Sexual behaviour and practices among adolescents and young people: study and results from a tertiary care centre of north India

INTRODUCTION

An adolescent is defined by the World Health Organization (WHO) as a person aged 10 to 19 years (while young people are those aged 10-24 years).¹ They are not a homogenous group; their needs vary enormously by age, gender, region, socioeconomic condition, cultural context, etc. Similarly, their sexual and reproductive health needs vary considerably across different groups, cultures and religion.²

Adolescents' and youngsters’ sexual activities are on the rise and rapidly emerging as a public health concern. Secondary sexual growth, changes in hormonal spurting, emotional, cognitive and psychosocial development result in sexual curiosity and experimentation, often in situations of little reproductive health information or services.³

There is consensus that adolescents and young adults engage in high risk sexual behaviour that predisposes them to reproductive health problems.² This is as a result of physiological and psychological changes that cause them to desire sexual intercourse and take risks, leading to unfavorable sexual and reproductive health indices.

Studies from several parts of the world have reported high level of sexual activity among unmarried adolescents of both sexes with progressively decreasing age of debut, change of sexual practices and preferences, risky sexual practices, including unprotected sexual intercourse with multiple partners which is a matter of concern. Sexual behaviour may be influenced by many physiological factors, in addition to the cultural and social pressures which can change rapidly from one generation to the next. Technological advancement and ease of access to explicit material on the web server has had a major impact in shaping today’s generation.⁴ Understanding the physiological influences that drive adolescent sexual activity, such as hormonal, chemical and neurological reactions and changes, can help form interventions to support such individuals in making appropriate choices regarding their sexual behaviour.

Physiology of adolescents and young adults sexual activity

The factors mainly implicated for early onset of sexual activity are described as under:

Hormonal influences⁵

Sexual behavior of female adolescents was positively affected by increasing levels of the sex hormones, testosterone and oestrogen. In contrast, for males, greater pubertal/physiological development in terms of Tanner staging (Marshall and Tanner, 1970), regardless of age, was is associated with greater sexual involvement, which is unrelated to friends’ sexual behavior.

Early physiological development (i.e. early onset of puberty) is associated with earlier sexual activity, especially in girls

Brain physiology⁶

A study examined the relationship between brain responses during a response inhibition task and past month health-risking behaviour. They found a negative correlation between substance use and brain responses (specifically in the left inferior frontal gyrus and right insula), and a positive correlation between risky sex and brain responses in the right inferior frontal gyrus and left middle occipital gyrus during response inhibition. The authors suggest that these findings indicate that engaging in risky sexual behaviour or substance use reflects more than the individual’s cognitive control capacities, but also their ability to assess the relevant socioemotional factors of that decision.

Associated psychosocial factors⁷

Psychosocial factors that preceded the onset of adolescent and sexual intercourse at young age include alcohol use, delinquency, and school. It is also found that the onset of adolescent sexual intercourse is correlated with depressive symptoms (especially for girls engaging in early sexual activity).

METHODS

This study was conducted at a tertiary care centre in north India. Adolescents and young adults attending the dermatology out patient department over a period of 6 months were exposed to a predetermined questionnaire consisting 15 open and closed questions.

Participation in the study was voluntary and participants were informed verbally and in writing at the top of the questionnaire about the purpose of the study. They were notified about the confidentiality of the information and were thanked for their collaboration.

Data so collected was then statistically assessed using the statistical product and services solutions (SPSS- 14) software.

RESULTS

The study consisted of 100 participants out of which 74 were male and 26 female. The age varied between 16- 24 years. 71 out of 100 participants were unmarried at the time of the study.

47% of participants began full sexual relations by the age of 16- 20 years where as the remaining 53% began sexual activity by 21-24 years of age. When questioned regarding the use of contraception in this case most commonly used method i.e condom, 68% participants reported non usage and 65% did not even talk to the partner about the use of contraception prior to intercourse. When asked about not taking contraception 42% of participants answered ‘it does not feel good’, 31% did not have contraception available at the time and 18 % were unaware. (Figure 1)

The participants were asked about their type of sexual partner, with three possible options: a stable partner (62%), only liked (15%) and casual sexual encounters (23%), likewise also the length of their relationship- one night stand (9%), 1-3 months (27%) and ≥4 months (64%), 74% females of the total female study population fell into this category as compared to 59% males of the total male study population .

The participants were asked about their sexual orientation with three possible options: heterosexual (54%), homosexual (22%) and bisexual (24%). (Figure 2)

71 % participants had partners elder to them with their age ranging from 23 years to 46 years when they had their first sexual encounter. 45% had multiple partners. 65% attributed their behavior to fun, 23% urge and 12% peer pressure. (Figure 3)

Majority individuals 46% had vagino penal intercourse, 26% vagino penal and anal, 19 % anal, 6% ano oral along with vagino penal and 3% had ano oral intercourse. 76% individuals did not report any symptoms after intercourse while the remaining 24% reported burning and discharge.

39% participants were addicted to alcohol, smoking or drugs. 21% gave history of use of performance drugs prior to intercourse.

58% of the study population did not receive sex education either in school, college, through internet or by their parents. 84 % were not vaccinated against HPV at the time of the study.

Through the study we also correlated that males had an earlier onset of sexual activity so much so that 51% of males fell in the 16-20 years category where as only 34% of females were in the same category. Females in the study had more stable relationship as compared to the males and their relationships lasted longer as compared to the males in the study.

DISCUSSION

The age of sexual debut is between 16-20 years in 47% of the participants. Our data coincides with the results of another study conducted by Munoz et al, where the age was 16.4-18 years.⁸ Majority of individuals included in the study were unmarried, the reasons for the same may be attributed to the fact that married people do not come forth with history of such behavior and due to increased age of marriage as compared to earlier times where people would get married early. Although there is no universal definition of early initiation of sexual activity, it is often classified as sexual intercourse during initial high school years or sexual intercourse before the age of legal consent.⁹

Condom was the method of contraception chosen because of it being the most commonly used method and due to it’s free and easy availablility. 68% partcipants reported non usage of condom or even considering talking to their partner about it, this finding can be explained as done by Marston et al, in their study where they write that young people also worry that asking their partner to use a condom implies that they think their partner is diseased; thus condom- free intercourse can be seen as a sign of trust.^10-12 This may also be attributed to the shyness associated with purchasing condoms from the store.

Reason for non usage of contraception corroborated with the findings in the study by Duru et al, where the reason for non usage was ‘it doesn’t feel good in 33.2%, unavailability in 22.3% and unawareness in 21.8% individuals.¹³

Most of the young people who have sex do so with stable partners, at all the age levels. There is a downward trend in casual sex, among both sexes, from the 2007 to the 2008 series, although at these ages of adolescence and youth they have still not found a definitive partner and try out different options. This trend and the evolution towards a stable partner coincides with other authors who have noted that there is less promiscuity in the generation born in the 2000s than halfway through the 1990s.¹⁴

Homosexual orientation was observed in 22% and bisexual in 24% of the study population. The engagement by adolescents in same sex intercourse – gay and lesbianism was not reported in the various studies, the reason given for which is due to the fact that people do not openly acknowledge their preference for same sex, Baams et al.⁷

Majority individuals had vagino- penal intercourse which was similar to the finding in an African review article and also in studies from various nations where vagino-penal intercourse was seen in 78% of the study population.^12,13

Indulging in drug abuse, smoking and alcohol consumption were reported in 39% participants the reason for which may be attributed to peer pressure, inquisitiveness to try out the new. Use of drugs/alcohol may reduce the inhibitory control thus leading to unsafe practices and risky behavior.¹⁵

Reason for not receiving sex education by any means may be due to the cultural and social barriers between children and their parents and similarly lack of HPV vaccination in 84% of the study population, despite government’s initiative to vaccinate all school going girls points to the need of strengthening the policies, guidelines and increasing awareness without affecting or hurting one’s cultural, social and religious beliefs.¹⁶

The females in the study were found to have more stable relations as compared to the males which is attributed to girls attaining physical and psychological maturity in advance of boys, to an average of 2 years.¹⁷

Nearly, 70% of total adolescent (10–19 years of age) population of the world resides in developing countries. Developing countries in recent decades are going through a rapid change due to – urbanization, migration, education, and mixing of cultures, which are having a definite impact on the attitude toward sexuality in adolescents.

Also extensively influenced by the western world, the Indian youth is adopting their practices being unaware of the fact that this may lead to adverse situations in their future in terms of acquiring and transmitting various STI’s, HIV infection and having tremendously harmful impact on their psychological health and as a result their overall growth and hence of the entire nation. This article points to the need of formulating new or modifying the existing policies in our country for the betterment of the future of the country.

Considering the need, the authors would like to lay certain recommendations which may prove to be of help.

CONCLUSION

Information, health services and support needed for adolescents to make informed decisions are lacking in many developing countries. Fortunately, health care providers are in a unique position to not only provide necessary services to teens in a confidential manner, but also to be educators and advocates within their communities about the educational and health care needs of our adolescents. The short and long-term consequences of early sexual debut and lack of contraceptive use, are grave to adolescents and the community. The practices and activities adopted by the generation cannot be curtailed but these can be made safe by implementing well planned sexual and reproductive health education all over the country.

Recommendations

In view of the evidence of widespread sexual activity among Indian adolescents and young adults, implementation of the following strategies will yield widespread positive results: Parents and guardians should be educated to overcome the cultural barriers that discourage giving adolescents early sex education at home. Advocacy and community mobilization to increase awareness towards the need for inclusion of sex education in school curriculum.

Effective health education programmes targeted at adolescents to improve knowledge on sexual issues, promote abstinence and motivate behaviours that reduce sexual risk. Where abstinence may not suffice, improve contraceptive counselling so as to increase contraception. In view of the overwhelming influence of peers, training of peer educators to transfer correct information to their peers.

ACKNOWLEDGEMENTS

The authors would like to thank Mrs. Payal Gagneja (MSW) for her support and co-operation in participant recruitment and counseling. The authors feel indebted to the participants because without them the study would not have taken shape.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: The study was approved by the Institutional Ethics Committee

REFERENCES

1. 1. World Health Organization. Adolescent health and development. http://www.searo.who.int/en/section13/section1245_4980.htm. Accessed on 12th January 2021.
2. 2. Okonta PI. Adolescent sexual and reproductive health in the Niger Delta region of Nigeria – issues and challenges. African J Reproduct Health. 2007;11(1):113-24.
3. 3. Okpani AOU, Okpani JU. Sexual activity and contraceptive use among female adolescents – a report from Port Harcourt, Nigeria. Afr J Reproduct Health. 2000;4(1):40-7.
4. 4. Daneback K, Månsson SA, Ross MW. Technological advancements and Internet sexuality: does private access to the Internet influence online sexual behavior?. Cyberpsychol Behavior Social Networking. 2012;15(8):386-90.
5. 5. Tanner JM, Marshall WA. Variations in the pattern of pubertal changes in boys. Arch Dis Child. 1970;45(239):13-23.
6. 6. Blakemore SJ, Mills KL. Is adolescence a sensitive period for sociocultural processing?. Annual review of psychology. 2014;65:187-207.
7. 7. Baams L, Dubas JS, Overbeek G, Van Aken MA. Transitions in body and behavior: A meta-analytic study on the relationship between pubertal development and adolescent sexual behavior. J Adolescent Health. 2015;56(6):586-98.
8. 8. Muñoz MA, Nitschke RG, Tholl AD. Sexual behavior in the everyday life of adolescents and young adults from the hip hop culture. Texto & Contexto-Enfermagem. 2014;23(1):126-33.
9. 9. Girma S, Paton D. Is education the best contraception: the case of teenage pregnancy in England?. Social Sci Med. 2015;131:1-9.
10. 10. Holland J, Ramazanoglu C, Scott S, Sharpe S, Thomson R. Between embarrassment and trust: young women and the diversity of condom use. AIDS: Responses, Interventions Care. 1991;127:148.
11. 11. Lear D. You're Gonna be Naked Anyway: College Students Negotiating Safer Sex. Qualitative Health Research. 1996;6(1):112-34.
12. 12. Hillier L, Dempsey D, Harrison L. 'I'd never share a needle'…[but I often have unsafe sex]: Considering the paradox of young people's sex and drugs talk. Culture, health & sexuality. 1999;1(4):347-61.
13. 13. Duru CB, Ubajaka C, Nnebue CC, Ifeadike CO, Okoro OP. Sexual behaviour and practices among secondary school adolescents in Anambra State, Nigeria. Afrimedic Journal. 2010;1(2):22-7.
14. 14. Pringle J, Mills KL, McAteer J, Jepson R, Hogg E, Anand N, Blakemore SJ. The physiology of adolescent sexual behaviour: A systematic review. Cogent Social Sci. 2017;3(1):1368858.
15. 15. White HR, Fleming CB, Catalano RF, Bailey JA. Prospective associations among alcohol use-related sexual enhancement expectancies, sex after alcohol use, and casual sex. Psychology of Addictive Behaviors. 2009;23(4):702.
16. 16. Sarojini NB, Srinivasan S, Madhavi Y, Srinivasan S, Shenoi A. The HPV vaccine: science, ethics and regulation. Econ Pol Wkly. 2010;45(27):27-34.
17. 17. Kail RV, Cavanaugh JC. Human development: A life-span view. Cengage Learning. 2018.