Issues in Mental Health Nursing, 35:509–516, 2014 Copyright © 2014 Informa Healthcare USA, Inc. ISSN: 0161-2840 print / 1096-4673 online DOI: 10.3109/01612840.2014.888602
Toward an Understanding of the Context of Anal Sex Behavior in Ethnic Minority Adolescent Women Jane Dimmitt Champion, PhD, DNP, FNP, AH-PMH-CNS, FAANP, FAAN The University of Texas at Austin, School of Nursing, Austin, Texas, USA
Carol F. Roye, EdD, RN, CPNP, FAAN Hunter College, City University of New York, School of Nursing, New York, New York, USA
Understanding the context of anal sex behavior among ethnic minority adolescent women has public health implications for behavioral sexual health promotion and risk reduction interventions. African-American (n = 94) and Mexican-American (n = 465) women (14–18 years of age) enrolled in a clinical trial completed semi-structured interviews to assess psychosocial and situational factors and relationships to sexual risk behavior, substance use, sexually transmitted infection/HIV acquisition, and violence. Bivariate analyses with comparisons by anal sex experiences identified differences by ethnicity and higher self-reported histories of sexual risk behaviors, substance use, violence, and stressful psychosocial and situational factors among adolescent women experiencing anal sex. Predictors of anal sex identified through logistic regression included Mexican-American ethnicity, ecstasy use, methamphetamine use, childhood sexual molestation, oral sex, and sex with friends for benefits.
The purpose of this article is to describe the context of sexual behavior among African and Mexican-American adolescent women with a history of sexually transmitted infection (STI), high risk sexual behavior, or violence, using comparisons by self-reported experience of anal sex. Conceptualization of sexual behavior within these sexual partner relationships is important for the modification of evidence-based, behavioral, sexual risk reduction interventions. The information from this study can be used with these interventions to enhance efficacy for the prevention of violence, substance use, unintended pregnancy, and STIs, including HIV, among ethnic minority adolescent women.
BACKGROUND HIV poses a substantial risk to the health of women, who represent more than 20% of new HIV infections and 25% of all infections in the US. Black or Hispanic women account for more
Address correspondence to Jane Dimmitt Champion, The University of Texas at Austin, School of Nursing, 1710 Red River St., Austin, TX 78701 USA. E-mail: [email protected]
than 80% of HIV-infected women (Centers for Disease Control and Prevention [CDC], 2013) The rate of new HIV infections among black women in 2010 was 20 times that of non-Hispanic white women. Hispanic women are becoming infected at nearly four times the rate of non-Hispanic white women (CDC, 2013). The majority of new infections occur among young women (CDC, 2013). Young women in particular are at risk; in 2006, 34% of adolescents aged 13 to 19 years who were diagnosed with HIV infection were female, compared to 26% of adults aged 25 and older (CDC, 2008). The CDC has found that the leading cause of disease transmission in women is “heterosexual contact,” accounting for of 80% of new cases (CDC, 2008, 2009a, 2009b). The CDC defines “heterosexual contact” as “heterosexual contact with a person known to have or be at high risk for HIV” (CDC 2009a; Roye, Krauss & Silverman, 2010). However, we do not know the specific unprotected sexual risk behaviors (i.e., vaginal, oral/penile, and/or anal intercourse) causing disease transmission in women (CDC 2009a; Roye, Krauss & Silverman, 2010). The CDC (2013) has recently indicated that unprotected anal sex is riskier than vaginal sex. There are variable risks associated with different sexual behaviors (Powers, Poole, Pettifor, & Cohen, 2008). For example, receptive anal intercourse has been estimated to be 5 to 20 times riskier than receptive vaginal intercourse (Boily et al., 2009) because of biological characteristics of intestinal tissue (Poles, Elliot, Taing, Anton, & Chen, 2001). In one study of in vitro viral replication, researchers inundated punch biopsies of healthy vaginal and cervical tissue with HIV for 6–24 hours and found that the virus was unable to infect it. However, healthy intestinal tissue was rapidly infected when subjected to the same treatment, modeling the level of immune barrier protection found in tissue lining the anus/rectum (Poles et al., 2001). Researchers who undertook a systematic review and metaanalysis of studies of HIV-transmission to evaluate the commonly cited assertion that heterosexual infectivity of HIV1 is a fixed value at approximately one transmission per 1,000 contacts (Powers et al., 2008) found that heterosexual
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transmission is more efficient during penile-anal than penilevaginal intercourse. If the index case is in early stage or late stage infection—heterosexual infectivity can exceed one transmission per ten contacts for penile-vaginal contact and one transmission per three contacts for penile-anal contact; the biggest transmission risk, one transmission event for every 3.1 contacts, was found for penile-anal sex between late-stage male index cases and susceptible women. Similarly, a meta-analysis of observational studies of HIVtransmission per heterosexual contact found that receptive anal intercourse carried a transmission risk that is more than twice as high (1.7% per act; CI = 0.3–8.9) as the overall male-to-female transmission rate (.08% per act; CI = 0.06–0.11) (Boily et al., 2009). Moreover, couples are much less likely to use condoms for anal intercourse than for vaginal intercourse (Gorbach, 2009; Halperin, 1999; Leichliter, 2008; Roye, Krauss, & Silverman, 2010). Other researchers (Kalichman, Simbayi, Cain, & Jooste, 2009) using data from South Africa similarly demonstrated that in sero-discordant couples, the estimated risk of HIV acquisition for females who only engage in vaginal intercourse is 0.2% but the risk increases by 7.5 times, to 1.5%, if they also engage in anal intercourse, with 89% of their risk attributable to anal intercourse. It is a great concern therefore that heterosexual anal intercourse is becoming a relatively common behavior among adolescents. It is a behavior that is practiced by 16–35% of teenage couples (Carter et al., 2010; Hensel, Fortenberry, & Orr, 2010; Koblin et al., 2009; Roye, Krauss, & Silverman, 2010). Although homosexuality and bisexuality among women has not received much attention from HIV researchers, there is some evidence that having both male and female sexual partners may be associated with HIV-risk for women. There is some evidence that women who have sex with women may be at elevated risk for HIV (Magnus et al., 2009). A study of STI clinic patients found that a higher proportion of women who have sex with women were HIV positive than women who exclusively had sex with men (Bevier, Chiasson, Heffernan, & Castro, 1995). A Washington, DC, study of a non-clinic-based sample found that compared to HIV-positive men, HIV-positive women were more likely to report being bisexual (Magnus et al., 2009). In fact, women who have sex with women are more likely to have vaginal and anal sex with men they know to be bisexual, and are less likely than other women to use condoms (Bevier et al., 1995; Richardson, 2000). Although this topic has not been thoroughly studied, researchers have thought about heterosexual anal intercourse as a way to either prevent pregnancy or the loss of virginity (Halperin, 1999). However, a study of adolescent women who were using hormonal contraception, found that 35% reported engaging in anal intercourse and less than one-third (29.4%) reported using a condom during their last act of anal intercourse (Roye, Krauss, & Silverman, 2010). These adolescents were less likely to use condoms for anal intercourse than for vaginal intercourse.
This approach to the study of heterosexual anal intercourse, as a way to prevent an unwanted outcome, does not adequately address the context of the behavior. While half of the respondents in a recent qualitative study of adolescent heterosexual anal intercourse described it as painful, one described it as feeling good and painful at the same time. Several spoke about the numbing effect of alcohol, which allowed them to enjoy the experience (Roye, Tolman, & Snowden, 2013). Although heterosexual anal intercourse has been discussed as a behavior that males seek out (Halperin, 1999), several young women reportedly initiated the behavior (Roye, Tolman, & Snowden, 2013). These findings emphasize the importance of describing the context of sexual behavior among black and Hispanic adolescent women. Conceptualization of anal sexual behavior within these sexual partner relationships is important and may provide information for modification of behavioral, sexual risk reduction interventions to enhance effectiveness of STI/HIV prevention efforts (CDC, 2013). METHODS The study was conducted in collaboration with the university and the metropolitan health district. Appropriate approval was obtained from both the university and metropolitan health district Institutional Review Boards for the protection of human subjects. African-American and Mexican young women were chosen as the study population because they account for more than 80% of HIV infected women (CDC, 2013). Africanand Mexican-American adolescent women (ages 14–18 years), with a history of STI or sexual, physical, or psychological violence, and who accessed sexual health care services from the metropolitan public health clinics were referred by metropolitan public health care providers for potential participation. Eligible, English speaking (to maximize homogeneity across ethnic groups), adolescent women (14–18 years old), with valid contact information were contacted and offered enrollment by study personnel between July 2006 and February 2008. Informed consent or assent as appropriate was obtained and then followed by a semi-structured interview at the study’s start. Research assistants administered the self-report semi-structured interview by reading the questions to each participant who then responded. Questions solicited information about the participant’s demographics and the psychosocial and situational factors associated with sexual risk behavior, including violence, STI, and substance use. Theoretical Framework The framework for the study (AIDS Risk Reduction Model; Catania, Kegeles, & Coates, 1990) encompasses social psychological theories, including the Health Belief Model, self-efficacy theory, decision-making models, and diffusion theory (Fishbein & Ajzen, 1975; Fishbein et al., 1992). This model was utilized for the research design and questionnaire development (Shain
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et al., 1999, 2002, 2004). The model has been found to be effective for developing interventions for reducing sexual risk. The model conceptualizes risk recognition, commitment to risk reduction, and the processes for identification and enactment of solutions. Both knowledge and social support are recognized as crucial for movement from one stage of risk reduction to the next. Extensive ethnographic fieldwork was undertaken to modify the model to focus on African- and Mexican-American adolescent women (Shain et al., 2004). This fieldwork portrayed risk perceptions, values and beliefs, knowledge and concerns regarding STI/HIV, sexual behaviors, sexual communication, male-female relationships, and approaches to stimulate commitment to behavior change. Insights were acquired to promote risk recognition, impart social support, inspire change, and isolate barriers.
Instruments Questions were formulated based upon these results to ascertain the configuration of psychosocial and situational factors associated with sexual partner relationships, high sexual risk behavior, and related factors that contribute to the context of substance use, STI/HIV, and violence. Questions concerning demographic (e.g., income and education), psychosocial (e.g., attitudes toward various aspects of sexual behavior), and situational (e.g., pregnancy status, substance use, violence history) factors directly or indirectly influencing sexual behavior (e.g., number and type of partners and types of sexual activity) were created. These questions ascertained which explanatory factors effect sexual behavior variables. Evidence deduces that social support has a protective effect against the adverse effects stress has on health outcomes among a variety of populations (Beitchman et al., 1992). Stressful life events, without benefit of social support, may impact susceptibility to substance use, unintended pregnancy, HIV/STI, and violence and are, therefore, measured. The SCL-R90 (Derogatis, 1994) was selected to measure psychological distress because it has been used extensively among minority groups and has good reliability and validity. A Cronbach’s alpha coefficient of .98 was obtained in this study. These variables were chosen because of their linkage to risk behavior as delineated in the AIDS Risk Reduction Model and as ascertained through prior modification of the AIDS Risk Reduction Model for use with African- and Mexican-American women, including adolescents (Champion & Collins, 2012; Shain et al., 1999, 2004). Overall, the questions were conceived largely through the principal investigator’s prior research; some questions were modified from established investigators. Assessment for the experience of anal sex was determined by the question, “Have you ever had anal sex?” The response to this question is either “yes” or “no.” Substance use was quantified by a sequence of questions on “ever use” and current use of drugs (cocaine, crack, heroin, “uppers,” “downers,” and hallucinogens). Alcohol use was quantified by a sequence of
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questions on ever or current use of wine, beer, and hard liquor; concurrent use of alcohol and substance also was assessed. Condom use was quantified as “ever and any condom use” for various types of sexual acts. Contraception use was quantified via questioning regarding “ever use” of various methods. Violence experience was quantified through questions that screened for physical, sexual, and psychological violence during childhood and adolescence. The Abuse Screen was created for use with this particular population and includes ten items (Champion & Collins, 2012). The sexual violence component of this screen has six questions: “Has anyone ever . . . (a) made you have sex when you didn’t want to, (b) made you afraid to say no to sex, (c) knowingly hurt you during sex, (d) made you have sex without a condom, (e) had sex with you when you were high or out of control, and (f) forced you to do things you didn’t want to by threatening to hurt you? The physical violence component has two questions: “Has anyone ever . . . (a) used a gun, knife, or other weapon against you, and (b) hit you, held you down, or tried to choke you?” The psychological violence component has two questions: “Has anyone ever . . . (a) constantly criticized you and put you down, and (b) acted with extreme jealousy?” Responses are coded as “yes” (1) or “no” (0) with a higher number of responses “yes” responses indicating more experiences and a higher level of violence. Protocols were followed to ensure uniformity in training and inter-rater reliability. Interviewers received extensive coaching by first observing interviews, and then being directly observed over a one-month interval. For months afterward, the principal investigator randomly selected interviews to appraise for completeness and internal consistency. Interviewers were gendermatched and were selected because they showed compassion concerning low-income minorities; were courteous and warm; and were at ease with questions about sexuality, violence, substance use, and STI/HIV. In order to promote internal consistency of data, the interviewers were trained to provide consistent clarification of questions when asked by participants. Statistical Analysis The statistical analysis examined the data carefully to determine relationships among variables before progressing to more complex levels of multivariable statistical models to assess effects. Statistical analyses included contingency tables, t-tests, and chi-square analyses to depict the context of sexual partner relationships and contrast sexual risk behaviors by experience of anal sex. Logistic regression was conducted subsequently to describe whether sexual risk behavior predicted anal sex among these adolescent women. RESULTS A total of 559 participants were in the study and responded to the question concerning experience of anal sex. Participants reported no anal sex (78.2%) or ever having had anal sex (21.8%) in a previous relationship.
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Comparisons of Characteristics of Adolescent Women by Experience of Anal Sex Comparisons of characteristics of women by their experience of anal sex are provided in Table 1. Socio-demographically, there was a difference by ethnicity. Mexican-American women reported anal sex significantly more often than African-American women did within relationships. Overall, women describing anal sex within relationships were significantly older. They also reported having ever been arrested more frequently and had run away from home more often than women who did not report having anal sex. More women who did not report anal sex were in school and had had to repeat a grade. The majority of all women had previous HIV testing, reported ever used condoms, and reported having sex without condoms. Significantly more women reporting anal sex had a history of STI, including HPV and Chlamydia. Over 98% of all women had ever used a form of birth control. Differences in birth control use were identified, including a greater use of withdrawal by women reporting anal sex. Other comparisons indicated that more women who did not report anal sex had been pregnant in the past (46.9% no anal sex experience vs. 38.5% anal sex experience); however, equivalent number of both groups were currently pregnant with the majority of pregnancies being unintended for both groups of women (89.8% no anal sex experience vs. 84.8% anal sex experience). Women reporting anal sex experienced significantly more violence overall (94.3% vs. 85.1%), with higher levels of violence (8.37 vs. 6.38) overall and higher levels of sexual, physical, and emotional violence (Table 1). This violence included significantly more reports of sexual molestation, forced sex, being afraid to say no to sex, being hurt during sex, and having sex when high and out of control. Psychological distress as measured by the SCL-R-90 identified women reporting anal sex as experiencing higher levels of distress than others (Table 1). Comparison of Sexual Risk Behavior of Adolescent Women by Experience of Anal Sex Comparisons of sexual risk behaviors of women by their experience of anal sex are described in Table 2. Women who reported anal sex also reported more often being bisexual. They had experienced significantly more oral sex, group sex, sex with women, sex with a bisexual man, sex with friends for benefits, sex to pay back favors or receive money, sex with IV drug users, or use of sex toys. No differences were noted between groups concerning age of either themselves or partners at their first act of sex; however, significantly fewer women reporting having had anal sex used a condom the first time they had sex. Significantly higher numbers of partners also were identified for women who reported having anal sex. These women also reported significantly more and higher levels of use of alcohol, cigarettes, and drugs, including marijuana, cocaine, ecstasy, heroin, and benzodiazepine than women who did not report having anal sex (Table 2).
Adolescent Women Experiencing Anal Sex Women reported their age at their first experience of anal sex as 15.85 years (Mean; SD ± 1.25 years) and their partner age as 18.43 (Mean; SD ± 2.78) years. Almost 74% of the participants (73.6%) reported only one anal sex partner in their lifetime, 79.5% had experienced anal sex within the past year, and 61.2% had anal sex within the past six months. Only 38% of the women reported ever using a condom for anal sex. When asked about their most recent partner, 36.7% indicated that they had anal sex within the past three months; 40.8% of those indicated they used a condom. Women provided the following responses regarding reasons for having anal sex: (1) Anal sex is pleasing to me (4.1%), (2) Anal sex is pleasing to my partner (24.0%), (3) Just trying or experimenting with anal sex (75.2%), (4) Cannot get pregnant with anal sex (.8%), and (5) Had anal sex because of menstruation (2.5%). When asked whether they could stop having anal sex, 86.0% indicated that they could. Women reporting having anal sex indicated that their most recent sex partner was a steady partner (68.6%), which is approximately the same as those who did not report having anal sex (63.8%). Of women who described their most recent sex partner as steady, more women who reported having anal sex were still in the relationship (73.3% vs. 60.0%, p = .036) and more women who did not report having anal sex had broken up with the partner (52.8% vs. 43.3%, p = .021). Of women reporting their most recent sex partner as steady and who also indicated that they had broken up during the relationship, more women who reported having anal sex indicated that, while broken up, they had sex with other persons (39.1% vs. 17.98%, p = .001) and less often indicated they could stop having sex with partners who were having sex with others (64.7% vs. 76.2%, p = .036). Among women who reported that they thought it was okay to have a man on the side, as a sexual partner in addition to their primary sexual partner (n = 252), more women who reported having anal sex indicated this was okay. Their reasons were: (1) It provides more variety/sex (43.9% anal sex vs. 18.3% no anal sex, p = 0.000), (2) He fools around so why shouldn’t I? (25.8% anal sex vs. 15.1% no anal sex, p = .051) and (3) I get high and lose control (24.2% anal sex vs. 14.5% no anal sex, p = .056). Equivalently these women reported having a man on the side was okay because they hadn’t found the right man yet (83.9% no anal sex vs. 80.3% anal sex). Logistic Regression of Sexual Risk Behavior Predicting Anal Sex Sexual risk behaviors, violence, and substance use variables were significantly different in comparisons of participants’ experiences of having anal sex and were included as independent variables in the logistic regression model. Since significantly more Mexican-American than African-American adolescent women reported experiences of having anal sex, ethnicity also was entered into the model. An assessment of the full
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TABLE 1 Comparisons of Characteristics of Adolescent Women by Experience of Anal Sex Variable Sociodemographic Characteristics Ethnicity Mexican-American Black Mean age, years ± SD∗ Ever arrested, convicted, incarcerated, on probation Ever run away Enrolled in school Enrolled in grade supposed to be in Sexual/Reproductive Health History Previous HIV testing Condom use ever Condomless sex ever STI history Pap smear with HPV Chlamydia ever Birth control use ever Condom use for birth control ever Withdrawal use ever Birth control pill use ever DepoProvera use for birth control ever Patch use for birth control ever Ever pregnant Pregnant now Unintended current pregnancy Any Violence (Physical, Sexual, Psychological) Violence composite score Physical abuse Physical violence composite score Sexual violence Sexual violence composite score Psychological violence Psychological violence composite score Forced sex Molested First sex forced Hurt during sex Afraid to say no to sex Sex when high and out of control SCL-R-90
No Anal Sex %∗ n = 437
Anal Sex %∗ n = 122
p 0.004∗∗
75.9 89.4 16.46 ± 1.34∗ 45.5 46.0 66.4 63.4
24.1 10.6 16.76 ± 1.20∗ 53.3 61.5 58.2 47.8
0.017∗∗ 0.130 0.002∗∗ 0.093 0.023∗∗
64.3 90.8 97.9 25.6 4.7 20.6 97.0 95.8 53.9 29.9 22.7 12.0 46.9 19.3 89.8 85.1 6.38 ± 6.37∗ 63.2 2.27 ± 2.56∗ 46.2 1.46 ± 2.36∗ 68.4 2.65 ± 2.64∗ 21.7 18.2 9.8 5.9 9.6 10.1 77.19
69.7 94.3 99.2 36.1 10.6 31.1 99.2 86.7 66.4 26.2 16.4 5.7 38.5 15.0 84.8 94.3 8.37 ± 6.11∗ 82.0 2.79 ± 2.45∗ 71.3 2.24 ± 2.28∗ 82.0 3.65 ± 2.80∗ 37.7 32.6 9.8 13.1 21.3 18.9 111.70
0.270 0.229 0.361 0.023∗∗ 0.040∗∗ 0.015∗∗ 0.176 0.657 0.014∗∗ 0.427 0.134 0.046∗∗ 0.177∗∗ 0.435 0.570 0.008∗∗ 0.000∗∗ 0.000∗∗ 0.045∗∗ 0.000∗∗ 0.000∗∗ 0.003∗∗ 0.000∗∗ 0.000∗∗ 0.000∗∗ 0.999 0.008∗∗ 0.000∗∗ 0.008∗∗ 0.000∗∗
Note. STI = sexually transmitted infection; SCL-R-90 = SCL-R-90 Symptom Checklist ∗ Mean and Standard Deviation, Student t-test as appropriate ∗∗ p < .05
model with all predictors compared to the constant-only model was significant, suggesting that the proposed model adequately predicted anal sex activity. Table 3 indicates the regression coefficients, Wald statistics, and odds ratios for the six indepen-
dent variables found to be predictive of anal sex. All predictors were statistically significant. Results of the Wald statistics suggest those who engaged in sex with friends for benefits (X2 = 22.53, p < .001) and who engaged in oral sex (X2 = 35.748,
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TABLE 2 Comparison of Sexual Risk Behavior among Adolescent Women by Experience of Anal Sex Sexual Risk Behavior
No Anal Sex %∗ n = 354
Anal Sex %∗ n = 192
p
9.4 74.6 4.8 1.6 11.0 25.4 1.4 .7 7.8 5.7 14.00 ± 1.80∗ 16.80 ± 3.14∗ 69.1 3.7 2.56 ± 2.06∗ 5.26 ± 5.79∗ 73.2 2.64 1.90 32.3 78.0 9.8 12.4 11.0 35.9 4.1 66.5
16.4 91.0 17.2 6.6 26.2 55.7 8.2 4.9 19.7 18.0 13.88 ± 1.79∗ 17.20 ± 4.20∗ 49.2 4.1 2.23 ± 1.57∗ 11.00 ± 15.08∗ 85.2 3.49 2.64 54.3 88.5 18.0 13.1 22.1 51.6 7.4 87.7
0.055 0.000∗∗ 0.000∗∗ 0.003∗∗ 0.000∗∗ 0.000∗∗ 0.000∗∗ 0.001∗∗ 0.000∗∗ 0.000∗∗ 0.504 0.251 0.000∗∗ 0.822 0.456 0.000∗∗ 0.006∗∗ 0.000∗∗ 0.000∗∗ 0.000∗∗ 0.010∗∗ 0.0130 0.823 0.001∗∗ 0.002∗∗ 0.138 0.000∗∗
Bisexual Give oral sex Group sex Sex with bisexual man Sex with women Sex with friends with benefits Sex to pay back favors Sex for money Sex with injection drug user Sex toys Age at first sex (years) Age of man at first sex (years) Condom use at first sex < 11 years of age at first sex Number of female sex partners Number of male sex partners Drink alcohol Alcohol/drug composite score Drug use composite score Cocaine Marijuana Heroin Methamphetamine Ecstasy Benzodiazepine Inhalants Smoke cigarettes ∗
Mean and Standard Deviation, Student t-test as appropriate p < .05
∗∗
p < .001) were more likely to engage in anal sex. Adolescent women who reported a history of sexual molestation (X2 = 22.53, p < .001) also were more likely to engage in anal sex activity. Results also show that the likelihood of engaging in anal sex differed according to participants’ previous drug history.
Adolescents reporting methamphetamine use were 2.7 times more likely than non-methamphetamine users to have ever had anal sex (X2 = 7.545, p < .01). Adolescents reporting ecstasy use also were more likely to have ever had anal sex (X2 = 4.870, p < .05).
TABLE 3 Binary Logistic Regression of Sexual Risk Behavior Predicting Anal Sex
Predictor Ethnicity Sex with friends with benefits Give oral sex Sexually molested Methamphetamine use Ecstasy use
B
Wald
Sig
Exp(B) 95% Confidence Interval for Exp (Upper Bound–Lower Bound)
−1.017 −1.149 −2.444 −.563 .999 −.714
6.950 22.530 35.748 5.170 7.545 4.870
0.008 0.000 0.000 0.023 0.006 0.027
.362 (.170–.770) .317 (.197–.510) .087(.039–.193) .570 (.351–.925) 2.716 (1.331–5.539) .490 (.260–.923)
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Limitations Context cannot be comprehensively addressed with a survey. However, survey methodology is a quantitative method that has the capacity to provide descriptive information and can inform modifications to existing interventions. Future studies, however, could include other methodologies, including qualitative inquiry. It must be emphasized that the survey developed for this study is based upon extensive qualitative work, including modification of the theoretical framework as described earlier in-text. This developmental work enhances the contextual description provided in this survey research. DISCUSSION Study results for modifying behavioral interventions for STI/HIV have significant implications for mental health nursing. This study is one of the first to look at anal sex behavior in a population of African-American and Mexican-American adolescent women in the United States. Data on heterosexual anal sex among young women are sparse, and these data augment existing findings on this high risk behavior and are consistent with findings from studies of adolescents. As in other studies that demonstrated higher rates of anal sex among Hispanic than black young women (Carter et al., 2010; Roye, Krauss, & Silverman, 2010), there was a higher rate of anal sex among Mexican-Americans than African-Americans in this study. In this study, the Hispanic population was Mexican-American; in previous studies, the Hispanic population was predominantly from the Dominican Republic. In addition, consistent with previous studies, the young women who reported a history of anal sex were more likely than other young women to have been younger at first vaginal intercourse, to have experienced violence, to report a sexually transmitted infection, and to have been pregnant (Roye, Krauss, & Silverman, 2010). They also were less likely to report condom use at first intercourse. Of interest, there are data from research with adults that suggest that women who have sex with women may be at high risk for HIV (Magnus et al., 2009). In this study, significantly more women who reported sex with women also reported having anal sex. There also was a trend (p = .055) for women who reported being bisexual to report having anal sex. Previous research suggests that bisexual men report a preference for anal sex with their female partners (Izazola-Licea, Gortmaker, de Gruttola, Tolbert, & Mann, 2003). In this study, young women who reported having sex with bisexual male partners were significantly more likely to report having anal sex. The young women in this sample who reported having anal sex were much more likely to report alcohol or drug use as well. In a qualitative study of heterosexual anal sex among adolescents (Roye, Tolman, & Snowden, 2013), some young women reported that they needed to be high before having anal sex because it numbed the pain, but not the pleasure. A study of anal sex behavior among adult women found that women reserved anal sex for a special partner (Maynard et al.,
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2009). Of women in this study who reported ever having anal sex, 42% had anal sex with their most recent partner and 35.3% used a condom. Young women who reported having anal sex with their most recent partner were more likely to still be with that partner, while young women who had vaginal sex were more likely to have ended the relationship. CONCLUSION This study provides additional evidence that anal sex is becoming a prevalent behavior among young women. Risk factors for heterosexual anal sex are highlighted, including the increased prevalence of anal sex among bisexual young women. Sexual health campaigns must address this behavior, which to date has received little attention from prevention researchers and practitioners. Incorporation of these study findings as a substantial component of HIV-prevention behavioral interventions has the potential to increase the effectiveness of health promotion for adolescent women. Declaration of Interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper. REFERENCES Beitchman, J. H., Zucker, K. J., Hood, J. E., daCosta, G. A., Akman, D., & Cassavia, E. (1992). A review of the long-term effects of child sexual abuse. Child Abuse and Neglect, 16(1), 101–118. Bevier, P. J., Chiasson, M. A., Heffernan, R. T., & Castro, K. G. (1995). Women at a sexually transmitted disease clinic who reported same-sex contact: Their HIV seroprevalence and risk behaviors. American Journal of Public Health, 85(10), 1366–1371. Boily, M. C., Baggaley, R. F., Wang, L., Masse, B., White, R. G., Hayes, R. J., & Alary, M. (2009). Heterosexual risk of HIV-1 infection per sexual act: Systematic review and meta-analysis of observational studies. Lancet: Journal of Infectious Diseases, 9(2), 118–129. Carter, M., Henry-Moss, D., Hock-Long, L., Bergdall, A., & Andes, K. (2010). Heterosexual anal sex experiences among Puerto Rican and black young adults. Perspectives on Sexual and Reproductive Health, 42(4), 267–274. Catania, J. A., Kegeles, S. M., & Coates, T. J. (1990). Towards an understanding of risk behavior: The AIDS risk reduction model (ARRM). Health Education Monographs, 17, 53–72. Centers for Disease Control and Prevention. (2008). Estimates of new HIV infections in the United States. CDC HIV Fact Sheet. Atlanta, GA: Author. Centers for Disease Control and Prevention. (2009a). Cases of HIV infection and AIDS in the United States and dependent areas, 2007. Atlanta, GA: Author. Centers for Disease Control and Prevention. (2009b). HIV/AIDS Surveillance Report, 2007 (vol. 19). Atlanta, GA: US Department of Health and Human Services, Centers for Disease Control and Prevention. Centers for Disease Control and Prevention. (2013). HIV in women. HIV Fact Sheet. Atlanta, GA: Author. Champion, J. D., & Collins, J. L. (2012). Comparison of a theory-based (AIDS risk reduction model) cognitive behavioral intervention versus enhanced counseling for abused ethnic minority adolescent women on infection with sexually transmitted infection: Results of a randomized controlled trial. International Journal of Nursing Studies, 49(2), 138–150. Derogatis, L. R. (1994). SCL-90-R Symptom Checklist-90-R: Administration, scoring and procedures manual (3rd ed.) Minneapolis, MN: National Computer Systems.
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Fishbein, M., & Ajzen, I. (1975). Belief, attitude, intention, and behavior: An introduction to theory and research. Reading, MA: Addison-Wesley. Fishbein, M., Bandura, A., Triandis, H. C., Kanfer, F. H., Becker, M. H., & Middlestadt, S. E. (1992). Factors influencing behavior and behavior change: Final report—theorist’s workshop. Rockville, MD: National Institutes of Health. Halperin, D. T. (1999). Heterosexual anal intercourse: Prevalence, cultural factors, and HIV infection and other health risks, part I. AIDS Patient Care, 13(12), 717–730. Hensel, D. J., Fortenberry, J. D., & Orr, D. P. (2010). Factors associated with event level anal sex and condom use during anal sex among adolescent women. Journal of Adolescent Health, 46(3), 232–237. Izazola-Licea, J., Gortmaker, S., de Gruttola, V., Tolbert, K., & Mann, J. (2003). Sexual behavior patterns and HIV risks in bisexual men compared to exclusively heterosexual and homosexual men. Salud P´ublica De M´exico, 45(suppl. 5), S662–S671. Kalichman, S. C., Simbayi, L. C., Cain, D., & Jooste, S. (2009). Heterosexual anal intercourse among community and clinical settings in Cape Town, South Africa. Sexually Transmitted Infections, 85(6), 411–415. Koblin, B. A., Hoover, D. R., Xu, G., Frye, V., Latka, M. H., Lucy, D., & Bonner, S. (2009). Correlates of anal intercourse vary by partner type among substance-using women: Baseline data from the UNITY study. AIDS Behavior, 14(1), 132–140. Leichliter, J. S. (2008). Heterosexual anal sex: Part of an expanding sexual repertoire? Sexually Transmitted Diseases, 35(11), 910–911. Magnus, M., Kuo, I., Shelley, K., Rawls, A., Peterson, J., Montanez, L., WestOjo, T., Hader, S., Hamilton, F., & Greenberg, A. E. (2009). Risk factors driving the emergence of a generalized heterosexual HIV epidemic in Washington, District of Columbia networks at risk. AIDS, 23(10), 1277–1284. Maynard, E., Carballo-Di´eguez, A., Ventuneac, A., Exner, T., & Mayer, K. (2009). Women’s experiences with anal sex: Motivations and implications
for STD prevention. Perspectives on Sexual and Reproductive Health, 41(3), 142–149. Poles, M. A., Elliott, J., Taing, P., Anton, P. A., & Chen, I. S. (2001). A preponderance of CCR5(+) CXCR4(+) mononuclear cells enhances gastrointestinal mucosal susceptibility to human immunodeficiency virus type 1 infection. Journal of Virology, 75(18), 8390–8399. Powers, K. A., Poole, C., Pettifor, A. E., & Cohen, M. S. (2008). Rethinking the heterosexual infectivity of HIV-1: A systematic review and meta-analysis. Lancet: Journal of Infectious Diseases, 8(9), 553–563. Richardson, D. (2000). The social construction of immunity: HIV risk perception and prevention among lesbians and bisexual women. Culture, Health and Sexuality, 2, 33–49. Roye, C. F., Krauss, B. J., & Silverman, P. L. (2010). Prevalence and correlates of heterosexual anal intercourse among black and Latina female adolescents. Journal of the Association of Nurses in AIDS Care, 21(4), 291–301. Roye, C., Tolman, D., & Snowden, F. (in press). Heterosexual anal intercourse among black and Latino adolescents and young adults: A poorly understood high-risk behavior. Journal of Sex Research, 50, 715–722. Shain, R. N., Perdue, S. T., Piper, J. M., Holden, A. E. C., Champion, J. D., Newton, E. R., & Korte, J. E. (2002). Behaviors changed by intervention are associated with reduced STD recurrence: The importance of context in measurement. Sexually Transmitted Diseases, 29(9), 520–529. Shain, R. N., Piper, J. M., Holden, A. E. C., Champion, J. D., Perdue, S. T., Korte, J. E., & Guerra, F. A. (2004). Prevention of gonorrhea and chlamydia through behavioral intervention: Results of a two-year controlled randomized trial in minority women. Sexually Transmitted Diseases, 31(7), 401–408. Shain, R. N., Piper, J. M., Newton, E. R., Perdue, S. T., Ramos, R., Champion, J. D., & Guerra, F. A. (1999). A randomized, controlled trial of a behavioral intervention to prevent sexually transmitted disease among minority women. New England Journal of Medicine, 340(2), 93–100.
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Toward an Understanding of the Context of Anal Sex Behavior in Ethnic Minority Adolescent Women Jane Dimmitt Champion, PhD, DNP, FNP, AH-PMH-CNS, FAANP, FAAN The University of Texas at Austin, School of Nursing, Austin, Texas, USA
Carol F. Roye, EdD, RN, CPNP, FAAN Hunter College, City University of New York, School of Nursing, New York, New York, USA
Understanding the context of anal sex behavior among ethnic minority adolescent women has public health implications for behavioral sexual health promotion and risk reduction interventions. African-American (n = 94) and Mexican-American (n = 465) women (14–18 years of age) enrolled in a clinical trial completed semi-structured interviews to assess psychosocial and situational factors and relationships to sexual risk behavior, substance use, sexually transmitted infection/HIV acquisition, and violence. Bivariate analyses with comparisons by anal sex experiences identified differences by ethnicity and higher self-reported histories of sexual risk behaviors, substance use, violence, and stressful psychosocial and situational factors among adolescent women experiencing anal sex. Predictors of anal sex identified through logistic regression included Mexican-American ethnicity, ecstasy use, methamphetamine use, childhood sexual molestation, oral sex, and sex with friends for benefits.
The purpose of this article is to describe the context of sexual behavior among African and Mexican-American adolescent women with a history of sexually transmitted infection (STI), high risk sexual behavior, or violence, using comparisons by self-reported experience of anal sex. Conceptualization of sexual behavior within these sexual partner relationships is important for the modification of evidence-based, behavioral, sexual risk reduction interventions. The information from this study can be used with these interventions to enhance efficacy for the prevention of violence, substance use, unintended pregnancy, and STIs, including HIV, among ethnic minority adolescent women.
BACKGROUND HIV poses a substantial risk to the health of women, who represent more than 20% of new HIV infections and 25% of all infections in the US. Black or Hispanic women account for more
Address correspondence to Jane Dimmitt Champion, The University of Texas at Austin, School of Nursing, 1710 Red River St., Austin, TX 78701 USA. E-mail: [email protected]
than 80% of HIV-infected women (Centers for Disease Control and Prevention [CDC], 2013) The rate of new HIV infections among black women in 2010 was 20 times that of non-Hispanic white women. Hispanic women are becoming infected at nearly four times the rate of non-Hispanic white women (CDC, 2013). The majority of new infections occur among young women (CDC, 2013). Young women in particular are at risk; in 2006, 34% of adolescents aged 13 to 19 years who were diagnosed with HIV infection were female, compared to 26% of adults aged 25 and older (CDC, 2008). The CDC has found that the leading cause of disease transmission in women is “heterosexual contact,” accounting for of 80% of new cases (CDC, 2008, 2009a, 2009b). The CDC defines “heterosexual contact” as “heterosexual contact with a person known to have or be at high risk for HIV” (CDC 2009a; Roye, Krauss & Silverman, 2010). However, we do not know the specific unprotected sexual risk behaviors (i.e., vaginal, oral/penile, and/or anal intercourse) causing disease transmission in women (CDC 2009a; Roye, Krauss & Silverman, 2010). The CDC (2013) has recently indicated that unprotected anal sex is riskier than vaginal sex. There are variable risks associated with different sexual behaviors (Powers, Poole, Pettifor, & Cohen, 2008). For example, receptive anal intercourse has been estimated to be 5 to 20 times riskier than receptive vaginal intercourse (Boily et al., 2009) because of biological characteristics of intestinal tissue (Poles, Elliot, Taing, Anton, & Chen, 2001). In one study of in vitro viral replication, researchers inundated punch biopsies of healthy vaginal and cervical tissue with HIV for 6–24 hours and found that the virus was unable to infect it. However, healthy intestinal tissue was rapidly infected when subjected to the same treatment, modeling the level of immune barrier protection found in tissue lining the anus/rectum (Poles et al., 2001). Researchers who undertook a systematic review and metaanalysis of studies of HIV-transmission to evaluate the commonly cited assertion that heterosexual infectivity of HIV1 is a fixed value at approximately one transmission per 1,000 contacts (Powers et al., 2008) found that heterosexual
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transmission is more efficient during penile-anal than penilevaginal intercourse. If the index case is in early stage or late stage infection—heterosexual infectivity can exceed one transmission per ten contacts for penile-vaginal contact and one transmission per three contacts for penile-anal contact; the biggest transmission risk, one transmission event for every 3.1 contacts, was found for penile-anal sex between late-stage male index cases and susceptible women. Similarly, a meta-analysis of observational studies of HIVtransmission per heterosexual contact found that receptive anal intercourse carried a transmission risk that is more than twice as high (1.7% per act; CI = 0.3–8.9) as the overall male-to-female transmission rate (.08% per act; CI = 0.06–0.11) (Boily et al., 2009). Moreover, couples are much less likely to use condoms for anal intercourse than for vaginal intercourse (Gorbach, 2009; Halperin, 1999; Leichliter, 2008; Roye, Krauss, & Silverman, 2010). Other researchers (Kalichman, Simbayi, Cain, & Jooste, 2009) using data from South Africa similarly demonstrated that in sero-discordant couples, the estimated risk of HIV acquisition for females who only engage in vaginal intercourse is 0.2% but the risk increases by 7.5 times, to 1.5%, if they also engage in anal intercourse, with 89% of their risk attributable to anal intercourse. It is a great concern therefore that heterosexual anal intercourse is becoming a relatively common behavior among adolescents. It is a behavior that is practiced by 16–35% of teenage couples (Carter et al., 2010; Hensel, Fortenberry, & Orr, 2010; Koblin et al., 2009; Roye, Krauss, & Silverman, 2010). Although homosexuality and bisexuality among women has not received much attention from HIV researchers, there is some evidence that having both male and female sexual partners may be associated with HIV-risk for women. There is some evidence that women who have sex with women may be at elevated risk for HIV (Magnus et al., 2009). A study of STI clinic patients found that a higher proportion of women who have sex with women were HIV positive than women who exclusively had sex with men (Bevier, Chiasson, Heffernan, & Castro, 1995). A Washington, DC, study of a non-clinic-based sample found that compared to HIV-positive men, HIV-positive women were more likely to report being bisexual (Magnus et al., 2009). In fact, women who have sex with women are more likely to have vaginal and anal sex with men they know to be bisexual, and are less likely than other women to use condoms (Bevier et al., 1995; Richardson, 2000). Although this topic has not been thoroughly studied, researchers have thought about heterosexual anal intercourse as a way to either prevent pregnancy or the loss of virginity (Halperin, 1999). However, a study of adolescent women who were using hormonal contraception, found that 35% reported engaging in anal intercourse and less than one-third (29.4%) reported using a condom during their last act of anal intercourse (Roye, Krauss, & Silverman, 2010). These adolescents were less likely to use condoms for anal intercourse than for vaginal intercourse.
This approach to the study of heterosexual anal intercourse, as a way to prevent an unwanted outcome, does not adequately address the context of the behavior. While half of the respondents in a recent qualitative study of adolescent heterosexual anal intercourse described it as painful, one described it as feeling good and painful at the same time. Several spoke about the numbing effect of alcohol, which allowed them to enjoy the experience (Roye, Tolman, & Snowden, 2013). Although heterosexual anal intercourse has been discussed as a behavior that males seek out (Halperin, 1999), several young women reportedly initiated the behavior (Roye, Tolman, & Snowden, 2013). These findings emphasize the importance of describing the context of sexual behavior among black and Hispanic adolescent women. Conceptualization of anal sexual behavior within these sexual partner relationships is important and may provide information for modification of behavioral, sexual risk reduction interventions to enhance effectiveness of STI/HIV prevention efforts (CDC, 2013). METHODS The study was conducted in collaboration with the university and the metropolitan health district. Appropriate approval was obtained from both the university and metropolitan health district Institutional Review Boards for the protection of human subjects. African-American and Mexican young women were chosen as the study population because they account for more than 80% of HIV infected women (CDC, 2013). Africanand Mexican-American adolescent women (ages 14–18 years), with a history of STI or sexual, physical, or psychological violence, and who accessed sexual health care services from the metropolitan public health clinics were referred by metropolitan public health care providers for potential participation. Eligible, English speaking (to maximize homogeneity across ethnic groups), adolescent women (14–18 years old), with valid contact information were contacted and offered enrollment by study personnel between July 2006 and February 2008. Informed consent or assent as appropriate was obtained and then followed by a semi-structured interview at the study’s start. Research assistants administered the self-report semi-structured interview by reading the questions to each participant who then responded. Questions solicited information about the participant’s demographics and the psychosocial and situational factors associated with sexual risk behavior, including violence, STI, and substance use. Theoretical Framework The framework for the study (AIDS Risk Reduction Model; Catania, Kegeles, & Coates, 1990) encompasses social psychological theories, including the Health Belief Model, self-efficacy theory, decision-making models, and diffusion theory (Fishbein & Ajzen, 1975; Fishbein et al., 1992). This model was utilized for the research design and questionnaire development (Shain
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et al., 1999, 2002, 2004). The model has been found to be effective for developing interventions for reducing sexual risk. The model conceptualizes risk recognition, commitment to risk reduction, and the processes for identification and enactment of solutions. Both knowledge and social support are recognized as crucial for movement from one stage of risk reduction to the next. Extensive ethnographic fieldwork was undertaken to modify the model to focus on African- and Mexican-American adolescent women (Shain et al., 2004). This fieldwork portrayed risk perceptions, values and beliefs, knowledge and concerns regarding STI/HIV, sexual behaviors, sexual communication, male-female relationships, and approaches to stimulate commitment to behavior change. Insights were acquired to promote risk recognition, impart social support, inspire change, and isolate barriers.
Instruments Questions were formulated based upon these results to ascertain the configuration of psychosocial and situational factors associated with sexual partner relationships, high sexual risk behavior, and related factors that contribute to the context of substance use, STI/HIV, and violence. Questions concerning demographic (e.g., income and education), psychosocial (e.g., attitudes toward various aspects of sexual behavior), and situational (e.g., pregnancy status, substance use, violence history) factors directly or indirectly influencing sexual behavior (e.g., number and type of partners and types of sexual activity) were created. These questions ascertained which explanatory factors effect sexual behavior variables. Evidence deduces that social support has a protective effect against the adverse effects stress has on health outcomes among a variety of populations (Beitchman et al., 1992). Stressful life events, without benefit of social support, may impact susceptibility to substance use, unintended pregnancy, HIV/STI, and violence and are, therefore, measured. The SCL-R90 (Derogatis, 1994) was selected to measure psychological distress because it has been used extensively among minority groups and has good reliability and validity. A Cronbach’s alpha coefficient of .98 was obtained in this study. These variables were chosen because of their linkage to risk behavior as delineated in the AIDS Risk Reduction Model and as ascertained through prior modification of the AIDS Risk Reduction Model for use with African- and Mexican-American women, including adolescents (Champion & Collins, 2012; Shain et al., 1999, 2004). Overall, the questions were conceived largely through the principal investigator’s prior research; some questions were modified from established investigators. Assessment for the experience of anal sex was determined by the question, “Have you ever had anal sex?” The response to this question is either “yes” or “no.” Substance use was quantified by a sequence of questions on “ever use” and current use of drugs (cocaine, crack, heroin, “uppers,” “downers,” and hallucinogens). Alcohol use was quantified by a sequence of
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questions on ever or current use of wine, beer, and hard liquor; concurrent use of alcohol and substance also was assessed. Condom use was quantified as “ever and any condom use” for various types of sexual acts. Contraception use was quantified via questioning regarding “ever use” of various methods. Violence experience was quantified through questions that screened for physical, sexual, and psychological violence during childhood and adolescence. The Abuse Screen was created for use with this particular population and includes ten items (Champion & Collins, 2012). The sexual violence component of this screen has six questions: “Has anyone ever . . . (a) made you have sex when you didn’t want to, (b) made you afraid to say no to sex, (c) knowingly hurt you during sex, (d) made you have sex without a condom, (e) had sex with you when you were high or out of control, and (f) forced you to do things you didn’t want to by threatening to hurt you? The physical violence component has two questions: “Has anyone ever . . . (a) used a gun, knife, or other weapon against you, and (b) hit you, held you down, or tried to choke you?” The psychological violence component has two questions: “Has anyone ever . . . (a) constantly criticized you and put you down, and (b) acted with extreme jealousy?” Responses are coded as “yes” (1) or “no” (0) with a higher number of responses “yes” responses indicating more experiences and a higher level of violence. Protocols were followed to ensure uniformity in training and inter-rater reliability. Interviewers received extensive coaching by first observing interviews, and then being directly observed over a one-month interval. For months afterward, the principal investigator randomly selected interviews to appraise for completeness and internal consistency. Interviewers were gendermatched and were selected because they showed compassion concerning low-income minorities; were courteous and warm; and were at ease with questions about sexuality, violence, substance use, and STI/HIV. In order to promote internal consistency of data, the interviewers were trained to provide consistent clarification of questions when asked by participants. Statistical Analysis The statistical analysis examined the data carefully to determine relationships among variables before progressing to more complex levels of multivariable statistical models to assess effects. Statistical analyses included contingency tables, t-tests, and chi-square analyses to depict the context of sexual partner relationships and contrast sexual risk behaviors by experience of anal sex. Logistic regression was conducted subsequently to describe whether sexual risk behavior predicted anal sex among these adolescent women. RESULTS A total of 559 participants were in the study and responded to the question concerning experience of anal sex. Participants reported no anal sex (78.2%) or ever having had anal sex (21.8%) in a previous relationship.
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Comparisons of Characteristics of Adolescent Women by Experience of Anal Sex Comparisons of characteristics of women by their experience of anal sex are provided in Table 1. Socio-demographically, there was a difference by ethnicity. Mexican-American women reported anal sex significantly more often than African-American women did within relationships. Overall, women describing anal sex within relationships were significantly older. They also reported having ever been arrested more frequently and had run away from home more often than women who did not report having anal sex. More women who did not report anal sex were in school and had had to repeat a grade. The majority of all women had previous HIV testing, reported ever used condoms, and reported having sex without condoms. Significantly more women reporting anal sex had a history of STI, including HPV and Chlamydia. Over 98% of all women had ever used a form of birth control. Differences in birth control use were identified, including a greater use of withdrawal by women reporting anal sex. Other comparisons indicated that more women who did not report anal sex had been pregnant in the past (46.9% no anal sex experience vs. 38.5% anal sex experience); however, equivalent number of both groups were currently pregnant with the majority of pregnancies being unintended for both groups of women (89.8% no anal sex experience vs. 84.8% anal sex experience). Women reporting anal sex experienced significantly more violence overall (94.3% vs. 85.1%), with higher levels of violence (8.37 vs. 6.38) overall and higher levels of sexual, physical, and emotional violence (Table 1). This violence included significantly more reports of sexual molestation, forced sex, being afraid to say no to sex, being hurt during sex, and having sex when high and out of control. Psychological distress as measured by the SCL-R-90 identified women reporting anal sex as experiencing higher levels of distress than others (Table 1). Comparison of Sexual Risk Behavior of Adolescent Women by Experience of Anal Sex Comparisons of sexual risk behaviors of women by their experience of anal sex are described in Table 2. Women who reported anal sex also reported more often being bisexual. They had experienced significantly more oral sex, group sex, sex with women, sex with a bisexual man, sex with friends for benefits, sex to pay back favors or receive money, sex with IV drug users, or use of sex toys. No differences were noted between groups concerning age of either themselves or partners at their first act of sex; however, significantly fewer women reporting having had anal sex used a condom the first time they had sex. Significantly higher numbers of partners also were identified for women who reported having anal sex. These women also reported significantly more and higher levels of use of alcohol, cigarettes, and drugs, including marijuana, cocaine, ecstasy, heroin, and benzodiazepine than women who did not report having anal sex (Table 2).
Adolescent Women Experiencing Anal Sex Women reported their age at their first experience of anal sex as 15.85 years (Mean; SD ± 1.25 years) and their partner age as 18.43 (Mean; SD ± 2.78) years. Almost 74% of the participants (73.6%) reported only one anal sex partner in their lifetime, 79.5% had experienced anal sex within the past year, and 61.2% had anal sex within the past six months. Only 38% of the women reported ever using a condom for anal sex. When asked about their most recent partner, 36.7% indicated that they had anal sex within the past three months; 40.8% of those indicated they used a condom. Women provided the following responses regarding reasons for having anal sex: (1) Anal sex is pleasing to me (4.1%), (2) Anal sex is pleasing to my partner (24.0%), (3) Just trying or experimenting with anal sex (75.2%), (4) Cannot get pregnant with anal sex (.8%), and (5) Had anal sex because of menstruation (2.5%). When asked whether they could stop having anal sex, 86.0% indicated that they could. Women reporting having anal sex indicated that their most recent sex partner was a steady partner (68.6%), which is approximately the same as those who did not report having anal sex (63.8%). Of women who described their most recent sex partner as steady, more women who reported having anal sex were still in the relationship (73.3% vs. 60.0%, p = .036) and more women who did not report having anal sex had broken up with the partner (52.8% vs. 43.3%, p = .021). Of women reporting their most recent sex partner as steady and who also indicated that they had broken up during the relationship, more women who reported having anal sex indicated that, while broken up, they had sex with other persons (39.1% vs. 17.98%, p = .001) and less often indicated they could stop having sex with partners who were having sex with others (64.7% vs. 76.2%, p = .036). Among women who reported that they thought it was okay to have a man on the side, as a sexual partner in addition to their primary sexual partner (n = 252), more women who reported having anal sex indicated this was okay. Their reasons were: (1) It provides more variety/sex (43.9% anal sex vs. 18.3% no anal sex, p = 0.000), (2) He fools around so why shouldn’t I? (25.8% anal sex vs. 15.1% no anal sex, p = .051) and (3) I get high and lose control (24.2% anal sex vs. 14.5% no anal sex, p = .056). Equivalently these women reported having a man on the side was okay because they hadn’t found the right man yet (83.9% no anal sex vs. 80.3% anal sex). Logistic Regression of Sexual Risk Behavior Predicting Anal Sex Sexual risk behaviors, violence, and substance use variables were significantly different in comparisons of participants’ experiences of having anal sex and were included as independent variables in the logistic regression model. Since significantly more Mexican-American than African-American adolescent women reported experiences of having anal sex, ethnicity also was entered into the model. An assessment of the full
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TABLE 1 Comparisons of Characteristics of Adolescent Women by Experience of Anal Sex Variable Sociodemographic Characteristics Ethnicity Mexican-American Black Mean age, years ± SD∗ Ever arrested, convicted, incarcerated, on probation Ever run away Enrolled in school Enrolled in grade supposed to be in Sexual/Reproductive Health History Previous HIV testing Condom use ever Condomless sex ever STI history Pap smear with HPV Chlamydia ever Birth control use ever Condom use for birth control ever Withdrawal use ever Birth control pill use ever DepoProvera use for birth control ever Patch use for birth control ever Ever pregnant Pregnant now Unintended current pregnancy Any Violence (Physical, Sexual, Psychological) Violence composite score Physical abuse Physical violence composite score Sexual violence Sexual violence composite score Psychological violence Psychological violence composite score Forced sex Molested First sex forced Hurt during sex Afraid to say no to sex Sex when high and out of control SCL-R-90
No Anal Sex %∗ n = 437
Anal Sex %∗ n = 122
p 0.004∗∗
75.9 89.4 16.46 ± 1.34∗ 45.5 46.0 66.4 63.4
24.1 10.6 16.76 ± 1.20∗ 53.3 61.5 58.2 47.8
0.017∗∗ 0.130 0.002∗∗ 0.093 0.023∗∗
64.3 90.8 97.9 25.6 4.7 20.6 97.0 95.8 53.9 29.9 22.7 12.0 46.9 19.3 89.8 85.1 6.38 ± 6.37∗ 63.2 2.27 ± 2.56∗ 46.2 1.46 ± 2.36∗ 68.4 2.65 ± 2.64∗ 21.7 18.2 9.8 5.9 9.6 10.1 77.19
69.7 94.3 99.2 36.1 10.6 31.1 99.2 86.7 66.4 26.2 16.4 5.7 38.5 15.0 84.8 94.3 8.37 ± 6.11∗ 82.0 2.79 ± 2.45∗ 71.3 2.24 ± 2.28∗ 82.0 3.65 ± 2.80∗ 37.7 32.6 9.8 13.1 21.3 18.9 111.70
0.270 0.229 0.361 0.023∗∗ 0.040∗∗ 0.015∗∗ 0.176 0.657 0.014∗∗ 0.427 0.134 0.046∗∗ 0.177∗∗ 0.435 0.570 0.008∗∗ 0.000∗∗ 0.000∗∗ 0.045∗∗ 0.000∗∗ 0.000∗∗ 0.003∗∗ 0.000∗∗ 0.000∗∗ 0.000∗∗ 0.999 0.008∗∗ 0.000∗∗ 0.008∗∗ 0.000∗∗
Note. STI = sexually transmitted infection; SCL-R-90 = SCL-R-90 Symptom Checklist ∗ Mean and Standard Deviation, Student t-test as appropriate ∗∗ p < .05
model with all predictors compared to the constant-only model was significant, suggesting that the proposed model adequately predicted anal sex activity. Table 3 indicates the regression coefficients, Wald statistics, and odds ratios for the six indepen-
dent variables found to be predictive of anal sex. All predictors were statistically significant. Results of the Wald statistics suggest those who engaged in sex with friends for benefits (X2 = 22.53, p < .001) and who engaged in oral sex (X2 = 35.748,
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TABLE 2 Comparison of Sexual Risk Behavior among Adolescent Women by Experience of Anal Sex Sexual Risk Behavior
No Anal Sex %∗ n = 354
Anal Sex %∗ n = 192
p
9.4 74.6 4.8 1.6 11.0 25.4 1.4 .7 7.8 5.7 14.00 ± 1.80∗ 16.80 ± 3.14∗ 69.1 3.7 2.56 ± 2.06∗ 5.26 ± 5.79∗ 73.2 2.64 1.90 32.3 78.0 9.8 12.4 11.0 35.9 4.1 66.5
16.4 91.0 17.2 6.6 26.2 55.7 8.2 4.9 19.7 18.0 13.88 ± 1.79∗ 17.20 ± 4.20∗ 49.2 4.1 2.23 ± 1.57∗ 11.00 ± 15.08∗ 85.2 3.49 2.64 54.3 88.5 18.0 13.1 22.1 51.6 7.4 87.7
0.055 0.000∗∗ 0.000∗∗ 0.003∗∗ 0.000∗∗ 0.000∗∗ 0.000∗∗ 0.001∗∗ 0.000∗∗ 0.000∗∗ 0.504 0.251 0.000∗∗ 0.822 0.456 0.000∗∗ 0.006∗∗ 0.000∗∗ 0.000∗∗ 0.000∗∗ 0.010∗∗ 0.0130 0.823 0.001∗∗ 0.002∗∗ 0.138 0.000∗∗
Bisexual Give oral sex Group sex Sex with bisexual man Sex with women Sex with friends with benefits Sex to pay back favors Sex for money Sex with injection drug user Sex toys Age at first sex (years) Age of man at first sex (years) Condom use at first sex < 11 years of age at first sex Number of female sex partners Number of male sex partners Drink alcohol Alcohol/drug composite score Drug use composite score Cocaine Marijuana Heroin Methamphetamine Ecstasy Benzodiazepine Inhalants Smoke cigarettes ∗
Mean and Standard Deviation, Student t-test as appropriate p < .05
∗∗
p < .001) were more likely to engage in anal sex. Adolescent women who reported a history of sexual molestation (X2 = 22.53, p < .001) also were more likely to engage in anal sex activity. Results also show that the likelihood of engaging in anal sex differed according to participants’ previous drug history.
Adolescents reporting methamphetamine use were 2.7 times more likely than non-methamphetamine users to have ever had anal sex (X2 = 7.545, p < .01). Adolescents reporting ecstasy use also were more likely to have ever had anal sex (X2 = 4.870, p < .05).
TABLE 3 Binary Logistic Regression of Sexual Risk Behavior Predicting Anal Sex
Predictor Ethnicity Sex with friends with benefits Give oral sex Sexually molested Methamphetamine use Ecstasy use
B
Wald
Sig
Exp(B) 95% Confidence Interval for Exp (Upper Bound–Lower Bound)
−1.017 −1.149 −2.444 −.563 .999 −.714
6.950 22.530 35.748 5.170 7.545 4.870
0.008 0.000 0.000 0.023 0.006 0.027
.362 (.170–.770) .317 (.197–.510) .087(.039–.193) .570 (.351–.925) 2.716 (1.331–5.539) .490 (.260–.923)
ANAL SEX BEHAVIOR AND MINORITY ADOLESCENT WOMEN
Limitations Context cannot be comprehensively addressed with a survey. However, survey methodology is a quantitative method that has the capacity to provide descriptive information and can inform modifications to existing interventions. Future studies, however, could include other methodologies, including qualitative inquiry. It must be emphasized that the survey developed for this study is based upon extensive qualitative work, including modification of the theoretical framework as described earlier in-text. This developmental work enhances the contextual description provided in this survey research. DISCUSSION Study results for modifying behavioral interventions for STI/HIV have significant implications for mental health nursing. This study is one of the first to look at anal sex behavior in a population of African-American and Mexican-American adolescent women in the United States. Data on heterosexual anal sex among young women are sparse, and these data augment existing findings on this high risk behavior and are consistent with findings from studies of adolescents. As in other studies that demonstrated higher rates of anal sex among Hispanic than black young women (Carter et al., 2010; Roye, Krauss, & Silverman, 2010), there was a higher rate of anal sex among Mexican-Americans than African-Americans in this study. In this study, the Hispanic population was Mexican-American; in previous studies, the Hispanic population was predominantly from the Dominican Republic. In addition, consistent with previous studies, the young women who reported a history of anal sex were more likely than other young women to have been younger at first vaginal intercourse, to have experienced violence, to report a sexually transmitted infection, and to have been pregnant (Roye, Krauss, & Silverman, 2010). They also were less likely to report condom use at first intercourse. Of interest, there are data from research with adults that suggest that women who have sex with women may be at high risk for HIV (Magnus et al., 2009). In this study, significantly more women who reported sex with women also reported having anal sex. There also was a trend (p = .055) for women who reported being bisexual to report having anal sex. Previous research suggests that bisexual men report a preference for anal sex with their female partners (Izazola-Licea, Gortmaker, de Gruttola, Tolbert, & Mann, 2003). In this study, young women who reported having sex with bisexual male partners were significantly more likely to report having anal sex. The young women in this sample who reported having anal sex were much more likely to report alcohol or drug use as well. In a qualitative study of heterosexual anal sex among adolescents (Roye, Tolman, & Snowden, 2013), some young women reported that they needed to be high before having anal sex because it numbed the pain, but not the pleasure. A study of anal sex behavior among adult women found that women reserved anal sex for a special partner (Maynard et al.,
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2009). Of women in this study who reported ever having anal sex, 42% had anal sex with their most recent partner and 35.3% used a condom. Young women who reported having anal sex with their most recent partner were more likely to still be with that partner, while young women who had vaginal sex were more likely to have ended the relationship. CONCLUSION This study provides additional evidence that anal sex is becoming a prevalent behavior among young women. Risk factors for heterosexual anal sex are highlighted, including the increased prevalence of anal sex among bisexual young women. Sexual health campaigns must address this behavior, which to date has received little attention from prevention researchers and practitioners. Incorporation of these study findings as a substantial component of HIV-prevention behavioral interventions has the potential to increase the effectiveness of health promotion for adolescent women. Declaration of Interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper. REFERENCES Beitchman, J. H., Zucker, K. J., Hood, J. E., daCosta, G. A., Akman, D., & Cassavia, E. (1992). A review of the long-term effects of child sexual abuse. Child Abuse and Neglect, 16(1), 101–118. Bevier, P. J., Chiasson, M. A., Heffernan, R. T., & Castro, K. G. (1995). Women at a sexually transmitted disease clinic who reported same-sex contact: Their HIV seroprevalence and risk behaviors. American Journal of Public Health, 85(10), 1366–1371. Boily, M. C., Baggaley, R. F., Wang, L., Masse, B., White, R. G., Hayes, R. J., & Alary, M. (2009). Heterosexual risk of HIV-1 infection per sexual act: Systematic review and meta-analysis of observational studies. Lancet: Journal of Infectious Diseases, 9(2), 118–129. Carter, M., Henry-Moss, D., Hock-Long, L., Bergdall, A., & Andes, K. (2010). Heterosexual anal sex experiences among Puerto Rican and black young adults. Perspectives on Sexual and Reproductive Health, 42(4), 267–274. Catania, J. A., Kegeles, S. M., & Coates, T. J. (1990). Towards an understanding of risk behavior: The AIDS risk reduction model (ARRM). Health Education Monographs, 17, 53–72. Centers for Disease Control and Prevention. (2008). Estimates of new HIV infections in the United States. CDC HIV Fact Sheet. Atlanta, GA: Author. Centers for Disease Control and Prevention. (2009a). Cases of HIV infection and AIDS in the United States and dependent areas, 2007. Atlanta, GA: Author. Centers for Disease Control and Prevention. (2009b). HIV/AIDS Surveillance Report, 2007 (vol. 19). Atlanta, GA: US Department of Health and Human Services, Centers for Disease Control and Prevention. Centers for Disease Control and Prevention. (2013). HIV in women. HIV Fact Sheet. Atlanta, GA: Author. Champion, J. D., & Collins, J. L. (2012). Comparison of a theory-based (AIDS risk reduction model) cognitive behavioral intervention versus enhanced counseling for abused ethnic minority adolescent women on infection with sexually transmitted infection: Results of a randomized controlled trial. International Journal of Nursing Studies, 49(2), 138–150. Derogatis, L. R. (1994). SCL-90-R Symptom Checklist-90-R: Administration, scoring and procedures manual (3rd ed.) Minneapolis, MN: National Computer Systems.
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