (Figure 1). The most important intermediate factors for teens are 1) age at initiation and frequency of partner switching or number of partners, 2) safer sexual practices and use of protection, and 3) use of treatment services. The literature on teen-age pregnancy has emphasized young women, but given the current importance of STDs and HIV, there has been a rediscovery of young men. While the quantity of research on adolescent male fertility has lagged behind that for adolescent female fertility, the level of methodological sophistication in recent studies of male fertility has improved greatly.15n’6 Finally, an exploration of intermediate factors underlines an important philosophical debate that has

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major implications for prevention programs. In essence, which is the problem: teen sexual activity or the consequences of teen sexual activity - teen childbearing, abortion, and STDs? Discussions of teen sexuality in the school context often obscure the precise issue. Adults must clearly articulate their goals if they expect to create effective prevention programs. Without such clarity, teens are not likely to understand or to make the behavior changes necessary to prevent pregnancy and STDs. Teens do not seem to have a problem dealing with dual goals; several prevention programs have been successfully implemented that focus simultaneously on delaying initiation of sexual intercourse and increasing the use of protection for sexually active teens.17J* The remainder of this article focuses on biopsychosocial risk factors for the key intermediate factors determining fertility and acquisition of STDs.

BI0 PSYCHOSOCIA 1 FACTORS Demographics

Demographic factors - age, ethnicity, and gender are important correlates of sexual intercourse initiation. 19 The percentage of adolescents who have experienced

Sexually Transmitted Diseases: IntermediateVariables

sexual intercourse rises rapidly between the early teens and early 20s. National surveys of youth in the 1970sZ0 and 1980s' document continuing increases in the percentage of 15-19-year-old women reporting premarital intercourse. The median age for first intercourse for women declined from age 19 in 1971 to approximately age 16.5 in 1988. A similar decline probably occurred for young men though this was not well documented. The median age for initiating sexual intercourse among adolescent men averages about one year earlier than that of women.zo Age is tied intrinsically to several adolescent developmental sequences: physical/hormonal changes, psychosocial development, life experience, and duration of exposure to other risk factors. Geography

Adolescent fertility varies among developed nations;* U.S.teens initiate intercourse at about the same age as western European and Canadian teens but are more likely to become pregnant. Clearly, effective contraception use is lower in the U.S.Regional differences within the U.S. are less prominent than these international ones.

Flgura 1 Bloprychoracisl Factors

Fertiii Intermedlatevariabies Intercourse

intercourse

A e at First Bntercourse Frequencyof Partner Switching Partner Choice/ Partner's Sexual Activitv

Use of Condoms/ Spermicide Use of Other Barrier Methods 7 Use of Oral Contraceptives

Access to Treatment

I

I

Biopsychosociai Determinants

Protection

Detectionflreatment

A e at First Bntercourse Frequencyof Intercourse Periodic Abstinence

Poverty Race/Ethnicity

f

Religiosity Puberty Peers School RiskTaking Behavior Family

9

Pregnancy Outcome Abortion Miscarriage LiveBirth

I

Birth Outcome

Short T e M o n g Term Consequences Sterility Cancer Chronic Ectopic Pain Pregnancy Death Perlnatal infection Transmissionto Others

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Use of Oral Contraceptives Use of Condoms Withdrawal, and other methods


Parenthood


Poverty and Ethnicity

Poverty and ethnicity have traditionally been important risk factors for initiation of sexual activity, contraception use, pregnancy, and parenthood. Because ethnicity and socioeconomic status (SES) are closely linked, and SES is difficult to measure in adolescents, it often is difficult to disentangle these. Nevertheless, ethnic differences diminish or disappear when the effect of SES and other social factors are statistically controlled.2 z Black teens living in impoverished neighborhoods are more likely to initiate sexual intercourse than Black peers not living in impoverished areas.*’ Likewise, ethnic differences in sexual initiation are mitigated when Black and White teens attend integrated school^.^^ As noted, during the 1970s and 1980s ethnic differences in the age of initiation of sexual intercourse narrowed considerably, as have differences between adolescents above and below the poverty The largest differences in sexual experience between Black and White adolescents exist at the youngest ages ( 16 years). Important ethnic and SES differences remain in use of contraception’ and abortions by teens.zs Consequently, rates of childbearing also remained higher in poor, minority communities. Religion

Religious practice and belief exert a protective effect in preventing early sexual initiation.* The strength of religious practice and belief is more important than belonging to any particular religious group.’ Young people who attend church frequently and who value religion in their lives have the least permissive sexual attitudes and are less sexually experienced;*6religious affiliation seems to be much less important.2 Religious young women, if sexually active, are less likely to use contraception. Sexual behavior and attitudes also may influence religious involvement; early initiation of sexual intercourse may result in reduced religious participation.*6 School Performance Teens who have low academic achievement, low academic ability, and low educational goals are more likely to experience sexual intercourse at an early age.1J,27,28 An adolescent’s negative experience with school also has been associated with early sexual activityz9and pregnan~y.~~J~J’ Difficulty in school also places males at risk for impregnating their partners.” Young women with higher achievement and a strong future orientation are more likely to choose to terminate a pregnan~y.~ Students performing poorly may engage in early sexual activity or become pregnant as alternatives to continued involvement in self-devaluing school experiences.zoLikewise, positive school experiences may result from the availability of personal, family, or other social resources that also protect the adolescent from a pregnancy. Higher SES and higher educational goals are related; better educated parents tend to have greater incomes. A lack of social resources may result in scholastic difficulties as well as initiation of early sexual activity and subsequent pregnancy. Family Factors

Family infuence has been examined in several con-

texts: the amount of parent-child communication concerning sexual matters, parental permissiveness, parent’s control of dating, family structure, and parent’s own dating/sexual behavior. These factors do not equally influence adolescent sexual activity, and they may have differential effects on initiation and use of contraception. Teen-parent communication does not seem very influential. First, not much communication exists between adolescents and their parents - especially fathers about reproductive mattem3* Teenagers’ primary sources of information on sexual issues are friends and partners. Most studies suggest no or, at best, minimal effects of family communication on initiation of sexual intercours&” except perhaps in certain subgroups such as daughters of parents with traditional values. l o Consistency between teens’ values and parents’ values and the closeness of family ties appear to be important factors in delaying a teen’s sexual b e h a v i ~ r . ~ Similarly, ~ . ~ ~ . ~ ~quality of the motherdaughter relationship may be positively correlated with the daughter’s decision to delay intercourse.” Parental attitudes in one study showed no effect on frequency of intercourse but were strongly related to use of contraception. ’ Hogan and Kitigawa’) showed that parental control of dating - supervision and control over hours, locations, and partners- was a strong inhibitor of adolescent sexual activity and pregnancy. This was true even after controlling for numerous other social risk factors. Early and frequent dating have been associated with and more perearly initiation of sexual missive attitudes towards premarital sex37.38Teens, especially females, in “committed relationships” where they are going steady with or are engaged to their partner - are more likely to initiate coitus. Teens in committed relationships also are more likely to have planned their first act of sexual intercourse than teens who initiated coitus with an acquaintance or more casual partner. Miller et al” found a curvilinear relationship between adolescents’ perception of parental permissiveness and the likelihood of having initiated intercourse. Children who view their parents as having few dating rules have the highest sexual experience, followed by teens having parents with “traditional” values. The lowest rates of sexual experience were associated with parents perceived to be moderately strict.js In contrast, Newcomer and Udry‘O found parental attitudes did not influence teen’s sexual behavior. In the Miller study, teens were reporting their perceptions of their parent’s attitudes, while Newcomer and Udry used parents’ actual attitudes. Teens’ perceptions of adults rules and attitudes may be more important in affecting adolescent fertility than adults’ actual attitudes. Newcomer and Udry‘O found a direct relationship between a mother’s level of sexual experience at various ages and the age for these same sexual behaviors for sons and daughters. This effect was not explained by attitudinal measures and they speculate this association may reflect a direct biological process such as age at physical maturity. Family structure or configuration such as coming



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from a single-parent family, having a sister that is a teen mother, or having a greater number of siblings may increase the likelihood of an adolescent engaging in sexual activity or becoming pregnant.23J9,41.42 Miller,41in a study controlling for other social factors, found a small effect of single-parent families but no effect of siblings on adolescent sexual initiation. Other factors such as low parent-friend compatibility have been suggested as possible risk factors for adolescent sexual activity.’ In sum, research on parents and teen-agers would suggest communication with parents is not important in influencing adolescent sexual behavior. The closeness of the relationship between adolescent and parents and firm and consistent rules about dating are much more important. Peer Influences

At adolescence, the peer group rivals and even supplants the family as a source of social influence. Not surprisingly, peers have been found to influence a range of behaviors including smoking43and ~ e x u a l i t y ?The ~.~ sexual behavior of adolescent boys and girls is influenced by the sexual behavior of best, same-sex friendsd5 and of close friends of both sexes.‘) Self-selection bias may explain some of this effect since teens pick their friends, at least in part, based on their friends’ behaviors Some programs have used peer educators or counselors to promote abstinence in teen-agers.I7J8 Using peer educators to promote contraception or protection from STDs is a potentially promising approach. .Isa

Puberty

Adolescent “hormones” often have been used as an explanation for adolescent behavior and misbehavior. Circulating (blood) levels of endogenous horm0neS0~.~ and physical de~elopment,‘~ and menarche**correlate highly with sexual motivation and behavior. Pubertal development as measured by secondary sexual characteristics such as pubic hair, breast development, and menarche are controlled by endogenous androgens and estrogen. For girls, androgen-mediated and estrogen-mediated development are independent influences in the initiation of sexual activity.‘$ Physically immature girls are much less influenced by the sexual behavior of their friends.” For boys, androgen-mediated development influences sexual motivation and behavior.” The free testosterone index (FTI) is the principal predictor of sexual motivation (libido). Once FTI is considered, there is no independent effect of physical development or age.48This is interpreted by Udry as a direct effect of testosterone. The close relationship between pubertal development, the pubertal hormones that control development, and the social interpretation of physical maturity has sparked debate over the relative importance of these in emerging teen sexuality. Ten years ago, the predominant explanation for sexual behavior was the social interpretation of physical development.’ According to this theory, the adolescent is perceived as sexually attractive and begins to be treated as a possible sexual partner.45 Udry and colleagues provide strong evidence for a direct effect of hormones.

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Social interpretation of development may be more important for girls.“ Combining biological (hormonal) variables and sociological variables in a single biosocial logistic regression model is more predictive of adolescent sexual behavior for both sexes than a model that contains only biological or social variables .22.45e47

Risk-Taking or Problem Behavior

Risk-taking or problem behavior has emerged as a central concept in understanding adolescent morbidity and mortality. Early initiation of sexual activity has been linked to problem drinking, drug use, smoking, poor school performance, and delinquent behavior in both Black and White teens.2994s54There is a growing understanding of the clustering of risk-taking behaviors.35-56 Problem behaviors increase sharply with age during adolescence and are inversely correlated with such conventional behaviors as church attendance and school achievement. Donovan and Jessors5 suggested problem behaviors are linked by an underlying construction they call “unconventionality.” Dryfoos5’ has estimated that as many as one-half of all teens show risk for involvement with problem behavior, with 15% at high risk (engaged in 2 or 3 behaviors) and an additional 10% at very high risk (multiple behaviors, heavy involvement). Drugs

Drug use, a risk-taking behavior, has a unique influence on sexual behavior. Drugs are frequently used before sexual intercourse and may decrease inhibitions, as well as impair the use of situation-dependent contraceptives such as condoms and the diaphragm. Rosenbaum and KandelJ3and ZabinJ0found strong associations between substance use and early sexual activity, even after controlling for various sociodemographic factors. The influence of drug use and sexual activity are reciprocal,J1 as seen in longitudinal studies; initiation of either behavior may lead to the other. The influence of drug use on sexual behaviors is also substance specific. Most disturbing are the associations of crack cocaine to the exchange of sex for drugs and money, multiple sexual encounters in a single day, and sexually transmitted diseases and HIV.58Crack, is highly addictive, functions as an aphrodisiac, and is associated with binging because of the very short high (2-20 minutes). Sexual Abuse

The relationship between sexual abuse and early initiation of teen-age sexual activity or pregnancy is not well described in the literature. Many clinicians recognize sexual abuse is not uncommon before age 15 and that a first sexual experience, particularly at a very young age, may involve rape or incest. In a national sample, 7% of young people ages 18-22 reported at least one episode of nonvoluntary intercour~e.’~ For women, one-half these episodes occurred before age 14. These data suggest that a substantial percentage of sexually active women under age 16 have experienced nonvoluntary sexual intercourse. In a study of Illinois teen-age mothers,60 61% reported some unwanted sexual experience and 33% reported unwanted sexual intercourse. Mean age for


first occurrence of these coercive sexual experiences was 11.5 years. The age of the abuser at first episode of abuse was much higher; 50% were 21 years or older. This age is much higher than the age reported for fathers of children with adolescent mothers. In another study of teen-age mothers from Washington state,6Lage at first intercourse was 13.2 years among abused and 14.5 years among nonabused mothers. More research is needed to better understand the relationship between sexual abuse and early onset of sexual activity. Self-Esteem and Psychological Variables

Most studies of teen-age pregnancy have focused on social variables. Psychological variables include intentions or values such as perceived ideal age for marriage or perceived value on independence, development status, or psychological states such as self-esteem or depression. Jessor6' found several measures associated with early onset of intercourse: value on independence, tolerance of deviance, and lower value on academic achievement. In general, research into adolescent sexuality and fertility often has not documented direct relationships between psychological variables and behaviors. This may relate to difficulties in measuring psychological variables. Likewise, psychological variables may be closely tied to other variables such as physical maturity and age. Some researchers have found paradoxical results. Bingham et al'* found age at first intercourse directly correlated with ideal age for first birth but inversely correlated with ideal age for first marraige. While raising self-esteem has been suggested as a prevention strategy, the connection of self-esteem to fertility-related behavior is unclear.'J7 Several researchers have found higher self-esteem among sexually experienced b o y ~ . OrP3 ~ ~ J found ~ no relationship of self-esteem to sexual experience in boys but lower selfesteem was related to sexual experience in girls. Others have found no relationship between these for girls. I Orr found lower self-esteem was associated with a history of STDs for both boys and girls. School Health Education and School-Based Clinics

Just as it is necessary to point out the risk factors that contribute to initiation of sexual intercourse, it is necessary to point out two important factors that do not seem to increase risk. Several studies have documented that neither school sex e d ~ c a t i o n ~nor ~ - school ~~ c l i n i c ~ increase ~ ~ . ~ ~ the rate of sexual activity among teen-agers. Zabin6' found availability of in-school counseling and school-linked reproductive health services actually resulted in a small delay in onset of first coitus. Marsiglio and Mott6' found a small increase in sexual activity among those who had received sex education at ages 15-16but not at ages 17-18.This effect was weaker than other significant predictors of first intercourse. Sexuality education clearly increases knowledge levels- and increases the use of contraception when teen-agers become sexually active.as65 Unfortunately, 40% to 50010 of teen-agers initiate sexual intercourse before they ever receive sex education.64School clinics also may increase contraceptive use among teen-ager~.~~,~ Opponents of school health programming often have incorrectly suggested that providing education or

health services encourages young people to engage in sexual activity. While little scientific evidence supports this contention, it has served as an unfortunate barrier to school health programs in some communities. CONTRACEPTIVE USE/STD PROTECTION Less is known about the social determinants of adolescent use of contraception and STD protection. This is especially true for males and for the use of condoms to prevent STDs and HIV infection. Studies on contraceptive use have focused on college students, a group which has little relevance to young teens. Periodic abstinence, temporary non-involvement in sexual activity, is a major, if unreliable, source of protection from both pregnancy and STDs; it is seldom considered a contraceptive choice. The demographics of contraceptive and clinic use are somewhat better understood. The most helpful measures for clinicians and researchers are use at first intercourse, use at last intercourse (current use), and delay time between first intercourse and first clinic visit to obtain contraception. Demographics of Contraceptive Use

While adolescent use of protection has improved over the past 20 years, many teen-agers never use protection and many others use it inconsistently. For first sexual experiences, male methods, including condoms and withdrawal, predominate. The 1988 National Survey of Family Growth (NSFG) showed contraception use at first intercourse by young women increased substantially over the 1982 NSFG from 48% to 65%! Use of the pill did not change (8.2%) but condom use increased sharply (22.6% vs. 47.4% at first coitus). Ethnic and income differentials in contraception use at first intercourse remain considerable. While Black and Hispanic teens made large strides during the past decade, both groups still lag substantially behind White teens in use at first intercourse (54.1% and 53.9% vs. 69.0%, respectively). Much of the difference is related to SES. Large differences remain between teens above and below 200% of poverty (72.6% vs. 57.8%). Surveys of young men also reveal a considerable increase in condom use during the 198Os.l5Reported use of condoms at last intercourse among young men ages 17-19increased from 21.1% to 57.5% between 1982 and 1988.Higher use of condoms was reported by men who had ever had homosexual intercourse, ever had an STD, and those with only one partner in the past year. Unfortunately, lower condom use was reported by young men with other STD/HIV risk factors, such as IV drug use and having five or more sexual partners in the past year. With increased time in a relationship adolescents shift from predominantly male methods of protection such as condoms and withdrawal to predominately female methods such as the birth control pill.7*12.20 Currently, the pill and condoms account for almost all methods used by teens.' Current use of the pill declined between 1982 and 1988 (64% to 59%),' which follows a Condom use as a cursimilar decline in the late 1970~.'~ rent method increased from 21 070 to 33%. The percentage of adolescents not using contraception declined from 9.9070to 7.6%.



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Determinants of Contraceptive Use

Hogan, Astone, and K i t i g a ~ in a ~a~study of unmarried Black adolescents from Chicago found clear social and environmental predictors for use of contraception at first intercourse for both young women and young men. Higher social class, married parents, and improved neighborhood quality all predicted contraceptive use in young women. Social class also was a significant predictor for adolescent men. For both sexes career aspirations showed a small effect in predicting contraception use at first intercourse. Hogan et a1 found social factors had little effect in influencing initiation of contraception beyond first intercourse. Nathanson and Becker’O examined the influence of family and peers on young women seeking contraception from a family planning clinic for the first time. They found considerable influence and support of both family and peers in young women’s contraceptive seeking. Young Black women were more likely to report parental involvement, while more affluent White women were least likely to report this. Milan,” reviewing studies of middle class, White, young adults, found little importance of parents in contraceptive behavior. Nathanson and Becker suggest that parent and peer support for contraception may represent alternative strategies. In two reviews of interpersonal (psychosocial) factors of adolescent contraceptive several potential factors were identified. Using meta-analysis, Whitley” found partner influence, acceptance of one’s sexuality, future orientation, positive attitudes toward contraception, an exclusive sexual relationship and frequency of intercourse influenced contraceptive use by young women. Major influences for young men were partners, frequency of intercourse, the positive attitudes towards contraception. Milan” found a variety of factors influencing contraceptive use including increased sexual experience, length, stability, or seriousness of a relationship, frequency of intercourse, communication with partners about contraception, partner support or opposition, parental attitudes, and parental communication. Planning first intercourse is strongly related to use of contraception at first intercourse, though planning itself is uncommon.36 This is true for both male and female methods. Clinic Use

Use of family planning clinics is an important factor in contraceptive use, especially for young women and poor women. A long delay exists between the onset of teen sexual activity and the first attempt to seek family The median planning care from a medical pro~ider.~’ delay is between nine and 12 months. The delay is longest for the youngest adolescent^.'^ Parents and friends are the main sources of referrals to family planning, For those under age 17, parents are a more important referral than friends. Of those young women presenting to a family planning clinic for the first time, one-third had come because they already suspected pregnancy.72Fear of pregnancy is the most common reason cited for making a first clinic visit. Adolescents give a variety of reasons for

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delaying clinic care including “just didn’t get around to it,” fear of family finding out about their clinic attendance, fear of being examined, thinking birth control is dangerous, and waiting for a closer relationship with their partner. This early period between initiation of sexual activity and a clinic visit is a vulnerable period for the adolescent because contraceptive use is poor and the risk of pregnancy is high. Zabin et al” found one-half of premarital first pregnancies to teen-agers occurred within six months of beginning sexual intercourse. Onefifth of first pregnancies occurred in the first month. Fear of contraceptive side effects, desire for pregnancy, and ambiguous feelings about one’s sexuality are common reasons why reproducitve health services are not used. DuRant et a P found compliance with initial contraceptive methods was important in predicting later use of contraception. In a multiple logistic model, five factors in descending order of importance influenced current contraceptive use: initial compliance with a method, not receiving contraception at first family planning visit, number of clinic visits, coital frequency, and the delay in accessing reproductive health care.” A 1985 international study has re-emphasized the United States’ failure in providing contraception to adolescents. Jones et a12’ compared the U.S. experience with teen-age sexuality, pregnancy, and abortion with that of five western countries. While American teenagers were no more likely to be sexually experienced, they were approximately twice as likely to become pregnant. Jones et a1 suggest that greater accessibility of contraceptive services, greater openness about sexuality, and the provision of sex education in those European countries account for much of the difference.

DETERMINANTS OF PREGNANCY CONTINUATION OR ABORTION Teen-agers undergo one-third of all abortions. Among school-age teens the ratio of abortions to live births begins to approach one to one. Factors increasing the likelihood of voluntary pregnancy termination include whether the pregnancy was unintended, younger age, better school performance and a strong future orientation, higher parental educational attainment and socioeconomic status, having less religious involvement, and more negative attitudes towards pregnancy from peers and boyfriends.’ Parents may be a major influence, especially for younger teens. Higher parental educational attainment is likely to increase the likelihood that a teen will have an abgrtion.zs Black and poor teens are less likely to choose abortion. Legalization and access to abortion services are important factors in determining the likelihood that a pregnancy will terminate in abortion. DETERMINANTS OF SEXUALLY TRANSMITTED DISEASES Sexually experienced adolescents have the highest rates of sexually transmitted diseases (STD) of any age group.76The number of STD cases contracted by teenagers probably rivals the number of teen-age pregnancies. There were 175,000 cases of gonorrhea reported in 1989 among teens.” Rates of gonorrhea, the most commonly


reported STD, increased dramatically among all age While 44.9% of white women ages 15-19 are sexually groups between the mid 1960s and the mid 1 9 7 0 ~ ~ experienced, ~ only 28.0% have had sex in the past Since 1980, rates have declined for all age/gender groups month, and only 14.9% have been consistently active except for men ages 15-19.” Rates for teen-age women during the past 12 months. Better understanding is have declined more slowly than rates for older women. needed of these adolescent sexual behaviors. Rates for Black teens actually increased between 1981 and 1988, accentuating ethnic difference^.^^ Black teenUsing Risk Factors for Prevention age males have reported rates of gonorrhea 44 times Understanding risk factors can contribute to those of White teen-age males.77For teen-age women, the successful school-based efforts to prevent adolescent difference is sixteen fold. These differences reflect many pregnancy and sexually transmitted diseases. Risk factors including poverty, differential access to health factors can be roughly divided into three groups: services, different ages at initiation of sexual activity, 1) those that cannot be changed or changed with great differential use of protection, and differential report2) those that can be changed primarily through effort, ing. A surge in cases of syphilis since 1985 has been community-based interventions, and 3) those that can linked to crack use and the exchange of drugs for sex be directly affected by school-based efforts. The first and money.” STDs for teen-agers are enormously costgroup cannot be changed: age, ethnicity, early physical ly, considering both short-term treatment costs and maturation, or changed only by massive social transforlong-term outcomes such as sterility, fetal damage, mation; such as poverty and family structure. However, cervical cancer from Human Papilloma Virus, and these immutable factors can be used to target primary death from sexually-transmitted HIV infection. prevention programs and to provide secondary prevention, screening, and early identification. For example, Intermediate Factors for STD Acquisition early maturing students can be confidentially counseled The probability of someone acquiring an STD is the and assessed by the school nurse. School clinics can product of certain sexual behaviors including age at first routinely screen for evidence of prior sexual abuse as intercourse, partner switching, and frequency of interpart of comprehensive care to teens. course, protective behaviors such as use of condoms, The second group of risk factors can be influenced and the likelihood of encountering the particular by special programs but these programs need the inorganism during sexual activity. The latter is determined volvement of the larger community: family and parent by community prevalence, the choice of partners, and factors and religion. These factors can be altered the sexual behavior of that partner. These behaviors are directly or used to target interventions. Schools can socially mediated. The research literature on social create partnerships with community groups and antecedents of sexually transmitted disease is extremely institutions, including churches, that are interested in thin, beyond the examination of demographic factors promoting adolescent reproductive health. Parentand proximal antecedents such as sexual behavior. focused programs are another example. Given the Many studies are clinic-based making the study of social understanding of family factors, programs need to stop risk factors problematic. Attempts to perform national focusing on family communication alone. Parenting programs that focus on skills building for parents and surveys of sexual behaviors in teens and adults has been providing social support to parents could be very mired in political dispute. effective. Parenting a teen-ager presents a new set of The biology, prevalence, and sequelae of each STD challenges to a parent; it requires new skills, particularly are distinct. Infection with one STD puts an adolescent regarding limit setting with dating. These skills can be at risk for being infected with other STDs, reflecting enhanced. Likewise, parents need support regarding both biological and social risk factors. Co-infection of limit setting. Fostering teen-parent communication may gonorrhea with chlamydia and of these two with vaginal increase the use of contraception. infections is common. Syphilis is highly associated with Finally, schools can directly address the third group HIV infection” which is thought to be a direct effect of of risk factors. These include peer influences, educasyphilis because it breaks down skin barriers and allows tional success, sex education and clinical services, and HIV to enter the body. A discussion of individual STDs other risk-taking behaviors. Peer educators have been is beyond the scope of this review. used successfully in programs to delay adolescent initiaThe understanding of periodic abstinence, frequency tion of sexual a~tivity.1~9’~ Peer influencs can be used in of intercourse, and partner switching is not strong6Few media materials to model preventive health behaviors or teens identify themselves as having multiple concurrent provide social endorsement for behavior change,79and sexual partners and partner switching is common. also could be used to promote use of contraception or Among sexually experienced teen-age women, 8% have reproductive health services. had two or more sexual partners in the past three Programs that foster educational success or increase months. This compares to 6% of women ages 20-24 and involvement in school may help prevent teen pregnancy 2% of women ages 30-44.’ For sexually experienced or STDs. Students performing below average or inwomen ages 18-19, 34% have had two or more partners volved in other problem behaviors can be targeted for in the past 12 months. For men ages 18-19, more than special prevention programs. This targeting can be done one-half have had two or more partners. These compare individually or by the school. Likewise, effective drug to 13% of women and 25% of men ages 18-44. prevention or treatment programs and programs designConversely, periodic abstinence for varying lengths ed to prevent other risk-taking behaviors may have of time is common among sexually experienced teem6 beneficial effects on reproductive behavior. Such efforts Few teens are consistently having sex on a weekly basis.



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may be more effective as part of a comprehensive effort to promote adolescent health and well-being. Sex education can promote a realistic understanding of contraception and decrease the myths that serve as barriers to contraceptive use. Schools can be vigorously involved in promoting condoms and contraception to sexually active teens. School-based clinics (SBC) and schoollinked clinics (SLC)may increase contraception use and decrease the delay time from initiation of sexual activity to first clinic visit for reproductive health ser~ices.~’ SBC and SLC clinics also can provide counseling and treatment for STDs.

CONCLUSION The biopsychosocial conditions that help explain teenage sexuality are important influences on young people. They work powerfully yet differentially on the intermediate stages of adolescent sexuality/fertility: initiation of intercourse, use contraception/clinics, and decisions to continue a pregnancy. Importantly, they influence the likelihood that a teen-ager will become infected with STD and HIV. The risk factors for adolescent sexual behavior/fertility can serve as warning signs to alert school health practitioners and the community to those adolescents most in need of assistance. They can help sensitize us to the difficult circumstances that many teens must overcome. An understnding of risk factors can form the basis for theoretically-grounded, effective programs to prevent the tragic consequences of these adolescent behaviors. m References 1. Hofferth SL. Factors affecting initiation of sexual intercourse. In: Hayes CD, ed. Risking the Future: Adolescent Sexuality, Pregnancy, and Childbearing - Yo1 2. Washington, DC: National Academy Press; 1987. 2. Miller BC, Moore KA. Adolescent sexual behavior, pregnancy, and parenting: research through the 1980’s. J Marriage Fam. 1990;52: 1025-1044. 3. McAnarney ER, Schreider C. Identvying Social and Psychological Antecedents of Adolescent Pregnancy: The contribution of research fo concepts of prevention. New York, NY: William T Grant Foundation Publications; 1984. 4. Hayes CD, ed. Risking the Future: Adolescent sexuality, pregnancy, and childbearing - Yo1 I , (Chapter 4). Washington, DC: National Academy Press; 1987. 5 . Davis K, Blake J. Social structure and fertility: An analytical framework. Econ Dev Cult Change. 19564211-235. 6. Aral SO, Cates W. The multiple dimensions of sexual behavior as risk factor for sexually transmitted disease: The sexually experienced are not necessarily sexually active. Sex Trans Dis. 1989; 16:173-177. 7. Mosher WD. Contraceptive practice in the United States, 1982-1988. Farn Plann Perspect. 1990;22:198-u)S. 8. Forrest JD, Singh S. The sexual and reproductive behavior of American women, 1982-1988. Farn Plann Perspect. 1990;22:206-214. 9. Furstenberg FF, Herceg-Baron R, Shea R, et al. Family communication and teenagers contraceptive use. Fam Plann Perspect. 1984; 16:163-170. 10. Moore KA, Peterson JL, Furstenberg FF. Parental attitudes and the occurrence of early sexual activity. J Marriage Farn. 1986;48: 777-782. 11. Newcomer SF, Udry JR. Parent-child communication and adolescent sexual behavior. Farn Plann Perspect. 1985;17:169-174. 12. Milan RJ, Kilmann PR. Interpersonal factors in premarital contraception. J Sex Res. 1987;23:289-321. 13. Eisen M, Zellman GL, Leibowitz A, Chow WK, Evans JR. Factors discriminating pregnancy resolution decisions of unmarried adolescents. Genet Psycho1 Monogr. 1983;108:69-95.

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46. Rodgers JL, Billy JOG,Udry JR. A model of friendship similarity in mildly deviant behaviors. J Appl SOC Pyschol. 1984;14: 413-425. 47. Udry JR. Biological predispositions and social control in adolescent sexual behavior. A m SOCRev. 1988;53:709-722. 48. Udry JR, Billy JOG,Morris NM, Groff TR. Raj MH. Serum

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50. Zabin LS, Hardy JB, Smith EA, Hirsch MB. Substance use and its relation to sexual activity among inner-city adolescents. J Adolesc Health Core. 1986;7:320-331. 51. Mott FL, Haurin RJ. Linkages between sexual activity and alcohol and drug use among American adolescents. Farn Plann Perspect. 1988;u): 128-136. 52. Ensminger ME. Adolescent sexual behavior as it relates to other transition behaviors in youth. In: Hayes CD. Risking the Future: adolescent sexuality, pregnancy, and childbearing - Vol 2 Washington, DC: National Academy Press; 1987. 53. Rosenbaum E, Kandel DB. Early onset of adolescent sexual behavior and drug involvement. J Marriage Fom. 1990;52:783-798. 54. Orr DP, Beiter M,Ingersoll G. Premature sexual activity as an indicator of psychosocial risk. Pediatrics. 1991;87: 141-147.

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Statement of Purpose The Journal of School Health, an official publication of the American School Health Association, p u b l i e s material related to health promotion in school settings. Journal readership includes administrators, educators, nurses, physicians, dentists, dental hygienists, psychologists, courwlors, social workers, nutritionists, dietitians, and other health professionals. These individuals work cooperatively with parents and the community to achieve the common goal of providing children and adolescents with the programs, services, and environment necessary to promote health and to improve learning. Contributed manuscripts are considered for publication in the following categories: general articles, research papers, commentaries, teaching techniques, and health service applications. Primary consideration is given to manuscripts related to the health of children and adolescents, and to the health of employees, in public and private pre-schools and child day care centers, kindergartens, elementary schools, middle level schools, and senior high schools. Manuscripts related to college-age young adults will be considered if the topic has implications for health programs in p d o o b through grade 12.Relevant international manuscripts also will be considered. Prior to submitting a manuscript, prospective authors should review the most recent ”Guidelines for Authors.” The guidelines are printed periodically in the Journal; copies also may be obtained from the Journal office, P.O.Box 708. Kent, OH 44240.



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Behavioral risk factors for sexually transmitted diseases in American households.

Patterns of adolescent sexual behavior predicting young adult sexually transmitted infections: a latent class analysis approach.

Risk behaviors for sexually transmitted diseases among crack users.

Sexually transmitted diseases.

Sexually transmitted diseases.

Sexually transmitted enteric diseases.

Sexually transmitted diseases.

Sexually transmitted diseases and travelers.

Women and sexually transmitted diseases.

Adolescents and sexually transmitted diseases.

Sexually Transmitted Infection Prevention Messaging: Targeting Root Causes of Sexual Risk Behavior.

Factors associated with sexually transmitted diseases among prostitutes in Singapore.

Sexually transmitted diseases in Africa.

Teaching about sexually transmitted diseases.

Sexually transmitted diseases in Ontario.

Sexually transmitted diseases in children.

Identifying Adolescent Patients at Risk for Sexually Transmitted Infections: Development of a Brief Sexual Health Screening Survey.

Sexually transmitted and anorectal infectious diseases.

Human papillomavirus vaccine-related risk perceptions and subsequent sexual behaviors and sexually transmitted infections among vaccinated adolescent women.

Sexually transmitted diseases and the mobility explosion.

Illness behaviour and sexually transmitted diseases.

Sexually transmitted diseases and tubal pregnancy.

Incident sexually transmitted infection as a biomarker for high-risk sexual behavior after diagnosis of acute HIV.

Sexual orientation disparities in sexually transmitted infection risk behaviors and risk determinants among sexually active adolescent males: results from a school-based sample.