Sexual resilience within intimate relations among unmarried adolescent girls seeking abortion in an abortion clinic of Delhi, India.

BACKGROUND AND OBJECTIVES: Sexually experienced, unmarried adolescent women, usually commence sex, with marriage in mind. Initially, they resist sex but are unsuccessful due to lack of resilience to end an oppressive relationship, or convince their partners to postpone sex or use protection. To retain partners, they accept unprotected sex and suffer its consequences such as unwanted pregnancies, sexually transmitted diseases, HIV/AIDS and cervical cancer. Considerable numbers of adolescents face this emotional stress and suffer the consequences, while some manage to endure and emerge from the ordeal. This study attempts to determine this resilience and extrapolate it to others who might not be so successful without an intervention.
METHODOLOGY: The study compares sexual resilience in 100 unmarried adolescent abortion-seekers, in terms of time taken from meeting the partner, to sexual debut and correlates this with background factors such as age, education, family income, self-esteem, sexual knowledge, attitude toward pre-marital sex (PMS) and partner pressure.
RESULTS: Mean debut age was 17.32 years. Partners took more initiative to form emotional (64%) and physical relationship (78%). Adolescent girls' initiative reduced markedly from emotional (22%) to physical relation (5%). Correlation of sexual resilience with age, family income education and knowledge was not significant. It was significantly correlated with attitude toward PMS, self-esteem and partner pressure. INTERPRETATION AND
CONCLUSION: It is desirable to improve self-esteem and attitude of young women to build negotiation skills in intimate relations. Counselors have to reorient the perspectives to improve attitude toward abstinence and increase self-esteem to resist pressure from partners.

INTRODUCTION

Adolescence is a time of sexual awakening and interest, when the level of mental maturation does not allow for complete understanding of risks involved in sexual indulgence. Although reported pre-marital fertility in India is negligible, it does not mean that there is no sexual activity before marriage. Pre-marital pregnancies are predominantly aborted in secrecy or obscured by marriage. Sometimes adolescents, who deny sexual experience in unmarried state, admit it once it does not affect their social future, especially if the sexual partner is now their husband. Pre-marital sex (PMS) is most likely with future spouses, as fiancιs or boyfriends. When marriage is imminent, PMS seems to occur even in conservative settings.[1]

Most young girls in India grow up in an environment of gender discrimination, low self-image and oppressive marital expectations of society. Families strongly resist romantic alliances and often arrange marriages themselves. Girls develop less favorable attitudes toward their own sex, their roles as the dominated-upon sex and toward their own selves as individuals.[2] Poor self-image manifests itself emotionally, as poor self-esteem, making girls more vulnerable to exploitive persuasion and male dominance in interpersonal relationships [Figure 1].

Figure 1

Personal and environmental factors in the context of Indian adolescent

On the other hand, adolescents in liberal urban environments develop strong affinitive needs and feel that sexual involvement is okay as long as you are in love.[3] The changed attitudes perceive sexual involvements as elevation of status among peers and thereafter elevation in self-esteem. Often they are unable to handle this liberation at that immature age and hence unwillingly accept unprotected sex and often suffer its adverse consequences.[4]

Considerable numbers of adolescents face this emotional stress, some give in and suffer consequences, while others emerge from the ordeal. This resilience needs to be studied and extrapolated to those who might not be so successful without an intervention. In the present study, resilience denotes the constraint that is exercised within a relationship before it transforms from emotional to sexual i.e., how long the adolescent is able to evade sexual debut before finally giving in.

METHODOLOGY

The study was conducted at Parivar Seva Sanstha, a non-government organization providing family planning and safe abortion services under the name of Marie Stopes. About 300 cases a month are recommended here by private practitioners, diagnostic laboratories, chemists, midwives etc., of which 10% are unmarried adolescents. Since the nature of the interview was sensitive, not many girls agreed to be interviewed, so a random sampling did not work. After a pilot study, the statistician advised a sample size of 100, to avoid biases of purposive sampling and based on willingness to respond.

A total of 100 unmarried adolescents, 12-20 years of age were selected. Being pregnant within a consensual relationship and the decision to abort the fetus were the main criteria for inclusion into the sample. Pregnancies due to rape were not included. Clearance was obtained from the Institutional Ethics Committee and an informed written consent was obtained from all the participants before enrolment.

Independent variables-age, education, family income, knowledge, attitude toward PMS, self-esteem, partner pressure.

Dependent variables-sexual resilience (time taken before sexual debut)-was calculated by subtracting the period of physical activity from the period of acquaintance for each respondent.

Control variables-the criteria under this head included, unmarried pregnant girls, 12-20 years seeking abortion.

Interview schedule-the adolescents were given a self-administered questionnaire with both structured and open-ended questions to collect baseline data about personal, family, sexual and reproductive history. It also covered items regarding the formation of romantic alliance, period of acquaintance, physical activity and sexual dominance. There were also questions on contraception, pregnancy and abortion. Since the questionnaire collected qualitative data no scoring was carried out.

Fixed response questionnaire had 20 items covering attitude and knowledge regarding:

Maternal and child health (4 items)-genital hygiene, anemia, maternal age and nutrition

Pregnancy and abortion (6 items)-single contact pregnancy, primi abortion, safe abortion, gestation period, post abortive fertility, emergency contraceptive pill

Sexually transmitted disease (STD) and HIV/AIDS (6 items)-unprotected sex, use of condoms, recognizing HIV symptoms, HIV transmission, risks in blood transfusion and HIV in monogamous women

Attitude toward sexual relations (4 items)-pre-marital virginity, gender bias, sex in love relations and negotiating condom use.

The scoring was on a two-point Yes and No pattern. An additional option of “I don’t know” was provided to avoid guessing. Each right answer was awarded a score of 1, while wrong options and I don’t know, were both scored 0. Maximum score could be 20 and minimum score 0. The tool was assessed and approved by specialists for face validity and had a test-retest reliability of 0.73.

The Rosenberg self-esteem scale[5]

The 10 items were answered on a four point scale ranging from strongly agree to strongly disagree. The scale generally has high reliability: Test-retest correlations were in the range of 0.82-0.88 and Cronbach's alpha for various samples were in the range of 0.77-0.88. Studies have demonstrated both a one-dimensional and a two-factor (self-confidence and self-deprecation) structure to the scale. To score the items, a value was attached to each of the 10 items as follows: For items 1, 2, 4, 6, 7: Strongly Agree = 3, Agree = 2, Disagree = 1 and strongly Disagree = 0. For items 3, 5, 8, 9, 10 (which are reversed in valence and noted with the asterisks*** below): Strongly Agree = 0, Agree = 1, Disagree = 2 and strongly Disagree = 3. The scale ranged from 0 to 30, with 30 indicating the highest score possible.

RESULTS

The pregnant adolescents were largely students or working girls, mostly first gestation and a few second abortions. Socio-economic status varied widely, from middle and upper-middle classes, office-goers to migrant labor girls working as housemaids. Most girls (72%) were sure they would continue the relation post-abortion.

Age at reporting for abortion did not indicate the age of sexual initiation because conception occurred after some time of sexual debut. Therefore, sexual debut age was considered, rather than the current age, with a mean of 17.32 years and standard deviation (SD) of 1.55 years.

The mean years of education was 12.13, corresponding to senior secondary level in India, (SD-0.841); 42% respondents were in the 11-15 years education group, while 15% were at the middle school level and 19% below primary education. Thus, 34% adolescents had below 10 years of education.

The mean family income was Rs. 9950 ($190)/month (SD-6893), with 35% having less than Rs. 5000, 22% in the Rs. 5000-10000 and 24% in the Rs. 10000-15000 bracket. The above Rs. 20000 income group had 14% adolescents.

The mean knowledge score was 9.31 (SD-3.1), with 14% respondents scoring above 13, while 44% had scores in the 9-12 range and 36% in 5-8. Only 6% had scores below 4.

The mean score for attitude toward PMS was 1.79 (SD-0.91), with 35% scoring below two and only 22% above two. Nine respondents scored 0, while only one scored full 4. The attitude scores were predominantly low.

Partners took more initiative to form both emotional (64%) and physical relationships (78%). Mutual agreement was reported in both types of relations but more so in physical relation (17%). Adolescent girls’ initiative was more in the emotional quarter (22%) than in physical (5%).

Nearly 17% knew their partners for 5 years or more, while 26% and 24% were acquainted for 3-5 years and 2-3 years, respectively. Two-thirds of adolescents (67%) knew their partners for more than 2 years [Figure 2]. 4% were in a relationship for more than 5 years, 9% for 3-5 years and 22% for 2-3 years.

Figure 2

Period of various intimacy phases

There were no respondents with above 5 years of physical relationship, 4% had 3-5 years of physical activity and 11% for 2-3 years, while 31% had 1-2 years of physical activity, 21% for 7-12 months, 29% for 4-6 months and 4% had begun sex less than 3 months ago. Most pregnancies had occurred within 1 year of sexual debut (54%).

Correlation of sexual resilience with background factors such as age, family income, education and knowledge was not significant. Only attitude toward PMS, self-esteem and partner pressure were significant [Table 1].

Table 1

Correlation matrix for sexual resilience (time taken to reach sexual debut) with background factors for unmarried adolescents

DISCUSSION

The study indicates that consensual sexual activity began at an early age even among socially empowered segments; unprotected sex commonly leading to unwanted pregnancy and abortion, thus further increasing vulnerability to STDs, HIV/AIDS and cervical cancer. Nearly three-fourth respondents intending to continue relationships after abortion, indicates an unending cycle of these problems.

There is universality in sexual responses irrespective of age, class, education and sexual knowledge, indicating that it requires more than a high social achievement to emerge successfully from the challenge of sexual pressure in intimate relations. Whatever the level of the individual in the social ladder, what mattered was the will to avoid PMS and confidence to exercise this right despite pressure from the partner. A study by Feltey et al.[6] found that men often believed that sexual coercion strategies were justifiable with future wives and steady girlfriends.

Adolescent girls’ initiative reduced considerably when emotional (22%) and physical (5%) initiatives were compared and most of them desired intimacy minus sex. This is consistent with other researches that young women often comply with partner's sexual wishes as a form of relationship maintenance.[478910] Most adolescents knew their partners for long periods of time (>2 years), indicating that sex occurred after considerable time of the meeting. Christopher and Cate[11] identified pathways in dating: Rapid involvement couples had sex early, often on the first date. Gradual involvement couples reported a gradual increase in sexual behavior. Delayed involvement couples delayed sexual involvement until they considered themselves to be a couple. In this study, most respondents fell in the gradual and delayed involvement categories.

Adolescent girls considered their first kiss as the biggest milestone in their relationships. Once it was crossed, the resistance to physical advance reduced dramatically. One-fourth of study respondents admitted to having intercourse, the very day they kissed for the first time. Couples place special significance on first time each milestone is crossed in a physical intimacy, especially the girls.[12]

Most girls (72%) intended to continue the relation post-abortion, indicating that once sexual activity began it was impossible to get out of it. When they return to the same environment, most likely sex would resume, exposing them to a vicious circle of unprotected sex, unwanted pregnancies and abortions. Desire to strengthen relations or prove love, fears of losing their partner, incurring his anger, or jeopardizing the relationship are some of the important factors inhibiting young women from delaying sexual activity or negotiating condom use. Thus, they unwillingly accepted unprotected sex and suffered its consequences.[13]

Table 1 shows that sexual resilience or, conversely, the speed of the relationship, is more likely to covariate with inter-personal factors such as partner pressure, attitude to PMS and self-esteem. This means that formulators of counseling and guidance programs, have to re-orient their perspectives and prepare the girls to handle partner/peer pressures. There is also a need to address men for discouraging dominance in intimate relations, for early sex.

Sexual resilience thus, is not affected by whether the girl is younger or older, rich or poor, educated or illiterate, has high or low knowledge of reproductive health. The capacity to delay sex in an emotional relation depends on:

Her own attitude toward PMS and male dominance. Those who accept that sex is fine in love are more likely to give in soon. Similarly, those who exhibit attitude of accepting male superiority are more likely to surrender to their dictates

Partner's pressure induces earlier sexual debut. Ehrenfield[14] reported that sexual activity was initiated in response to subtle pressure and promises of a permanent relationship by the partner. Such women were faced with options of offering sex or losing the relationship, which markedly reduces their resilience

High self-esteem is another important factor that helps adolescents cope with pressure. Our findings agree with another study that low self-esteem girls are more likely to be sexually active.[15]

In the present study, the correlation between attitude and self-esteem was insignificant but positive (P < 0.122). Yet, there was a negative correlation with partner pressure, significant at P < 0.01 level. On cross tabulation it was found that despite partner pressure, girls with a positive attitude regarding PMS could resist and delay sex longer if the self-esteem scores were high. Positive self-image helps prevent partners from intimidating them. The interplay of these factors, in the wake of partner pressure, is explained in Figure 3.

Figure 3

Partner pressure and sexual resilience

The study does not agree with earlier studies in the linkage between self-esteem and sexual behavior,[16] one study states that sexual risk was related to psycho-social deprivation linked to low self-esteem.[17] These studies fail to take into account the specific interplay of gender, beliefs and attitudes. For girls, sexual activity leads to a drop in self-esteem. Masculine preoccupation with sex as a conquest acts as a boost to their self-esteem, whereas for girls it is viewed as surrender.[1518]

Furthermore, self-esteem is positively related to sexual intercourse experience for adolescents who believe that it is right, but negatively for those who think it is wrong. Therefore, sexual behavior that contradicted personal values was associated with lower self-esteem and emotional distress.[19]

To summarize, the typical unmarried, adolescent abortion-seeker is not a disadvantaged, vulnerable girl. The notion that, these girls are social deviants and therefore, ought to be punished makes them suffer bias from counselors, doctors and other abortion providers. It is important to re-orient perspectives while counseling and improve their attitudes and negotiating skills, along with environmental inputs.

Although every effort was made to avoid bias, some limitations emerged, because the study could include only abortion seeking adolescents, while other sexually active girls were difficult to identify and enroll, due to a high degree of denial. Furthermore, private practitioners and traditional birth attendants did not cooperate for various reasons such as, patient privacy, under-reporting, tax evasion etc., Hence, the cases reporting to them could not be accessed. And, finally, not all patients agreed to be interviewed and hence a random sampling could not be followed.

CONCLUSION

The average adolescent girl attempts to control her destiny by selecting a mate herself. However, the control is seldom achieved, they rather tend to lose it further and in order to retain social acceptability, their health is sacrificed. Often these women are looked upon with a prejudiced eye as, in India, social norms are conditioned to outcaste pre-maritally sexually active girls as amoral.[20] Just because she was an equal partner in love (quite likely not in sex), should not reduce her vulnerability to men's culturally conditioned behavior and biases. She is rather a victim of male dominance, lack of negotiation skills and no marriage as a social guard to protect her future. In fact, this category of adolescents is a challenge to researchers and policy makers, who need to respond with adequate programs and policies to support and rehabilitate such unapparent vulnerability.