JOURNAL OF ADOLESCENT HEALTH 199.2;13:623-630
INTERNATIONAL
SECTION
MARIE
Ph.D.,
CHOQUET,
AND ROBERT MANFREDI,
An epidemiological study was carried out among 4,255 adolescents, aged 11-19 years, randomly selected from
secondary schools in a northern urban area of France. The questionnaire concerned sexual activity, contracep tion, health status, licit and illicit drug consumption, and
other risk-taking behavior. A total of 31% of the adolescents had had sexual relations (45% of the boys, 20% of the girls). Sexual activity increased with age. A large majority (70%) of the sexually active adolescents used some form of contraception. The study confirms the relationship between smoking, drinking, illicit drug consumption, and sexual activity, but shows that contracep tive behavior is not related to problem behavior. KEY WORDS
Sexual behavior Contraceptive behavior Problem behavior French adolescents Epidemiologic4 survey
Adolescent sexual behavior has been lLheobject of numerous studies from which two main lines of fo-
cus emerge: 1. The first one deals with the measurement of sexual behavior and contraceptive use and their evolution throughout adolescence, either in unselected populations (l-6) or among deviants (7,8). The aim of these studies has been to plan the prevention of undesirable effects of sexual activity, such as pregFra??rlNS&lXM CNatioml fnstitute ofHeu/th
and Medical
France. Address reprint requests fo: Unit 269, 16, PV Courturier 94807, France. Marie Choquet, Ph.D. INSERM. Mnnuscript accepted April 21. 1992.
Research), Vilkjuif
M.D.
nancy, abortion, and sexually transmitted diseases (STDs). Accordingly, the influence of social variables (e.g., age, ethnic origin, scholastic level, religion, sexual standards),. personal factors (e.g., knowledge of and attitudes toward sex and birth control), and relational aspects (e.g., stability of the couple, information with respect to contraception, parental factors) have been explored. 2. The second places juvenile sexuality in the broader framework of risk-taking behavior in general (9-14). Underlying this research is the hypothesis that adolescent risky behavioral patterns are not fortuitous, but the outcome of the adolescent’s profile (problem behavior theory). These include delinquency, alcohol and drug consumption, school misbehavior, aggressive behavior, etc. The aim of this research has been to explain risk-taking behavior in general, with sexual intercourse as only one of its many manifestations. Attitudes with respect to contraception are rarely broached, as if precocious smear _a I..._in+~r,-nllrc~ _-.-_____-“_iiecessarily implied an absence of birth control, because both are manifestations of risk-taking behavior (15). In an urban school-based clinic population, Galavotti and Lovick (16) found a significant positive correlation between risk-taking behavior and sexual activity and a significant negative correlation between risk-taking behavior and contraceptive use. This relationship proved nonsignificant, however, when all other variables were I:ontrolled. But one could hypothesize that the mug;itude and diversity of factors taken into account (including variables concerning sex life, beliefs with respect to abortion, self-esteem, welfare indicators L!tc.), as well as characteristics of the sample (size, origin) do not allow
D Societyfor Adolescent Medicine, 1992 Published by Elsevier Science Publishing Co., Inc., 655 Avenue of the Americas, New York, NY IWi!
623
624
CIWQUET AND MANFREDIT
to confirm a relationship between risk-taking behavior and contraception. This examines the foBow~g issues: 1. The possible relationship between risk-taking behavior and sexual intercourse within a French adolescent population. 2. The negative relations~p between contraception and risk-taking behavior, according to sex and age.
Procedure The survey was carried out from December 1988 to January 1989 in the northern French district of Arras (population approximately 70,000). Participating in this survey were 42 schools (of which 35 high schools and 7 vocational schools) randomly selected from among all the private and public schools in the area. In each school, one class of three was randomly selected. A total of 4,255 adolescents (95% of the initial sample) participated in the survey, 4% were absent on the day of the enquiry, and 1% refused to participate. The pupils filled out a q~estionn~re in class (duration: 1 hr) under the guidance of the school nurse or school doctor, who explained the procedure to them and remained available for further questions. Measurement of Variables The questionnaire was derived from that developed by Choquet and Menke (17) and included 250 multiple-choice questions dealing with eight top its: sociodemographics, scholastic situation and problems, lifestyle, quality of family and peer relationships, self-perception, sexual activity and contraceptive habits, licit (alcohol, tobacco, psychotropic drugs) and illicit drug use, and recent health-slated insulations. The no-response rate varied from 2% to 5% depending on tht; question. StatisticalAnalysis The subjects were divided into two groups in relation to their sexual activity: those who had sexual intercourse @I),those who had never had (NSI). The SI group was f&her subdivided into two groups with respect to contraception: those who used it (CTC) and those who did not (NCTC). Data were analyzed through x2 analysis. Stepwise logistic regression analyses were carried out in order to test whether the risk-taking behavior
JOURNAL OF ADOLESCENT HEALTH Vol. 13, No. 7
was independently related to sexual intercourse and contraceptive behavior. Relative odds ratio (OR) and logistic regression assessed the unique contribution (~de~ndently of the other variables in the model) of each variable for predicting outcome. The analyses were performed using the BMDP logistic regression computer program (18). The data were recorded at INSERM on a VAX/ VMS computer, using SAS (Statistical Analysis System) software.
Results Sociodem~aphic
Data on the Subjects
Of the 4,255 adolescents included in the study, 52.3% were boys, and 47.7% girls. Mean age was 15.8 years (boys, 15.9; girls, 15.7). A majority of the adolescents were French citizens (97%) and of French origin (94%). Most of the parents were employed (86.8% of the fathers, 51.3% of the mothers); 13% of the fathers were executives, 8% shopkeepers, 13% middle managers, 19% office employees, 32% blue collar workers, and 6% farmers. A majority of the parents (81%) were married, 2% separated, and 10% divorced; 6% of the fathers or mothers had died. A majority (90%) of the adolescents lived with their parents (married or not), 6% were school boarders who returned home for the weekend, 1% lived with a relative other than a par ent, and 1% lived independently. No differences were observed between boys and girls. Frequency of Sexual Intercourse and Contraceptive Behavior Among French Adolescents A total of 43% of the boys and 20% of the girls reported having had sexual intercourse (p < 0.001). One-half of these were sexually active on a regular basis. While having interlude, 71% of the boys and 76% of the girls used some form of contraception (p < 0.05); 50% sf the boys and 69% of the girls used contraception systematically (p c 0.001). The most commonly used method was condoms for the boys (76%>)and oral contraceptives for the girls (68%). Sexual activity increased with age, among both boys and girls (Table 1). It should be noted that in the youngest age group (cl3 years) 16% of the boys and 4% of the girls had had sexual relations, whereas in the oldest group (18 years and over), 70% (boys) and 44% (girls) had. Prior to age 15 years, sexual activity was primarily occasional for the girls. Contraceptive use also increased between age 11
November 1992
RISK TAKING IN FRENCH ADOLESCENTS
625
Table 1. Sexual Intercourse and Contraceptio.k by Age and Sex (%) _Cl5 yr n = 895 (%)
Bols
Girls 215 yr n = 1227 (%)
Statistical difference (x’)
Cl5 yr n = 905 (%)
69.7 24.1 6.2
39.3 60.6 0.1
p < 0.001 p < 0.001 p c 0.001
88.1 5.9 6.0
65.1 32.8 2.1
p c 0.001
50.4 49.6
49.4 50.6
NS NS
67.9 32.1
51.2 49.8
p c 0.01 p < 0.001
38.9 52.8 8.3
23.8 76.2 -
p < 0.001 p c 0.001
18.0 79.6 2.4
p c 0.001
p c 0.001
45.3 52.8 1.9
NS NS NS
28.1 17.8 54.1
16.2 14.1 69.7
NS NS
n
=15 yr = 1136 W)
Statistical difference (x’)
Sexual intercourse No (NSI) Yes (SI) No response If SI, Frequency of sexual intercourse Occasionally Frequently Contraception No (NCTC) Yes (CTC) No response
If CTC, frequency of contraception 31.6 28.2 occasionally 19.3 26.0 frequently 49.1 50.8 systematically .Note: Statistical difference is for within sex between age groups.
and 20 years, but the frequency of this use was rather stable. Only 70% of the oldest girls used some form of contraception systematically. Relationship Between Sexual Intercourse and Risk-taking Behavior Table 2 shows a clear relationship for both boys and girls between risk-taking behavior and sexual activity, whatever the age of the subjects. In the youngest age group, alcohol consumption (wine, beer, and hard liquor at least twice a week) and smoking were much more prevalent among the SI youngsters than the NSI group. With regard to illicit drug use and absenteeism, the differences were similar, but not statistically significant. Among the younger than 15year-olds adolescents, sexual activity was highly related to repeated risk-taking behavior. The results of the logistic regression analysis (the dependent variable being sexual activity and the independent variables age and various forms of risktaking behavior) suggest that 1. For the boys (Table 3), each s-ype of risky behavior, independent of the others, was linked to sexual activity, although in differing proportions depending on the type of variable and the frequency of the behavior. For example, among the one-half-packper-day smokers, the proportion of sexually active adolescents was five times higher than among the nonsmokers, keeping constant all the other variables
p < 0.001 p c 0.001
p c 0.001 NS
p < 0.05
included in the model (age, absenteeism, lifetime drunkenness, alcohol consumption, drug use). The OR was also high (2 3) for repeated drug users and for those who reported frequent drunkenness. In contrast, the OR was less than 2 for irregular absenteeism, drunkenness less than 10 times and irregular alcohol consumption. As for age, its specific ,weight was not negligible. 2. For the girls (Table 4), the findings show the same trend as for the boys. Heavy smoking and repeated consumption of illicit drugs were the independent variables correlating most significantly with sexual activity. Sexual differences were, however, observed: certain behaviors such as drunkenness less than I.0 times and frequent absenteeismwhich have a non-negligible specific weight in the regression model-correlated stronp,ly with female sexual activity, while others did not (irregular absenteeism, frequent drunkenness, one-time experiment with illicit drugs and regular or irregular consumption of alcohol). As found for the boys, age had a non-negligible specific weight. Relationship Behveen Contraceptive Use and Risk-Taking Behavior Table 5 suggests that among the sexually active adolescents, there was no difference between the CTC and NCTC groups with respect to risky behavior either for @As or for boys, In the younger group,
626
moQUE’r
JOURNAL OF ADOLESCENT HEALTH Vol. 13, No. 7
AND MANFREDIT
TabIn 2. Ri&Taking
Behavior and Sexual Intercourse by Sex and Age (%) Age zr 15 yr
Age < 15 yr
Boys
. . . .._.__..-- -.I
NSI n = 623 (%I
SI n = 216 (%I
27.3 3.0
NSI n = 432 -2
SI n = 743
X
ma)
(%)
X2
31.1 22.5
NS p < 0.001
49.3 11.7
52.3 29.5
NS p < 0.001
10.3 0.4
25.7 4.3
p c 0.001 p c 0.001
36.8 3.2
48.7 23.1
p
INTERNATIONAL
SECTION
MARIE
Ph.D.,
CHOQUET,
AND ROBERT MANFREDI,
An epidemiological study was carried out among 4,255 adolescents, aged 11-19 years, randomly selected from
secondary schools in a northern urban area of France. The questionnaire concerned sexual activity, contracep tion, health status, licit and illicit drug consumption, and
other risk-taking behavior. A total of 31% of the adolescents had had sexual relations (45% of the boys, 20% of the girls). Sexual activity increased with age. A large majority (70%) of the sexually active adolescents used some form of contraception. The study confirms the relationship between smoking, drinking, illicit drug consumption, and sexual activity, but shows that contracep tive behavior is not related to problem behavior. KEY WORDS
Sexual behavior Contraceptive behavior Problem behavior French adolescents Epidemiologic4 survey
Adolescent sexual behavior has been lLheobject of numerous studies from which two main lines of fo-
cus emerge: 1. The first one deals with the measurement of sexual behavior and contraceptive use and their evolution throughout adolescence, either in unselected populations (l-6) or among deviants (7,8). The aim of these studies has been to plan the prevention of undesirable effects of sexual activity, such as pregFra??rlNS&lXM CNatioml fnstitute ofHeu/th
and Medical
France. Address reprint requests fo: Unit 269, 16, PV Courturier 94807, France. Marie Choquet, Ph.D. INSERM. Mnnuscript accepted April 21. 1992.
Research), Vilkjuif
M.D.
nancy, abortion, and sexually transmitted diseases (STDs). Accordingly, the influence of social variables (e.g., age, ethnic origin, scholastic level, religion, sexual standards),. personal factors (e.g., knowledge of and attitudes toward sex and birth control), and relational aspects (e.g., stability of the couple, information with respect to contraception, parental factors) have been explored. 2. The second places juvenile sexuality in the broader framework of risk-taking behavior in general (9-14). Underlying this research is the hypothesis that adolescent risky behavioral patterns are not fortuitous, but the outcome of the adolescent’s profile (problem behavior theory). These include delinquency, alcohol and drug consumption, school misbehavior, aggressive behavior, etc. The aim of this research has been to explain risk-taking behavior in general, with sexual intercourse as only one of its many manifestations. Attitudes with respect to contraception are rarely broached, as if precocious smear _a I..._in+~r,-nllrc~ _-.-_____-“_iiecessarily implied an absence of birth control, because both are manifestations of risk-taking behavior (15). In an urban school-based clinic population, Galavotti and Lovick (16) found a significant positive correlation between risk-taking behavior and sexual activity and a significant negative correlation between risk-taking behavior and contraceptive use. This relationship proved nonsignificant, however, when all other variables were I:ontrolled. But one could hypothesize that the mug;itude and diversity of factors taken into account (including variables concerning sex life, beliefs with respect to abortion, self-esteem, welfare indicators L!tc.), as well as characteristics of the sample (size, origin) do not allow
D Societyfor Adolescent Medicine, 1992 Published by Elsevier Science Publishing Co., Inc., 655 Avenue of the Americas, New York, NY IWi!
623
624
CIWQUET AND MANFREDIT
to confirm a relationship between risk-taking behavior and contraception. This examines the foBow~g issues: 1. The possible relationship between risk-taking behavior and sexual intercourse within a French adolescent population. 2. The negative relations~p between contraception and risk-taking behavior, according to sex and age.
Procedure The survey was carried out from December 1988 to January 1989 in the northern French district of Arras (population approximately 70,000). Participating in this survey were 42 schools (of which 35 high schools and 7 vocational schools) randomly selected from among all the private and public schools in the area. In each school, one class of three was randomly selected. A total of 4,255 adolescents (95% of the initial sample) participated in the survey, 4% were absent on the day of the enquiry, and 1% refused to participate. The pupils filled out a q~estionn~re in class (duration: 1 hr) under the guidance of the school nurse or school doctor, who explained the procedure to them and remained available for further questions. Measurement of Variables The questionnaire was derived from that developed by Choquet and Menke (17) and included 250 multiple-choice questions dealing with eight top its: sociodemographics, scholastic situation and problems, lifestyle, quality of family and peer relationships, self-perception, sexual activity and contraceptive habits, licit (alcohol, tobacco, psychotropic drugs) and illicit drug use, and recent health-slated insulations. The no-response rate varied from 2% to 5% depending on tht; question. StatisticalAnalysis The subjects were divided into two groups in relation to their sexual activity: those who had sexual intercourse @I),those who had never had (NSI). The SI group was f&her subdivided into two groups with respect to contraception: those who used it (CTC) and those who did not (NCTC). Data were analyzed through x2 analysis. Stepwise logistic regression analyses were carried out in order to test whether the risk-taking behavior
JOURNAL OF ADOLESCENT HEALTH Vol. 13, No. 7
was independently related to sexual intercourse and contraceptive behavior. Relative odds ratio (OR) and logistic regression assessed the unique contribution (~de~ndently of the other variables in the model) of each variable for predicting outcome. The analyses were performed using the BMDP logistic regression computer program (18). The data were recorded at INSERM on a VAX/ VMS computer, using SAS (Statistical Analysis System) software.
Results Sociodem~aphic
Data on the Subjects
Of the 4,255 adolescents included in the study, 52.3% were boys, and 47.7% girls. Mean age was 15.8 years (boys, 15.9; girls, 15.7). A majority of the adolescents were French citizens (97%) and of French origin (94%). Most of the parents were employed (86.8% of the fathers, 51.3% of the mothers); 13% of the fathers were executives, 8% shopkeepers, 13% middle managers, 19% office employees, 32% blue collar workers, and 6% farmers. A majority of the parents (81%) were married, 2% separated, and 10% divorced; 6% of the fathers or mothers had died. A majority (90%) of the adolescents lived with their parents (married or not), 6% were school boarders who returned home for the weekend, 1% lived with a relative other than a par ent, and 1% lived independently. No differences were observed between boys and girls. Frequency of Sexual Intercourse and Contraceptive Behavior Among French Adolescents A total of 43% of the boys and 20% of the girls reported having had sexual intercourse (p < 0.001). One-half of these were sexually active on a regular basis. While having interlude, 71% of the boys and 76% of the girls used some form of contraception (p < 0.05); 50% sf the boys and 69% of the girls used contraception systematically (p c 0.001). The most commonly used method was condoms for the boys (76%>)and oral contraceptives for the girls (68%). Sexual activity increased with age, among both boys and girls (Table 1). It should be noted that in the youngest age group (cl3 years) 16% of the boys and 4% of the girls had had sexual relations, whereas in the oldest group (18 years and over), 70% (boys) and 44% (girls) had. Prior to age 15 years, sexual activity was primarily occasional for the girls. Contraceptive use also increased between age 11
November 1992
RISK TAKING IN FRENCH ADOLESCENTS
625
Table 1. Sexual Intercourse and Contraceptio.k by Age and Sex (%) _Cl5 yr n = 895 (%)
Bols
Girls 215 yr n = 1227 (%)
Statistical difference (x’)
Cl5 yr n = 905 (%)
69.7 24.1 6.2
39.3 60.6 0.1
p < 0.001 p < 0.001 p c 0.001
88.1 5.9 6.0
65.1 32.8 2.1
p c 0.001
50.4 49.6
49.4 50.6
NS NS
67.9 32.1
51.2 49.8
p c 0.01 p < 0.001
38.9 52.8 8.3
23.8 76.2 -
p < 0.001 p c 0.001
18.0 79.6 2.4
p c 0.001
p c 0.001
45.3 52.8 1.9
NS NS NS
28.1 17.8 54.1
16.2 14.1 69.7
NS NS
n
=15 yr = 1136 W)
Statistical difference (x’)
Sexual intercourse No (NSI) Yes (SI) No response If SI, Frequency of sexual intercourse Occasionally Frequently Contraception No (NCTC) Yes (CTC) No response
If CTC, frequency of contraception 31.6 28.2 occasionally 19.3 26.0 frequently 49.1 50.8 systematically .Note: Statistical difference is for within sex between age groups.
and 20 years, but the frequency of this use was rather stable. Only 70% of the oldest girls used some form of contraception systematically. Relationship Between Sexual Intercourse and Risk-taking Behavior Table 2 shows a clear relationship for both boys and girls between risk-taking behavior and sexual activity, whatever the age of the subjects. In the youngest age group, alcohol consumption (wine, beer, and hard liquor at least twice a week) and smoking were much more prevalent among the SI youngsters than the NSI group. With regard to illicit drug use and absenteeism, the differences were similar, but not statistically significant. Among the younger than 15year-olds adolescents, sexual activity was highly related to repeated risk-taking behavior. The results of the logistic regression analysis (the dependent variable being sexual activity and the independent variables age and various forms of risktaking behavior) suggest that 1. For the boys (Table 3), each s-ype of risky behavior, independent of the others, was linked to sexual activity, although in differing proportions depending on the type of variable and the frequency of the behavior. For example, among the one-half-packper-day smokers, the proportion of sexually active adolescents was five times higher than among the nonsmokers, keeping constant all the other variables
p < 0.001 p c 0.001
p c 0.001 NS
p < 0.05
included in the model (age, absenteeism, lifetime drunkenness, alcohol consumption, drug use). The OR was also high (2 3) for repeated drug users and for those who reported frequent drunkenness. In contrast, the OR was less than 2 for irregular absenteeism, drunkenness less than 10 times and irregular alcohol consumption. As for age, its specific ,weight was not negligible. 2. For the girls (Table 4), the findings show the same trend as for the boys. Heavy smoking and repeated consumption of illicit drugs were the independent variables correlating most significantly with sexual activity. Sexual differences were, however, observed: certain behaviors such as drunkenness less than I.0 times and frequent absenteeismwhich have a non-negligible specific weight in the regression model-correlated stronp,ly with female sexual activity, while others did not (irregular absenteeism, frequent drunkenness, one-time experiment with illicit drugs and regular or irregular consumption of alcohol). As found for the boys, age had a non-negligible specific weight. Relationship Behveen Contraceptive Use and Risk-Taking Behavior Table 5 suggests that among the sexually active adolescents, there was no difference between the CTC and NCTC groups with respect to risky behavior either for @As or for boys, In the younger group,
626
moQUE’r
JOURNAL OF ADOLESCENT HEALTH Vol. 13, No. 7
AND MANFREDIT
TabIn 2. Ri&Taking
Behavior and Sexual Intercourse by Sex and Age (%) Age zr 15 yr
Age < 15 yr
Boys
. . . .._.__..-- -.I
NSI n = 623 (%I
SI n = 216 (%I
27.3 3.0
NSI n = 432 -2
SI n = 743
X
ma)
(%)
X2
31.1 22.5
NS p < 0.001
49.3 11.7
52.3 29.5
NS p < 0.001
10.3 0.4
25.7 4.3
p c 0.001 p c 0.001
36.8 3.2
48.7 23.1
p
