The male cohorts differed significantly in terms of several measures of sexual and behavioral risks including illicit drug use, having an STI at intake, shorter relationship length, shorter length of monogamy, and more sexual partners per year sexually active. However, other measures of sensation seeking were not significantly different between the male cohorts, including their mean sensation seeking scores and having an overall high composite sensation seeking score. When looking at the 11 individual measures of sensation seeking and sexual impulsivity, the mean score for each question was not significantly different between the men paired with teens versus the men paired with adults (data not shown).
Although the male cohorts were similar in their responses to what they received from the relationship with the index female, we used principal component analysis with varimax factor rotation and found that the 8 components of the relationship fell into 2 categories: practical (he receives housing, food, other financial help, and drugs and alcohol from the relationship) versus emotional factors (he receives emotional support, feelings of warmth and closeness, sense of family and belonging, and good sex from the relationship). When these factors were grouped, we found that the male cohorts were similar in what they received emotionally from the relationship (P = 0.84), but men paired with adult women were significantly more likely to report that they received practical/instrumental items from the relationship, as compared to male partners of teens (P = 0.04). There was an interaction between this finding and relationship length and marital status, as men paired with adult women were more likely to be married to her and had, on average, longer relationship length.
Teen girls enrolled in Project SAFE had an average of 2.34 ± 2.87 sexual partners per year sexually active, compared to adult women, who had a mean of 1.45 ± 1.51 sexual partners per year sexually active (P <0.001). Having concurrent sexual relationships in the last year was reported by 12.5% of teen girls and 11.9% of adult women (P = 0.84). The average age of the teen girls was 18.5 ± 1.3 years, while the adult women were on average 24.4 ± 3.8 years (P <0.001).
Table 2 examines risky sexual dyads, composed of a man and a woman who reported engaging in risky actions or behaviors that would limit communication and respect within the relationship. We included the variable of reporting that it was important to both him and her that she have his baby because pregnancy intentions are associated with condom use.10,11 Although all of the dyads were high risk, which was based on the fact that all women had an STI at intake, adult female dyads were more likely to be composed of a woman who used douches and a man who preferred that she use douches. The mean number of sexual partners per year sexually active for a teen girl and her male partner combined was significantly higher than for an adult woman and her male partner combined. Finally, teen girl dyads were more likely to be composed of a man and a girl who agreed that having a baby together was very important.
Table 3 contrasts the female’s perceptions of the man’s behavior, versus the actual behavior reported by the man. In all behaviors studied, the teen girls were not more naïve to their male partner’s behavior, as compared to the adult women. Because our study focused on risk factors for STI acquisition related to the male, we report on dyads where the male is participating in risky behavior, unbeknownst to the female.
Table 4 compares the level of closeness, commitment, and satisfaction that men and the women reported in their relationship. In addition, we contrast the female’s perception of her male partner’s report with his actual report. There was a trend that teen girls and their male partners reported similar levels of closeness, commitment, and satisfaction, and the teen girl correctly estimated her male partner’s report. In contrast, adult women reported significantly higher levels of closeness, commitment, and satisfaction than their male partners. In addition, adult women significantly overestimated the level of closeness and relationship satisfaction, reported by their male partners.
We performed a forward stepwise logistic regression analysis using the variables which were significant in the bivariate comparisons (P <0.05) to determine the essential risky features of men partnered with teens. Using the variables of his age, intake STI, drug use, number of sexual partners per year sexually active, and his desire to have a baby with the index female, we found that men partnered with teens were characterized by young age (P <0.001) (AOR: 0.73; 95% CI: 0.68, 0.79), current drug use (P = 0.01) (AOR: 1.81; 95% CI: 1.16, 2.81) and more sexual partners per year sexually active (P = 0.002) (AOR: 1.04; CI: 1.01, 1.06).
Finally, we performed logistic regression to describe what variables predicted STI infection in the male at intake. Using the variables of the index woman’s age, the man’s age, current drug use by the male, his and her number of sexual partners per year sexually active, and he believes it is really important for the index female to have his baby, we found that young age, measured as a continuous variable, was the factor that was independently predictive of the man having any STI at intake (P = 0.03) (AOR: 0.97; 95% CI: 0.94, 0.99).
We found that male partners of teen girls infected with an STI were more likely to be younger, have more sexual partners per year, sexually active, and were currently using any illegal drugs, as compared to the male partners of adult women infected with a nonviral STI. Like women, the variable which independently predicted infection in men was young age.1,2 Our data will assist clinicians in providing age-appropriate and partner-specific counseling to a teen girl or an adult woman diagnosed with an STI.
In an earlier analysis of teens with STIs, we found that 3 behaviors were highly associated with reinfection: rapid partner turnover (<3 months), unprotected sex with untreated partners, and nonmonogamy.5 In this analysis, we found that men partnered with teens, who are significantly younger, switch partners more rapidly as they begin having intercourse. As they encounter new sexual partners, their risk of infection is increased.2 We previously reported that teens who had unprotected sex with untreated partners were up to 10 times more likely to become reinfected with an STI.5 While this behavior was associated with reinfection in adults, the association was not as strong.5
Although all women entered our study with a laboratory-verified STI, only 257 of 514 (50%) of the men had an STI. It may be that the woman was infected by a man who was not invited to our study. However, all men enrolled in Project SAFE had risky sexual histories, reporting rates of concurrent sexual relationships in the past year that were more than double the rates reported in other national surveys.10,11 The male partners of teens were more likely to have an STI at intake. It is known that male-to-female transmission of STIs is generally more efficient than female-to-male transmission,2,12 although confounders such as anal intercourse, circumcision status, and comorbidities such as immune-suppression and STI coinfections must be considered.13 We initially hypothesized that the differences in male infection rates would be related to exposure frequency. However, the male cohorts reported similar frequencies of vaginal intercourse with the index female within the last 3 months. The mens’ cohorts were also not different in their low rates of consistent condom use. The higher incidence of STI infection among the men partnered with teens may be explained by the fact that these men had shorter periods of monogamy, and more sexual partners per year sexually active than men paired with adults. Thus, men matched with teens were more likely to be a “new partner,” which is a known risk for STI acquisition.2 Our data are consistent with previous work showing that young male age was an independent risk factor for infection with TV.14
Men partnered with teens were significantly more likely to report using any illegal drug once a month or more. Drug use among young men and women has been associated with STI acquisition, nonuse of condoms, and multiple sexual partners, likely due to complex interactions including risk disinhibition.15 Our data suggests that clinicians who diagnose teen girls with an STI should discuss the possible contributions of drug use and disinhibition on STI reinfection.
When comparing behavioral surrogates which we previously found to be associated with reinfection,5 we found that adult female dyads were more likely to be composed of a man who wanted his female partner to use douches and a woman who used douches. Douching has been associated with an increase in STI risk, but may be confounded by the fact that some women use douches in response to STI symptoms.16,17
Although our study highlights the risk characteristics of the men, we also found that teen dyads were characterized by specific risky behaviors. The mean combined number of sexual partners per year sexually active for the teen dyads was higher than for the adult dyads. Teen dyads were more likely to be composed of a male and female who thought it was very important to have children together. This may be because men paired with teens were younger, and had not yet fathered children. Although condom use has been shown to be low even among adolescents who want to avoid pregnancy, vigilance for consistent condom use is markedly decreased among teens who are ambivalent regarding future pregnancy, and those desiring pregnancy.18 Furthermore, a teen girl’s desire for pregnancy is highly influenced by her male partner’s wishes.19 Our data suggests that clinicians counseling teens on STI prevention may want to emphasize the implications of untreated STIs on fertility and pregnancy complications.
It has been shown that teen girls paired with older men are more likely to not use contraception, to desire pregnancy, drop out of school, use drugs, be diagnosed with an STI, and be involved in casual rather than committed relationships with multiple partners.20–27 Age difference is a surrogate for power differences and influence in the relationship, as age discordant couples have differences in maturity, sexual and life experiences, financial resources, education, and work attainment.27–29 We chose a 25% difference in age because this correlates with a 16-year-old girl partnered with a 20-year-old man, which meets 1 definition of statutory rape in Texas.30 Our data are in agreement with Kissinger et al, that although having an older male partner was a marker of various risks for teen girls, infection was most prevalent in young men and most adolescents are paired with young men.28
We found markers of influence by the male partners of teens, for example, they were more likely to be the father of the teen’s children and to report that it was very important for the teen to have his baby, which has been associated with sabotaging a teen girl’s request for condom use or contraception.31
Our data have several limitations. The cross sectional design of the study may not reflect ongoing behavior of the dyads, particularly dyads who received the Project SAFE behavioral intervention. The female had to invite a male sexual partner from within the past 2 months. It is not clear if the man who participated in the study was the man involved in the initial STI exposure. However, our method of our data collection, in which sexual dyads are interviewed separately by a gender matched individual, strengthens of our data. In addition, we have detailed, partner specific information on over 500 high risk sexual dyads, where at least 1 partner (the female) has a current, laboratory verified STI. The focus of this study was to provide data to help clinicians counsel women with STIs more effectively by describing their male partners and risky relationships. We certainly understand that women participate in risky behaviors, which increase the likelihood of recurrence in themselves or their partners.
In conclusion, a clinician who diagnoses an STI in a teen girl should know that her male partner is more likely to be young, infected with an STI, using illegal drugs, and have rapid partner turnover, as demonstrated by having more sexual partners per year sexually active. These men may exhibit influence over the teen by encouraging pregnancy or being the father of her children. These distinct characteristics are important triage questions to ask, when attempting to effectively counsel the teen on partner notification, partner treatment, and STI prevention practices.
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