Factors that shape young people's sexual behaviour

TeeJay · 06 Nov 06 :: 12:05

Yes, another scientific article. But in light of Adam's cheating on Joan and the show trying to touch on the subject of safe sex a couple of times, I thought it might be interesting, especially with regard to some people here writing fan fiction.

Background
Since nearly half of new HIV infections worldwide occur among young people aged 15–24 years, changing sexual behaviour in this group will be crucial in tackling the pandemic. Qualitative research is starting to reveal how social and cultural forces shape young people's sexual behaviour and can help explain why information campaigns and condom distribution programmes alone are often not enough to change it. We undertook a systematic review to identify key themes emerging from such research, to help inform policymakers developing sexual health programmes, and guide future research.

Findings
Seven key themes emerged: young people assess potential sexual partners as "clean" or unclean"; sexual partners have an important influence on behaviour in general; condoms are stigmatising and associated with lack of trust; gender stereotypes are crucial in determining social expectations and, in turn, behaviour; there are penalties and rewards for sex from society; reputations and social displays of sexual activity or inactivity are important; and social expectations hamper communication about sex. The themes do not seem to be exclusive to any particular country or cultural background, and all themes were present, in varying degrees, in all countries assessed.

Introduction:

With nearly half of new HIV infections worldwide occurring in young people aged 15–24 years, changing sexual behaviour in this group will be crucial in tackling the growing pandemic. Campaigns targeting young people have encouraged safer sex, either through condom use or avoiding penetration. Prevention efforts have often involved giving out condoms free of charge and providing information through school talks and leaflets. Yet even where condoms have been freely available and awareness of sexual disease high, such campaigns have often had disappointing results. Qualitative research is starting to show that strong social and cultural forces shape sexual behaviour and is helping to explain why providing information and condoms—while important—are often not enough to change this behaviour. In particular, such work helps us understand why some HIV prevention programmes have been ineffective and how they might be improved.

Since the advent of HIV/AIDS, the number of studies in this field has grown. Previously the realm of sex specialists, sexual behaviour is now scrutinised by sociologists, anthropologists, and public-health specialists in a way that would not have happened before the epidemic. However, whereas earlier work sought to describe and understand sexual behaviour in general, current research tends to focus on identifying, explaining, and changing sexual practices relevant to HIV transmission. Although quantitative research is effective at answering questions such as "what percentage of young people report using a condom the first time they had sex?", it is less useful if we want to know the reasons for their behaviour; nor will it give a broad description of what happened during the sexual encounter. Qualitative research helps describe, and find the reasons for, behaviour and its social context.

Because this is a comparatively new field and qualitative work is usually published in specialist journals, such research tends not to be read by other researchers, clinicians, or policymakers. This systematic review provides a critical synthesis of existing qualitative evidence for a wider audience, to inform research and policy. We show how the findings illuminate our understanding of sexual behaviour, and help to answer key questions. Finally we ask: where does the research go from here? To our knowledge, this paper is the first comprehensive review of this literature.

Discussion:

Our review of research suggests that there are striking similarities in young people's sexual behaviour worldwide.

The seven common themes we have outlined can be used to help answer specific questions, for example why some young people are inconsistent condom users, even with high levels of knowledge and access to condoms. Young people may choose not to use a condom with a partner they perceive to be "clean" (theme 1); they may not have discussed sex with their partners in advance and so be unprepared (theme 7); the social importance for men of achieving penetrative sex, particularly for the first time (themes 4 and 6), may mean they prioritise the experience of sex over any risks; and women may not suggest condom use for fear of appearing too experienced (theme 6), or wish to strengthen the relationship by complying with their partners' desires (theme 5). Similarly, we can explore why a young couple might have sexual intercourse without any form of contraception: they might be ignorant of methods, or one or both might want pregnancy (theme 2); the man might assume his partner will take responsibility for pregnancy prevention (theme 4), although the woman might feel unable to obtain, carry, or use contraceptive methods because of concern for her reputation (themes 3 and 6); finally, either might be reluctant to raise the topic beforehand, wishing to retain ambiguity about whether sexual intercourse will take place (theme 7), or avoid seeming too forward (themes 4, 6, and 7).

Our review only covered publications in English—although these included studies from a wide range of countries. Second, while every effort was made to identify books and other items not listed on databases searchable by key words, some may have been omitted. Third, we did not discuss homosexual behaviour because studies of this in young people are rare; however, our analysis of the few that do exist suggests similar themes to those identified for heterosexual behaviour.

Our findings help explain why many HIV programmes have not been effective. Researchers have identified many reasons for young people not using condoms beyond the most obvious: "ignorance" and "barriers to access to contraception". Therefore, programmes that merely provide information and condoms, without addressing the crucial social factors identified are only tackling part of the problem.

The importance of social influences on behaviour seems obvious in light of evidence from qualitative research—yet is often overlooked by policymakers. Undoubtedly, policymakers are beginning to address factors such as gender inequalities and stereotypes. The challenge now is to design locally tailored programmes that take all seven themes into account and address the important factors for each setting.
The seven themes form a useful, evidence-based checklist of social influences that can be a starting point for local needs assessments and developing programmes. Policymakers should ask themselves how each theme manifests itself locally, for instance: "in what ways are condoms stigmatising in this setting?", and how important it is.

By gathering qualitative and quantitative data relevant to each theme, policymakers can build a local profile of possible influences on sexual behaviour. This systematic exercise may highlight gaps in local knowledge and inadequacies in existing programmes. The profile could also be used to brief local public health practitioners, determine which programmes are likely to work best, and identify suitable measures for programme evaluation. One key insight from this review is that the research risks becoming repetitive. For example, there is a wealth of material on the sexual double standard (theme 4):

"In general, both sexes were strongly aware that the gender scripting was such that the man made the sexual advances and the woman was expected to resist"
Thailand

"Social norms dictate that boys should initiate [the process of developing sexual relationships]; for a girl to do so (at least if this is too explicit) suggests loose morality or prostitution"
Uganda

"Boys were expected to be 'in charge', to 'take chances', and to 'sleep around', girls to be glad, interested and attentive, but not too assertive"
Sweden

Such findings provide important foundations for understanding young people's sexual behaviour, but researchers must move beyond these initial insights. Future work should explore four main areas. First, we need to understand what causes deviance from expected or stereotypical behaviour, particularly when this leads to health benefits: for instance, which men refuse sexual intercourse? Why? How do they interact with their peers?

Second, research should ask more detailed questions. For instance, rather than asking, "Why do young people not use condoms?", one might ask, "What makes young people who demand condoms in long-term relationships different from those who do not?" Researchers have also begun to collect more detail about social context through ethnographies. We need more work like this to capture the full range of influences on sexual behaviour. Third, there are some areas that research has so far only touched on. For instance: what is the relation between pleasure and sexual behaviour? (And how do we define pleasure?) How do men view their responsibility for pregnancy? How does this affect their contraceptive use? Finally, we need to analyse, not just the forces that shape behaviour, but the forces that drive changes in behaviour. How and why do young people change over the course of their lives? For instance, how do their contraceptive practices alter as they become more sexually experienced? Also, what are the differences between age cohorts? For instance, how were 15-year-olds in 2005 different from 15-year-olds in 2000?

Social expectations, especially ideas about how men and women should behave, are a powerful influence on behaviour; the influence of sexual partners is also considerable, as are young people's ideas about stigma and risk; and social pressures make it difficult to communicate clearly with partners, which makes safer sex less likely.

Lancet 2006; 368: 1581–86
Department of Public Health and Policy, London School of Hygiene and Tropical Medicine,
London WC1E 7HT, UK (C Marston PhD, E King MSc (Med))
Correspondence to: Cicely Marston (Cicely.Marston@lshtm.ac.uk)

-TeeJay

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Factors that shape young people's sexual behaviour

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