The Contexts for Adolescent Female Sexual Decision-making Robert Wm. Blum, MD, MPH, PhD William H. Gates, Sr. Professor and Chair Department of Population, Family and Reproductive Health Johns Hopkins Bloomberg School of Public Health Prepared for: Girls Decide Conference Amsterdam, The Netherlands 16-17 September 2010

A Contextual Model Macrolevel Environmental Factors Proximal Level Environmental Individual Factors Factors Response Outcome Biological Factors Neighborhood Involuntary Response Family Individual Response Poverty Early Sexual Engagement Peers Discrimination School Voluntary Response Inequality Temperament & Cognitive Factors

Early Sexual Engagement A Contextual Model Outcome Individual Response Early Sexual Engagement 3

Early Sexual engagement A Contextual Model Macrolevel Environmental Factors Outcome Policies Individual Response Neighborhood Early Sexual engagement Customs Policies: Delay in marriage; rising value of education, globalization Social change

Neighborhood Factors: Poverty Lower grades Lower educational attainment More school drop out More precocious sexual activity/child bearing

How does Poverty Impact Outcomes? Less social and financial capital More social disorganization Less collective efficiency More discrimination More inequality Poor communities are associated with: more social disorganization, less communal efficacy, more discrimination, less social and financial capital.

Early sexual engagement A Contextual Model Macrolevel Environmental Factors Proximal Level Environmental Factors Outcome Policies Family Individual Response Neighborhood Early sexual engagement Customs Social Change

Family Factors Globally family has consistently been shown to be the most protective factor in the lives of young people. When adolescent girls report connection to parents they are less likely to engage in early sexual behaviors Disintegration of family structures with rural to urban migration Clash of values

Elements of Positive Parenting Behavioral Monitoring Closeness and Connectedness Emotional Responsiveness Knowing child’s friends, their friends’ parents, their teachers Setting high behavioral and educational expectations

Early Sexual engagement A Contextual Model Macrolevel Environmental Factors Proximal Level Environmental Factors Outcome Policies Family Individual Response Neighborhood Early Sexual engagement Customs School Social change

School Factors Young girls who are attached to school marry later and delay first sexual encounters. Increase of 5% in school 44 to56% 1980 to 2010 Delayed marriage, Delayed pregnancy, Fewer children Rise in out-of-wedlock births; Rise in clandestine abortions; Rise in number of sexual partners with associated risks of AIDS and other STIs.

Factors that Appear to Influence School Attachment Perceiving teachers as emotionally caring Experiencing academic support Not experiencing discrimination based on gender or SES Parental support for schooling Believing that education will improve future prospects

Behavioral Consequences of Low School Engagement (Vietnam data) Ever smoked Ever been drunk Less likely to always wear a motorcycle a helmet Low self esteem More often hanging out on streets and causing public disorder Less optimistic about the future More likely to think of suicide More often having premarital sex Blum et al. 2010

Early sexual engagement A Contextual Model Macrolevel Environmental Factors Proximal Level Environmental Factors Outcome Policies Family Individual Response Neighborhood Early sexual engagement Peers customs School Social change

Peers tend to be a positive socializing force.

Close Prosocial Peer Relationships are associated with: Later age first sex Less tobacco use, Less depression Less drug use Better academic performance

Peer Pressure Youth are more likely to conform behaviorally to the views of peers than parents. Additionally, they conform more to their perceptions of peer behaviors than what their friends actually do.

A Contextual Moel Macrolevel Environmental Factors Proximal Level Environmental Individual Factors Factors Outcome Biological Factors Policies Family Individual Response Neighborhood Early Sexual engagement Peers Customs School Social change

Brain development occurs within the context of the environment Brain development occurs within the context of the environment. Environments have both direct and indirect effects. Competence vs. Maturity and capacity

Adolescent Neurodevelopment and behavior During adolescence the frontal lobe fully develops Frontal lobe controls executive functioning: emotional reactivity, impulse control, reasoned actions “Toxic” environments diminish emotional control

A Contextual Model Macrolevel Environmental Factors Proximal Level Environmental Individual Factors Factors Response Outcome Biological Factors Policies Involuntary Response Family Individual Response Neighborhood Early Sexual engagement Peers Customs School Voluntary Response Social change Temperament & Cognitive Factors