Sexual Knowledge, Attitudes, and Practice of Israeli Adolescents M. LANCET, BA, MD, FICS, B. MODAN, MD, PHD, S. KAVENAKI, MA, PHD, H. ANTONOVSKI, PHD, AND I. SHOHAM, BA
Abstract: A study of 4,976 high-school students in Israel, representative of this age group for the entire country except for 13 percent who attend religious schools, revealed that about one-third of the boys aged 14-15 and almost one-half of those in the 16-17 age category have had sexual intercourse. The respective figures for girls are 6 percent and 16 percent. Age at onset of sexual activity was found to be higher and the level of knowledge about the same as in reports from the Western world. Students of Oriental origin, as well as those considering themselves religious or traditional tended to be less active sexually, more conservative in
their attitudes, and less knowledgeable. In contrast, students of both sexes residing in kibbutzim were found to be more active sexually and more knowledgeable. A double standard for girls was accepted, especially among the female respondents, except in the kibbutzim. A subgroup of girls highly sexually active, in contrast to their own attitudes, has been identified, and possible reasons for this discordance discussed. As sexual activity among teenagers is becoming more prevalent, comprehensive and early sex education school programs should be encouraged. (Am. J. Public Health 68:1083-1089, 1978.)
Throughout the world pregnancy and childbearing are occurring at younger ages, and adolescents are entering the cycle of human reproduction without adequate preparation.1-5 Only a few comprehensive reports on sexual knowledge/attitudes/practice (KAP) in adolescents have been published, and those that have appeared were usually based on relatively small samples, some comprising less than 500 individuals.6-13 Israel is geographically and culturally in a mid-position between the developed and the developing countries; in addition its population is of very mixed ethnic origin. The sexual KAP of adolescents in this country should therefore be of special interest. The present study was undertaken under the auspices of the Center of Demography in the Prime Minister's Office. In addition to its general interest, study results were to be used in the construction of a sex education curriculum in Israeli schools. The full results were published in the form of a booklet in 1974.14 This article is an abbreviated version of
the original report, giving the main highlights thought to be of interest to health workers outside Israel.
Address reprint requests to Dr. M. Lancet, Head, Department of Obstetrics and Gynecology, Kaplan Hospital, Rehovot, Israel. Dr. Lancet is also associate clinical professor of OB/GYN, Hadassah-Hebrew University Medical School; Dr. Modan is head, Department of Clinical Epidemiology, Sheba Medical Center, Tel-Hashomer, and professor of epidemiology, Tel-Aviv University School of Medicine; Dr. Kavenaki is senior teacher, Department of Psychology, Tel-Aviv University; Dr. Antonovski is senior lecturer in psychology, Ben Gurion University School of Life Sciences, BeerSheba; and I. Shoham is research assistant, the Israel Institute of Applied Social Research, Jerusalem. This paper, submitted to the Journal October 17, 1977, was revised and accepted for publication May 25, 1978.
AJPH November 1978, Vol. 68, No. 11
Methods Permission to conduct the study was obtained from the Ministry of Education, through a letter of introduction to the school principals (headmasters). Schools designated as religious had to be excluded by the request of the Ministry, but as they form not more than 13.1 percent of all the secondary schools, our results should not be too heavily biased because of this exclusion. The youngsters were nevertheless categorized as religious, traditional, or unobservant according to the replies given to relevant questions in the questionnaire.* A stratified sample of 50 secondary schools was drawn from the complete list of all schools in Israel (excluding the religious). Type of school and type of settlement** were considered as stratification criteria. There are four main types of non-religious schools in Israel: regular, vocational, agricultural (boarding), and the schools in the cooperative settlements called "kibbutzim". Owing to the mixed origin of the Israeli Jewish population, three categories of parental origin *"Religious" was defined as regular synagogue attendance and observation of most or all Mosaic laws; "traditional" was defined as sporadic synagogue attendance and observation of the main Mosaic laws; the remainder were considered "unobservant". **All types of settlements were included, namely large urban centers, medium and small towns, subdivided into old and new ones (established before or after the founding of the State in 1948) and rural settlements, again subdivided into old and new ones; the kibbutzim were considered a separate category. 1 083
LANCET. ET AL. TABLE 1-The Study Sample by Age and Sex Age
(years)
Male
Female
Total
14-15
1,459 1,228 2,687
1,360 1,363 2,723
2,819 2,591
16.17 TOTAL
5,410
were considered: Israeli born, western and eastern (North Africa and the Middle East). As the sample is not a proportional random one, it had to be weighted in order to get an unbiased estimate of the different parameters of the student population of the country. As a result of the method of sampling described, we believe that the students questioned represent the entire Israeli high school student population, with the noted exception of students attending the religious schools. After consent of the headmaster had been received, an hour during the regular teaching time was designated for completing a self-administered written questionnaire. In each school included in the sample, four classes were chosen randomly, one for each grade (in many schools there are several parallel classes for each grade). The students were in their usual room and no teachers were present when the questionnaire was completed. A male and female member of our field staff distributed the questionnaires and explained the purpose and method of the study. These staff members remained in the room and answered any questions or problems raised by the subjects. The mean time taken to answer the questionnaire was about 35 minutes. Anonymity and secrecy of the answers were assured. Any student who did not want to answer the questionnaire could leave. None did. During the coding, only 25 questionnaires had to be eliminated due to incompleteness or irrelevant answers. Parental acceptance of the study was not specifically requested by the investigators who left this issue to the judgment of the headmasters. No objections from the parents were voiced either before or after the administration of the
questionnaires. The questionnaire covered a wide range of topics in addition to sexual knowledge, attitudes and behavior, including peer-relationships, parent-adolescent relationships, and attitudes towards sex education in the schools. It consisted mainly of precoded questions, but a number of the sex information questions were open-ended and coded afterwards. Data were analyzed by sex and age (14-15 and 16-17) within the four school types and according to ethnic origin and degree of religious observance.
Material The full sample consisted of 5,410 Jewish youngsters, almost equally divided between the sexes and the two age groups (Table 1). A small group of respondents (212) that were not attending the four types of schools mentioned was 1 084
excluded from in the analysis, leaving 5,198. The distribution by types of schools is shown in Table 2. More vocational and agricultural school students were of oriental origin and religious (not shown in Table). All agricultural schools were boarding schools and most were co-educational. The distribution according to the origin of the parents is shown in Table 3. To simplify matters, this parameter was analyzed only for those pupils both of whose parents were of the same origin; these constituted over 80 percent of the sample in each age-sex group. Table 4 shows the distribution of the sample according to the three religious groups.
Results Knowledge Students were asked about their knowledge of anatomy and physiology, contraception, signs of pregnancy, venereal diseases, and sexual deviations. The overall level of knowledge was very low. For questions on anatomy and physiology, the highest average score of any group analyzed was 1.9 out of a maximum obtainable score of 7. Although contraception knowledge scores were better, with at least one method known by 90 percent of the students, the best group average score was 2.6 out of a maximum of 5. The percentage of those who knew how VD was contracted ranged between 21 percent and 42 percent. Boys' knowledge was better than girls', older students were better informed than the younger ones (as expected) and kibbutz and regular school students, both male and female, fared better than students in other schools. A significant positive correlation was found between the degree of education of fathers and the knowledge scores of their children. Main sources of information about six are listed in Table 5. Literature ranked first and friends second among youngsters age 16-17; whereas friends ranked first and literature second among the 15-16 year olds. Most of the youngsters have received some sex information at school, but ranked it below most other sources. Mothers were important sources of information only for girls. Heterosexual Behavior Sexual activity was divided into the following six stages:6 going steady, kissing, petting over clothes, petting under clothes, genital stimulation, and actual intercourse. As TABLE 2-Study Group by Sex and Type of School Total
Type of High School
Males
Females
N
%
Regular Vocational
832 1,308
1,425 729
2,257 2,037 418 486 5,198
43.4 39.2 8.0 9.3 100.0
Agricultural (boarding) Kibbutz* TOTAL
244
174
228 2,612
258 2,586
*Colective settlement AJPH November 1978, Vol. 68, No. 11
SEXUAL KAP IN ISRAEL TABLE 3-Study Group Distribution According to Parental Origin (by Sex and Age) Females
Males
Israeli Westem Eastem Mixed parentage*
TABLE 4-Study Group Distribution According to Religious Observance (by age and sex) Females Males
Age
Age
Age
Age
14-15
16-17
14-15
18-17
14-15
16-17
14-15
16-17
(N: 1,440)
(N: 1,209)
(N: 1,351)
(N: 1,350)
(N: 1,440)
(N: 1,209)
(N: 1,351)
(N: 1,352)
9.0 35.2 39.0 16.8
8.7 42.1 33.3 14.9
9.7 33.8 41.7 14.9
7.8 44.1 32.0 16.1
14.8 37.7 47.5 100.0
8.0 36.5 55.5 100.0
9.8 28.5 61.7 100.0
7.2 25.6 67.2 100.0
Age
Religious Traditional Non-observant TOTAL
Age
Age
Age
*In the analysis, the group of mixed parentage was not included
expected, activity was reported more often among boys and increased with age in both sexes (Table 6). With the exception of younger boys, the activity formed a continuous Guttman scale in all age and sex groups. Table 7 displays the proportion of students who reported ever having engaged in sexual intercourse according to various subject characteristics. Subjects of second Israeli generation, boys in agricultural schools and girls in kibbutzim schools reported highest frequency of activity while girls of North African and Middle-Eastern parentage or with a religious background reported the least frequency. There is far less discrepancy by sex among kibbutzim students than among other groups analyzed. Table 8 presents responses of 16 and 17 year olds to the question of age at first intercourse, demonstrating an obvious time lag among girls. Ninety-five per cent of the older girls and 67 per cent of the younger ones who reported having engaged in sexual intercourse had intercourse for the first time with a steady partner, while the respective percentages for boys were 40 per cent and 44 per cent (not shown in table). Fourteen per cent of the boys reported an experience with a prostitute, a rate that was highest in agricultural schools. More than 80 per cent of all sexually active girls reported intercourse with only one partner, while only 40 per cent of the boys so reported. The primary reasons for first intercourse are given in Table 9. A pre-coded list had to be checked by the respondents, and more than one reason could be given. Some differences between the two sexes are demonstrated. Love and sexual drive were important for all, and the latter assumed greater prominence as age increased. More boys than girls claim to have been urged into having coitus by the partner. The youngsters were also asked about their feelings after their first intercourse and more boys than girls had positive feelings, e.g., satisfaction, happiness or pride, while negative reactions, e.g., shame, fear, guilt, revulsion and confusion were more prevalent among girls. Contraception Only one-third of the sexually active girls and one-half of the sexually active boys used contraceptives. (This difference is highly significant, p < 0.01). When asked why no contraceptive measures had been taken, the most prevalent AMPH November 1978, Vol. 68, No. 11
answers were "I did not think of it" or "I was not prepared-it just happened." However, in view of the extremely low rate of pregnancies in the group as a whole, it seems likely that withdrawal (the most prevalent contraceptive measure in Israel)"5 was not reported as a contraceptive method, but considered "natural." Among those who had engaged in intercourse, pregnancies were reported by 6.7 per cent of the younger girls and 2.6 per cent of the 16-17 years olds, all ending in an induced abortion. The lower incidence in the more active group of older girls may reflect better contraceptive protection or the fact that more older pregnant girls have left school. Pregnancy occurred before the age of 16 in more than 75 per cent of all the girls who became pregnant. There were no significant differences either by ethnic origin or by degree of religious observance. Masturbation Table 10 presents the frequency of masturbation by age and sex. The percentage is higher in boys and in the older age groups. There was no significant difference in coital activity between those reporting masturbation and those not
reporting it. Attitudes
Questions on attitudes dealt mainly with premarital sex and feelings about the partner's sexual behavior. Girls and younger students had a more conservative attitude than boys and older students. Seventeen per cent of the 14-15 year old boys and 10 per cent of the older boys thought that intercourse should not be engaged in before marriage, while the respective percentages for girls were 50 per cent and 33 per cent. Those with the more conservative attitude stressed the importance of sex with a steady partner only, with the exception of kibbutz students. A double standard was very evident among all sex/age groups, but more so among the females. Students categorized as religious were the most conservative, with 90 per cent of the religious females holding the view that a girl should remain a virgin until marriage. Students of oriental parentage were more conservative than those of Israeli or western parentage. However, a great deal of discordance was found: e.g., many of those who approved of premarital intercourse had abstained (especially among 1085
LANCET, ET AL. TABLE 5-Main Sources of Sexual Information by Age and Sex
Age 14-15
Girls
Boys Age
Age
Age
Age
14-15
16-17
14-15
16-17
Source
%
%
%
%
Friends Books Mother Doctor (specialist) Pamphlets Teacher Father Films
44
39 52 7 14 13 8 6 9
37 30 29 12 8 5 4 7
41 38 21 15 7 4 3 9
40 6 5 15 5 6 13
TABLE 6-Type of Sexual Activity by Age and Sex
boys), and, among the sexually active girls, 46 per cent of the sexually active 14-15 year old girls, and 25 per cent of the 1617 year olds, thought that virginity should be maintained until marriage.
Comment The level of sexual knowledge among all adolescent groups leaves very much to be desired, and the situation in this respect is no better in Israel than that reported from other countries 1 6 7, 11. The most logical place for formal sex information is the school, but it still does not play its role well, and there is much room for improvement. Israeli high school students apparently start their sexual activity at a later age than adolescents in most other countries for which reports exist.6' 7. 8, 10, 11. 16 As expected, boys were consistently more active sexually than girls, but as only 14 per cent of the boys resorted to prostitutes, it is conceivable that many of their female partners were not in-
Age 16-17
Boys %
Girls %
Boys %
Girls
Type of acivity
Going steady Kissing Petting over clothes Petting under clothes Genital stimulation Sexual intercourse
73.5 68.8 65.6 41.6 30.8 34.6
71.1 57.6 38.0 16.3 8.0 6.5
86.2 80.2 79.8 63.5 46.9 46.4
88.6 78.9 68.3 46.1 29.2 16.0
%
cluded in our sample because they were outside the schools investigated. The possibility that some of the girls have had more than one partner cannot be ruled out. Low frequency of contraceptive use, despite apparent knowledge seems typical for this age group. A number of explanations have been suggested for this inconsistency.2' 3, 11,13,16-19 The most logical seems to be that "it just happened", i.e., the intercourse was not premeditated. Lack of available specific contraceptive means and advice may also play an important role.20 Despite the fact that orthodox religious schools were not included in our sample, a lower activity among those defining themselves as "religious" or "traditional" emerged in line with other reports.9 This relationship was, in part, an expression of the fact that the religious groups included more students of North African and Middle Eastern parentage. Residents of collective settlements (kibbutzim) of both sexes, and irrespective of age, emerged as more active sexually and with more liberal attitudes. They were also better contraceptors and the "double standard" was not prevalent
TABLE 7-Percentage* Having Experienced Sexual Intercourse by Age and Sex According to Parental Origin, Religious Category, and Type of School Girls Boys
Parental Origin1 Israeli Western North Africa & Middle East Religious Category2 Religious Traditional Non-observant Type of School3 Regular Vocational Agricultural (boarding) Kibbutz
Age 14-15
Age 16-17
Age 14-15
Age 16-17
42.0 30.9 36.0
45.7 42.4 46.9
8.5 7.7
5.0
29.8 20.0 9.3
28.0 35.1 33.1
38.2 42.1 39.9
3.4 4.6 5.7
6.1 13.9 18.2
23.6 35.2 49.3 26.1
39.6 42.0 64.8 42.2
4.6 5.7 9.0 18.0
15.9 11.9 7.9 40.3
*Percentage of total sample of each group 'P < 0.05 for girls 2p < 0.05 for girls 3AJI differences highly significant (P < 0.001)
1 086
AJPH November 1978, Vol. 68, No. 11
SEXUAL KAP IN ISRAEL TABLE B-Age of First Intercourse by Sex, among 16-17 year olds
TABLE 9-Reasons for First Intercourse (expressed as percentage of respondents checking off given reason) Girls
Boys Boys
Girls
Reason Age at First Intercourse
14 or younger 15 16 17 Not answered TOTAL
Age 16-17 (N = 570)
17.2 22.4 36.3 20.6 3.5 100.0
Age 14-15
Age 16-17
Age 14-15
Age 16-17
39.0 62.4 56.4 54.5 21.5 18.9
49.9 64.6 80.8 43.3 23.7 19.6
22.1 81.5 38.7 27.0 36.4 2.7
56.1 91.6 59.3 30.1 23.1 3.7
Age 16-17 (N = 218)
4.8 15.9 29.5 37.5 12.3 100.0
Curiosity Love Sexual drive Urged by partner Unpremeditated Conformity
Boys start earlier than girls: P < 0.001
REFERENCES among them. Although kibbutzim are not novel in Israel, they still serve as a sort of human laboratory, especially in educational matters. Children are raised in communal homes, which in many of the settlements are completely coeducational, although the link with the parents is also very strong. In this sense, a kibbutz is not just a type of school, but also a mode of life. The small subgroup of young girls of non-European descent who have been sexually active in spite of their own basic attitudes deserves special attention. It seems clear that at least in the sexual area, situational and motivational factors may lead to behavior incompatible with expressed attitude. The disapproving attitude may operate to lessen the frequency of occurrence of the behavior by keeping the individual out of situations which may induce or encourage the behavior. Once the individual gets into these situations, however, the disapproving attitude may not prevent the behavior from occurring. It is also possible that the more conservative attitudes expressed by this active group serve as lip service to the norms held by their families. Sexual activity among teenagers appears to be on the increase; with their lack of factual information and inadequate contraceptive practice, the number of pregnancies is growing rapidly. In order to check what has been called "the epidemic of teenage pregnancies'"21 sex information and education must become available at a relatively early age, as part of the curriculum of all schools.
ACKNOWLEDGMENTS
This study was made possible by a generous grant from the Center of Demography at the Israeli Prime Minister's Office, and financial aid from Messrs. Teva, Rafa and Ikapharm.
TABLE 10-Masturbation Activity by Age and Sex Age Group
Boys
Girls
14-15 16-17
59.7 79.7
12.3 20.6
AJPH November 1978, Vol. 68, No. 11
1. Conwell EB and Jacobson L: Pregnancy, the teenager and sex education, Am J Public Health, 61:1840-1845, 1971. 2. Cole JB, Beighton FCL and Jones IH: Contraceptive practice and unplanned pregnancy among single university students, Brit Med J 4:217-219, 1975. 3. Kantner JF and Zelnik M: Contraception and pregnancy experience of young unmarried women in the United States, Fam. Plan. Persp. 5:21, 1973. 4. Ruzicka LT: Non-marital pregnancies in Australia since 1947, J. Biosoc. Sci. 7:113-132, 1975. 5. Hunt WB: Adolescent fertility-risk and consequences, Population Reports, Ser. J., No. 10, July 1976. 6. Schofield M: The Sexual Behavior of Young People. Penguin Books, Hammondsworth, 1968. 7. Sorenson RC: Adolescent Sexuality in Contemporary America. World Publishing, New York, 1973. 8. Kantner JF and Zelnik M: Sexual experience of young unmarried women in the United States, Fam Plan Persp 4:(No. 4), 9, 1972. 9. Osofsky HJ: Adolescent sexual behavior, Clin Obstet Gynecol, 14:393, 1971 10. Packard V: The Sexual Wilderness. Longmans, London, 1968. 11. Finkel ML and Finkel DJ: Sexual and contraceptive knowledge, attitudes and behaviour of male adolescents. Fam Plan Persp 7(6):256-260, 1975. 12. Lancet M, Modan B and Kavenaki S: Sex behaviour and knowledge in young Israelis, 1st Internat. Sympos. Sex Educ., Tel Aviv, 1972. 13. Munz D, Carson S, Brock B, et al: Contraceptive knowledge and practice among undergraduates at a Canadian university. Am J Obstet Gynecol 124:499-505, 1976. 14. Lancet M, Antonovsky H, Modan B, et al: The behaviour, attitudes and knowledge on sex by Israeli youth. Public. No. HA/ 441/H, The Israel Institute for Applied Social Research, Jerusalem, 1974 (Hebrew). 15. Bacchi R, Mattras J, Toaff R, and Ayalon D: Birth rate and contraception among the women of Tel-Aviv-Yaffo. (Hebrew) The Dpt. of Statistics, Hebrew University, Jerusalem (1961). 16. Apkom CA and Apkom KL: Prior sexual behaviour of teenagers attending RAP sessions for the first time. Fam Plan Persp 8:203206, 1976. 17. Windhom 0: Medical and social aspects of adolescent pregnancies, Acta Obstet Gynaec Scand 53:347-353, 1974. 18. Goldsmith S, Galerielson MO, Galerielson J et al: Teenagers, sex and contraception. Fam Plann Perspect, 4:32, 1972. 19. McCance C and Hall DJ: Sexual behaviour and contraceptive practice in unmarried female undergraduates. Brit Med J 2:694700, 1972. 20. Kinch RA and Kruger E: Some sociomedical aspects on the adolescent pregnancy. Int J Gynec Obstet 8:480-486, 1970. 21. 11 Million Teenagers, The Allan Guttmacher Institute, Planned Parenthood Federation of America, New York, 1976.
1089
Abstract: A study of 4,976 high-school students in Israel, representative of this age group for the entire country except for 13 percent who attend religious schools, revealed that about one-third of the boys aged 14-15 and almost one-half of those in the 16-17 age category have had sexual intercourse. The respective figures for girls are 6 percent and 16 percent. Age at onset of sexual activity was found to be higher and the level of knowledge about the same as in reports from the Western world. Students of Oriental origin, as well as those considering themselves religious or traditional tended to be less active sexually, more conservative in
their attitudes, and less knowledgeable. In contrast, students of both sexes residing in kibbutzim were found to be more active sexually and more knowledgeable. A double standard for girls was accepted, especially among the female respondents, except in the kibbutzim. A subgroup of girls highly sexually active, in contrast to their own attitudes, has been identified, and possible reasons for this discordance discussed. As sexual activity among teenagers is becoming more prevalent, comprehensive and early sex education school programs should be encouraged. (Am. J. Public Health 68:1083-1089, 1978.)
Throughout the world pregnancy and childbearing are occurring at younger ages, and adolescents are entering the cycle of human reproduction without adequate preparation.1-5 Only a few comprehensive reports on sexual knowledge/attitudes/practice (KAP) in adolescents have been published, and those that have appeared were usually based on relatively small samples, some comprising less than 500 individuals.6-13 Israel is geographically and culturally in a mid-position between the developed and the developing countries; in addition its population is of very mixed ethnic origin. The sexual KAP of adolescents in this country should therefore be of special interest. The present study was undertaken under the auspices of the Center of Demography in the Prime Minister's Office. In addition to its general interest, study results were to be used in the construction of a sex education curriculum in Israeli schools. The full results were published in the form of a booklet in 1974.14 This article is an abbreviated version of
the original report, giving the main highlights thought to be of interest to health workers outside Israel.
Address reprint requests to Dr. M. Lancet, Head, Department of Obstetrics and Gynecology, Kaplan Hospital, Rehovot, Israel. Dr. Lancet is also associate clinical professor of OB/GYN, Hadassah-Hebrew University Medical School; Dr. Modan is head, Department of Clinical Epidemiology, Sheba Medical Center, Tel-Hashomer, and professor of epidemiology, Tel-Aviv University School of Medicine; Dr. Kavenaki is senior teacher, Department of Psychology, Tel-Aviv University; Dr. Antonovski is senior lecturer in psychology, Ben Gurion University School of Life Sciences, BeerSheba; and I. Shoham is research assistant, the Israel Institute of Applied Social Research, Jerusalem. This paper, submitted to the Journal October 17, 1977, was revised and accepted for publication May 25, 1978.
AJPH November 1978, Vol. 68, No. 11
Methods Permission to conduct the study was obtained from the Ministry of Education, through a letter of introduction to the school principals (headmasters). Schools designated as religious had to be excluded by the request of the Ministry, but as they form not more than 13.1 percent of all the secondary schools, our results should not be too heavily biased because of this exclusion. The youngsters were nevertheless categorized as religious, traditional, or unobservant according to the replies given to relevant questions in the questionnaire.* A stratified sample of 50 secondary schools was drawn from the complete list of all schools in Israel (excluding the religious). Type of school and type of settlement** were considered as stratification criteria. There are four main types of non-religious schools in Israel: regular, vocational, agricultural (boarding), and the schools in the cooperative settlements called "kibbutzim". Owing to the mixed origin of the Israeli Jewish population, three categories of parental origin *"Religious" was defined as regular synagogue attendance and observation of most or all Mosaic laws; "traditional" was defined as sporadic synagogue attendance and observation of the main Mosaic laws; the remainder were considered "unobservant". **All types of settlements were included, namely large urban centers, medium and small towns, subdivided into old and new ones (established before or after the founding of the State in 1948) and rural settlements, again subdivided into old and new ones; the kibbutzim were considered a separate category. 1 083
LANCET. ET AL. TABLE 1-The Study Sample by Age and Sex Age
(years)
Male
Female
Total
14-15
1,459 1,228 2,687
1,360 1,363 2,723
2,819 2,591
16.17 TOTAL
5,410
were considered: Israeli born, western and eastern (North Africa and the Middle East). As the sample is not a proportional random one, it had to be weighted in order to get an unbiased estimate of the different parameters of the student population of the country. As a result of the method of sampling described, we believe that the students questioned represent the entire Israeli high school student population, with the noted exception of students attending the religious schools. After consent of the headmaster had been received, an hour during the regular teaching time was designated for completing a self-administered written questionnaire. In each school included in the sample, four classes were chosen randomly, one for each grade (in many schools there are several parallel classes for each grade). The students were in their usual room and no teachers were present when the questionnaire was completed. A male and female member of our field staff distributed the questionnaires and explained the purpose and method of the study. These staff members remained in the room and answered any questions or problems raised by the subjects. The mean time taken to answer the questionnaire was about 35 minutes. Anonymity and secrecy of the answers were assured. Any student who did not want to answer the questionnaire could leave. None did. During the coding, only 25 questionnaires had to be eliminated due to incompleteness or irrelevant answers. Parental acceptance of the study was not specifically requested by the investigators who left this issue to the judgment of the headmasters. No objections from the parents were voiced either before or after the administration of the
questionnaires. The questionnaire covered a wide range of topics in addition to sexual knowledge, attitudes and behavior, including peer-relationships, parent-adolescent relationships, and attitudes towards sex education in the schools. It consisted mainly of precoded questions, but a number of the sex information questions were open-ended and coded afterwards. Data were analyzed by sex and age (14-15 and 16-17) within the four school types and according to ethnic origin and degree of religious observance.
Material The full sample consisted of 5,410 Jewish youngsters, almost equally divided between the sexes and the two age groups (Table 1). A small group of respondents (212) that were not attending the four types of schools mentioned was 1 084
excluded from in the analysis, leaving 5,198. The distribution by types of schools is shown in Table 2. More vocational and agricultural school students were of oriental origin and religious (not shown in Table). All agricultural schools were boarding schools and most were co-educational. The distribution according to the origin of the parents is shown in Table 3. To simplify matters, this parameter was analyzed only for those pupils both of whose parents were of the same origin; these constituted over 80 percent of the sample in each age-sex group. Table 4 shows the distribution of the sample according to the three religious groups.
Results Knowledge Students were asked about their knowledge of anatomy and physiology, contraception, signs of pregnancy, venereal diseases, and sexual deviations. The overall level of knowledge was very low. For questions on anatomy and physiology, the highest average score of any group analyzed was 1.9 out of a maximum obtainable score of 7. Although contraception knowledge scores were better, with at least one method known by 90 percent of the students, the best group average score was 2.6 out of a maximum of 5. The percentage of those who knew how VD was contracted ranged between 21 percent and 42 percent. Boys' knowledge was better than girls', older students were better informed than the younger ones (as expected) and kibbutz and regular school students, both male and female, fared better than students in other schools. A significant positive correlation was found between the degree of education of fathers and the knowledge scores of their children. Main sources of information about six are listed in Table 5. Literature ranked first and friends second among youngsters age 16-17; whereas friends ranked first and literature second among the 15-16 year olds. Most of the youngsters have received some sex information at school, but ranked it below most other sources. Mothers were important sources of information only for girls. Heterosexual Behavior Sexual activity was divided into the following six stages:6 going steady, kissing, petting over clothes, petting under clothes, genital stimulation, and actual intercourse. As TABLE 2-Study Group by Sex and Type of School Total
Type of High School
Males
Females
N
%
Regular Vocational
832 1,308
1,425 729
2,257 2,037 418 486 5,198
43.4 39.2 8.0 9.3 100.0
Agricultural (boarding) Kibbutz* TOTAL
244
174
228 2,612
258 2,586
*Colective settlement AJPH November 1978, Vol. 68, No. 11
SEXUAL KAP IN ISRAEL TABLE 3-Study Group Distribution According to Parental Origin (by Sex and Age) Females
Males
Israeli Westem Eastem Mixed parentage*
TABLE 4-Study Group Distribution According to Religious Observance (by age and sex) Females Males
Age
Age
Age
Age
14-15
16-17
14-15
18-17
14-15
16-17
14-15
16-17
(N: 1,440)
(N: 1,209)
(N: 1,351)
(N: 1,350)
(N: 1,440)
(N: 1,209)
(N: 1,351)
(N: 1,352)
9.0 35.2 39.0 16.8
8.7 42.1 33.3 14.9
9.7 33.8 41.7 14.9
7.8 44.1 32.0 16.1
14.8 37.7 47.5 100.0
8.0 36.5 55.5 100.0
9.8 28.5 61.7 100.0
7.2 25.6 67.2 100.0
Age
Religious Traditional Non-observant TOTAL
Age
Age
Age
*In the analysis, the group of mixed parentage was not included
expected, activity was reported more often among boys and increased with age in both sexes (Table 6). With the exception of younger boys, the activity formed a continuous Guttman scale in all age and sex groups. Table 7 displays the proportion of students who reported ever having engaged in sexual intercourse according to various subject characteristics. Subjects of second Israeli generation, boys in agricultural schools and girls in kibbutzim schools reported highest frequency of activity while girls of North African and Middle-Eastern parentage or with a religious background reported the least frequency. There is far less discrepancy by sex among kibbutzim students than among other groups analyzed. Table 8 presents responses of 16 and 17 year olds to the question of age at first intercourse, demonstrating an obvious time lag among girls. Ninety-five per cent of the older girls and 67 per cent of the younger ones who reported having engaged in sexual intercourse had intercourse for the first time with a steady partner, while the respective percentages for boys were 40 per cent and 44 per cent (not shown in table). Fourteen per cent of the boys reported an experience with a prostitute, a rate that was highest in agricultural schools. More than 80 per cent of all sexually active girls reported intercourse with only one partner, while only 40 per cent of the boys so reported. The primary reasons for first intercourse are given in Table 9. A pre-coded list had to be checked by the respondents, and more than one reason could be given. Some differences between the two sexes are demonstrated. Love and sexual drive were important for all, and the latter assumed greater prominence as age increased. More boys than girls claim to have been urged into having coitus by the partner. The youngsters were also asked about their feelings after their first intercourse and more boys than girls had positive feelings, e.g., satisfaction, happiness or pride, while negative reactions, e.g., shame, fear, guilt, revulsion and confusion were more prevalent among girls. Contraception Only one-third of the sexually active girls and one-half of the sexually active boys used contraceptives. (This difference is highly significant, p < 0.01). When asked why no contraceptive measures had been taken, the most prevalent AMPH November 1978, Vol. 68, No. 11
answers were "I did not think of it" or "I was not prepared-it just happened." However, in view of the extremely low rate of pregnancies in the group as a whole, it seems likely that withdrawal (the most prevalent contraceptive measure in Israel)"5 was not reported as a contraceptive method, but considered "natural." Among those who had engaged in intercourse, pregnancies were reported by 6.7 per cent of the younger girls and 2.6 per cent of the 16-17 years olds, all ending in an induced abortion. The lower incidence in the more active group of older girls may reflect better contraceptive protection or the fact that more older pregnant girls have left school. Pregnancy occurred before the age of 16 in more than 75 per cent of all the girls who became pregnant. There were no significant differences either by ethnic origin or by degree of religious observance. Masturbation Table 10 presents the frequency of masturbation by age and sex. The percentage is higher in boys and in the older age groups. There was no significant difference in coital activity between those reporting masturbation and those not
reporting it. Attitudes
Questions on attitudes dealt mainly with premarital sex and feelings about the partner's sexual behavior. Girls and younger students had a more conservative attitude than boys and older students. Seventeen per cent of the 14-15 year old boys and 10 per cent of the older boys thought that intercourse should not be engaged in before marriage, while the respective percentages for girls were 50 per cent and 33 per cent. Those with the more conservative attitude stressed the importance of sex with a steady partner only, with the exception of kibbutz students. A double standard was very evident among all sex/age groups, but more so among the females. Students categorized as religious were the most conservative, with 90 per cent of the religious females holding the view that a girl should remain a virgin until marriage. Students of oriental parentage were more conservative than those of Israeli or western parentage. However, a great deal of discordance was found: e.g., many of those who approved of premarital intercourse had abstained (especially among 1085
LANCET, ET AL. TABLE 5-Main Sources of Sexual Information by Age and Sex
Age 14-15
Girls
Boys Age
Age
Age
Age
14-15
16-17
14-15
16-17
Source
%
%
%
%
Friends Books Mother Doctor (specialist) Pamphlets Teacher Father Films
44
39 52 7 14 13 8 6 9
37 30 29 12 8 5 4 7
41 38 21 15 7 4 3 9
40 6 5 15 5 6 13
TABLE 6-Type of Sexual Activity by Age and Sex
boys), and, among the sexually active girls, 46 per cent of the sexually active 14-15 year old girls, and 25 per cent of the 1617 year olds, thought that virginity should be maintained until marriage.
Comment The level of sexual knowledge among all adolescent groups leaves very much to be desired, and the situation in this respect is no better in Israel than that reported from other countries 1 6 7, 11. The most logical place for formal sex information is the school, but it still does not play its role well, and there is much room for improvement. Israeli high school students apparently start their sexual activity at a later age than adolescents in most other countries for which reports exist.6' 7. 8, 10, 11. 16 As expected, boys were consistently more active sexually than girls, but as only 14 per cent of the boys resorted to prostitutes, it is conceivable that many of their female partners were not in-
Age 16-17
Boys %
Girls %
Boys %
Girls
Type of acivity
Going steady Kissing Petting over clothes Petting under clothes Genital stimulation Sexual intercourse
73.5 68.8 65.6 41.6 30.8 34.6
71.1 57.6 38.0 16.3 8.0 6.5
86.2 80.2 79.8 63.5 46.9 46.4
88.6 78.9 68.3 46.1 29.2 16.0
%
cluded in our sample because they were outside the schools investigated. The possibility that some of the girls have had more than one partner cannot be ruled out. Low frequency of contraceptive use, despite apparent knowledge seems typical for this age group. A number of explanations have been suggested for this inconsistency.2' 3, 11,13,16-19 The most logical seems to be that "it just happened", i.e., the intercourse was not premeditated. Lack of available specific contraceptive means and advice may also play an important role.20 Despite the fact that orthodox religious schools were not included in our sample, a lower activity among those defining themselves as "religious" or "traditional" emerged in line with other reports.9 This relationship was, in part, an expression of the fact that the religious groups included more students of North African and Middle Eastern parentage. Residents of collective settlements (kibbutzim) of both sexes, and irrespective of age, emerged as more active sexually and with more liberal attitudes. They were also better contraceptors and the "double standard" was not prevalent
TABLE 7-Percentage* Having Experienced Sexual Intercourse by Age and Sex According to Parental Origin, Religious Category, and Type of School Girls Boys
Parental Origin1 Israeli Western North Africa & Middle East Religious Category2 Religious Traditional Non-observant Type of School3 Regular Vocational Agricultural (boarding) Kibbutz
Age 14-15
Age 16-17
Age 14-15
Age 16-17
42.0 30.9 36.0
45.7 42.4 46.9
8.5 7.7
5.0
29.8 20.0 9.3
28.0 35.1 33.1
38.2 42.1 39.9
3.4 4.6 5.7
6.1 13.9 18.2
23.6 35.2 49.3 26.1
39.6 42.0 64.8 42.2
4.6 5.7 9.0 18.0
15.9 11.9 7.9 40.3
*Percentage of total sample of each group 'P < 0.05 for girls 2p < 0.05 for girls 3AJI differences highly significant (P < 0.001)
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AJPH November 1978, Vol. 68, No. 11
SEXUAL KAP IN ISRAEL TABLE B-Age of First Intercourse by Sex, among 16-17 year olds
TABLE 9-Reasons for First Intercourse (expressed as percentage of respondents checking off given reason) Girls
Boys Boys
Girls
Reason Age at First Intercourse
14 or younger 15 16 17 Not answered TOTAL
Age 16-17 (N = 570)
17.2 22.4 36.3 20.6 3.5 100.0
Age 14-15
Age 16-17
Age 14-15
Age 16-17
39.0 62.4 56.4 54.5 21.5 18.9
49.9 64.6 80.8 43.3 23.7 19.6
22.1 81.5 38.7 27.0 36.4 2.7
56.1 91.6 59.3 30.1 23.1 3.7
Age 16-17 (N = 218)
4.8 15.9 29.5 37.5 12.3 100.0
Curiosity Love Sexual drive Urged by partner Unpremeditated Conformity
Boys start earlier than girls: P < 0.001
REFERENCES among them. Although kibbutzim are not novel in Israel, they still serve as a sort of human laboratory, especially in educational matters. Children are raised in communal homes, which in many of the settlements are completely coeducational, although the link with the parents is also very strong. In this sense, a kibbutz is not just a type of school, but also a mode of life. The small subgroup of young girls of non-European descent who have been sexually active in spite of their own basic attitudes deserves special attention. It seems clear that at least in the sexual area, situational and motivational factors may lead to behavior incompatible with expressed attitude. The disapproving attitude may operate to lessen the frequency of occurrence of the behavior by keeping the individual out of situations which may induce or encourage the behavior. Once the individual gets into these situations, however, the disapproving attitude may not prevent the behavior from occurring. It is also possible that the more conservative attitudes expressed by this active group serve as lip service to the norms held by their families. Sexual activity among teenagers appears to be on the increase; with their lack of factual information and inadequate contraceptive practice, the number of pregnancies is growing rapidly. In order to check what has been called "the epidemic of teenage pregnancies'"21 sex information and education must become available at a relatively early age, as part of the curriculum of all schools.
ACKNOWLEDGMENTS
This study was made possible by a generous grant from the Center of Demography at the Israeli Prime Minister's Office, and financial aid from Messrs. Teva, Rafa and Ikapharm.
TABLE 10-Masturbation Activity by Age and Sex Age Group
Boys
Girls
14-15 16-17
59.7 79.7
12.3 20.6
AJPH November 1978, Vol. 68, No. 11
1. Conwell EB and Jacobson L: Pregnancy, the teenager and sex education, Am J Public Health, 61:1840-1845, 1971. 2. Cole JB, Beighton FCL and Jones IH: Contraceptive practice and unplanned pregnancy among single university students, Brit Med J 4:217-219, 1975. 3. Kantner JF and Zelnik M: Contraception and pregnancy experience of young unmarried women in the United States, Fam. Plan. Persp. 5:21, 1973. 4. Ruzicka LT: Non-marital pregnancies in Australia since 1947, J. Biosoc. Sci. 7:113-132, 1975. 5. Hunt WB: Adolescent fertility-risk and consequences, Population Reports, Ser. J., No. 10, July 1976. 6. Schofield M: The Sexual Behavior of Young People. Penguin Books, Hammondsworth, 1968. 7. Sorenson RC: Adolescent Sexuality in Contemporary America. World Publishing, New York, 1973. 8. Kantner JF and Zelnik M: Sexual experience of young unmarried women in the United States, Fam Plan Persp 4:(No. 4), 9, 1972. 9. Osofsky HJ: Adolescent sexual behavior, Clin Obstet Gynecol, 14:393, 1971 10. Packard V: The Sexual Wilderness. Longmans, London, 1968. 11. Finkel ML and Finkel DJ: Sexual and contraceptive knowledge, attitudes and behaviour of male adolescents. Fam Plan Persp 7(6):256-260, 1975. 12. Lancet M, Modan B and Kavenaki S: Sex behaviour and knowledge in young Israelis, 1st Internat. Sympos. Sex Educ., Tel Aviv, 1972. 13. Munz D, Carson S, Brock B, et al: Contraceptive knowledge and practice among undergraduates at a Canadian university. Am J Obstet Gynecol 124:499-505, 1976. 14. Lancet M, Antonovsky H, Modan B, et al: The behaviour, attitudes and knowledge on sex by Israeli youth. Public. No. HA/ 441/H, The Israel Institute for Applied Social Research, Jerusalem, 1974 (Hebrew). 15. Bacchi R, Mattras J, Toaff R, and Ayalon D: Birth rate and contraception among the women of Tel-Aviv-Yaffo. (Hebrew) The Dpt. of Statistics, Hebrew University, Jerusalem (1961). 16. Apkom CA and Apkom KL: Prior sexual behaviour of teenagers attending RAP sessions for the first time. Fam Plan Persp 8:203206, 1976. 17. Windhom 0: Medical and social aspects of adolescent pregnancies, Acta Obstet Gynaec Scand 53:347-353, 1974. 18. Goldsmith S, Galerielson MO, Galerielson J et al: Teenagers, sex and contraception. Fam Plann Perspect, 4:32, 1972. 19. McCance C and Hall DJ: Sexual behaviour and contraceptive practice in unmarried female undergraduates. Brit Med J 2:694700, 1972. 20. Kinch RA and Kruger E: Some sociomedical aspects on the adolescent pregnancy. Int J Gynec Obstet 8:480-486, 1970. 21. 11 Million Teenagers, The Allan Guttmacher Institute, Planned Parenthood Federation of America, New York, 1976.
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