A cross-sectional study of factors associated with adolescent sexual activity.

CONTEXT: Adolescents constitute about 20% of our population and increasingly more of them are initiating sexual activity at an early age. Several behaviors associated with adolescence like masturbation, expression of masculinity/femininity, lifestyle habits like attending late night parties, and consumption of alcohol have been variously implicated in initiating sexual activities. Sexual abuse can also lead to premature sexualization. In view of few worthwhile studies from India that have dealt with these issues this study was undertaken. AIMS: To elicit information from two co-education schools adolescent boys and girls on matters related to pubescence, sexual experiences, and sexual health. SETTINGS AND
DESIGN: Study subjects involved students from class IX to XII in two co-education schools. Consent of parents was taken to administer the questionnaire to their wards.
MATERIALS AND METHODS: A total of 586 out of 1580 students completed a self-reporting questionnaire on matters related to sexuality. Statistical Analysis EpiInfo6 Software was used.
RESULTS: Significant association was found among those holding the view that having sex proves their masculinity, being sexually abused, masturbation among boys, and sexual activity. A significantly large number of boys and girls are unaware of role of alcohol on sexual activity and that pregnancy can be caused by single intercourse.
CONCLUSIONS: This was probably the first such comparative study from India. Mechanisms need to be evaluated to help adolescents understand their sexual attitudes and situations that are likely to provoke sexual activity. Therefore, not only more detailed and longitudinal studies are needed to understand these relations in a better perspective, but also a well-planned educational program for adolescents is a need of the hour.

INTRODUCTION

Adolescents constitute about 20% of our population and their number is only going to increase further. They are growing up in an environment that is dramatically different from that in which their parents grew up. Increasingly more adolescents are initiating sexual activity at an early age.[1] Adolescence is a period when an individual's personality develops which includes his/her masculinity/femininity ideas also. This could have overbearing influence on his sexual attitudes and behaviors.[2] Exposure to sexual abuse put adolescents at risk of early initiation of sexual activity.[3]

Masturbation is a unique human behavior, often regarded as an appropriate sexual outlet, but it has also been related variously to early onset of sexual activity.[4-6] Masturbation in India is known to be associated with positive feelings when outlook toward it is positive.[7]

With growing urbanization, liberal attitudes and mingling of both genders in school and social contexts, there is an increasing opportunity for boys and girls to party together and also consume alcohol.[8-10] Such occasions are known to increase the likelihood of their indulgence in sexual activity.[11]

Many children are prone to be sexually abused.[1213] It is known that such children grow up and initiate sexual activity at an early age.[14] Since early age of initiation of sexual activity puts adolescents at risk of pregnancy, HIV infection/STDs, and a myriad of social and health consequences, it is essential that they need to be educated on these aspects. In a study from Kolkata of adolescent girls, Das et al. found that many of them had poor knowledge on matters related to sexuality, sexually transmitted diseases. They also suggested that regular surveys on sexual attitudes, knowledge, and behaviors are essential in understanding the epidemic of sexually transmitted diseases.[15] TSS Rao in an editorial had emphasized the need for assessment of attitudes and beliefs in regard to sexuality.[16] In view of the above, this study was undertaken to ascertain what kind of attitudes and behaviors are likely to be associated with increased chances of sexual activity.

MATERIALS AND METHODS

This study was conducted in two co-education schools of Pune. After having taken permission of principals of both schools and due consent from the parents of students of class IX to XII was taken as the study sample.

They were administered a self-report questionnaire which contained four sections. First one dealt with socio-demographic data, second one pubescence, the third sexual experience, and fourth attitudes, knowledge with regard to sexual health including HIV infection. The demographic data collected included questions regarding duration of television/ unsupervised internet use, the type of channels usually seen on television. Questions like whether they thought that attending late night parties and consuming alcohol increases chances of indulging in sexual activities. Sexual abuse was described as anyone having touched their private parts, shown pornographic material, unsolicited exposure to private parts of others or non-consensual sexual activity. They were asked to report if anyone had experienced such abuse. They were also asked about masturbation and ideas about masculinity and femininity.

Only those girls and boys who volunteered were separately presented the questionnaire. The questionnaire was given on separate days in two schools. The lady worker clarified the questionnaire to girls and principal worker clarified for the boys. The identity of the students was kept confidential. Sexual contact was described as having kissed sensuously, touched/fondled private parts of opposite sex, and having had engaged in sexual intercourse.

This study restricted itself to evaluating the relation of masturbation, masculinity/femininity ideas, views on attending late night parties/drinking alcohol, and sexual abuse to sexual activity of the students.

Questionnaires that were not complete or had not given demographic data were excluded from the analyses. Analyses were done using EpiInfo6 software.

RESULTS

The combined strength of students from class IX to XII in both schools was 1580 of which 822 (52.25%) parents had given consent. A total of 642 (40.63%) students filled up the Proforma. Others were absent on the days of study, of these only 586 were taken up for further analysis. As those that were incomplete were not taken up for the study. It comprised of 357 (61.93%) boys and 229 (39.07%) girls.

Sexual contact was described as having touched private parts, kissing, or sexual intercourse. About 30.08 % of boys and 17.18 % of girls reported having had sexual contact. About 37 (6.31%) boys and 03 (1.31%) girls had reported having had experienced sexual intercourse. Average age at first sexual contact for boys was 13.72 yrs and for girls was 14.09 yrs, while average age at first intercourse in those who had it was 15.25 yrs for boys and 16.66 yrs for girls. Masturbation was more common among boys (45.9%) than girls (12.7%).

It is evident here that a highly significant number of boys who had sexual contact think that having sex proves masculinity.

Here it is evident that a significantly larger percentage of sexually abused boys are likely to have sexual contact than those who have not been abused, while there is no such difference among girls.

The practice of masturbation is only 21.9% among girls while it is 55.7% among boys. Although this table shows significant difference, it is significantly only among boys with a larger proportion of boys practicing masturbation also having had sexual contact, while there is no such difference in the two groups of girls.

Here we do not see any significant difference in knowledge levels regarding pregnancy after one sexual intercourse among those having sexual contact and those not having. Overall, 41.9% of girls and 53.0% of boys have the knowledge in this regard.

Here we see that while only 40.8% girls accept the concept that attending late night party is likely to increase indulgence in sex, up to 50.45% of boys think so. However, there is no significant difference between those who have had sexual contact and those who have had not.

This table shows that 28.3% girls and 37.2% boys consider consumption of alcohol to increase indulgence in sex. However, there is no significant difference between those who have had sexual contact and those who have had not.

DISCUSSION

Fifty-two percent of parents had given consent for their children to fill up the questionnaire. It could be because either they were not shown the consent form by their children or that they were apprehensive of it. However, it was heartening to note that 78.10% children of consenting parents completed the questionnaire, implying that adolescent students per se were not much averse to it. Others could not as they were absent on the day of survey.

Femininity and masculinity or one's gender identity refers to the degree to which persons see themselves as masculine or feminine given what it means to be a man or woman in society. Femininity and masculinity are rooted in the social (one's gender) rather than the biological (one's sex). Societal members decide as to what being male or female means e.g. dominant or passive, brave or emotional. Males will generally respond by defining themselves as masculine while females will generally define themselves as feminine.[17] The concept of masculinity in India usually implies having good physical looks and penis size. It is usually is associated with sexuality that often involves coercive sexual behaviors.[18] It was thus not surprising to find in our study that a large number of boys agreeing to the fact that sexual act proves their masculinity (~29% of boys) [Table 1]. Barker & Lowenstein reported in a study from Brazil that becoming sexually active is perceived as an easier way of ascertaining masculinity rather than by proving their productivity and ability to financially support family.[2] Verma et al reported that many young men indulged in unwarranted, unsolicited verbal comments, whistling, jostling, touching, and harassing girls as a form of proving their masculinity.[18]

Table 1

Gender-wise relation of sexual contact with concept of femininity and masculinity

The concept of femininity generally inculcated into girls in India is that of being submissive, being coy about their sexuality, and being obedient.[3] In the present study therefore, it is not very surprising to find that only 17.64% of girls agreed that having sex proves their femininity and of those who have had sexual contact only 13.5% agreed to such a view, whereas among boys the percentage was significantly higher on both accounts (46.25% and 27.55%, P=0.004) [Table 1].

Impett et al had reported that increasing femininity is associated with less sexual self-efficacy. Sexual self-efficacy is a girl's conviction that she can act upon her own sexual needs in a relationship. Diminished self-sufficiency in turn predicted less sexual experience and less use of protection.[19] However, in our study we had not asked for their ability to use protection during sexual acts. Tolman reported a significant association between early adolescent girl's espousals of more conventional beliefs about femininity and diminished positive sexual health. It is not quite common for women to assert their femininity by indulging in sexual activity. When they have poor social skills, they may offer sex for social support or staying in marriage.[20] Such behaviors put both boys and girls at risk of HIV infection/STDs/pregnancy. Therefore, they should be encouraged to assert their masculinity/femininity by engaging in pursuance of good social skills, improving their intellectual assertiveness rather than sexual assertiveness. Further studies are warranted to understand the construct of femininity among our adolescents.

Sexual abuse of a child is defined as involvement of a child in a sexual activity that he/she does not fully comprehend, is unable to give informed consent, or to those acts that violate the laws or social taboos of society.[12] While we had found that 7.84% boys and 13.53% girls having had experienced sexual abuse, it is not surprising as Patel et al also had reported sexual abuse from educated high school students.[21] Stewart et al had in a study found that such children are likely to indulge in risky sexual behavior, be unable to use contraception correctly, and are prone to various STDs/HIV infections.[14] In our study we found a significant association of sexual abuse with sexual contact but only among boys (P=0.0017) [Table 2]. We had not asked for the time of abuse so cannot say if the sexual activity preceded or followed sexual abuse. More comprehensive longitudinal studies are hence needed as the number of those reporting abuse is not small. This is especially so as Sobtia et al in a cross-sectional study found that one fourth of the students surveyed had been sexually abused and had long-term psychological impact on the victim but they had not looked for any increased sexual activity among them.[13] Risky sexual behavior could often be a manifestation of the abuse victims′ inability to cope up with the shame and guilt and to distinguish sexual behavior from affectionate behavior.[14]

Table 2

Relation of sexual abuse to having sexual contact

The human species is probably the only one to practice masturbation and often is regarded as an appropriate sexual outlet for them.[4] Masturbation is universally practiced ranging from 10% to 33% among girls and 39.7% to 63% among boys.[35] However, masturbation has also been associated with sexual activity in that earlier the age of initiation more the sexual activity.[22] Sathe & Sathe had reported that 44.6% of males felt that masturbation made them feel more masculine, so it is not surprising that we also found a significant association between masturbation and having sexual contact among boys (P=0.00) [Table 3].[7] Yeong et al had also found diminished sexual activity (coital rate) among non-masturbators when compared to masturbators.[22] However, there was no such association among girls. This probably is due to the fact that only small number of them actually reporting masturbation (12.7%) and much smaller number of sexual activities (17.18%). It therefore becomes imperative that educational programs on sexuality should also deal with issues related to masturbation.

Table 3

Relation of sexual contact with masturbation

Adolescent pregnancy can lead to cascading health and psychosocial consequences in the girl. In our study we found that up to 40.2% of students (41.9% girls and 53% boys) had no knowledge that a single intercourse can lead to pregnancy [Table 4]. But this awareness was much better that that reported by Shittu et al, who found that 80% of students from urban schools did not know about it.[23]

Table 4

Relation of sexual contact with knowledge that single intercourse can cause pregnancy

Partying together for fun or to celebrate an occasion is not quite uncommon among school going adolescents. When girls do attend parties they do so in a group and stay as a group. This helps them in keeping boys at bay and prevents them from making sexual advances. However, as the party prolongs the group tends to break up and leads to a let up in such defense.[24] In this context we wanted to know if these adolescents believed that partying late into the night would lead to increased indulgence in sexual activity. We found that 40.8% girls and 50.45% boys agreed that such parties do lead to increased chances of indulging in sexual activities. On further analysis we found a significantly larger percentage (P=0.001) of those having sexual contact agreeing to such a view (58.6%). Further among those having such a view point 31.9% had sexual contact, while among those who did not hold such a view only 19.7% has sexual contact [Table 5].

Table 5

Is late night partying associated with indulgence in sex?

Late night parties are often associated with use of alcohol by students. Alcohol has been varyingly related to indulgence in sexual activity among adolescent boys and girls, but many do agree that alcohol increases indulgence in sexual activity.[82526] We studied the view of the students in regard to role of alcohol in increasing the chances of indulgence in sexual activities. We did not find any significant association between having sexual contact and professing the view that consumption of alcohol increases the chances of indulgence in sexual activity. It could probably have been due to consumption of alcohol not being a significant issue among these students or that they have not been exposed to such situations. This lack of association is evidence of good health of our students as the concoction of early initiation (preteens) of alcohol ingestion, smoking, and sexual intercourse represents an important predictor of later suicidal ideation and attempts irrespective of gender.[27] It was found that only 33.6% agree that alcohol increases the chances of indulgence in sexual activity [Table 6]. This is in much variance to findings from various studies that have found such an association. These studies have found that often the availability of alcohol in a setting where girls are present itself is an indicator that sex would be also available, alcohol is known to increase both desire to communicate to have sex and in initiating/participating in sex. Alcohol use is more likely in new sexual relationships and among those who are not much committed to the relationship and lead to risky/unsafe sexual practices.[8102428]

Table 6

Is consumption of alcohol associated with indulgence in sex?