Brady, Sonya S. PHD*; Tschann, Jeanne M. PHD†; Ellen, Jonathan M. MD‡; Flores, Elena PHD§
From the *Division of Epidemiology and Community Health, University of Minnesota School of Public Health, Minneapolis, Minnesota; the †Department of Psychiatry, University of California, San Francisco, California; the ‡Department of Population, Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland; and the §Counseling Psychology Department, University of San Francisco School of Education, San Francisco, California
The authors thank the participants in the Salud de Jovenes–Young Adult Health Research Project and the Kaiser Foundation Research Institute, which provided access to members of Kaiser Permanente; the project directors, Angela Gallegos-Castillo and Mimi Wolff; Adrian Aguilera, Janette Alvarez, Pedro Arista, Vanessa Avila, Nayeli Cerpas, Mario Garcia, Mateo Munoz, Alejandro Nuno, Diana Oliva, Saul Ramos, Raul Tejeda, and Cara Torruellas for assistance with data collection; and Seth Duncan and Cynthia de Groat for data management. Supported by grant R01AI49146 from the National Institute of Allergies and Infectious Diseases (to J.M.T.).
Correspondence: Sonya S. Brady, PhD, Division of Epidemiology and Community Health, University of Minnesota School of Public Health, 1300 South 2nd Street, Suite 300, Minneapolis, MN 55454. E-mail: email@example.com.
Received for publication June 12, 2008, and accepted October 3, 2008.
Latino adolescents and young adults living in the United States are at greater risk for contracting sexually transmitted infections (STIs) in comparison with non-Hispanic white youth. In 2005, Hispanic youth aged 13 to 19 were over 4 times as likely to be diagnosed with HIV/AIDS in comparison with non-Hispanic white youth, and Hispanic youth aged 20 to 24 were over 3 times as likely to be diagnosed.1 In 2006, Hispanic youth aged 10 to 24 were roughly twice as likely as non-Hispanic white youth to be diagnosed with chlamydia, gonorrhea, or syphilis.2 Disparities in STIs between Latino and non-Hispanic white youth are perhaps less researched than disparities between black and white youth because blacks experience the highest rates of STIs.3,4
High rates of STIs among Latino youth highlight the importance of identifying factors that may be associated with condom use and in turn, influence the likelihood of disease transmission. Several factors may be responsible for racial and ethnic disparities in STIs (e.g., prevalence of STIs within a racial/ethnic group, couple dynamics).4 Youth in long-term relationships may be more concerned about preventing pregnancy than sexually transmitted diseases.5 Among black and multiethnic samples of youth, condom use declines over the length of main relationships.6–8 In 1 multiethnic sample of youth, adolescents who used hormonal contraceptives were less likely to use condoms with main partners.5 A review of qualitative research suggests that adolescents and young adults associate condom use with a lack of trust for their partner, which may serve to decrease condom use in the context of main relationships.9
Sexual concurrency may be an important route of disease transmission and may partially explain ethnic disparities in the prevalence and incidence of STIs. In 1 sample of sexually experienced Latino youth, roughly one-fifth reported having concurrent partnerships.10 National data show that non-Hispanic black and Hispanic men are more likely to report sexual concurrency in comparison with non-Hispanic white men.11 In contrast, non-Hispanic black women are more likely and Hispanic women are less likely to report sexual concurrency in comparison with non-Hispanic white women.12 National data suggest that there are no ethnic differences in sexual concurrency between adolescents of white, black, and Latino background, however.13
Little research has examined whether sexual concurrency is associated with condom use. National data show that adolescents who have engaged in sexual concurrency are more likely to have ever used a condom with at least 1 partner.13 Among 1 clinic-based sample of black adults, male sexual concurrency was not associated with condom use in the context of heterosexual relationships with main partners.14 Among Latino and black young adults with a history of injection or other “hard” drug use, beliefs in support of nonmonogamy15 and reported sexual concurrency16 were associated with more consistent condom use.
In the current study, we examine whether relationship characteristics (length of sexual relationship, overall trust in partner, perception of partner’s potential infidelity, one’s own sexual concurrency) are associated with condom use among heterosexual Latino adolescents and young adults, adjusting for gender, desire to avoid pregnancy, and woman’s use of hormonal contraceptives.
MATERIALS AND METHODS
Youth between the ages of 16 to 22 years were randomly selected from the membership lists of a large health maintenance organization (HMO) and recruited for participation in a study about dating relationships and health behavior. Relatively little research has examined risk behavior among adolescents recruited through HMOs, and a still smaller number of studies have examined sexual risk variables (e.g., Boyer et al.).17 We recruited additional youth from the waiting areas of 4 participating HMO clinics and 4 community health clinics.
Eligibility criteria included being aged 16 to 22 years, being of Mexican, Nicaraguan, or Salvadoran heritage, and having had heterosexual intercourse within the previous 3 months. Of 6688 adolescents randomly selected from the HMO or recruited at health clinics, 800 met eligibility criteria, and 694 participated in interviews. Analyses in the current study were conducted on 647 participants with complete data on all study variables. Two hundred eighty-one of these participants were recruited through random selection using HMO lists; 193 youth were recruited from waiting areas of participating HMO clinics (between 6–145 individuals from each clinic); 172 participants were recruited from waiting areas of participating community health clinics (between 6–88 individuals from each clinic). We could not determine the recruitment method for 1 HMO participant post interview. The mean age of participants was 18.5 (SD = 1.7). Fifty-six percent of participants were of Mexican heritage, 8% were Nicaraguan, 16% were Salvadorian, and 20% were of mixed eligible ethnicities. One-quarter of participants were born outside of the United States. Young men and women did not differ in ethnic heritage, place of birth, and whether they were recruited via the HMO or community clinic. Men were slightly older than women (18.7 vs. 18.4, t = −2.3, P < 0.05), and the percentage of men recruited through random selection was smaller than the percentage of women (37% vs. 48%, χ2 = 7.15, P < 0.01).
All participants and parents of minors provided informed consent/assent. Participants were individually interviewed in person. Measures were developed and pilot-tested by our research team.
Length of Sexual Relationship With Main Partner
Main partners were defined to participants as “someone you have sex with and consider to be the person you’re serious about.” We calculated the difference in months between the first time participants engaged in sexual intercourse with their main partner and the interview date. For 49 participants (7.5%) not currently involved with their main partner, we calculated the difference between the first and last time participants reported engaging in sexual intercourse with their former main partner.
Overall Trust in Main Partner
This 8-item scale was developed based on focus groups. Using a 4-point scale (1 = definitely no, 4 = definitely yes), participants rated the following items: “do you trust your partner?,” “do you worry whether your partner really cares about you?,” “do you worry about your partner using you?,” “do you worry that your partner will tell others about what you’ve done sexually?,” “do you think that your partner plays mind games with you?,” “do you think that your partner would like to control you?,” “do you worry that your partner might cheat on you?,” “do you worry about your partner taking advantage of you?” Items were reverse scored as necessary and averaged so that higher values indicated greater overall trust (α = 0.83).
Perception of Partner’s Potential Infidelity
Participants rated how faithful they thought their partner had been during their entire relationship, using a 4-point scale (1 = definitely faithful–that is, my partner has had sex with me and nobody else, 4 = definitely not faithful). Values of 1 were scored as 0 and all other values were scored as 1.
Sexual concurrency was defined as having sexual intercourse with at least 1 other person during the past year, or for those participants involved with their main partner for less than 1 year, during the length of one’s sexual relationship with the main partner in the past year. Thus, sexual concurrency refers to having sex with other partners during the time participants were still dating and sexually involved with their main partner.
Desire to Avoid Pregnancy
Participants rated how much they wanted to get pregnant “at this time” using a 5-point scale (1 = definitely do not want to get pregnant, 5 = definitely want to get pregnant). Values of 1 were scored as 1 and all other values were scored as 0.
Consistent Use of Hormonal Contraceptives With Main Partner
Participants reported how often they (for women) or their girlfriends (for men) used birth control pills or the hormonal shot or patch during the month before the last time participants had sex with their main partner, using a 5-point scale (1 = never, 5 = all the time). Values of 5 were scored as 1 and all other values were scored as 0.
Consistent Condom Use
Condom use during vaginal or anal intercourse was assessed during the month before the last time participants had sex with their main partner. Participants were asked how many times they had had sex with main partners, and how many times they had used condoms during intercourse. These questions were also asked for other partners with whom participants engaged in sexual concurrency during the same month. For main partners, number of times condoms were used was divided by the total number of times participants had sex. For other partners, number of times condoms were used across all other partners was divided by the total number of times participants had sex across all other partners. Consistent condom use was scored as 1 if a resulting proportion was 1; all other proportions were scored as 0.
Number of Sexual Intercourse Acts Unprotected by Condom Use
In addition to consistency of condom use (100% or less), we examine the total number of unprotected sexual intercourse acts with main partners during the assessed month of sexual activity.
Table 1 shows the distribution of study variables within the total sample and by gender. Within the total sample, participants engaged in an average of 6 sexual intercourse acts unprotected by condom use with main partners during the past month. The proportion of youth reporting consistent use of condoms or consistent use of hormonal contraceptives were both slightly over one-third. Roughly three-quarters of youth reported definitely wanting to avoid a pregnancy. The mean sexual relationship length was 17 months, and overall trust in partners was closer to the “low trust” than “high trust” anchor of the scale. The proportion of youth who perceived that their partners had been unfaithful or who reported that they themselves had engaged in sexual concurrency were roughly one-third and one-fifth, respectively. Men were more likely than women to report consistent condom use with their main partner, a desire to avoid pregnancy, and sexual concurrency with at least 1 other person. Women were more likely than men to report a higher number of sexual intercourse acts with main partners that were unprotected by condom use, longer sexual relationships with their main partner, and greater overall trust in their main partner. Men and women did not differ in report of hormonal contraceptive use within the context of their main relationship and perceptions of their main partner’s potential infidelity. Findings remained when adjusting for age and recruitment strategy (not shown).
Study variables were simultaneously entered in a logistic regression predicting consistency of condom use with one’s main partner (see left half of Table 2) and a linear regression predicting number of sexual intercourse acts unprotected by condom use with one’s main partner (see right half of Table 2). Although bivariate associations suggested that women engaged in less condom use than men, these associations became nonsignificant when adjusting for other factors. Condoms were used less often with main partners when hormonal contraceptive use was consistent, youth did not definitely want to avoid pregnancy, youth had been sexually involved with their main partner for a longer period of time, and youth had greater overall trust in their partner. Participants who doubted their main partners’ fidelity were more likely to engage in 100% condom use and engaged in fewer acts of sexual intercourse unprotected by condoms. However, one’s own history of sexual concurrency was not associated with either condom use variable.
Possible interactions between gender and each study variable in predicting condom use were sequentially examined, adjusting for all other study variables. One interaction term reached statistical significance. Gender interacted with length of sexual relationship to predict consistency of condom use with one’s main partner and number of unprotected sexual intercourse acts with one’s main partner. Greater length of sexual relationship was associated with inconsistent condom use among both women [OR = 0.65, P < 0.001, 95% CI = (0.51, 0.82)] and men [OR = 0.45, P < 0.001, 95% CI = (0.34, 0.60)], and with a higher number of unprotected sexual intercourse acts among both women [B = .19, P < 0.001, 95% CI = (0.09, 0.29)] and men [B = 0.31, P < 0.001, 95% CI = (0.19, 0.43)], but these associations were more pronounced among men.
Thirty-nine male and 28 female youth reported being sexually concurrent with other partners during the past month. Regression analyses showed that in comparison with sexually concurrent youth who engaged in consistent condom use with other partners, those who used condoms inconsistently with other partners were more likely to use condoms inconsistently with main partners [OR = 4.57, P < 0.05, 95% CI = (1.43, 14.67)] and were also more likely to engage in a higher number of unprotected sexual intercourse acts with main partners [B = 0.64, P < 0.05, 95% CI = (0.06, 1.22)], adjusting for gender in each analysis.
Only one-third of Latino youth engaged in 100% consistent condom use with their main partners. Inconsistent condom use and number of sexual intercourse acts unprotected by condom use were partially explained by ambivalence about avoiding pregnancy and women’s use of hormonal contraceptives. However, longer sexual relationship and greater overall trust in one’s partner were associated with inconsistent condom use and more acts of unprotected sexual intercourse independent of reproductive factors. Increasing attachment between youth may be a risk factor for the transmission of STIs, via normative declines in condom use.18 The developmental task of forming and strengthening romantic relationships may overshadow any concerns youth have about protecting their physical health. Many youth may also not perceive main partners as a potential risk in terms of contracting STIs.9
Perception that one’s partner has potentially been unfaithful may increase the likelihood that youth engage in 100% consistent condom use or reduce the number of times they engage in unprotected sexual intercourse. However, it is alarming that one’s own sexual concurrency did not predict 100% consistent condom or fewer acts of unprotected sexual intercourse use in the current study. Many Latino adolescents and young adults who engage in sexual concurrency may not take adequate steps to protect their partners from contracting STIs. Some youth may be more focused on the emotional and social repercussions of potentially confronting or revealing infidelity by advocating condom use than the physical repercussions of unsafe sex. Adjusting for gender, sexually concurrent youth who used condoms inconsistently with casual partners were more likely to use condoms inconsistently and engage in a greater number of unprotected sexual intercourse acts with main partners. These findings may partially reflect personality; for example, sensation seeking is associated with greater sexual risk taking among youth.19
There is no literature to suggest that associations observed in the current study would not be found among adolescents of other ethnic backgrounds. However, further research is needed to determine generalizability of results to other populations. Health promotion efforts should focus on potential barriers to condom use among adolescents (e.g., perceived incompatibility between trust and condom use; potential reluctance to discuss infidelity) and work to establish greater norms of condom use with both main and casual partners.
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