An assessment of sexual risk behavior among adolescent detainees.
Adolescent detainees (ADs) represent a high-risk subset of youth (Council on Scientific Affairs, 1990) partly due to increased risk activity across a broad spectrum of behaviors. These include delinquent activity, substance use and sexual risk behavior. Studies have shown that these youth are more sexually experienced and engage in fewer sexual protective practices than youth who are not incarcerated (DiClemente, Lanier, Horan, & Lodico, 1991; Forrest, Tambor, Riley; Ensminger & Starfield, 2000) thereby placing them at increased risk for the negative health outcomes associated with unprotected sexual activity (sexually transmitted infections [STIs], including HIV, and also unintended pregnancies). Several factors associated with these negative health outcomes have been identified in detained youth, including early onset of sexual activity, multiple partners and non-condom use (Bell, Farrow, Stamm, Critchlow, & Holmes, 1985; Canterbury et al., 1995; DiClemente, 1991; Elfenbein, Weber, & Grob, 1991; Forst, 1994; Gillmore, Morrison, Lowery, & Baker, 1994; Harwell, Trino, Rudy, Yorkman, & Gollub, 1999; Kelly, Blair, Baillargeon, & German, 2000; Lanier, Pack, DiClemente, 1999; Magura, Shapiro, & Kang, 1994; Morris, Baker, Valentine, & Pennisi, 1998; Morris et al., 1995; Oh et al., 1994; Pack, DiClemente, Hook, & Oh, 2000; Rickman et al., 1994; Sharer et al., 1993; Weber, Gearing, Davis, & Conlon, 1992; Weber, Elfenbein, Richards, Davis, & Thomas, 1989).
In contrast to approximately half of high school youth who are sexually active (Kann et al., 2000), findings show that upwards of 80% of juvenile offender samples report initiation of sexual activity (Forst, 1994; Harwell et al., 1999; Kelly et al., 2000; Morris et al., 1998; Morris et al., 1995; Weber et al., 1992; Weber et al., 1989; Lanier et al., 1991). Weber and colleagues examined sexual activity in delinquent adolescents and found that 83% reported previous sexual experience. More recent studies have found that over 90% of these youth report being sexually active (Harwell et al., 1999; Kelly et al., 2000; Morris et al., 1998), many initiating before age 13.
A large majority of detained youth have initiated sexual activity at an early age. Several studies have found that the average age of initiation falls between 12 and 13 (Forst, 1994; Gillmore et al, 1994; Harwell et al., 1999); one study of minority males reported a mean age of 11.9 for sexual initiation (Pack et al., 2000). Kelly and colleagues (2000) found that 69% of the sample initiated sex before age 13, while another study of an all-male sample found that approximately 27% had a sexual experience by age 11 (Weber et al., 1992). The latter researchers also found that males who had their first sexual experience before age 11, or with a female 2 or more years older, reported significantly larger numbers of sexual partners in their lifetime and during the year preceding their incarceration.
Other studies have documented adolescent detainee populations as high-risk due to their involvement with multiple sex partners. Canterbury et al. (1995) found that 76% of youth in their sample reported having three or more sexual partners, while others found that almost half (46.5%) their sample had greater than five lifetime partners (Kelly et al., 2000). A study including only male detainees found that the majority of those interviewed (55%) had 13 or more partners in the three months preceding the survey (Shafer et al., 1993). Another examination of an all male sample found the median number of lifetime partners to be 8, ranging from 1-100 with the mean number of lifetime partners being 10.4 and 17.9 for youth with first time and multiple admissions, respectively (Rickman et al., 1994). While the documented number of partners is high for these youth, consistent condom use has not been observed (Kingree, Braithwaite, & Woodring, 2000).
Condom use has been measured in a variety of ways in studies with adolescent detainee populations. Researchers have measured condom use at last intercourse, condom use in the previous 3-4 months, as well as the frequency of condom use ranging from always to never. Studies indicate that detained youth are not consistent in their use of condoms. Consistent use was reported by only 37% of youth participating in two separate all male samples (Pack et al., 2000; Rickman et al., 1994). An examination of two additional all male samples found that inconsistent condom use was the norm, with 17% and 20% reporting that they "never" used condoms (Magura et al., 1994; Shafer et al., 1993). One study documenting condom use of females in a juvenile detention center found that 68% reported no use of any form of contraception (Bell et al., 1985). Studies have also found differences in condom use between steady and casual partners where condom use was less frequent with steady (or primary) partners (Gillmore et al., 1994, Magura et al., 1994; Sharer et al., 1993). A more recent study found that 38% of youthful offenders surveyed did not use a condom at last intercourse (Kelly et al., 2000).
Undoubtedly, juvenile detainees exhibit high-risk sexual behavior. It becomes important to characterize their sexual risk behavior to identify trends in risk activity and determine best approaches to address these risks. The purpose of this study was to report and assess demographic differences in vaginal, anal and oral sexual risk behavior, including early onset of sexual activity, multiple (lifetime) partners and condom/latex barrier use in a sample of ADs participating in an HIV and substance use prevention intervention. The current study also allows for a more accurate report of risk behavior in adolescent females due to the significant number present in this sample.
ADs (N = 2280) sentenced to two gender-specific, secured, Youth Development Campuses (YDCs) were recruited for the study. The YDCs served youth from the entire state and were privately operated under contracts with the State Department of Juvenile Justice. Youth were typically mandated to the YDCs for 90 days although sentences ranged between 30 and 180 days. Female detainees were oversampled (N = 1341) and composed more than half the sample (59%). Participants ranged in age from 11 to 18 years (M = 15.2; SD = 1.2) with male detainees (M = 15.6, SD = 0.88) being statistically significantly older than female (M = 14.9; SD = 1.2) detainees (F(1, 2280) = 256.1, p < .0001). Fifty-seven percent of the youth in this sample identified themselves as black, and 37% identified as white. Approximately 2% were Hispanic, and less than 1% reported being Asian (0.7%). Native Americans made up a very small portion of the sample (0.4%), and approximately 3% classified themselves as "other." Significantly more girls (d = 41.3,p < .0001) had an 8th grade or less education (59.1% vs. 40.5%) when compared to boys (45.9% vs. 54.1%). Fifty-six percent had been detained previously because of a separate offense. (See sample demographics in Table 1.)
Data were collected through Project SHARP (Stop HIV and Alcohol Related Problems)--a randomized controlled investigation on the effects of an intervention designed to reduce future drug and alcohol use, risky sexual behavior, and delinquency. All youth sentenced to the YDC during the study period were approached by a university research team member within 3 days of their admission and asked to participate. Youth were informed that participation was voluntary and that their information would not be shared with the YDC staff. Those who agreed signed an assent form authorizing the researcher to request permission for their participation from parent(s) or guardian(s). This research was approved by both the University Human Investigation Committee as well as the Department of Juvenile Justice Institutional Review Board. During the enrollment period for this study, 4031 youth were approached, and 2766 gave personal assent and received parental consent to participate. Refusals after initial assents, releases, confinements, out of facility passes, kitchen duty, and simple misses resulted in a participation rate of 57% (N = 2280).
Baseline questionnaires were completed through interviews approximately 4 weeks after the youth were admitted to the YDCs. The interviews were conducted by trained research staff recruited from communities located near the two YDCs. All interviewers completed a criminal background check and participated in an 8-hour training session prior to conducting the interviews. This training included a thorough description of the rationale and aims of the project, didactic and practical instruction of interviewing techniques, and a discussion of ethical guidelines for interviewing adolescent research participants. Interviewers were gender-matched for females.
Demographic and Other Variables. Gender and age were assessed using standard measures. Race was measured by asking youth to describe their racial/ethnic group as White (non-Hispanic), Black/African American (non-Hispanic), Hispanic, Asian or Pacific Islander, Native American or Alaskan Native, or Other. Youth were asked to report the highest grade completed given a choice of grades 4-12, and history of previous detention was assessed using a measure asking if youth had ever been "locked up" before this time.
Sexual Risk Variables. Sexual activity was measured using a series of questions to assess whether youth had ever willingly engaged in each sex type--vaginal, anal and oral (performed by them and received by them). Youth who reported participation in any of the individual sex type categories were then asked to provide the following information for each type: age at which they first willingly had sex, the number of lifetime partners, the number of times they had sex in the month before entering a detention center or YDC, and the number of times they had not used a condom or latex barrier in the month prior to entering a detention center or YDC. A rate of condom use in the month before entering a facility was calculated using the latter two variables.
For purpose of analysis, ages 11-13 were grouped together as were the 17-18 year olds because of the small number in each group. The race/ethnicity variable was also collapsed to 4 groups to include Black, White, Hispanic and "Other" where "Other" included Asian or Pacific Islander, Native American or Alaskan Native, and Other. In addition, the rates of condom use were used to create an additional variable categorizing condom use as either "No use," "Inconsistent Use," or "Consistent Use" in the month preceding entrance into a facility.
For this cross-sectional study, analyses of variance (ANOVA) tests were used to examine demographic differences for age at first willing sexual episode. Chi-square analyses were also conducted to examine linear associations between demographic variables and condom use behavior categorized as never, inconsistent, or consistent. Kruskall-Wallis H tests were used to examine differences on lifetime number of partners, a variable that did not meet the assumptions for a parametric test. In addition, severe outliers for this variable were excluded from analysis (e.g., one case reported 1500 lifetime partners). Analysis of demographic differences on sexual measures were limited to cases who reported engaging in that type of sexual behavior (vaginal, anal and oral) in the month before entering the facility.
Approximately 89% (n = 2021) of the sample had willingly engaged in vaginal sex. A much smaller percentage (5%; n = 115) indicated a history of willingly engaging in anal sex. Participants did report consensual oral sex activity, and differences were observed between performing oral sex and receiving oral sex, 25% (n = 576) vs. 52% (n = 1178), respectively. Differences on age of sexual initiation, number of lifetime partners and condom use are presented for each type of sexual activity.
AGE OF SEXUAL INITIATION
The sample's mean age of sexual initiation for vaginal sex was 13.2 years (SD = 1.6). Responses to this measure for age of sexual initiation of vaginal sex ranged from 5 to 17 years (Table 2 indicates the variables for which statistically significant differences between groups exist). A statistically significant difference between males and females was observed (F [1,2016] = 62.6,p < .001). Males were younger than females at the age of initiation for vaginal sex (M = 12.8, SD = 1.8 vs. M = 13.4, SD = 1.4). A difference among age categories on age of sexual initiation for vaginal sex was also observed (F [4, 2013] = 45.7, p < .001) (See Table 3). Post hoc analysis indicated statistically significant differences between each age group with the exception of the 16 and 17-18 year olds. Overall, younger participants in the sample had a lower mean age of sexual initiation for vaginal sex. No differences were observed on age of vaginal sex initiation among race/ethnicity categories.
No statistically significant differences were found on age of anal sex initiation by gender or race/ethnicity. A difference, however, was observed among the age categories (F [4, 108] = 8.20, p < .05). Overall, younger participants had a lower mean age of anal sex initiation.
Although no difference by gender was observed on age of sexual debut for performing oral sex, a statistically significant difference was found between males and females on age of sexual initiation for receipt of oral sex (F [1, 1169] = 5.12, p < .05). Males were younger than females at the age of sexual debut for receiving oral sex (M = 13.83, SD = 1.5 vs. M = 14.02, SD = 1.35). A difference was found among age categories on age of sexual debut for performing oral sex (F [4, 566] = 30.82, p < .001) and for receiving oral sex (F [4, 1166] = 53.73, p < .001). Post hoc analysis indicated that in general, participants in younger age groups had a younger mean age of sexual debut for performing and receiving oral sex than participants in older age groups. No difference was observed on age of sexual debut for receipt of oral sex among the race/ ethnicity groups, however differences were observed for performing oral sex (F [3,567] = 3.85, p < .05). White youth were statistically significantly younger than Black youth (p < .05) on age at first episode of performing oral sex.
LIFETIME NUMBER OF PARTNERS
A statistically significant difference between males and females was observed on lifetime number of partners (H  = 138.18, p < .001). Males had a higher number of lifetime vaginal partners than females. As expected, the number of lifetime vaginal partners was higher for older youth in the sample (H  = 110.77, p < .001). No differences were observed among racial/ ethnic groups.
Males also had a statistically significantly higher number of lifetime anal partners than females (H  = 8.54, p < .01). A difference was also found among racial/ethnic groups on lifetime number of anal partners (H  = 14.51, p < .01). Table 4 identifies the median and range of lifetime partners for the overall sample and according to race/ethnicity. Youth classified as "Other" had the highest number of lifetime anal partners, followed by black youth, Hispanic youth and white youth, in that order.
Although no statistically significant difference between males and females was observed on lifetime oral sex partners on whom participants performed, a difference was found on lifetime oral sex partners from whom participants received oral sex (H  = 46.01, p < .001). Males had a higher lifetime number of partners from whom they had received oral sex. Age groups also differed on lifetime number of oral sex partners from whom participants received oral sex (H  = 30.21, p < .001). Sixteen year-olds had the highest number of partners from whom they received oral sex, followed by 15 year-olds, then 17-18 year-olds, 14 year-olds and finally those participants 11-13 years old. White youth had the highest number of lifetime oral sex partners on whom they had performed, followed by Hispanic youth, then "Other" youth, then black youth. A difference was observed among race/ ethnicity groups on lifetime number of oral sex partners from whom participants received oral sex (H  = 12.88, p < .05). Black youth had the highest number of partners from whom they received oral sex, followed by white youth, those classified as "Other" and Hispanic youth in that order.
CONDOM/LATEX BARRIER USE IN THE PRECEDING MONTH
Females (68.1%) were more likely than males (31.9%) to not use condoms in the month preceding entrance into the YDC ([c.sup.2]  = 16.10, p < .001). Table 5 presents categorized condom/latex barrier use in the month preceding entry into the facility for both males and females. Overall, more than half (52%, n = 761) of those who had engaged in vaginal sex in the month preceding entrance into the YDC were consistent condom users (used condoms 100% of the time). Black youth were more likely than white youth to report consistent condom use (62.5% vs. 31.9%, respectively), and white youth were more likely than Black youth to have not used condoms at all in the past month (52.5% vs. 41.5%, respectively) ([c.sup.2]  = 48.9, p < .001).
Fifty-two percent of those who reported anal sexual activity in the month preceding entrance into the YDC also reported consistent condom use. Forty percent did not use condoms at all. Black youth were slightly more likely to be consistent condom users than white youth (55.6% vs. 40.7%) ([c.sup.2]  = 15.9, p < .05). Little difference was observed between black and white youth who were inconsistent users or did not use condoms at all.
Females were more likely to report no use of a latex barrier when performing oral sex than males (60.4% In = 122] vs 39.6% In = 80], p < .05). Females were also more likely to report no use of a latex barrier when receiving oral sex than males (58.1% [n = 284] as compared to 41.9% [n = 205], p < .05). As expected, with both males and females, a greater percentage of youth reported "no use" for giving and receiving than consistent and inconsistent use combined.
Findings from this study support previous research that ADs do indeed engage in high-risk sexual behavior. As with other studies, almost 90% of the current sample had engaged in sexual activity. A prior study examining the prevalence of vaginal, anal and oral sexual activity among ADs found that 91%, 3%, and 23%, respectively, had engaged in these behaviors (Forst, 1994). The study presented here reports similar findings. Further, most studies of adolescent delinquents have included limited numbers of female participants, if any. This study is unique in that females make up over half the sample making gender comparisons much more suitable.
This study finds that younger participants generally initiated sexual activity at younger ages for all types of sex supporting the trend that youth have been steadily debuting at earlier ages. While males had more lifetime partners for both vaginal and anal sex, females were more likely than males to have not used condoms in the month preceding detainment. Statistically significant racial/ethnic differences were found on the lifetime number of anal sex partners. Those classified as "Other" had the highest number of anal sex partners, followed by black youth, Hispanic youth, and white youth, however the number of youth reporting anal sex was small and findings should be considered in this context. Findings also indicated that black youth made up a higher percentage of those who were consistent condom users.
While previous studies have inquired about oral sexual activity, the current research also includes an assessment of the number of youth who have not only performed oral sex but who have also received it. By measuring this additional aspect of participation in oral sex, this study reveals that over half of the sample participated in this type of sexual activity--twice as many as those who reported only performing oral sex. This disparity may well be related to the taboo associated with oral sex and not a true reflection of the performance of oral sex in the sample. Males were younger than females for receipt of oral sex, and white youth were younger than black youth on age of debut for performing oral sex. Young men also had more partners from whom they received oral sex than young women, and black youth had the highest number of oral sex (receiving) partners. Youth are generally not using a latex barrier when performing or receiving oral sex, placing themselves at risk for genito-oral infections. Sexual health education should address risk associated with unprotected oral sexual activity and highlight prevention specific to oral sex.
ADs are a highly sexually active group of youth who are engaging in vaginal, anal, and oral sexual risk behavior. The frequency of sexual activity in this sample is consistent with other juvenile offender data. The findings reiterate the need to direct efforts toward enhancing the sexual risk-reduction practices within this population. As detainees, these youth represent a captive audience with whom the opportunity exists to intervene across multiple risk behaviors. The need to target youth at earlier ages is evident based on these results.
Like other high-risk groups, condom use is inconsistent with sexual activity. While the sample size for this study is large, the authors recognize certain limitations. Hispanic participants made up a very small percentage of the sample. The conclusions drawn related to Hispanic participants and those classified as "Other" should be considered in this context. In addition, participants self-reported their risk behavior to interviewers who administered the study instrument face-to-face. Recall bias and interviewer effects due to the sensitive nature of this topic may have contributed bias to the study. Further, while participants were asked to report on consensual sexual behavior, it is possible that some mistakenly reported on sexually abusive activity instead.
In 2000, over two million persons under the age of 18 years were arrested (Snyder, 2002). Estimates from the most recent census of juvenile offenders held in residential placement placed the number at approximately 110,000 (Sickmund, 2002). This represents a large number of high-risk youth. The early age of sexual debut, the high number of sexual partners, and the rates of non-condom use identified in this study remain a major concern. Results from this study also provide behavioral data on various types of sexual activity and highlight differences within this population. Adolescents who engage in unprotected sexual activity are at risk for unwanted health outcomes such as sexually transmitted infections (STIs), including HIV. This study reinforces the need to provide comprehensive HIV risk reduction messages to these youth. Future studies should also examine relationships between sexual risk behavior and potential predictors, such as substance use.
Responsibility I: Assessing individual and community needs for health education
Competency A: Obtain health related data about social and cultural environments, growth and development factors, needs, and interests.
Competency B: Distinguish between behaviors that foster and those that hinder well-being.
Competency C: Infer needs for health education on the basis of obtained data.
Funding for this research was provided through a grant from the National Institute on Alcohol Abuse and Alcoholism (Grant RO1 AA11767). The authors would also like to acknowledge the administration and staff of the Department of Juvenile Justice and Youth Development Campuses as well as those individuals who were instrumental in data collection and program implementation.
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Alyssa G. Robillard, PhD, CHES is an Assistant Professor of Health, African & African American Studies at Arizona State University. Rhonda C. Conerly, PhD, Ronald L. Braithwaite, PhD, and Torrance T. Stephens, PhD are affiliated with the Department of Community Health and Preventive Medicine, Morehouse School of Medicine. Tammy M. Woodring, MPH is affiliated with Georgia State University. Address all correspondence to Alyssa G. Robillard, PhD, Arizona State University, P.O. Box 873802, Tempe, Arizona, 85287-3802; PHONE: 480-965-6193; FAX: 480-965-7229; E-MAIL: Alyssa.Robillard@asu.edu.
Table 1. Sample Demographics (N=2280) % N Gender Male 41.2 939 Female 58.8 1341 Race/Ethnicity * Black 56.8 1296 White 37.1 847 Hispanic 2.2 51 Other 3.6 84 Age * 11-13 8.4 192 14 17 387 15 31.3 713 16 2.2 739 17-18 3.6 247 8th grade education or less 54 1232 Previous detention for separate offense 55.5 1265 * Missing data where cumulative % does not equal 100. Table 2. Analysis of Variance for Age of Sexual Initiation Between Subjects Source df F p Vaginal Sex Gender 1 62.6 <.001 Age (categorized) 4 45.7 <.001 Race/ethnicity 3 1.8 .149 Anal Sex Gender 1 0.5 .472 Age (categorized) 4 8.2 <.001 Race/ethnicity 3 2.0 .116 Oral Sex (performing) Gender 1 0.4 .506 Age (categorized) 4 30.8 <.001 Race/ethnicity 3 3.8 .010 Oral Sex (receiving) Gender 1 5.1 .024 Age (categorized) 4 53.7 <.001 Race/ethnicity 3 2.3 .078 Table 3. Mean Age of Sexual Initiation by Age Categories Age of Sexual Initiation Age Categories M (SD) Vaginal (overall) 13.16 (1.5) 11-13 12.05 (1.0) 14 12.61 (1.4) 15 13.06 (1.4) 16 13.57 (1.9) 17-18 13.60 (1.6) Anal (overall) 14.37 (1.4) 11-13 12.00 (1.0) 14 13.50 (0.7) 15 14.33 (0.8) 16 14.63 (1.7) 17-18 15.41 (1.4) Oral (performing) (overall) 14.10 (1.6) 11-13 12.28 (0.8) 14 12.99 (1.4) 15 13.78 (1.1) 16 14.61 (1.4) 17-18 14.63 (2.2) Oral (receiving) (overall) 13.93 (1.4) 11-13 12.16 (0.9) 14 13.09 (1.2) 15 13.74 (1.1) 16 14.31 (1.4) 17-18 14.48 (1.8) Table 4. Median Number of Lifetime Partners by Race/Ethnicity. Lifetime Number of Partners Median (Range) Race/Ethnicity Vaginal (overall) 4 (199) Black 4 (194) White 4 (199) Hispanic 4 (84) "Other" 4 (129) Anal (overall) 1 (49) Black 1 (49) White 1 (14) Hispanic 1 (11) "Other" 3 (6) Oral (performing) (overall) 2 (200) Black 1 (79) White 2 (200) Hispanic 2 (2) "Other" 1 (22) Oral (receiving) (overall) 2 (79) Black 2 (79) White 3 (79) Hispanic 3 (24) "Other" 3 (39) Table 5. Condom/Latex Barrier Use * by Gender Condom Use (%) Never Inconsistent Consistent Vaginal (N=1476) ([dagger]) 22.7 25.7 51.6 Male 17.5 57.0 55.5 Female 26.4 24.9 48.8 Anal (N=52) 40.4 7.7 51.9 Male 29.6 11.1 59.3 Female 52.0 4.0 44.0 Oral (performing) (N=289) 69.9 4.5 25.6 ([dagger]) Male 62.0 7.0 31.0 Female 76.3 2.5 21.3 Oral (receiving) (N=695) 70.4 3.3 26.3 ([dagger]) Male 65.3 4.5 30.3 Female 74.7 2.4 22.9 * Includes only those who reported sexual activity in the month preceding detention ([dagger]) Significant at p<.05
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|Author:||Woodring, Tammy M.|
|Publication:||American Journal of Health Studies|
|Date:||Jan 1, 2005|
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