Recent trends in adolescent sexual behavior offer mixed messages. It is very encouraging that teenagers' overall rates of sexual activity, pregnancy and childbearing are decreasing, and that their rates of contraceptive and condom use are increasing. (1) However, the proportion of young people who have had sex at an early age has increased. (2) Moreover, while adolescent females' contraceptive use at first sex is rising, their use at most recent sex is falling. (3)
There is general consensus that the proportion of teenagers who engage in behaviors that put them at risk of pregnancy and of HIV and other sexually transmitted infections (STIs) remains too high. Each year, approximately one million young women aged 15-19-or one-fifth of all sexually active females in this age-group-become pregnant; the vast majority of these pregnancies are unplanned. (4) In the United States, the risk of acquiring an STI is higher among teenagers than among adults. (5) Moreover, rates of unprotected sexual activity, STIs, pregnancy and childbearing continue to be substantially higher among U.S. adolescents than among young people in comparable industrialized countries. (6)
Research has also begun to highlight an alarmingly high rate of involuntary sex among young people. In the 1995 National Survey of Family Growth, 13% of 15-19-year-old females reported that they had been forced to have sex. (7) When asked about their first sexual experience, 22% of 15-44-year-old women for whom it occurred before age 15 reported that the act was involuntary, as did 16% of those who first had sex before age 16. Involuntary sexual activity is typically unprotected and thus puts its victims at very high risk of pregnancy and STIs.
Finally, recent research and clinical observations suggest that a substantial proportion of teenagers, including those who report having never had vaginal sex, are engaging in oral sex. (8) This trend has negative implications for teenagers' sexual health because many seem unaware that STIs can be acquired through unprotected oral sex.
Adolescent health professionals are faced with the dilemma of how to refine programmatic and research efforts to maintain the progress that has been made while reducing those risk behaviors that remain too prevalent. The solution may lie, in part, in bridging the gap between research and programs. For more than 30 years, researchers have studied the antecedents of teenagers' high-risk sexual behaviors, and service providers have designed programs to prevent those behaviors. Their efforts have typically proceeded independently, however, and each professional community's work has not routinely informed that of the other. This lack of communication is understandable, given the differences in professional backgrounds and training, work settings and day-to-day activities. We believe, however, that this lack of communication inevitably compromises the quality of both research and programs related to teenage sexual health and behaviors.
We are an interdisciplinary group of public health researchers and service providers who are committed to bridging the chasm between research and programs. In this comment, we suggest ways in which work to reduce levels of teenage pregnancy and risk-taking can proceed in a more integrated and collaborative fashion. We believe that research on prevention should be designed and conducted to inform the development of programs and policy. The issues that emerge as these programs and policies are implemented, in turn, will raise questions that promote further research, which ultimately will inform the next generation of programs and policies.
The structure of this comment models this process. We begin on-the research side and give a brief overview of findings on the antecedents of adolescent sexual risk behaviors and pregnancy, and discuss their implications for program and policy development. This effort is grounded in a comprehensive literature review that we conducted for the Centers for Disease Control and Prevention (CDC). * We then move to the program side. On the basis of our own clinical observations and discussions with other providers in a variety of settings, we identify a set of critical programmatic issues that hinder success in reducing adolescents' sexual risk-taking. Finally, we outline the specific research questions raised by these service-related issues. The answers to these questions will potentially enhance program efficacy.
RESEARCH SIDE
Antecedents of Risky Sexual Behaviors and Pregnancy
In our literature review for the CDC, we targeted three risky sexual behaviors--early onset of sexual activity, nonuse of contraceptives and nonuse of condoms--and one possible outcome of those behaviors, teenage pregnancy. Major literature reviews on these topics were published in 1987 and 1995; (9) we supplemented and updated them by systematically examining the research published in peer-reviewed journals from 1994 to 2002.
The literature identifies four key sets of factors that have been associated with risky sexual behaviors and pregnancy: race and ethnicity; socioeconomic status; social influences; and attitudes toward contraception, condoms and pregnancy and safer-sex behavioral skills. Differences by race and ethnicity vary across risk behaviors. For example, black teenagers are more likely to have very early vaginal sex than Hispanics, who are more likely to do so than whites. (10) (Specifically, black males initiate vaginal sex more than two years earlier than Hispanic males, and three years earlier than white males. (11) Hispanic adolescents are the least likely to have used a condom or another contraceptive method at last intercourse. (12) The combined influences of earlier sexual debut among blacks and greater nonuse of contraceptives among Hispanics yield higher teenage pregnancy rates among nonwhite than white teenagers. (13)
These racial and ethnic differences in sexual risk-taking and pregnancy are partly attributable to differences in socioeconomic disadvantage. More broadly, socioeconomic status is related to each of the four outcomes studied. Among the socioeconomic indicators that significantly predict risky sexual behaviors and pregnancy are the adolescent's having a parent with low educational attainment and living in a single-parent family. (14) A teenager's own level of academic achievement is positively related to age at sexual debut. (15)
Young people's social influences clearly affect their likelihood of engaging in risky behaviors, particularly early sexual debut and nonuse of condoms. For example, having friends who are sexually active or who do not use condoms enhances one's own risk of these behaviors. (16) Moreover, teenagers who perceive that their mother disapproves of their having sex or who talked with their mother about condom use before first intercourse are less likely than others to become sexually active or to fail to use condoms. (17) Finally, teenagers who are more actively involved in religious activities and those who avoid general nonsexual high-risk behaviors tend to initiate sex later than other teenagers. (18) In all likelihood, the effects of religiosity and avoidance of risk operate through social influence mechanisms.
Sexual risk behaviors are also related to attitudes and behavioral skills. Adolescents' attitudes toward practicing contraception, using condoms and becoming pregnant predict the likelihood that each will occur. (19) In addition, their specific attitudes toward pregnancy affect the likelihood that they will practice contraception and use condoms. (20) Furthermore, teenagers who feel they have the requisite skills to use condoms (i.e., they can obtain them and successfully negotiate their use with a partner) are more likely than others to use condoms. (21) Similarly, young people who have demonstrated to themselves that they can use contraceptives (i.e., they used them once) are more likely than others to use them again. (22)
Not surprisingly, age and age at menarche strongly affect the likelihood of sexual initiation and teenage pregnancy. (23) Older female adolescents and those who reach menarche at younger ages, because of their longer intervals of exposure, are more likely than their younger peers to become sexually active and to get pregnant. (24) Despite the positive correlation between age and pregnancy, older sexually active teenagers are, paradoxically, more likely than younger ones to have used a contraceptive method at last sex. (25)
Programmatic Implications of the Research
Taken together, these research findings have implications for programs that are designed to reduce high-risk behaviors among adolescents. The programmatic implications yield the following eight broad recommendations.
