Transcript Sexual behaviour in female teenagers: using grounded

Associate Professor Rachel Skinner
Sydney University Discipline of Paediatrics &
Child Health, at Children’s Hospital,
Westmead
Overview
 what is normal sexual behaviour and what’s risky
 Understanding why and when young females have their
first sexual experience, their use of contraception, and
pregnancy decision-making
 Understanding young males use of condoms and role in
pregnancy prevention
 What does the literature tell us about sexual health
promotion in young people?
 Implications for clinical and public health strategies
Historical changes in sexual development
Trend in age of first intercourse
C. Rissel, J. Richters and A. Grulich et al. 2003
What is risky sexual behaviour?
 Leads to unplanned pregnancy or STI spread
 High abortion rate, poor outcomes for teen mothers and
babies, morbidity of STIs
 Early age of sexual debut
 Poor use of condom use/ contraceptives
 Number of partners over a short time period
Is normal actually risky in adolescence?
 Reducing age of onset of sexual activity
 Romantic relationships- shorter duration, shorter
between gap
 Inconsistent condom use
 Access to methods
 Biological vulnerability
 Social vulnerability-Risk taking, impulsivity, social
contexts and norms important, low perception of risk,
alcohol use
Key points SSASH
 Increasing sexual intercourse, oral sex
 Majority sexual active in some way from year 10
 Condom use stable
 40% just happened, 31% trust, knowing partners history
(27%)
 58% Y12, 37% Y10 use OCP
 Increasing % with higher number of recent partners (oral
and intercourse)
 HIV knowledge good, other STIs poor but has improved
 Very few thought they were at risk of STI
 Perceived risk not associated with condom use, only casual
partner
Key points SSASH
 Unwanted sex in females has increased
 Drunk/high, partner pressure
 Mostly “happy” feelings after sexual encounter
 lower for females, <10% experienced negative emotions, F
sl. higher regret or feeling used.
Experience of sexual intercourse
60
50
40
sexual intercourse year 10
30
sexual intercourse year 12
20
10
0
1992
1997
2002
2008
Research- understanding teen
sexual behaviour
 First sexual experience
 Use of contraception, condoms for STI and pregnancy
prevention in females and males
 Choices around pregnancy outcomes
 Teenage motherhood- outcomes and repeat pregnancy
Smith, Fenwick, Skinner et al, J Adol Health, 2008; J
Reproductive Health Care 2010, Sexual Health 2009,
Archives of Sexual Behaviour 2010, Journal of Adolescent
Research 2011 (in press), Women and Birth 2009
Themes around first sexual experience
 I was ready for sex- a natural happening, right time- right
person
 I wanted to see what it was all about- unrealistic perceptions
about sex
 Everyone else was doing it- perceptions of peer sexual activity
 I did it to keep him happy- importance of romantic relationship
 When you’re drunk you just do it- intoxication
Findings re 1st intercourse
 Loss of personal control over first intercourse
 through drunkenness, social norms, peer norms
 Partner pressure
 Perceived control influenced how they reflected on their
first experience and the meanings
 Regret was linked to loss of personal control
 Loss of control tended to be younger age (earlier
developmental stage)
 Control linked with self-efficacy
 Implications for sexual health education/ promotion
Variation in contraceptive use explained through...
Causal-consequence model of
PRIORITISING PREGNANCY PROTECTION
Bi-causal pathways...
Accepting
Rejecting
teen
pregnancy risk
motherhood
Anticipating
Personalising
the impact
Pregnancy
of motherhood
Risk
worststuff
fearup my life
expected
lose your friends
paranoid
have fun as a teenager
I knew I’d fall pregnant
healthy career first
scared
I couldn’t
if it happens
keep itit happens
Accepting
Denyingteen
pregnancy
motherhood
risk
unprotected
sex
a year
Change
my life
forforthe
better
& it was still a shock
more mature than girls my age
won’t happen to me
my mum was a young mum
thought I couldn’t get pregnant
a new start
we’ll
be fine just
one child
time
murdering
an this
unborn
Retracing contraceptive histories
1. Pregnancy ‘avoiders’ (never-pregnant)
wouldn’t have sex if he
didn’t use anything
Rejecting teen
motherhood
HOLDING
THE REINS
Accepting
pregnancy risk
when I went on the Pill
we stopped using them
I’ll set my alarm for 7
everyday & take it (Pill)
& go back to sleep
double
insurance
Retracing contraceptive histories
1. Pregnancy ‘escapers’ (pregnant-terminated)
think I just
procrastinated
Rejecting teen
motherhood
made me stack
on weight
LOWERING
THE GUARD
Denying
pregnancy risk
couldn’t get into
the daily habit
too drunk to care
caught up in the heat
of the moment
Retracing contraceptive histories
1. Pregnancy ‘embracers’ (pregnant-continued)
we were in love so
there was no need
(to use condoms)
Accepting teen
motherhood
I really wanted
to be a mum
LETTING NATURE
TAKE ITS COURSE
Accepting
pregnancy risk
I’m not big on contraception
so if it happens it happens
we used a couple of condoms
then we just stopped & let
nature take its course
Beliefs of teen females regarding
contraception use/ pregnancy risk
 Sexually active girls fall into 3 groups
 Those who have accurate risk perceptions about fertility,
don’t use contraception and are happy to fall pregnant
 Those who have accurate risk perceptions, use
contraception well, and don’t fall pregnant
 Those who have inaccurate risk perceptions, don’t use
protection consistently or effectively, and are shocked when
they fall pregnant
 These 3 groups should have different approaches in
education, management
Beliefs of young males regarding
condom use
 Use is linked to the nature of the sexual relationship
 Pregnancy main concern- condoms used mainly for
contraception rather than STI prevention, with regular
partner
 Responsibility for use of hormonal contraception is
considered to be the role of female partner
 No discussion with partner about effective contraception
use, or attitudes to hormonal contraception, pregnancy
Reasons for using condoms or not
 Risk Avoidance
 Dual methods of protection (very few)
 Staying safe with casual partners
 Rationalising condom cessation through assumed safety
 Reliance on hormonal contraception
 Clean STI tests
 Lacking consequential thought
 Disregarding risk in the immediate context
 Prioritising sexual satisfaction
Responsibility for birth control
 Pregnancy as the main concern
 Compared to STIs
 Fatherhood as a future event
 Pregnancy prevention as the girls job
 Going the extra mile with dual methods of protection
 Very few had this view
Conclusions from both studies
 Condoms used when hormonal contraception not being
used
 Condoms considered when STI risk a concern (casual
encounters, history)
 Boys assume that girls are using contraception
 Barriers to some girls using contraception consistently
 Similarities in the “heat of the moment” encounter
 Parenthood not on the agenda for their current life
 But some girls did not regret
 Small group who insist on dual protection
Implications for education/ clinical care
 Don’t assume that all female teens want to avoid pregnancy
 For some, motherhood a logical choice
 pregnancy intentions & contraceptive behaviour doesn’t always
follow
 contraceptive attitudes, sexual context & accuracy of risk
perceptions, intentions to remain non-pregnant
 Main concern is pregnancy, risk perceptions regarding STIs may
be flawed for both males and females
 Responsibility for pregnancy prevention in a relationship is left
to female partner, with little discussion regarding effective use
Systematic review of STI interventions
in Australia
 Direct access to STI screening in non-clinical setting
achieved the highest participation rates
 More support for STI screening in GP practice is needed
 School based sexual health education has not been
evaluated in Australia
 Use of new social media technology for education/
promotion and improving access
 Good media campaigns can influence behaviour
Spreading the message online
 “A lot of people use the internet now and I guess that’s
probably the best place to go because it’s so anonymous
too. You don’t actually have to talk to anyone face to
face. It might be a lot less confronting for people.”
Providing the groundwork in school
 “They’re busting to talk about the complexities of things,
not just oh it goes in and phfw, and oh oops there’s a baby
in nine months, like everyone knows that... any education
that goes forward has a lot to do with, a lot broader than
sort of facts and figures, you know.”
Making condoms easier to access
 “For a lot of people it’s a very daunting experience
walking up to a counter and putting a packet of condoms
on there. I’m not sure how you combat that, perhaps
there’s vending machines...”
 “One of the things we went through high school was
about whether we were going to get condom vending
machines in the males’ toilets... the school was like oh no
we don’t want to do that cause then we’re just
encouraging sex. Well isn’t it better to encourage safe sex
than just to turn a blind eye to it?”
Teenage pregnancy
 Aus’s teen fertility rate ↓ over last 3 decades
 conceals much higher pregnancy & abortion rates
 Earlier age pregnancy & childbearing → adverse outcomes
 maternal age or prior disadvantage primary cause??
 Up to 90% teen pregnancies ‘unintended’
 ‘unintended’... ‘unplanned’... ‘unwanted’??
 Overall improvements in contraceptive use in Aus
 discontinuation, switching & poor compliance common
Teenage mothers in Australia
 Indigenous
 Pregnant before
 Single
 Living in an area of socio–economic disadvantage
 Uncertain EDC and fewer antenatal visits
 A smoker
 > Perinatal mortality
 Risk of STI
Van der Kliss et al, 2002; Meade & Ickovics 2005; Lewis et al 2009.
Teenage births have poor outcomes

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Preterm birth, LBW, NND
Postnatal depression
Domestic violence
Abuse
Low educational attainment, welfare dependence
Children- learning difficulties, emotional and behavioural
problems, early pregnancy
Pregnancy outcomes in teenage
mothers, preventing repeat pregnancy
Lewis, Doherty, Hickey, Skinner et al, MJA 2009,
Contraception 2010, MJA 2011
 Retrospective review of births at KEMH over a 2.5 year
period (<5000 births)
 Prospective study of 150 teenage mother, recruited in
pregnancy followed for 2 years
Main findings
 Higher obstetric and medical risks associated with
teenage pregnancy and birth (anaemia, smoking, HT,
UTIs, LBW)
 Indigenous teenagers need special attention, and
there is significant scope for public health
interventions around anaemia and smoking in this
population
 Implantable contraceptives should be used
postpartum