+ Children at Risk Spring 2013 Melissa Boone February 26, 2013 Adolescent Sexual Risk

+ Who are we talking about here? People aged approximately 11 to 24. Most studies of “adolescent” risk behavior define adolescents as between roughly 14 and 19 – “middle adolescence” Many studies have focused on late adolescence or “emerging adulthood,” looking at young people between the ages of 18 and 25. Researchers may use these terms interchangeable or nebulously: Adolescents (usually reserved for year-olds) Young adults (usually reserved for year-olds) Emerging adults (usually reserved for year-olds) Youth Young people

+ Average age of sexual initiation: 17.3

+ Why should we care? 46% of all adolescents will have sex before they graduate from high school. Young people aged make up 21% of the US population, but 39% of all new HIV infections in the US The pregnancy rate for young women was 6.8% in Although year-olds are only 25% of the sexually active population, they acquire nearly half of all new STDs. CDC, 2009

+ What is sexual risk behavior? Penile-vaginal intercourse without condoms Penile-anal intercourse without condoms PV intercourse without contraceptive birth control Drug and alcohol use before and during sexual situations Multiple sexual partners Partner type: HIV-positive Injection drug user Age of partner

+ Factors Influencing Risky Sex in Adolescents

Sex, age, race, mental health Economic System Stigma, stereotyping, prejudice

+ Biopsychosocial Model of Health

+ Race Race contributes to: Age differences in sexual initiation Differences in condom use and contraceptive behavior Different number of sexual partners It’s theorized that culture, stereotyping, stigma, and systemic discrimination contribute to some of these problems. Very little research has been done on Asian American, Pacific Islander, and Native American adolescents! EthnicityMalesFemales White40%45% Black72%58% Hispanic53%45% Native American 65.9%52.3% Sexual initiation in high school

+ Remember this?

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+ Mental health & stress Adolescents with depressive symptoms are more likely to not use birth control than those who do not have those symptoms. Adolescents who were sexually active were much more likely to experience suicidal ideation than lower risk adolescents. Adolescents who have been psychiatrically hospitalized are more likely to be sexually active, not use condoms, and have a history of STDs. Researchers aren’t sure of the direction of this relationship Most studies done are cross-sectional – done only at one time. More recent longitudinal studies seem to indicate that depression leads to more risky behavior. Several hypotheses: Risky sex as a coping technique Psychiatric disorders contribute to cognitive deficits Psychiatric disorders are associated with abuse

+ + Suicidal ideation was measured on a scale from The low-risk and sexual abstainers weren’t significantly different from each other, but the high-risk group was significantly different from the other two.

+ LGB adolescents and mental health There’s no evidence that healthy LGB adolescents are inherently more risky than comparable heterosexual counterparts. However, studies show that lesbian, gay, and bisexual adolescents have higher rates of every day depressive and anxious symptoms. LGB adolescents are more likely to use drugs and alcohol before and during sexual encounters. They were also at increased risk for major depressive disorder, generalized anxiety disorder, drug dependence, and suicidal ideation. Minority stress has been hypothesized as one reason why this may be.

+ Drug and alcohol use Drug use has been consistently linked to risky sexual behavior Both overall drug use and drug use before sexual situations is risky. Alcohol and cigarettes contribute to risk, but illicit drugs (cocaine, marijuana, etc.) are the riskiest. Researchers are not sure of a causal direction in the relationship …but recent research makes it looks as if it’s substance use that causes risky sex, and not the other way around.

Drug Use and Sexual Risk Behavior Youth Risk Behavior Study

+ Media exposure Adolescents who watched more sex on TV started having sex at earlier ages than adolescents who watched less sex. The reverse is also true – adolescents who were sexually active watched more sex on TV. Sexual media makes adolescents perceive media and societal support for teen sexual behavior. Media that glamorizes sexual behavior was more strongly associated with adolescent sexual risk behavior. Adolescents also reported getting the majority of their information about sex and sexuality from media sources.

+ …and plenty of other things Sex and gender Age Family structure Number of parents in the home Older siblings Socioeconomic status Personality characteristics Sensation-seeking Impulsivity Risk proneness Biological development Age at menarche Media exposure Cognitive competence/academic achievement Other problem behaviors

+ Intervention Science How do we decrease risk behavior, and increase safe sexual practices, in adolescents?

+ The problem is… Interventions that just impart knowledge don’t work. Simply informing adolescents about the effects of risky behaviors isn’t very effective. Why?

Demographics Culture Stigma, stereotyping, prejudice Personality and emotions Perceived risk, sensation-seeking, etc. Exposure to media Theory of Planned Behavior Fishbein & Yzer, 2003

+ Self-efficacy Adolescents need to feel like they actually can protect themselves when needed in order to actually practice safer sex. Self-efficacy is better at predicting condom use than sexual attitudes, HIV knowledge, and perceived vulnerability to HIV. Many of the previous named factors are associated with self- efficacy, making it a mediator in most relationships: Psychological disorders/distress Race and sexual orientation Age Drug use There actually has not been a lot of research on this, even though current indications show that it may be one of the best predictors of problem behaviors. The most effective intervention programs target self-efficacy in adolescents. (the perception that one can successfully execute some kind of skill)

+ Effective intervention strategies Four overall factors impact program effectiveness Specific skills for reducing sexual risk behaviors Program duration and intensity Content of the program Training the facilitators

+ Federal Guidelines on Sex Ed In 1996, Congress began to shift funding to programs that taught only abstinence. This was strengthened in The federal government funds community-based organizations directly, and prohibits disseminating information on contraception, sexual orientation and gender identity, and other aspects of sexuality.

+ Choosing the Best The most popular abstinence-only program Fits the federal guidelines for funding Has modules for elementary through high school children, focusing on healthy relationships and abstinence until marriage Medically accurate Example of a Lesson Plan: cs/CTB_Life_Contraception_Discussi on.pdf cs/CTB_Life_Contraception_Discussi on.pdf

+ …but it doesn’t work. There have been numerous studies indicating that abstinence-only programs do not work to protect adolescents. A few of them are moderately successful in delaying sexual initiation, but adolescents who do go on to have sex are less likely to use condoms or contraception. when they do. Most non-peer-reviewed studies of abstinence-only programs have methodological flaws or flawed interpretation of data. States that have only abstinence-only programs have the highest rates of teen pregnancy in the country. Many abstinence only programs have been found to have medically inaccurate information. Abstinence-only programs also ignore large swaths of the adolescent population: Sexually experienced teenagers who don’t wish to stop Teenagers who want to have sex LGB adolescents, especially those who live in states where their marriage is illegal

+ Comprehensive sex education Covers abstinence as well as condom use and other contraceptive use Comprehensive sex education has consistently shown evidence of effectiveness Delays sexual initiation Makes adolescents more likely to use protection when they do have sex Cultural relevance is a new wave in CSE Delivered in a wide variety of places Schools Community clinics Churches and community centers

+ BART: Becoming a Responsible Teen Rated “Best” by the CDC for sexual risk reduction in adolescents. Targeted towards African American adolescents hour sessions delivered over 8 weeks Uses theories of learning and science to drive its development Sample Lesson plan: BART_sampleLesson.pdf BART_sampleLesson.pdf

+ Scarleteen An “inclusive, healthy, and sex-positive sex ed resource for teens” created in