Risky Adolescent Sexual Behavior: A Psychological Perspective for Primary Care Clinicians

Peter A. Hall, PhD; Maxine Holmqvist, BA; Simon B. Sherry, MA

Disclosures

Topics in Advanced Practice Nursing eJournal. 2004;4(1) 

In This Article

Identification of Risky Sexual Behavior

Assessment of risky sexual behavior is somewhat challenging, particularly when adolescents are involved. Measurement of behavior usually relies on verbal reports, which can suffer from a number of biases, both intentional and unintentional.

Sexual behavior is a sensitive topic that many adolescents find difficult to discuss with adults. Clinicians can facilitate such discussions by adopting a nonjudgmental attitude toward the adolescent. Many adolescents are concerned that adults may strongly disapprove of their behavior, even if the same behavior is condoned among their group of peers.[22,23] Furthermore, sexual behavior is a sensitive topic to some clinicians, and they too may be uncomfortable exploring it with adolescents. Either of these barriers can hamper the flow of accurate information about the status of adolescents' sexual behavior.

Not all barriers are incidental. Adolescents may actively construct barriers that make it difficult to accurately identify risky sexual behavior. For example, adolescents may be reluctant to disclose sexual activity to a clinician because of concerns about the implications of the admission for them. They may, for instance, be fearful that their sexual behavior will be reported to their parents or to others they know. It may be helpful in these cases to make clear to the adolescent the limits of confidentiality and what they can expect with respect to information sharing.

Mental illness can figure prominently in the appearance of promiscuous sexual behavior in adolescents and warrants careful consideration. Red flags might include behavior that is out of character (eg, a normally conservative and well-behaved adolescent starts to engage in excessive and dangerous sexual activity), or reports from the adolescent that they feel "out of control" with respect to the behavior (eg, they say that they want to stop, but feel that they cannot despite their most concerted efforts).

A comprehensive review of 66 relevant studies concluded that mentally ill adolescents engage in more risky sexual behaviors than their nonmentally ill counterparts.[32] Compared with adolescents in the general population, those who have been hospitalized in a psychiatric facility report less frequent condom use and more frequent sexual activity, along with a higher lifetime prevalence of pregnancy and STIs.[33] This elevated risk is likely due to the complex interaction of social, family, peer, and environmental influences.

While the causal links are not entirely clear, it appears that for the majority of youths with an STI and a psychiatric illness, the diagnosis of the psychiatric illness precedes the diagnosis of the STI. One study conducted in Washington demonstrated that while 85% of their sample of HIV-positive adolescents had a current psychiatric disorder, 53% had received psychiatric diagnoses prior to their treatment at the clinic. Furthermore, 50% had a documented history of sexual abuse and 82% had a history of substance abuse.[34]

There is some evidence to suggest that different psychiatric diagnoses may be differentially related to risk behavior. Adolescents with a history of externalizing behavior, including substance use and conduct disorder, tend to be younger at first intercourse, have a larger number of sexual partners, and use condoms less often when they engage in intercourse.[35] Antisocial, dependent, and paranoid personality disorders are also associated with high-risk sexual behavior in adolescents, especially in females, even after concurrent psychiatric disorders are controlled.[36]

Depression can also be a risk factor for risky sexual behavior. Analyses conducted on the National Longitudinal Survey of Adolescent Health data found that among boys, depressive symptoms were associated with a decreased likelihood of condom use, while among girls, depressive symptoms were associated with a history of STIs.[37] This relationship is often found even at a preclinical level; feelings of depression and stress in the general adolescent population are associated with the nonuse of birth control.[38]

There are a multitude of explanations for the paradoxic finding that dramatically different symptom profiles can result in similar outcomes. Depressed adolescents, for example, often experience feelings of hopelessness and lowered self-esteem, which may make them less likely to engage in self-protective behavior. Youths with conduct disorder have a "double whammy" in the sense that not only are there individual risk elements, like cognitive deficits (eg, impaired judgment, problem-solving difficulties, problems with risk assessment, impulsivity, self-destructive tendencies, and affective instability),[39] but these adolescents are likely to be involved with peers who condone risky behavior, which is an important mediating factor.[40]

Substance abuse, in particular, can play a significant role in the etiology of both voluntary and involuntary sexual behavior among adolescents; the two are highly likely to occur together.[37] With respect to the latter, some adolescents who abuse substances -- both illegal "hard" drugs like cocaine, heroine, and PCP, as well as legally attainable or "softer" drugs, like alcohol and marijuana -- may frequently find themselves in compromising situations where it is more likely that they will engage in risky sexual behaviors (eg, unprotected sexual intercourse with others) or be the victim of unwanted sexual advances from others (eg, during acute intoxication). With respect to the former, a few adolescents may engage in sexual behavior for the sake of procuring drugs or money to buy them. As uncomfortable and, perhaps, rare this scenario may be, it must be considered.

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