This study provided important data documenting the risk behaviors that place adolescents at risk of sexually transmitted infections (STIs), including HIV. Risk behaviors were substantial among the youth who had unprotected sex in the past 90 days. For example, many adolescents reported never using condoms in the past 90 days, most had not used a condom at the time of last intercourse, and the median number of unprotected sex acts in the past 90 days was substantial. Adolescents reported a mean of two partners during the last 90 days. Seventeen percent were living with a main sexual partner—which is not surprising given the age of the sample—and was a significant predictor of sexual risk. This overall risk was documented in an ethnically and racially diverse sample of sexually active at-risk adolescents and young adults.
In analyses controlling for multiple aspects of this diverse sample (e.g., race, age, gender, geography), we quantified the significant impact of the psychosocial correlates of adolescents' sexual risk behavior. Adolescents' perceptions regarding loss of sexual pleasure because of condom use, their perceptions concerning negative reactions from a partner regarding condom use, and their lack of communication with partners all predicted less condom use. These factors were each independently associated with lack of condom use despite being considered in a model that controlled for several demographics and other variables. We also found that these factors were associated with two indices of sexual risk (condom use at last sex and unprotected sex in the past 90 days). These findings emphasize the relationship that adolescent perceptions of loss of sexual pleasure and from partners' reactions have with condom use and imply the need to focus on such attitudes in clinical and public health sexual risk-reduction efforts.
The findings can inform clinical care in several ways. First, the findings suggest that adolescents' sexual risk behavior should be carefully and routinely assessed at all clinical encounters. More specifically, clinicians can target several attitudes of adolescents to promote increased condom use. For example, the perceived negative reactions of partners to condom use could be mitigated by teaching adolescents how to effectively communicate with partners to use condoms. Clinicians could, for example, teach adolescents when to initiate condom use discussions and how to approach this discussion in a tactful and respectful manner. With these communication skills, adolescents' fears of negative partner reactions could be reduced. Further, many adolescents may say that sex with condoms is less pleasurable for them or their partners. Therefore, clinicians have an opportunity to counsel adolescent clients about finding condom brands and sizes that provide optimal fit, comfort, and sensation. Unfortunately, the pace and complexity of clinical care may make extensive counseling about condom use impractical. Also, the lack of reimbursement for prevention services and other systemic factors may make these recommendations difficult to implement. Clinics, however, can provide adolescents with a variety of condoms to, perhaps, find a brand and size that improves their level of sexual pleasure. Also, clinicians have the opportunity to refer adolescents to small-group sexual risk-reduction programs.
Data also have implications for community-based sexual risk-reduction programs for adolescents. For example, small-group workshops are an excellent opportunity to challenge adolescents' perceptions that partners will have negative reactions to condom use. Facilitators can engage in norm-setting exercises designed to dispel the perception that negative reactions are inevitable. Further, facilitators can engage adolescents in discussions that bring out instances where partners have agreed to use condoms, thereby reinforcing the idea that partners may be agreeable to using condoms. To demonstrate and reinforce effective condom negotiation skills, facilitators can use role-play techniques that emphasize timing, style, and content of effective communication. Also, it may be useful to include adolescents' partners in these intervention efforts, further enhancing program efficacy. This study found that nearly 20% of the sample was living with a main sex partner, thereby suggesting the potential to incorporate partners into interventions. Indeed, involving partners may be the most direct strategy to dispel misconceptions and build healthy communication. Recent meta-analyses and reviews of adolescent HIV prevention interventions suggest that these strategies are likely to be effective.15,16
Findings are limited by the validity of the self-reported data; however, the design included multiple strategies to enhance validity. For example, A-CASI was used because it has been demonstrated to increase the reporting of sexual behaviors and consistency checks in A-CASI queried adolescents when they provided conflicting data.17
In addition, the observed associations are cross-sectional; thus, causality cannot be determined. Clearly, prospective analyses and interventions that target relevant condom use attitudes are needed to corroborate these findings. Also, adolescents with a history of unprotected sex were enrolled, so these findings may not generalize to less-at-risk youth. Nevertheless, the multiple recruitment methods employed at each site resulted in a convenience sample of ethnically and racially diverse sexually active adolescents in several locations in the U.S. These conditions allow for conclusions that are not limited to one city or ethnic/racial group.