DiCLEMENTE, RALPH J. PhD*†‡; WINGOOD, GINA M. ScD, MPH,*‡; CROSBY, RICHARD A. PhD,*‡; SIONEAN, CATLAINN PhD,*; COBB, BRENDA K. PhD, RN,§; HARRINGTON, KATHY MPH,∥; DAVIES, SUSAN L. PhD, MPH,∥; HOOK, EDWARD W. III MD,¶ AND; OH, M. KIM MD#
From the *Department of Behavioral Sciences and Health Education, Rollins School of Public Health, Atlanta, Georgia; the †Department of Pediatrics, Division of Infectious Diseases, Epidemiology, and Immunology, Emory University School of Medicine, Atlanta, Georgia; the ‡Emory/Atlanta Center for AIDS Research, Atlanta, Georgia; the §Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, Georgia; the ∥Department of Health Behavior, School of Public Health, University of Alabama, Birmingham, Alabama; and the ¶Department of Medicine, Division of Infectious Diseases, and the #Department of Pediatrics, School of Medicine, University of Alabama, Birmingham, Alabama
The authors thank Dr. Jane R. Schwebke for provision of cultures of Trichomonas vaginalis and Kim Smith, MT (ASCP), for assistance and oversight of testing for Neisseria gonorrhoeae and Chlamydia trachomatis.
This study was supported by a grant from the Center for Mental Health Research on AIDS, National Institute of Mental Health (1R01 MH54412), to the first author. Drs. Crosby and Sionean were supported through an Association of Teachers of Preventive Medicine/Centers for Disease Control and Prevention STD Prevention Fellowship.
Correspondence: Ralph J. DiClemente, PhD, Rollins School of Public Health, Department of Behavioral Sciences and Health Education, 1518 Clifton Road NE, Room 520, Atlanta, GA 30333. E-mail: firstname.lastname@example.org
Received for publication March 1, 2001,
revised May 21, 2001, and accepted May 30, 2001.
SEXUALLY TRANSMITTED DISEASES (STDs) are a common source of adolescent morbidity, and their sequelae are especially problematic and costly for females. 1 Likewise, more than one-fifth of all females in the United States ever infected with HIV were probably infected during their teens. 2 Understanding why adolescents at risk for STD/HIV infection engage in unprotected sex is an important aspect of developing and implementing prevention programs. 1,3 However, this issue has not been sufficiently addressed with regard to adolescent females, particularly blacks, who may be at greatest risk of STDs.
One important aspect of adolescent females’ STD/HIV infection–associated risk behavior is the age of their male sex partners. Recent analysis of data collected from the National Survey of Family Growth indicated that adolescent females having sex with male partners who were at least 6 years older were more likely to intentionally become pregnant than those having sex with male partners no more than 2 years older. 4 These survey data have also shown that contraceptive use at first intercourse was less likely among female adolescents reporting their sex partner was at least 6 years older. 5 Miller and colleagues found that minority female adolescents having first intercourse with a male partner who was 3 or more years older were less likely to use condoms during their first and most recent sexual intercourse, during the past 6 months, and since becoming sexually active. 6 Similarly, a recent study found that black male youths (15–24 years of age) were more likely to report condom use with female partners closer to their own age. 7
Although these studies are highly informative, they did not assess associations between having partners who typically were older (as opposed to most recent or first sex partner) and STD/HIV infection–associated risk behavior. Furthermore, with the exception of Miller et al, 6 investigators have not reported significant associations of having partners who are only slightly older than the females studied. This is important because adolescent females may commonly have sex with males who are only 2 years older. A recent analysis of a nationally representative survey indicated that about 40% of female adolescents in the United States reported their most recent sex partner was at least 2 years older. 8 Thus, it is important to assess whether the influence of having a partner who is as little as 2 years older is a significant risk factor for unprotected sex among adolescent females. Such an assessment may show that the 6-year difference found in the National Survey of Family Growth 4 and the 3-year difference found by Miller and colleagues 6 may overestimate the age difference needed to find an association with the unsafe sex practices of adolescent females.
One potential explanation for higher-risk behavior among adolescent females who have older partners is an increased power imbalance due to the age difference. 6 Such power imbalances may lead to male-controlled sexual decision-making. Males may be less likely than their younger female partners to desire condom use. Thus, this desire of older males may prevail.
Empirical investigations of associations between having partners just 2 years older and adolescent females’ sexual risk behaviors are particularly needed for the benefit of those at high risk of STD/HIV infection. Accordingly, the primary purpose of this study was to assess the relation between having male sex partners who were typically older and adolescent females’ STD/HIV infection–associated sexual risk behaviors.
From December 1996 through April 1999, project recruiters screened 1,130 female teens at adolescent medicine clinics, health department clinics, and school health classes to assess eligibility for participating in an HIV/STD prevention trial. Recruitment sites were in neighborhoods characterized by high rates of unemployment, substance abuse, violence, and STDs. Of those screened, 609 adolescents were eligible to participate in the study. Of those adolescents not eligible to participate (n = 521), the majority (98%) were not sexually active. The current study included 522 eligible adolescents (85.7%) who were enrolled and completed baseline assessments. The majority of eligible teens who did not participate in the study were unavailable because of conflicts with their employment schedules. Adolescents were eligible to participate in the trial if they were black females between the ages of 14 and 18 years at the time of enrollment, were sexually active in the previous 6 months, and provided written informed consent. The study protocol was approved by the Institutional Review Board Committee on Human Research, University of Alabama, before implementation.
Data collection was conducted at the UAB Family Medicine Clinic by means of two components: a self-administered survey and a structured personal interview. The self-administered survey was conducted in a group setting, with monitors providing assistance to adolescents with limited literacy and helping assure them of the confidentiality of responses. The questionnaire assessed psychosocial measures, e.g., constructs relevant to adolescents’ perceptions of their male partners’ desire for pregnancy, partners’ reactions to suggestions of condom use, and their perceived ability to negotiate condom use. Subsequently, adolescents completed a face-to-face interview that assessed sexual risk behaviors and contextual factors related to sexual behavior, e.g., typical age of partners and length of relationship with current steady partner. We chose to assess adolescents’ sexual behavior and the corresponding contextual factors by using face-to-face interviewing that was specifically designed to maximize comfort levels and therefore facilitate recall as well as valid responses. The interview was administered by trained black female interviewers in private examination rooms. The adolescents were given $20.00 for their participation.
The key determinant was assessed by a single item at the beginning of the face-to-face interview. Adolescents were asked, “In general, how old are the people you have sex with? Are they much younger than you (5 or more years younger), younger than you (2–4 years younger), about the same age, older than you (2–4 years older), or much older than you (5 or more years)?” Thus, adolescents’ responses were assumed to represent the age difference of their typical sex partners. Adolescents reporting that their typical sex partners were at least 2 years older were compared with those who reported that their typical sex partners were of the same age or less than 2 years older. Adolescents were also asked whether, during the previous 6 months, they had had sex with a steady partner (i.e., a boyfriend who was not a casual sex partner). Those who did not report having a steady sex partner (n = 45) were excluded from the analyses.
Several measures of recent condom use with steady partners were assessed by interview: condom use at most recent intercourse, use during the last five sexual intercourse occasions, and use during the past 30 days. Because the percentage of condom use may not fully capture the absolute number of risk exposures for STD/HIV infection, 9,10 we also assessed frequency of unprotected vaginal sex (UVS) among adolescents for retrospective periods of 30 days and 6 months.
Identification of Covariates
Adolescents’ age, their length of relationship with the current sex partner, and their use of hormonal contraceptives in the past 6 months were identified as covariates. Adolescents’ current pregnancy status was not related to having older partners. We also tested adolescents’ perceptions of their current sex partner's level of desire for them to become pregnant. However, their perceptions of the partners’ desire for pregnancy were not significantly associated with having an older partner, even after adolescents who were currently pregnant were excluded from the analysis (prevalence ratio = 1.18; 95% CI = 0.95–1.45;P = 0.14).
The relations between having an older partner and STD/HIV infection–associated risk behaviors were assessed with use of contingency table analyses. Prevalence ratios, 95% confidence intervals, and corresponding P-values were calculated to determine the magnitude and significance of the bivariate relationships. Logistic regression was used to calculate adjusted odds ratios, their 95% confidence intervals, and corresponding P values, in the presence of three identified covariates.
Characteristics of the Sample
The average age of the adolescents was 16.0 years (SD = 1.2). About 23% reported primary reliance on hormonal contraception during the past 6 months (oral contraceptives, injections, or implants). Nearly 12% of the adolescents reported current pregnancy. About 91% (n = 477) of the adolescents reported having sex with a steady male partner in the past 6 months. Of these adolescents, nearly 53% reported that their typical sex partners were 2 to 4 years older, and another 10% reported their typical sex partners were at least 5 years older. Of the remainder, 36% reported that their typical partners were about the same age and 1% reported their typical partners were 2 to 4 years younger. Adolescents who reported having typical partners that were at least 2 years of age older (63%) were compared with the remaining adolescents, who reported that their typical sex partners were about the same age or at least 2 years younger (37%).
Table 1 displays the observed bivariate relations between having older partners and each of the five measures of STD/HIV infection–associated risk behaviors. All of the bivariate relationships were significant, indicating that adolescent females with typically older sex partners were more likely to report never using condoms and to report having any unprotected vaginal sex.
Table 2 displays the observed adjusted odds ratios, showing the strength of the relation between having older partners and STD/HIV infection–associated risk behaviors. After controlling for adolescents’ age, their recent use of hormonal contraception, and the length of their relationship, we noted that those with older partners were more than twice as likely to report they had not used condoms during their most recent and last five sexual episodes. Similarly, adolescents having older partners were somewhat more likely to report never using condoms during the past 30 days. Adolescents with older partners were about 1.6 times and 2.2 times more likely to report any unprotected vaginal sex in the past 30 days and 6 months, respectively.
After determining that adolescent females with older partners were more likely to report risky sex, we hypothesized that they would report more partner-related barriers to condom use than the adolescents who did not report having older partners. The self-administered questionnaire assessed adolescents’ perceptions of their ability to negotiate condom use (4-item scale with an α of 0.79), their fear of negative partner reactions if condom use was discussed (6-item scale with an α of 0.81), and their perception of general partner-related barriers to using condoms (7-item scale with an α of 0.83). Scores from each scale measure were dichotomized, given the markedly skewed distributions, by a median split.
Table 3 displays prevalence ratios assessing strength of the bivariate relations between the three scale measures and having older partners. Adolescents having older partners were significantly more likely than those not having older partners to indicate fear of negative reactions from partners if condom use was discussed and were more likely to indicate general partner-related barriers to condom use. In turn, fear of negative reactions from the partner was associated with not using a condom during the last sexual encounter (P = 0.050) and having any unprotected vaginal sex during the past 6 months (P = 0.011). The measure of general partner-related barriers to condom use was associated with all five measures of sexual risk behavior shown in Tables 1 and 2 (P for each < 0.002).
Controlled analyses indicated that adolescent females who reported that their typical sex partners were at least 2 years older were more likely to report risk behaviors for STD/HIV infection than adolescents who did not report their typical sex partners were at least 2 years older. Compared with the findings in previous studies, 4–7 this finding was observed at a much lower age difference, i.e., 2 years, as contrasted with the 3 years reported in one study 6 and 6 years reported in two other studies. 4,5 This finding is important because a substantial percentage of female adolescents are having sex with male partners who are at least 2 years older. 8
In addition, the current study assessed the age of typical sex partners as opposed to the age of the first sex partner. Thus, our findings suggest that adolescent females commonly have sex partners who are at least 2 years older. Furthermore, our findings indicate that the relationship dynamics of these partnerships with older males do not favor adoption of STD/HIV infection–associated protective behavior. This was particularly true with respect to the finding that the seven-item scale of partner-related barriers to using condoms was associated with each of the sexual risk behaviors. This scale included items that assessed whether the partner “might get angry” or might think “I was cheating on him,” “I didn't trust him,” or “I was accusing him of cheating.” The barriers assessed may best be summarized as adolescents’ perceptions about possible reactions from their partner if condom use were suggested. Thus, our findings suggest that adolescents with older partners are more likely to perceive a partner's reaction as negative to the idea of condom use and in a corresponding manner are less likely to report safer sex behaviors.
Findings are limited by at least three factors. Foremost, the findings are based on self-reported measures. Second, the measures did not assess a one-to-one correspondence between age of each sex partner and an adolescent's sexual risk behavior with that specific partner. Instead, we chose to simplify the interview by asking adolescents to indicate the typical age of their sex partners, and then we compared this variable to measures of risk behavior with steady partners over various periods of time during the 6 months preceding the survey. This strategy assumed that associations between the reported age of the typical sex partner and the actual age of the current sex partner were randomly distributed between the two groups of adolescents, thereby preventing systematic error. Although the strategy lacked one-to-one correspondence, it identified adolescents’ general tendencies, e.g., those who typically have sex with older partners are less likely to engage in safer sex. While this finding does not definitively address relational dynamics, it does suggest that “older partners” may be a very useful indicator of risk for adolescent females receiving clinical care and counseling. Finally, the sample was limited to economically disadvantaged black adolescents. Therefore, the findings may not be generalized to other racial/ethnic groups or to adolescents from different socioeconomic strata. Further research is needed to corroborate these findings within diverse adolescent populations.
Implications for Prevention
The findings have implications for the design of clinic-based and community-based STD/HIV infection prevention programs targeting high-risk black adolescent females. For example, health care providers for adolescents may chose to inquire about the age of female patients’ sex partners. Adolescents responding that their partners are at least 2 years older may then be selected for more intensive counseling designed to help them handle potential partner-related barriers to practicing safer sex.
Providers may also opt to refer adolescent females who are at risk of STD/HIV infection due to perceived resistance from an older male partner to a prevention program conducted by local community-based organizations. Our findings suggest that it may be beneficial for these programs to address relational factors such as fear of negative partner reactions to discussion about condom use.
An important theory for conceptualizing these relational factors is the Theory of Gender and Power. 11 This theory posits that power differentials favoring the male constitute health risks for females. Our findings suggest that adolescent females may perceive their older male partners as being resistant to condom use and that this perception is strongly associated with comparatively lower frequencies of safer sex behaviors. This suggests that power differentials favoring the male may be operative within these relationships. However, alternative explanations are also plausible, e.g., adolescent females who select older sex partners may have a greater tendency to yield to those partners’ desire to avoid condom use. Clearly, our findings warrant more intensive, in-depth investigation of relational dynamics between adolescent females and their older male partners. A particular area of emphasis in these investigations could be the determination of why and how older male partners avoid condom use. Although our study did not assess motives of the older male partners to avoid condom use, we did show that male partners’ desire for conception was not a factor. Further investigations with male youths who have younger female partners are needed to sufficiently clarify the apparent power differential with respect to STD/HIV infection protective behavior. Further investigations should also be conducted among younger adolescent females to assess the association between having older male boyfriends and initiation of sexual activity. 11
Model intervention programs designed to reduce the risks of HIV infection/STD among young adult black women have included content based on the Theory of Gender and Power. 12 A similar program has recently been developed for black female adolescents. 13 These programs can be used to provide female adolescents with the knowledge, motivation, and skills needed to make decisions about protecting themselves from STD/HIV infection, without these decisions being adversely influenced by their male partners.
The findings suggest that a majority of black adolescent females may typically select sex partners who are sufficiently old enough–in comparison with themselves—to create a power imbalance that may preclude the adoption of STD/HIV infection protective behaviors. This age difference is relatively narrow: 2 years. Fortunately, identification of this risk factor is possible by simple assessment. Previous research suggests that referral of adolescent females who currently experience a power-imbalanced relationship to community-based intervention programs may be an important step in promoting their safer sex behaviors.
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