Sexual behaviors and condom use: a study of suburban male adolescents.

Nguyet, Nguyen T. Minh ; Maheux, Brigitte ; Beland, Francois 等

The sexual revolution of the 1960s, characterized by more permissive attitudes toward sexual relations (Hamburg, 1986), resulted in a substantial increase in sexual activity in adolescents (Chilman, 1986). The percentage of sexually active adolescents increased from 10 to 20% in the early 1960s to approximately 50 to 60% by the end of the decade and has remained at this level (Brooks-Gunn & Furstenburg, 1989; Centers for Disease control, 1992; King et al., 1989; Sante Quebec, 1991).

A consequence of greater sexual permissiveness was an increase in sexually transmitted diseases (STDs). According to Werner and Biro (1990), sexually active adolescents have the highest rates of gonorrhea and chlamydia, infections which are responsible for more than half the cases of pelvic inflammatory disease (PID) (Stewart, 1987) and can result in infertility (Elkins, McNeeley, & Tabb, 1986; Johnson, 1987; MMWR, 1991). Also, an increasing number of adolescents are being infected by HIV (Elmslie, 1990; Siegel et al., 1991).

STDs could be prevented if adolescents adopted adequate preventive behaviors. Yet the condom, considered to be the most effective protection against their spread, was until the mid-1980s used by only a third of adolescents at their first sexual intercourse and by less than a quarter at their most recent intercourse (Ellefsen, 1985; Herold, 1984; Zelnik & Kantner, 1980). Recent studies have found that condom use at first intercourse has doubled, yet less than a third use condoms at each intercourse (Hingson et al., 1990; Sonenstein & Ku, 1991).

Because of these risks behaviors, efforts have been initiated throughout North America and the international community to control the spread of STDs and, in particular, that of AIDS (Nutbeam & Blakey, 1990). For the past five years, in the Province of Quebec, Canada, publicity about STDs and AIDS has been mainly through television and radio. For three years, in certain junior colleges, universities, and other public places, the provincial government has made condoms available in vending machines. In 1988, the Quebec Ministry of Health and Social Services launched a multi-media campaign to promote condom use and STD prevention. This campaign lends support to ongoing educational activities already begun in schools by educators and health professionals.

Historically, sexually risky behaviors have more often been found in boys than in girls (Chilman, 1986; Earle & Perricone, 1986). Boys tend to have their first sexual experience at a younger age than do girls, and are more prone to have relations with an acquaintance. Sociocultural norms also tend to be more permissive for boys. Given the sporadic nature of adolescent sexual activity and the fact that sexual relations are more often initiated by the male partner, the decision to use condoms is usually relegated to boys.

The purpose of this study, therefore, was to examine sexual behaviors and condom use in boys. To do so, a survey was conducted on 1,312 male adolescents in Laval, Quebec. The influence of age, certain sociodemographic variables, and school structure on sexual behaviors and condom use was also assessed in the sample.

METHODS

The survey was conducted from April to June 1989 on a sample of male adolescents registered in French secondary schools in Laval. Laval is a mainly French-speaking middle-class suburb of Montreal and is the second most populous city in the province of Quebec (population 314,398). Out of 16 secondary schools, six were chosen to participate in the study. The schools were selected in order to represent different school structures: junior high only (grades 7-8), high school only (grades 9-11) and junior high and high school combined (grades 7-11), as well as different socioeconomic milieus (upper-middle-, middle-, and lower-class). In each school, three to five classes were sampled by grade level, providing a total population of 1,328 male adolescents from grades 7 to 11.

Data were obtained via a self-administered questionnaire that included questions on sexual behaviors, condom use (including use of other contraceptive methods), personal attitudes regarding condom use, sources of information on condoms, perceived parental attitudes on sexuality and contraceptives, and sociodemographic variables. For the purpose of this paper, only the results of the sociodemographic variables, sexual behaviors, and condom use are presented.

The clarity and pertinence of the questionnaire were evaluated by various health professionals working in universities, high schools, and the public health field. The questionnaire was then pretested for validity and reliability on 75 adolescents aged 12-19 years in a Laval school not sampled for the survey. The results of the pretest were used in preparing a finalized version of the questionnaire that took approximately 20 minutes to complete. Of the 1,328 adolescents invited to participate in the survey, 1,312 returned completed questionnaire for a response rate of 98.8%. Participation was voluntary and anonymity guaranteed.

Measures of sexual behaviors included the same variables employed in the studies of Geiss and Gerard (1984), and Zelnik and Kantner (1980), namely, age at first intercourse, frequency of sexual intercourse, and number of partners. As suggested by Hingson et al. (1990) and Pleck, Sonenstein, & Ku (1991), use of condoms and other contraceptive methods were studied at first and most recent sexual intercourse, as well as at each intercourse, providing an indication of the constancy of preventive methods used. According to Herold (1981), correlations between "at each intercourse" and "most recent intercourse" are greater than 0.72 (p |is less than~ 0.01).

Sexual activity and preventive behaviors were assessed with respect to age. The study further examined the influence of family structure, parents' socioeconomic status, and school structure on these variables.

RESULTS

Examination of the sociodemographic characteristics of the sample showed that 92.9% of the boys were of French Canadian origin, approximately half were 14 years of age or younger, and 85% were from two-parent families. As expected, adolescents were primarily from upper-middle and middle-class backgrounds. Two-thirds of the fathers were employed as either professional, technical, or office workers; more than two-thirds of the mothers worked.

Half the adolescents attended schools which consisted of grades 7-11; the other half, either grades 7-8 or 9-11. Slightly more than a third of the adolescents went to an all-boys school consisting of grades 7-11.

Sexual Behaviors

Sexual behaviors of male teenagers are presented by age group in Table 2. Overall, 33% (n = 433) of adolescent boys in the sample were sexually active. By age 12, one in ten boys had at least one sexual intercourse. By age 13, this figure increased to one in four. By age 17, more than two out of three male adolescents had at least one sexual intercourse. With respect to age at first intercourse, approximately one-third started having sexual relations between the ages of 10 and 13, with the average age being 13.9 years.

Frequency of sexual intercourse was sporadic. In sexually active 12-year-olds, approximately two-thirds had intercourse only once; less than 10% had intercourse three or more times. The proportion of those who had three or more intercourses increased with age.

The number of partners was also limited (data not shown). In adolescents who had two sexual intercourses, 45% did so with only one partner. In those who had three or more sexual intercourses, 28.3% did so with only one partner, 12.1% with two partners. The number of partners was not associated with any of the variables in this study. Frequency of sexual relations was found to be associated with age only. Family structure, parents' socioeconomic status, and school structure were found to have a negligible effect, if any, on sexual behaviors and condom use in the sample.

Condom Use and Other Contraceptive Methods

Approximately 60% of sexually active adolescents reported using a condom at their first sexual intercourse. Condom use was greatest in 14-year-olds (72.7%) and decreased in older teenagers, being replaced by the birth control pill. In those 12 to 13 years old, approximately one in 10 boys had a partner who was taking the pill; at 17 years of age and older, this increased to one in five. Approximately 20% or more in all age categories reported using ineffective methods of protection at their first intercourse, the proportion being highest in those 12 to 13 years of age (31.8%).

TABLE I

SOME CHARACTERISTICS OF THE STUDY SAMPLE MALE ADOLESCENTS, LAVAL, QUEBEC (N =
1312)

SOCIO-DEMOGRAPHIC %
CHARACTERISTICS

Age

12 years 10.1
13 years 16.9
14 years 23.7
15 years 21.4
16 years 18.3
17 years 7.5
18 years 1.8
19 years 0.3

Family Structure:

Two-parent family 85.2
Single-parent family 12.0
Recomposed family (a) 2.8

Parents' Educational Level

Father (13 years or 61.7
more)

Mother (13 years or 58.9
more)

Father's Occupation 35.1
Professionals 32.0
Office workers or 32.9
technicians
Other

Percentage of Mothers 72.7
Employed

French Speaking 92.9

(a) Recomposed family is defined as a parent living with another spouse or
partner.
TABLE 2

SEXUAL ACTIVITY AMONG SEXUALLY ACTIVE MALE ADOLESCENTS BY AGE LAVAL, QUEBEC (N
= 433)

 Had at Numbers of
 Least One Age at Sexual
 Sexual First Intercourses
Age n Intercourse Intercourse
 (a) (b) One 3 or
 (%) (%) only more
 (%) (%)

10 - 2.3
11 - 4.8
12 15 11.6 9.6 64.3 7.1
13 54 24.8 19.9 46.3 13.0
14 79 25.9 25.3 35.9 21.8
15 86 31.2 21.2 31.4 30.2
16 117 49.6 15.1 20.5 37.6
17+ 82 67.5 1.8 19.0 45.2

TOTAL 433 33.0(c) 100.0 27.9 32.6

(a) for each group age, number of sexually active/number of adolescents x 100

(b) average age at first intercourse: 13.9 years |+ or -~ 1.7 standard
deviation

(c) 33.0% of the total sample of 1312 adolescents
TABLE 3
USE OF PREVENTIVE METHODS AT FIRST INTERCOURSE AMONG MALE ADOLESCENTS BY AGE,
LAVAL, QUEBEC (N = 429)

 USE OF PREVENTIVE METHODS
 Age n Condom Pill Ineffective
 Methods(1)
 (%) (%) (%)

12-13 66 56.1 12.1 31.8
14 77 72.7 7.8 19.5
15 86 65.1 9.3 25.6
16 116 60.3 14.7 25.0
17 and + 84 51.2 23.5 25.3

TOTAL 429 61.1 11.9 27.0

1 withdrawal, rhythm, foam, no method

Similar trends were observed for the use of preventive methods at each intercourse. Condom use was greatest in 14-year-olds (64.7%) and decreased in older adolescents, being replaced by the pill. Use of the pill reached nearly 30% in those who were 17 years of age and older. Approximately 35% or more in all age categories reported using ineffective methods of protection at each intercourse, the proportions being highest in those 12 to 13 years of age (43.8%) and in those 17 years of age and older (47.4%). Overall, at each intercourse, two out of five adolescents used the condom; one out of five, the birth control pill; and two out of five, ineffective methods.

DISCUSSION

Despite greater social awareness of STDs and AIDS, the results of this study reveal that age at first intercourse in male adolescents appears to be decreasing. Previous studies in the U.S. and Canada have shown that close to 20% of sexually active adolescents had their first intercourse at 13 years of age, with the average age varying between 14.5 and 15.9 years (Ellefsen, 1985; Pleck, Sonenstein, & Swain, 1988). In the present study, 37% of sexually active adolescents had their first sexual intercourse between the ages of 10 and 13 (17% between the ages of 10 and 12), the average age being 13.9.

TABLE 4
USE OF PREVENTIVE METHODS AT EACH INTERCOURSE AMONG MALE ADOLESCENTS BY AGE,
LAVAL, QUEBEC (N = 140)

 USE OF PREVENTIVE METHODS

 Age n
 Condom Pill Ineffective
 Methods(1)
 (%) (%) (%)

12-13 16 50.0 6.2 43.8
14 17 64.7 0.0 35.3
15 26 50.0 15.4 34.6
16 43 46.5 14.0 39.5
17 and + 38 23.7 28.9 47.4

TOTAL 140 43.6 15.7 40.7

1 withdrawal, rhythm, foam, no method

Although male adolescents are tending to begin their sexual experiences earlier (King et al., 1989), 60% of the boys studied had only one or two sexual experiences at most. Those having more frequent sexual relations did so mainly with one partner as opposed to several, suggesting as Wilkins et al. (1985) and Sonenstein, Pleck, & Ku (1991) noted, that the sexual experiences of adolescents today consist of a series of monogamies.

Overall, 60% of male adolescents in this study used condoms at their first intercourse. These results corroborate the recent findings of Pleck, Sonenstein, & Ku (1991) where a comparison of two national surveys in the U.S. revealed that the proportion of sexually active, never-married males using condoms at both first and recent intercourse more than doubled in the last decade to reach 57%. Similar to our results, condom use decreased to about a third when utilization at each intercourse was examined--which places a substantial number of adolescents at increased risk for STDs and AIDS.

The study also found that condom use peaked around the age of 14, and decreased thereafter, being replaced in older adolescents by the birth control pill. This decline in use by older adolescents can perhaps be attributed to the fact that, as relationships become more stable, adolescents prefer to use the pill (Geiss & Gerrard, 1984; Whitley, 1990). It has also been suggested that older adolescent girls grow in acceptance of their sexuality by assuming the entire responsibility of contraception (Gruber & Chambers, 1987; Hayes, 1987).

The study further found that the 12- to 13-year-olds were less likely to use condoms and more likely to use ineffective methods than were 14-year-olds, suggesting that they are less knowledgeable and less competent in this area. These findings also tend to support the view that young adolescents have a great desire for risk taking (Cvetkovich, Grote, Bjorseth, & Sarkissian, 1975). Adolescents often believe themselves to be immune to danger. Each intercourse that does not result in a pregnancy or STD reinforces the idea of invulnerability, encouraging them to take even more risks (Herold, 1983). This young age group, therefore, represents a population that is at increased risk for unwanted pregnancies and STDs.

The findings of this study have several implications. First, although condoms seem to be gaining a following among male adolescents, their use is transitory, being replaced by the pill and other methods with low protective value against STDs and AIDS. This finding suggests that teenagers are more concerned about the risk of unwanted pregnancy than that of contracting a sexually transmitted disease. Indeed, STDs and AIDS are often associated in the public's mind with prostitution, promiscuity, and homosexuality (Kaemingk & Bootzin, 1990), sexual behaviors with which adolescents do not necessarily identify themselves. To be effective, educational messages aimed at promoting condom use will have to make adolescent males more aware of their vulnerability to these health problems.

Second, a substantial proportion of male adolescents (30-40%) use ineffective methods of protection suggesting that they have not been adequately prepared to experience their sexuality in a responsible way. Until now, preventive efforts have been aimed primarily at the school environment and the general public. While these interventions may be effective for a good number of male adolescents, many are still not being reached, including high school dropouts, whose numbers are increasing in recent years (Shea, 1989), and those teenagers who tend to reject messages from school authorities, whatever they may be. It is possible that young males at risk would be more receptive to educational messages if they were targeted at specific boys' groups, such as social, cultural or sports organizations outside the school structure (Fisher, 1990). In this way, they could identify with the groups' values and find the necessary support for adopting adequate preventive behaviors in their sexual relationships.

Finally, given that adolescent boys are beginning their sexual experiences at an earlier age than before, sex education has to be started even sooner, such as in elementary school. Although this recommendation has already been made in the literature (Herold et al., 1990), its importance is underlined here.

The results of this study highlight the necessity to reorient our educational activities in STD prevention to the realities of this target group. These findings can be generalized to populations of other North American satellite cities with socioeconomic characteristics that are similar to those of Laval.

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Brigitte Maheux, Department of social and Preventive Medicine, Faculty of Medicine, University of Montreal.

Francois Beland, Department of Health Administration, Faculty of Medicine, University of Montreal.

Lucille A. Pica, Department of Community Health, Cite de la Sante de Laval (Laval City of Health).

Nguyen T. Minh Nguyet, Department of Community Health, Cite de la Sante de Laval (Laval City of Health), 3333 Blvd. Souvenir, Chomedey, Laval, Quebec, Canada, H7V 1X1.